Is technological change in medicine always worth it? The case of acute myocardial infarction

Abstract

We examine Medicare costs and survival gains for acute myocardial infarction (AMI) during 1986-2002. As David Cutler and Mark McClellan did in earlier work, we find that overall gains in post-AMI survival more than justified the increases in costs during this period. Since 1996, however, survival gains have stagnated, while spending has continued to increase. We also consider changes in spending and outcomes at the regional level. Regions experiencing the largest spending gains were not those realizing the greatest improvements in survival. Factors yielding the greatest benefits to health were not the factors that drove up costs, and vice versa.

Exhibit 1. The Association Between Adjusted One-Year Survival Post-AMI and One-Year Expenditures by Hospital Referral Region: 2002

Legend: Each dot represents a hospital referral region (HRR) with at least 250 individuals experiencing a heart attack in 1986. (N = 56) The sample is the elderly (65+) fee-for-service Medicare population, and both survival rates and expenditures are adjusted for age, sex, rate, comorbidities, and the severity of the heart attack.

Exhibit 2. Adjusted One-Year Survival For Elderly Medicare Enrollees with an AMI: 1986–2002

Legend: The vertical axis measures the percentage who survive the index acute myocardial infarction (AMI). This is equal to 100 minus the percentage one-year mortality. The left dashed line (1984–94) is from D. M. Cutler and M. McClellan, “Is Technological Change in Medicine Worth It?” The right solid line (1986–2002) is from the authors’ calculations.

Exhibit 3. Adjusted One-Year Medicare Expenditures For Elderly Medicare Enrollees with an AMI: 1986–2002

Legend: The vertical axis measured risk-adjusted real Medicare expenditures following the index acute myocardial infarction (AMI) for each year 1986–2002. All expenditures are adjusted for inflation using the GDP Deflator. The higher line includes Part B expenditures, from 1993–2002.

Exhibit 4. The Change in Survival and the Change in Medicare Expenditures by Hospital Referral Regions: 1986–2002

Legend: Each dot represents a hospital referral region (HRR) with at least 250 individuals experiencing a heart attack in 1986. (N = 56) The sample is the elderly (65+) fee-for-service Medicare population, and both survival rates and expenditures are adjusted for age, sex, rate, comorbidities, and the severity of the heart attack.

Exhibit 5

Exhibit 5A: Association of Regional Quality of Care for AMI with Changes in Survival and Expenditures, 1986–2002 Exhibit 5B: Association of Average Number of Physicians Per AMI Patient (Quartiles) with Changes in Survival and Expenditures 1986–2002 Notes: Each bar shows the impact on the dependent variable (the change in dollar expenditures) of a shift from the 10^th to the 90^th percentile for each variable in a multiple regression framework. Ninety-five percent confidence intervals shown by whiskers.

Exhibit 5

Exhibit 5A: Association of Regional Quality of Care for AMI with Changes in Survival and Expenditures, 1986–2002 Exhibit 5B: Association of Average Number of Physicians Per AMI Patient (Quartiles) with Changes in Survival and Expenditures 1986–2002 Notes: Each bar shows the impact on the dependent variable (the change in dollar expenditures) of a shift from the 10^th to the 90^th percentile for each variable in a multiple regression framework. Ninety-five percent confidence intervals shown by whiskers.

Exhibit 6. Technological Change in the Treatment of Heart Attacks: A Graphical Analysis