Spending and mortality in US acute care hospitals

Abstract

Background: Despite evidence that greater US Medicare spending is not associated with better quality of care at a regional level, recent studies suggest that greater hospital spending is associated with lower risk-adjusted mortality. Studies have been limited to older data, specific US states and conditions, and the Medicare population.

Objectives: To analyze the association between hospital spending and risk-adjusted inpatient mortality for 6 major medical conditions in US acute care hospitals.

Study design: Retrospective cohort study of risk adjusted inpatient mortality, with hospital spending taken from the Dartmouth Atlas of Health Care. The study population included 2,635,510 patients admitted to 1201 US hospitals between 2003 and 2007.

Methods: Patient-level logistic regression models were used to estimate the effect of hospital spending on inpatient mortality, controlling for mortality risk, comorbidities, community characteristics (eg, median household income in a patient's zip code), hospital volume and ownership, and admission year.

Results: Patients treated at hospitals in the highest spending quintile (relative to the lowest) had lower risk-adjusted inpatient mortality for acute myocardial infarction (odds ratio [OR] 0.751, 95% confidence interval [CI] 0.656-0.859), congestive heart failure (OR 0.652, 95% CI 0.560-0.759), stroke (OR 0.852, 95% CI, 0.739-0.983), and hip fracture (OR 0.691, 95% CI 0.545-0.876). Greater spending was associated with lower mortality primarily in nonteaching hospitals, hospitals with fewer than the median number of beds, and nonprofit/public hospitals.

Conclusions: Greater hospital spending is associated with lower risk-adjusted inpatient mortality for major medical conditions in the United States.

Figure 1

Average Hospital Spending, 2003 to 2007, by Quintile^{a a}Hospital spending was obtained from the Dartmouth Atlas of Health Care.

Figure 2. Odds Ratio of Risk-Adjusted Inpatient Mortality by Hospital Spending Quintile for 6 Major Medical Conditions, 2003 to 2007^a

AMI indicates acute myocardial infarction; CHF, congestive heart failure; GI, gastrointestinal. ^aVertical bars represent 95% confidence intervals around the odds ratios (green dashes).