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Higher-spending hospitals in Ontario have better patient outcomes

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Patients treated at hospitals in Ontario with higher levels of spending had lower rates of deaths, hospital readmissions and repeat cardiac events according to a new study released by the Institute for Clinical Evaluative Sciences (ICES).

Higher levels of spending were associated with greater use of specialists and advanced procedures, higher nursing staff ratios and greater use of evidence-based care.

“These results suggest that while it is important to know the amount of money that is spent, it is also critical to understand how the money is spent and whether it is spent on effective procedures and services,” says Therese Stukel, lead author and scientist at ICES.

Many studies have investigated whether higher health care spending produces better patient outcomes and higher quality of care, often with conflicting results. This study investigated the relationship in Ontario which, unlike the United States, has global hospital budgets, selective access to medical technology, and far lower supply of specialists and specialized services.

The study looked at Ontario patients admitted for heart attacks (AMI), congestive heart failure (CHF), hip fracture or colon cancer during 1998 to 2008, and followed up to 1 year. A hospital’s spending was calculated as the average adjusted spending on hospital, emergency department, and physician services provided to patients. Spending varied about 2-fold across hospitals.

    Higher-spending hospitals tended to:

    • be larger, teaching or community hospitals
    • be located in urban areas
    • be associated with regional cancer centers
    • have specialized services such as onsite cardiac catheterization, cardiac surgery and diagnostic imaging facilities
    • have attending physicians who were more likely to be specialists or to care for a higher volume of patients with that condition

    Patients admitted to higher-spending hospitals:

    • had longer lengths of stay
    • were less likely to be admitted to an intensive care unit
    • had more medical specialist visits during their hospital stay
    • were more likely to receive cardiac interventions and evidence-based discharge medications (cardiac patients)

    The 30-day mortality rates in highest- vs. lowest-spending hospitals were:

    • 12.7 per cent vs. 12.8 per cent for AMI
    • 10.2 per cent vs. 12.4 per cent for CHF
    • 7.7 per cent vs. 9.7 per cent for hip fracture
    • 3.3 per cent vs. 3.9 per cent for colon cancer

    The 30-day rates of major cardiac events (e.g. heart attack) in highest- vs. lowest-spending hospitals were:

    • 17.4 per cent vs. 18.7 per cent for AMI
    • 15.0 per cent vs. 17.6 per cent for CHF

    The 30-day readmission rates in highest- vs. lowest-spending hospitals were:

    • 23.1 per cent vs. 25.8 per cent for hip fracture
    • 10.3 per cent vs. 13.1 per cent colon cancer

    Results were similar after 1 year of follow-up. All rates were age- and sex-adjusted.

    Higher-spending hospitals had higher nursing staff ratios. Their patients received more inpatient medical specialist visits, interventional (AMI) and medical (AMI and CHF) cardiac therapies, preoperative specialty care (colon cancer), and post-discharge collaborative care with a cardiologist and primary care physician (AMI and CHF).

    “There are limits to how much better health we can buy with more spending, especially since there are diminishing returns to health with increased use of specialized medical technology” said Dr. Stukel. She pointed to a study in the US that found that higher spending was not related to better survival or quality of care. The lesson for Canada is to manage health resources in such a way that they continue to be used efficiently.

    Authors: Therese A. Stukel, Elliott S. Fisher, David A. Alter, Astrid Guttmann, Dennis Ko, Kinwah Fung, Walter P. Wodchis, Nancy N. Baxter, Craig C. Earle, Douglas S. Lee.

    The study “Association of Hospital Spending Intensity With Mortality and Readmission Rates in Ontario Hospitals,” will be published in the March 14, 2012 issue of the Journal of the American Medical Association.

    ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of health care issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting health care needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy.

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    Read the Journal Article