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Breaking News: Higher Spending Linked to Better Outcomes

Coleman, Matthew

doi: 10.1097/01.EEM.0000407846.24220.c7
Breaking News


Emergency physicians know all too well how often Medicare is threatened, but a new study aims to caution those wanting to lower reimbursement.

The results of the research are striking: Patients treated in hospitals that spent more on health care had significantly lower mortality rates compared with those in low-spending ones, according to Joseph J. Doyle, Jr., the Alfred Henry and Jean Morrison Hayes Career Development Associate Professor of Economics at the MIT Sloan School of Management.

An increase in hospital expenditures of about $4,000 per patient led to a 1.4 percentage-point decrease in the mortality rate, Mr. Doyle found. A 50 percent increase in spending intensity, which he described as “end-of-life spending,” reduced mortality rates from cardiac causes to about 26 percent below the mean, which he attributed to facilities spending the most on patients who die generally spending a lot more overall.

Mr. Doyle selectively studied visitors from Michigan to Florida with cardiac emergencies seeking care at hospitals in high- and low-spending areas. It was comparing apples with apples, he said.

Using discharge data from Florida hospitals for the years 1996 to 2003, Mr. Doyle studied nearly 37,000 hospitalizations for patients who resided outside Florida, representing five percent of all cardiac emergency admissions. Acute myocardial infarction, cardiac dysrhythmia, and heart failure were among the top 10 diagnoses for emergency admissions with mortality rates higher than three percent.

“I am finding that the high-spending areas are more likely to have patients go into intensive care units,” said Mr. Doyle. “It is expensive to have people in the ICU, but I am finding lower mortality. [T]he places that do a lot of ICU care have the better outcomes.”

Mr. Doyle said high spenders also do more diagnostic testing, and they typically, while there is some variation, have better equipment,” he said.

Higher-spending areas also perform more expensive cardiac procedures, according to the study. Mr. Doyle noted that arteriography, a lower cost substitute for angiocardiography, is more commonly performed in low-cost areas, while the latter is more common in high-cost areas. Patients who have an emergency in a high-spending area also tend to be treated in teaching hospitals, which past studies have shown generally have higher costs and lower mortality, something Mr. Doyle confirmed in his study of visitors to Florida.

“Teaching hospitals have the most state-of-the-art technology and typically have the most prestigious physicians in the area,” said Mr. Doyle. “When I look through my spectrum of comparing people who went to a vacation area and went to a teaching hospital and those who did not, I am finding that teaching hospitals have better outcomes.”

Jesse Pines, MD, MBA, the director of the Center for Health Care Quality and an associate professor of emergency medicine and health policy at George Washington University Medical Center in Washington, D.C., said having resources ready in the ED for heart attack patients is expensive but definitely leads to lower mortality rates for higher-spending facilities.

“There needs to be sufficient resources in the ED to identify heart attack patients early on and get them the care they need to minimize the door-to-needle time, which is the time when the patients arrive at the door to when they actually have definitive therapy,” said Dr. Pines. “Having a cath lab available 24/7 and having other resources at the ready is expensive. I think that Doyle's study showed that an investment in these high-priced resources is associated with better survival.”

But it remains to be seen whether Mr. Doyle's study will influence the President and members of Congress, who looking to spend less on health care.

“This study was new because it actually did show that higher spending was associated with lower mortality rates,” said Dr. Pines. “But in terms of spending on EDs, I'm not sure if this study is going to have enough power to really change the trend of spending less on health care.”

Mr. Doyle stressed, however, that the study does not represent causation but demonstrates that there is a strong correlation between higher spending and better results. He cautioned that the push for hefty cuts to Medicare should be slowed to avoid any rash decisions.

“Once you compare apples to apples, it looks like high-spending areas do have better outcomes so you wouldn't be as ready to leap to the conclusion that there is 30 to 50 percent waste in the U.S. system. The nuance is that I can't say if you lower spending in Miami they would continue having better outcomes or if you raise spending in, let's say, West Palm Beach, then maybe they'd improve their outcomes,” Mr. Doyle said. “What I can say is that when you compare apples to apples, you see that people actually do better in Miami. I am confident in saying that existing studies should compare apples to apples because you do find differences, and this just means that making those strong policy claims based on existing evidence might be a little premature.”

While Dr. Pines said he does not think the study will engender a major change in thinking, he said he hopes that people heed Mr. Doyle's caveat. “My hope is that this will provide some evidence to justify the major investment in resources that are required to take care of heart attack patents,” said Dr. Pines. “My hope is that policy makers will look at this study, and will see the importance of the ED as a place that truly does extend life, particularly when it comes to heart attack care, which is so time-sensitive. Clearly, according to the study, when you put more resources into emergency care — getting people to the cath lab quicker, for example — does improve mortality.”

© 2011 Lippincott Williams & Wilkins, Inc.