Does Higher Spending Improve Survival Outcomes for Myocardial Infarction? Examining the Cost-Outcomes Relationship Using Time-Varying Covariates

End-of-life cohorts from the Dartmouth Institute: risk adjustment across health care markets, the relative efficiency of chronic illness utilization, and patient experiences near the end of life

Since their inception, small area studies intended to measure health system performance have been challenged by concerns that regional variation in health care may be primarily explained by differences in patient health risk. Controlling for regional population differences depends on appropriate risk adjustment, but the adequacy of the methods used in early analyses was contested. A novel response to these concerns was the development of end-of-life cohorts by Dartmouth Atlas investigators. These were used initially to control for differences in population health status in studies investigating relative efficiency across regions. Later, they became useful for studying hospital-level variation in chronic illness care, and for measuring utilization and patient experiences at the very end of life. Altogether, end-of-life cohorts have been invaluable for clarifying the contribution of health system and provider factors to health care variation and outcomes.

Observational Trends in Publicly Reported Quality Measures of Hospital Outpatient Quality Reporting Program, 2013-2019

In 2011, the Centers for Medicare & Medicaid Services (CMS) implemented the Hospital Outpatient Quality Reporting Program to assess the quality of outpatient imaging efficiency (OIE). In this study, trends in hospital performance on these national hospital OIE measures a year after inception and public reporting were described. An observational trend analysis was conducted using 2013-2019 data from CMS 6 OIE measures. The trend analysis of metric scores indicates year-to-year variability in all 6 OIE variables. The reporting of these measures appears to have effectively improved the efficiency of most of the measures since the inception of the program.

Association between periodontal care and hospitalization with acute myocardial infarction

BACKGROUND

Each year there are 800,000 myocardial infarctions in the United States. There is an increased risk of hospitalization for acute myocardial infarction (AMI) for those with periodontal disease. Yet, there is a paucity of knowledge about downstream care of AMI and how this varies with periodontal care status. The authors' aim was to examine the association between periodontal care and AMI hospitalization and 30 days after acute care.

METHODS

Using the MarketScan database, the authors conducted a retrospective cohort study among patients with both dental insurance and medical insurance in 2016 through 2018 who were hospitalized for AMI in 2017.

RESULTS

There were 2,370 patients who had dental and medical coverage for 2016 through 2018 and received oral health care in 2016 through 2017 and had an AMI hospitalization in 2017. Forty-seven percent received regular or other oral health care, 7% received active periodontal care, and 10% received controlled periodontal care. More than one-third of patients (36%) did not have oral health care before the AMI hospitalization. After adjusting for patient characteristics, we found that patients in the controlled periodontal care group were significantly more likely to have visits during the 30 days after AMI hospitalization (adjusted odds ratio, 1.63; 95% CI, 1.07 to 2.47; P = .02).

CONCLUSIONS

We found that periodontal care was associated with more after AMI visits. This suggests that there is a benefit to incorporating oral health care and medical care to improve AMI outcomes.

PRACTICAL IMPLICATIONS

Needing periodontal care is associated with more favorable outcomes related to AMI hospitalization. Early intervention to ensure stable periodontal health in patients with risk factors for AMI could reduce downstream hospital resource use.

Impact of reimbursement rates on the length of stay in tertiary public hospitals: a retrospective cohort study in Shenzhen, China

OBJECTIVE

To examine the association between reimbursement rates and the length of stay (LOS).

DESIGN

A retrospective cohort study.

SETTING

The study was conducted in Shenzhen, China by using health administrative database from 1 January 2015 to 31 December 2017.

PARTICIPANTS

6583 patients with acute myocardial infarction (AMI), 12 395 patients with pneumonia and 10 485 patients who received percutaneous coronary intervention (PCI) surgery.

MEASURES

The reimbursement rate was defined as one minus the ratio of out-of-pocket to the total expenditure, multiplied by 100%. The outcome of interest was the LOS. Multilevel negative binomial regression models were constructed to control for patient-level and hospital-level characteristics, and the marginal effect was reported when non-linear terms were available.

RESULTS

Each additional unit of the reimbursement rate was associated with an average of an additional increase of 0.019 (95% CI, 0.015 to 0.023), 0.011 (95% CI, 0.009 to 0.014) and 0.013 (95% CI, 0.010 to 0.016) in the LOS for inpatients with AMI, pneumonia and PCI surgery, respectively. Adding the interaction term between the reimbursement rate and in-hospital survival, the average marginal effects for the deceased inpatients with AMI and PCI surgery were 0.044 (95% CI, 0.031 to 0.058) and 0.034 (95% CI, 0.017 to 0.051), respectively. However, there was no evidence that higher reimbursement rates prolonged the LOS of the patients who died of pneumonia (95% CI, -0.013 to 0.016).

CONCLUSIONS

The findings indicate that the higher the reimbursement rate, the longer the LOS; and implementing dynamic supervision and improving the service capabilities of primary healthcare providers may be an important strategy for reducing moral hazard in low-income and middle-income countries including China.

The trade-off between costs and outcome after cardiac surgery. Evidence from an Italian administrative registry

Effective resource allocation policies relating to the long-term effects of complex surgical procedures require accurate prediction of the likelihood of future hospitalization. By approximating clinical conditions with administrative data and controlling for complex case-mix scenarios, we provide evidence of a trade-off between costs and outcome in cardiac surgery. We modelled administrative data to account for clinical conditions in a population of patients admitted for cardiac surgery and their readmissions for complications. Costs were calculated at first admission, the outcome variable was defined as time to readmission within six months post-discharge. Risk factors for readmission were defined as comorbidities and postoperative complications, derived by clinical judgement from the International Classification of Diseases. We predicted health outcome as a function of costs and other patient- and hospital-level features using a two-stage residual inclusion estimation method to tackle endogenous relationships applied to Cox proportional hazard models. We confirmed the trade-off and negative association between costs and hazard of readmission when controlling for all complex risk factors. Accurate matching of standard codes for diseases and procedures with clinical conditions may be a reliable methodology to assess time to readmissions and costs on a large population scale.

A Systematic Review of the Association Between Hospital Cost/price and the Quality of Care

BACKGROUND

Limited empirical evidence exists regarding the effect of price changes on hospital behavior and, ultimately, the quality of care. Additionally, an overview of the results of prior literature is lacking.

OBJECTIVE

This study aims to provide a synthesis of existing research concerning the relationship between hospital cost/price and the quality of care.

METHODS

Searches for literature related to the effect of hospital cost and price on the quality of care, including studies published between 1990 and March 2019, were carried out using four electronic databases. In total, 47 studies were identified, and the data were extracted and summarized in different tables to identify the patterns of the relationships between hospital costs/prices and the quality of care.

RESULTS

The study findings are highly heterogenous. The proportion of studies detecting a significant positive association between price/cost and the quality of care is higher when (a) price/reimbursement is used (instead of cost); (b) process measures are used (instead of outcome measures); (c) the focus is on acute myocardial infarction, congestive heart failure, and stroke patients (instead of patients with other clinical conditions or all patients); and (d) the methodological approach used to address confounding is more sophisticated.

CONCLUSION

Our results suggest that there is no general relationship between cost/price and the quality of care. However, the relationship seems to depend on the condition and specific resource utilization. Policy makers should be prudent with the measures used to reduce hospital costs to avoid endangering the quality of care, especially in resource-sensitive settings.

Healthcare spending in the State of Louisiana

Background

The State of Louisiana spends the most on Medicare beneficiaries per capita, but reports greater disparities in health status and death rates than other states. This project sought to investigate the associations between healthcare intensity, healthcare spending, and mortality in Louisiana.

Methods

We used a 100% sample of 2014 Medicare claims data with beneficiaries assigned to hospital referral regions in Louisiana using small area analysis. We used simple and multivariable linear regression modelling to evaluate associations between healthcare intensity, healthcare spending rates, and mortality rates. We adjusted for age, sex, race, and population health risk factors.

Results

We found no statistically significant associations between our measured variables when adjusted for age, sex, and race. These results were consistent after further adjusting mortality for population health risk factors.

Conclusions

To our knowledge, no prior studies have investigated the associations between healthcare intensity, healthcare spending, and mortality in Louisiana. Our findings suggest that increased healthcare spending in Louisiana may not improve survival. Identifying more granular aspects of healthcare contributing to spending patterns in Louisiana may provide targets for future quality improvement work.

Regional variation in healthcare spending and mortality among senior high-cost healthcare users in Ontario, Canada: a retrospective matched cohort study

Background

Senior high cost health care users (HCU) are a priority for many governments. Little research has addressed regional variation of HCU incidence and outcomes, especially among incident HCU. This study describes the regional variation in healthcare costs and mortality across Ontario’s health planning districts [Local Health Integration Networks (LHIN)] among senior incident HCU and non-HCU and explores the relationship between healthcare spending and mortality.

Methods

We conducted a retrospective population-based matched cohort study of incident senior HCU defined as Ontarians aged ≥66 years in the top 5% most costly healthcare users in fiscal year (FY) 2013. We matched HCU to non-HCU (1:3) based on age, sex and LHIN. Primary outcomes were LHIN-based variation in costs (total and 12 cost components) and mortality during FY2013 as measured by variance estimates derived from multi-level models. Outcomes were risk-adjusted for age, sex, ADGs, and low-income status. In a cost-mortality analysis by LHIN, risk-adjusted random effects for total costs and mortality were graphically presented together in a cost-mortality plane to identify low and high performers.

Results

We studied 175,847 incident HCU and 527,541 matched non-HCU. On average, 94 out of 1000 seniors per LHIN were HCU (CV = 4.6%). The mean total costs for HCU in FY2013 were 12 times higher that of non-HCU ($29,779 vs. $2472 respectively), whereas all-cause mortality was 13.6 times greater (103.9 vs. 7.5 per 1000 seniors).

Regional variation in costs and mortality was lower in senior HCU compared with non-HCU. We identified greater variability in accessing the healthcare system, but, once the patient entered the system, variation in costs was low. The traditional drivers of costs and mortality that we adjusted for played little role in driving the observed variation in HCUs’ outcomes. We identified LHINs that had high mortality rates despite elevated healthcare expenditures and those that achieved lower mortality at lower costs. Some LHINs achieved low mortality at excessively high costs.

Conclusions

Risk-adjusted allocation of healthcare resources to seniors in Ontario is overall similar across health districts, more so for HCU than non-HCU. Identified important variation in the cost-mortality relationship across LHINs needs to be further explored.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0952-7) contains supplementary material, which is available to authorized users.