Higher spending intensity was associated with substantially better hospital care in Ontario, which has a universal health care system, according to a report in the March 14 issue of JAMA.
Patients with acute illness treated at hospitals with higher spending intensity had lower mortality, lower readmission rates, and fewer adverse events than did those treated at hospitals with lower spending intensity, said Therese A. Stukel, Ph.D., of the Institute for Clinical Evaluative Sciences, Toronto, and her associates.
However, it would be "facile" to conclude that more spending necessarily leads to better patient outcomes, and that providing more money to lower-spending facilities would necessarily improve their patient 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," the investigators noted.
Many studies have examined whether higher health care spending produces better patient outcomes, but until now, none have assessed the issue in an area with universal access to health care but a lower supply of specialists and of medical technology than in the United States. "Our objective was to assess whether acute care patients admitted to Canadian hospitals that treat patients more intensively (and at higher cost) have lower mortality and readmissions and higher quality of care," Dr. Stukel and her colleagues said.
They analyzed the medical records of adults with an index admission to one of 129 acute care hospitals in Ontario in 1998-2008 for any of four common conditions for which treatment follows relatively standard protocols: acute myocardial infarction (179,139 patients), heart failure (92,377 patients), hip fracture (90,046 patients), or surgical resection of colon cancer (26,195 patients). The study subjects were followed for 1 year after the index admission.
Several quality-of-care measures were assessed: whether patients received preoperative visits from a surgeon and an anesthetist, whether surgery took place within 2 days of admission, whether patients received in-hospital rehabilitation, whether MI patients underwent same-day percutaneous coronary intervention, and the number of visits from medical specialists during the hospital stay.
Higher-spending hospitals tended to be high-volume centers in urban areas. They tended to be affiliated with regional cancer centers and to have on-site CT, MRI, cardiac catheterization, and cardiac surgery capabilities. They also tended to employ critical care response teams, as well as attending physicians who were specialists. And they provided 30% more inpatient nursing hours per patient-day and per bed than did lower-spending hospitals.
At higher-spending hospitals, 30-day mortality was 12.7% (vs 12.8%) for acute MI, 10.2% (vs. 12.4%) for CHF, 7.7% (vs. 9.7%) for hip fracture, and 3.3% (vs 3.9%) for colon cancer. The 30-day major cardiac event rate was 17.4% (vs.18.7%) for acute MI and 15.0% (vs. 17.6%) for CHF. And the 30-day readmission rate was 23.1% (vs. 25.8%) for hip fracture and 10.3% (vs 13.1%) for colon cancer.
After the data were adjusted fully to account for patient age, sex, illness severity, and other variables, mortality and readmission rates remained significantly lower in high-spending hospitals for every study subgroup, Dr. Stukel and her colleagues said (JAMA 2012;307:1037-45).
Compared with patients at lower-spending hospitals, those at higher-spending hospitals were more likely to see a medical specialist during their stay. Cardiac patients at higher-spending hospitals were more likely to receive the indicated cardiac interventions and evidence-based medications, to attend ambulatory care within 1 month, and to visit a cardiologist within 1 year.
CHF patients at higher-spending hospitals were less likely than were those at lower-spending hospitals to receive contraindicated medications. Those with hip fracture were more likely to begin rehabilitation during their inpatient stay. And those with colon cancer were more likely to have a preoperative consultation with a surgeon and an anesthetist, and to undergo CT for preoperative staging, compared with colon cancer patients at lower-spending hospitals.
The study findings "suggest that it is critical to understand not simply how much money is spent but whether it is spent on effective procedures and services," the researchers noted.
This study was supported by the Canadian Institute of Health Research, the U.S. National Institute on Aging, the Institute for Clinical Evaluative Sciences, and the Ontario Ministry of Health and Long-Term Care. No relevant financial conflicts of interest were reported.