More Variation in Spending Research

By October 19, 2009November 2nd, 2009Commentary

A group of researchers at a set of California teaching hospitals has reported on a study which challenges the notion that more resource use does not lead to better outcomes.  (Circulation Article) The researchers examined treatment of heart failure over a 180 day period at six hospitals, with variables of number of hospital days and direct costs and an endpoint of mortality.  They found that both more days in the hospital and more resource use, reflected in direct costs, were correlated with less mortality.

The research is a direct challenge to both the method and one conclusion of the Dartmouth Atlas researchers.  The Dartmouth studies have found that there was no correlation between spending and outcomes such as mortality, and concluded from those findings that the additional spending between low-using and high-using hospitals represented waste.  The Dartmouth studies were conducted by starting with patients who died and looking back at resource use 180 days prior to death.  The new research points out that this method does not allow adequate comparison because it assumes the same endpoint, all patients died.  This new study used a look forward method, starting with a hospitalization for heart failure and examining resource use and outcomes in the next 180 days, as well as a look back subset for those patients who did die.

This new research adds further caution to drawing conclusions from variation in spending research.  But the study may have its own issues.  Using mortality as the sole measure of health outcomes may not give a full picture.  Just because a hospital can use a lot of resources to keep a patient from dying doesn’t mean that the patient’s quality of life or health status was better or even that the care was consistent with the patient’s wishes if he or she had been fully informed of care alternatives.  Numerous studies suggest that many patients want less intensive care as they near the end of their lives.  It would be useful to see variation studies which focus on individualized outcomes other than just mortality.

A second study examines the supply of MRI machines in a particular geography and the relation of that supply to use of imaging for low back pain and low back surgery.  It finds that supply is positively correlated with both more imaging and more surgery.  This could just be the result of underservice before MRI supply was increased, but consensus guidelines and past research suggests that the great majority of low back pain resolves on its own in a few weeks.  Imaging is expensive and often starts a cycle of testing and interventions which add more cost and do little to improve outcomes.  Back surgery has a very checkered record of creating real improvements for patients.  This study is a further indication that allowing unlimited supply of health resources may encourage overutilization.  (Health Affairs Article)

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