AIM: Hospitals that spend more have fewer inpatient deaths

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Hospitals that spend more have lower inpatient mortality for six common medical conditions, including acute MI, congestive heart failure and acute stroke, based on the results of a retrospective study published Feb. 1 in the Annals of Internal Medicine.

While evidence shows that high Medicare spending is not associated with better health outcomes at a regional level and that high spending in hospitals is not associated with better quality, the relationship between hospital spending and inpatient mortality is less well understood, wrote the study authors.

Therefore, John A. Romley, PhD, from the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California, Los Angeles, and colleagues sought to determine the association between hospital spending and risk-adjusted inpatient mortality by evaluating 2.55 million patients hospitalized during 1999 to 2008 with one of six major medical conditions—acute MI, congestive heart failure, acute stroke, gastrointestinal hemorrhage, hip fracture and pneumonia.

For each of six conditions, the researchers found that patient admission to higher-spending hospitals was associated with lower risk-adjusted inpatient mortality.

During 1999 to 2003, for example, patients admitted with acute MI to California hospitals in the highest quintile of hospital spending had lower inpatient mortality than did those admitted to hospitals in the lowest quintile (odds ratio, 0.862). The authors wrote that predicted inpatient deaths would increase by 1,831 if all patients admitted with acute MI were cared for in hospitals in the lowest quintile of spending rather than the highest.

Also, Romley and colleagues noted that the association between hospital spending and inpatient mortality did not vary by region or hospital size.

“Although our analysis demonstrates that intensive spending by hospitals is associated with lower mortality, it does not identify the specific costly interventions that high spending hospitals undertake to achieve this mortality benefit,” the authors wrote. "Prior work suggests that patients at moderate and high risk for death have lower mortality when admitted to hospitals in which larger proportions of patients spend time in the intensive care unit, undergo mechanical ventilation or receive dialysis.”

They added that these interventions are “probably” only proxies for the additional costly diagnostic work-up and management that higher-spending hospitals may do, and they may include early and more frequent coronary revascularizations for acute MI, for example.

As a limitation of their study, the researchers acknowledged that unobserved predictors of mortality create uncertainty about whether greater inpatient hospital spending leads to lower inpatient mortality.

“Higher hospital spending on these six major medical conditions may not produce better health outcomes outside of California, although we know of no reason to doubt it,” Romley and colleagues concluded. “Furthermore, hospital spending would not necessarily be cost effective, because alternative interventions might enhance population health at lower cost. The cost-effectiveness of hospital spending depends on its effect on inpatient and postdischarge mortality. ... Hence, important questions about the efficacy and value of hospital care remain to be asked and answered.”

The National Institute on Aging and Rand Health Bing Center for Health Economics provided funding for the study.