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Hospital spending may pay off for some conditions

By Genevra Pittman

NEW YORK (Reuters Health) -- Hospitals that spend more money treating patients with acute illnesses may be better at keeping those patients alive, suggests a new study.

The finding is in line with recent research, but it challenges an assumption held by many policymakers that hospitals can be forced to spend less without significant consequences for patient health.

"The traditional literature on spending is that quality isn't higher (in hospitals that spend more)," said Mary Beth Landrum, who studies health care policy at Harvard Medical School and did not participate in the research. But, "when you start looking at specific groups of patients, you may actually find that there is some benefit for some of the increased spending," she told Reuters Health.

The current study included people treated for heart attack, heart failure, stroke, hip fracture, pneumonia and serious stomach bleeding. Researchers led by Dr. John Romley of the University of Southern California looked at records for more than 2.5 million of these patients admitted to California hospitals during the years 1999 through 2008.

Romley's team calculated how likely the patients were to survive their hospital stay, then compared those numbers to how much money the hospitals typically spent to treat the conditions in question.

For each of the six conditions, they found the highest-spending hospitals spent more than three times as much as the lowest-spenders.

Those hospitals ranking in the bottom-fifth for expenditures on heart failure and hip fracture, for instance, averaged $5,100 caring for a heart failure patient and $8,000 treating a hip fracture. The top-fifth-spending hospitals for the same conditions averaged $19,000 on a heart failure patient and $29,000 on one with hip fracture.

For each of the conditions examined higher spending was also linked to higher patient survival.

Patients treated at the highest-spending hospitals for heart failure, for example, had a 25 percent smaller chance of dying while they were there than patients treated at lowest-spending hospitals.

During the second half of the study (2004 to 2008) the mortality differences seen with high or low spending on hip fracture patients were extremely small, but overall the researchers say the numbers show money does seem to make a difference in survival.

If all patients in the study who were treated at the lowest-spending hospitals had instead been treated at the highest-spending facilities, the authors calculated that about 18,000 fewer people would have died during the first half of the study, and 14,000 fewer during the second half.

What exactly high-spending hospitals are doing to save lives is not completely clear.

Previous research suggests hospitals that spend more money don't have fewer complications during care -- they may just be more prepared to notice and address complications quickly, said Dr. Amber Barnato, who studies end-of-life care at the University of Pittsburgh and was not involved in the current study.

"There must be something about paying close attention, which might mean more staff, more eyes on the patients," Barnato told Reuters Health. In addition, she said, "there might be a greater willingness to do intensive things to rescue someone, like put them on a breathing machine (or) put them in the (intensive care unit)."

The findings, published in the Annals of Internal Medicine, are in line with a few recent studies, including one showing that hospitals where heart failure is treated frequently give better care but also spend more money per patient than hospitals that treat the condition less frequently.

Together such studies challenge the assumption that much of hospital spending is inefficient and that hospitals could perform just as well with smaller budgets, researchers say.

That debate has been an important part of the controversy surrounding new health care reform legislation, which will cut back Medicare spending on hospitals, Romley noted.

"If the results are real ... that would suggest these reductions across the board in hospital spending might lead to worse outcomes for some patients," Romley told Reuters Health. That doesn't mean cuts wouldn't still be cost-effective, if money elsewhere could better improve public health. But, he added, "it is important to understand the trade-offs."

The new findings need to become part of the national debate on how best to allocate money to protect the health of the general population -- but they don't change the fact that health care funding isn't in unlimited supply, Barnato said.

Even if patients with serious illnesses such as the ones examined in the current study do make it out of the hospital alive, many die within a year, and some of the money used on end-of-life care might save more lives if it was used to address preventable childhood diseases or obesity, for example, she said.

"A hospital that spends more money can have slightly better quality or safety," Barnato explained, "and that spending might still not result in better population health."

SOURCE: http://bit.ly/an7XRm Annals of Internal Medicine, online January 31, 2011.

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