Increased resource use linked with lower mortality in patients with HF

Hospitals that used a greater amount of resources on Medicare beneficiaries with HF tended to report lower rates of mortality, study results suggested.

Researchers examined data from 3,999 Medicare beneficiaries hospitalized with HF in California — the “looking forward” cohort — and selected a subset of 1,639 patients who died during the study period as the “looking back” cohort. Patients in the looking forward cohort were analyzed with multivariate risk-adjustment models for total hospital days and total hospital direct costs within 180 days after initial admission. Patients in the looking back cohort were analyzed with multivariate risk-adjustment models for total hospital days and total hospital direct costs within 180 days before death.

Patients in the looking back cohort tended to be older, white and had a slightly lower proportion of Medicaid coinsurance vs. the looking forward cohort. The researchers reported that the mean number of hospital days at 180 days was from 9.1 days to 21.7 days in the looking back cohort and from 7.8 days to 14.9 days in the looking forward cohort. The adjusted mean indexed value of total direct hospital costs at 180 days was from 0.91 (95% CI, 0.69-1.14) to 1.79 (95% CI, 1.61-1.97) in the looking back cohort and from 0.66 (95% CI, 0.57-0.76) to 1.30 (95% CI, 1.21-1.39) in the looking forward cohort. The Spearman rank correlation coefficient between adjusted mortality and adjusted total hospital days at 180 days was –0.68 (P=.12) and –0.93 (P,.01) between adjusted mortality and adjusted indexed total direct costs at 180 days. The Spearman rank correlation coefficients between the looking forward and looking back cohorts were 0.62 (P=.17) for total adjusted hospital days and 0.87 (P=.02) for adjusted indexed total direct costs at 180 days.

“Contrary to public discussion of variation, it is likely that not all variation is inefficient or wasteful. However, much more work is needed to truly distinguish inefficient from beneficial resource use,” the researchers concluded. “The six hospitals involved in our study are currently investigating the underlying processes and practice that contribute to the variation in resource use and outcomes for HF that we identified. Their goal is to improve the outcomes of patients with HF and to provide care to those patients as efficiently as possible.” – by Eric Raible

The researchers have demonstrated that contrary to what was discovered in the Dartmouth analysis, which demonstrated that for those Medicare recipients who had died, the expenditures six months prior to death showed extreme regional variations. This really takes us back full circle. The complexity of the health care cost calculation is very important, and we have to exercise some pause before we accept a single metric and say that identifies a high-cost vs. a low-cost provider.

We also must be very careful in assuming that a low-cost provider is the best provider. Occasionally, the higher-cost provider is in fact delivering a higher-quality care when the totality of that care is measured, rather than just the poor outcomes. Again, this attests to the complexity of many of these health care cost analyses.

For the practitioner, it tells us that there is no certainty once we see a patient with advanced disease. Some of them will go on to have poor outcomes, but some of those patients are in fact amenable to processes of care and expert application of guidelines that can yield better results. The mere fact that in several hospitals one could find a variation statistically important in outcomes for a high-risk population tells us not that there are better doctors in one place or another but that there may be different processes. Some processes may embrace the guidelines more fervently, resulting in better outcomes — albeit at a higher cost.

– Clyde W. Yancy, MD

Medical Director, Baylor Heart and Vascular Institute

Ong MK. Circulation: Cardiovascular Quality and Outcomes. 2009;doi: 10.1161/CIRCOUTCOMES.108.825612.