JAMA: Higher-spending Canadian hospitals see better acute care outcomes
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"Numerous studies have investigated whether higher healthcare spending produces better patient outcomes and higher quality of care,” Therese A. Stukel, PhD, of the Institute for Clinical Evaluative Sciences in Toronto, and colleagues wrote. However, these previously published studies are conflicting, with some finding that being treated in higher-spending hospitals improved outcomes and others finding the opposite.
Because it remains unknown whether patients who receive care at higher-spending hospitals see better outcomes, Stukel et al evaluated hospital spending and patient outcomes within acute care hospitals located in Ontario, Canada, between April 1, 1998, and March 31, 2008.
The authors aimed to evaluate whether treating acute care patients “more intensively” (at a higher cost) had an impact on mortality rates, readmissions and quality of care. Thirty-day and one-year mortality, readmission and major adverse cardiac event (MACE) rates for acute MI and congestive heart failure (CHF) were analyzed.
Hospital spending across Canadian hospitals varied two-fold, the authors wrote. And patients who were admitted to hospitals in the highest vs. lowest spending quartiles had reduced rates of adverse events. The 30-day mortality rates for acute MI in the highest spending hospitals were 12.7 percent compared with 12.8 percent in the lowest spending hospitals. The rates for CHF were 10.2 percent vs. 12.4 percent, respectively.
After the researchers adjusted for patients’ sex, the 30-day MACE rate was 17.4 percent in higher-spending hospitals vs. 18.7 percent at lower-spending hospitals for patients for acute MI. The rates for CHF were 15 percent vs. 17.6 percent, respectively.
The one-year rates of mortality, readmission and MACE rates were similar. Additionally, the authors reported that hospitals located in the higher-spending quartile had higher nursing staff ratios, patients received more inpatient medical specialist visits and interventional and medical patient cohorts who received cardiac therapy were more likely to undergo joint care by both primary care physicians and cardiologists.
One-year costs within the study most frequently occurred during the index hospital episode and varied from 42 percent for CHF to 64 percent to 72 percent for other conditions. The hospitals considered to be higher spending were more likely to be teaching or community hospitals located in more urban areas. Additionally, physicians within these hospitals were more likely to be specialists who cared for higher patient volumes.
Additionally, the authors found that patients treated at higher-spending hospitals were less likely to be admitted to the ICU, but visited more medical specialists during the visit. Patients treated at higher-spending hospitals also had longer length of stay, were more likely to receive cardiac intervention and medication at discharge.
Results showed that acute patients see better overall outcomes when treated at higher-spending hospitals. These results may be due to the fact that these hospitals had the most innovative medical technologies and utilized care and rapid response teams.
“Higher spending on evidence-based services delivered in the acute phase of care for severely ill hospitalized patients—by far the largest component of spending for our cohorts—is indeed likely to be beneficial,” the authors wrote.
However, the researchers said that it would be incorrect to assume that putting more money into lower-spending hospitals could improve outcomes. “Higher-spending hospitals differed in many ways, such as greater use of evidence-based care, skilled nursing and critical care staff, more intensive inpatient specialist services, and high technology, all of which are more expensive."
Compared to Canada, the U.S. has a three- to four-times higher per capita supply of technology such as CT and MRI scanners; however, the U.S. has a similar number of acute care beds. The U.S. also has higher rates of cardiac tests and revascularization.
“It is therefore possible that Canadian hospitals, with fewer specialized resources, selective access to medical technology, and global budgets, are using these resources more efficiently, especially during the inpatient episode for care-sensitive conditions,” the authors wrote. Canada’s healthcare expenditures are 57 percent of those in the U.S.
“This study shows that in Ontario, a province with global hospital budgets and fewer specialized healthcare resources than the United States, outcomes following an acute hospitalization are positively associated with higher hospital spending intensity,” Stukel et al summed.