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Stukel TA, Fisher ES, Alter DA, et al. Association of Hospital Spending Intensity With Mortality and Readmission Rates in Ontario Hospitals. JAMA. 2012;307(10):1037–1045. doi:10.1001/jama.2012.265
Author Affiliations: Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (Drs Stukel, Alter, Guttmann, Ko, Wodchis, Baxter, Earle, and Lee and Ms Fung); Department of Health Policy, Management and Evaluation (Drs Stukel, Alter, Guttmann, Ko, Wodchis, and Baxter), Clinical Epidemiology Unit, Sunnybrook Health Sciences Centre (Dr Stukel), Division of Paediatric Medicine, Hospital for Sick Children (Dr Guttmann), and Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre (Dr Ko), University of Toronto, Toronto; Center for Population Health, Dartmouth Institute for Health Policy and Clinical Practice and Dartmouth Medical School, Lebanon, New Hampshire (Drs Stukel and Fisher); Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Drs Alter and Baxter); Toronto Rehabilitation Institute, Toronto (Drs Alter and Wodchis); and University Health Network, Toronto General Hospital, Toronto (Dr Lee).
Context The extent to which better spending produces higher-quality care and better patient outcomes in a universal health care 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 CHF; fully adjusted relative 30-day mortality rates were 0.93 (95% CI, 0.89-0.98) for AMI, 0.81 (95% CI, 0.76-0.86) for CHF, 0.74 (95% CI, 0.68-0.80) for hip fracture, and 0.78 (95% CI, 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 cohort) and medical (AMI and CHF cohorts) cardiac therapies, preoperative specialty care (colon cancer cohort), and postdischarge collaborative care with a cardiologist and primary care physician (AMI and CHF cohorts).
Conclusion Among Ontario hospitals, higher spending intensity was associated with lower mortality, readmissions, and cardiac event rates.
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