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Original Research |

Hospital Spending and Inpatient Mortality: Evidence From California: An Observational Study

John A. Romley, PhD; Anupam B. Jena, MD, PhD; and Dana P. Goldman, PhD
[+] Article and Author Information

From Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California, and Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.


Acknowledgment: The authors acknowledge the comments of Daniel Hunt, MD, and William Kormos, MD.

Grant Support: Dr. Romley received support from the National Institute on Aging (1R03AG031990-A1), and Dr. Goldman was supported by the Roybal Center for Health Policy Simulation (P30AG024968).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-1980.

Reproducible Research Statement:Study protocol: Not available. Statistical code: Available from Dr. Romley (e-mail, romley@sppd.usc.edu). Data set: Public use discharge databases are available from the California Office of Statewide Health Planning and Development.

Requests for Single Reprints: John A. Romley, PhD, University of Southern California Schaeffer Center, 650 Childs Way, Los Angeles, CA 90089-0626.

Current Author Addresses: Drs. Romley and Goldman: University of Southern California Schaeffer Center, 650 Childs Way, Los Angeles, CA 90089-0626.

Dr. Jena: Massachusetts General Hospital, Harvard Medical School, Wang Ambulatory Care Center, 15 Parkman Street, Boston, MA 02114.

Author Contributions: Conception and design: J.A. Romley, A.B. Jena, D.P. Goldman.

Analysis and interpretation of the data: J.A. Romley, A.B. Jena, D.P. Goldman.

Drafting of the article: J.A. Romley, A.B. Jena.

Critical revision of the article for important intellectual content: J.A. Romley, A.B. Jena, D.P. Goldman.

Final approval of the article: J.A. Romley, A.B. Jena, D.P. Goldman.

Statistical expertise: J.A. Romley, A.B. Jena.

Obtaining of funding: J.A. Romley, D.P. Goldman.

Administrative, technical, or logistic support: J.A. Romley, D.P. Goldman.

Collection and assembly of data: J.A. Romley.


Ann Intern Med. 2011;154(3):160-167. doi:10.7326/0003-4819-154-3-201102010-00005
Text Size: A A A

Background: Evidence shows that high Medicare spending is not associated with better health outcomes at a regional level and that high spending in hospitals is not associated with better process quality. The relationship between hospital spending and inpatient mortality is less well understood.

Objective: To determine the association between hospital spending and risk-adjusted inpatient mortality.

Design: Retrospective cohort study.

Setting: Database of discharge records from 1999 to 2008 for 208 California hospitals included in The Dartmouth Atlas of Health Care.

Patients: 2 545 352 patients hospitalized during 1999 to 2008 with 1 of 6 major medical conditions.

Measurements: Inpatient mortality rates among patients admitted to hospitals with varying levels of end-of-life hospital spending.

Results: For each of 6 diagnoses at admission—acute myocardial infarction, congestive heart failure, acute stroke, gastrointestinal hemorrhage, hip fracture, and pneumonia—patient admission to higher-spending hospitals was associated with lower risk-adjusted inpatient mortality. During 1999 to 2003, for example, patients admitted with acute myocardial infarction to California hospitals in the highest quintile of hospital spending had lower inpatient mortality than did those admitted to hospitals in the lowest quintile (odds ratio, 0.862 [95% CI, 0.742 to 0.983]). Predicted inpatient deaths would increase by 1831 if all patients admitted with acute myocardial infarction were cared for in hospitals in the lowest quintile of spending rather than the highest. The association between hospital spending and inpatient mortality did not vary by region or hospital size.

Limitation: Unobserved predictors of mortality create uncertainty about whether greater inpatient hospital spending leads to lower inpatient mortality.

Conclusion: Hospitals that spend more have lower inpatient mortality for 6 common medical conditions.

Primary Funding Source: National Institute on Aging and RAND Health Bing Center for Health Economics.

Figures

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Appendix Figure.
Risk-adjusted odds ratios of inpatient mortality, by hospital spending quintile, for 6 major medical conditions during 1999 to 2003 and 2004 to 2008.

Odds ratios of inpatient mortality for a given hospital spending quintile are calculated with respect to the lowest quintile. Vertical bars represent 95% CIs around the predicted lives saved. AMI = acute myocardial infarction; CHF = congestive heart failure; GI = gastrointestinal.

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Figure.
Predicted lives saved if all patients were treated in hospitals in the top spending quintile versus the bottom spending quintile during 1999 to 2003 and 2004 to 2008.

Vertical bars represent 95% CIs around the predicted lives saved. AMI = acute myocardial infarction; CHF = congestive heart failure; GI = gastrointestinal.

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Comments

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The poorer can pay less
Posted on February 5, 2011
Takeharu Koga
Asakura Medical Association Hospital
Conflict of Interest: None Declared

The results of the study by Romley et al deserve attention as a notable aspect of medicine, however, we need to be careful when thinking of causative relationship between the spending and the mortality. It's important to appreciate that low-income patients can spend less in hospitals in comparison with higher-income counterparts (1). On the other hand, it is well documented that socioeconomic status is an independent determinant of outcome of some of the diseases targeted in the study (2). Thus, although the investigation accounted for sociodemographic characteristics by ZIP code of the subjects, it is still possible that the background socioeconomic status contributes to the difference in mortality more significantly than the difference in the spending itself.

References

1. Shen YC, McFeeters J. Out-of-pocket health spending between low-and higher-income populations: who is at risk of having high expenses and high burdens? Med Care. 2006;44(3):200-9.

2. Mackenbach JP, Bos V, Andersen O, Cardano M, Costa G, Harding S, et al. Widening socioeconomic inequalities in mortality in six Western European countries. Int J Epidemiol. 2003;32(5):830-7.

Conflict of Interest:

None declared

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