Association of hospital spending intensity with mortality and readmission rates in Ontario hospitals

Context — The extent to which higher spending produces higher-quality care and better patient outcomes in a universal healthcare system with selective access to medical technology is unknown.

Objective — To assess whether acute care patients admitted to higher-spending hospitals have lower mortality and readmissions.

Design, Setting and Patients — The study population comprised adults (>18 years) in Ontario, Canada, with a first admission for acute myocardial infarction (AMI) (N=179,139), congestive heart failure (CHF) (N=92,377), hip fracture (N=90,046) or colon cancer (N=26,195) during 1998–2008, with follow-up to 1 year. The exposure measure was the index hospital’s end-of-life expenditure index for hospital, physician and emergency department services.

Main Outcome Measures — The primary outcomes were 30-day and 1-year mortality and readmissions, and major cardiac events (readmissions for AMI, angina, CHF, or death) for AMI and CHF.

Results — Patients’ baseline health status was similar across hospital expenditure groups. Patients admitted to hospitals in the highest vs. lowest spending intensity terciles had lower rates of all adverse outcomes. In the highest vs lowest spending hospitals, respectively, the age and sex-adjusted 30-day mortality rate was 12.7% vs 12.8% for AMI, 10.2% vs 12.4% for CHF, 7.7% vs 9.7% for hip fracture, and 3.3% vs 3.9% for colon cancer; fully adjusted relative 30-day mortality rates were 0.93 (95% CI, 0.89–0.98) for AMI, 0.81 (0.76–0.86) for CHF, 0.74 (0.68–0.80) for hip fracture, and 0.78 (0.66–0.91) for colon cancer. Results for 1-year mortality, readmissions and major cardiac events were similar. Higher spending hospitals had higher nursing staff ratios, and their patients received more inpatient medical specialist visits, interventional (AMI) and medical cardiac therapies (AMI, CHF), pre-operative specialty care (colon cancer), and post-discharge collaborative care with a cardiologist and primary care physician (AMI, CHF).

Conclusions — Among Ontario hospitals, higher spending intensity was associated with lower mortality, readmissions and cardiac event rates.