AEJ: Higher ER spending associated with lower mortality rates

Assessing the outcomes of nearly 37,000 visitors to Florida who became ill and needed emergency treatment, researcher Joseph J. Doyle, economist with the Massachusetts Institute of Technology, found that high spending areas have significantly lower inpatient mortality rates compared to low-spending areas, according to a study published in the American Economic Journal.

“More intensive and expensive treatment leads to better outcomes,” Doyle wrote. “The higher-spending hospitals use more ICU service, and they have higher staff-to-patient ratios, so they use more labor, and that’s expensive.”

Doyle assessed hospital discharges in Florida from 1996 to 2003 and studied the cross-sectional variation in spending intensity by comparing patients who were exposed to different healthcare systems while away from home. Florida was chosen as the study location for three reasons: it’s a top travel destination state, it provides detailed discharge data and there is a wide variation in spending across the state. The main measure for resource use was total costs reported in discharge summaries, according to the study.

Results showed that among similar groups of patients with similar destinations and a wide variety of emergency conditions, higher-spending areas were associated with greater levels of intensive care services, treatment and higher staff-to-patient ratios. Notably, Doyle found that high-spending areas do not appear to reflect the income level of residents or travelers and age was found to be relatively unrelated to hospital spending as well.

“The main results suggest that more expensive healthcare systems do achieve lower inpatient mortality rates among visitors,” Doyle wrote. Alternative explanations, however, may include the possibility that high-spending areas attract healthier patients. Additionally, areas that provide better care for heart-related emergencies may happen to be high-spending areas, or another possibility is that high-spending areas admit healthier patients into the hospital, Doyle added.

Doyle wrote that estimated returns on healthcare spending “can be confounded by the fact that individuals in worse health receive more care.” There is a strong correlation between spending and mortality at the individual level, according to Doyle, even after factoring in age and comorbidity levels.

“The finding that this bundle of characteristics is associated with higher costs and lower mortality is in contrast to prior cross-sectional evidence, but is consistent with better outcomes,” Doyle concluded. “While these results may relate, in particular, to the types of patients who are likely to travel, they suggest that high returns may be present, at least for emergency care.”

Sandra M. Schneider, MD, president of the American College of Emergency Physicians, stated that emergency visits are going to increase, citing the nation’s growing elderly population and millions of Medicaid patients who can’t find doctors to treat them. She added that Doyle’s study emphasizes the need to preserve emergency care.

“This study shows the critical value of emergency medicine and how people’s lives are saved,” she said. “It demonstrates that the focus of healthcare policy must be on preserving our nation’s emergency care system and strengthening it to serve more people.”