Expensive Hospitals Can Be Better For Your Health, Says Canadian Study

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EXPENSIVE HOSPITALS BETTER
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TORONTO - When it comes to certain kinds of medical conditions, people may get better treatment at Ontario hospitals that spend more on care than hospitals at the other end of the spending spectrum, a new study suggests.

While that may seem unsurprising, the Canadian findings are in sharp contrast to research some of the same authors did about a decade ago when a similarly structured study looking at U.S. hospital spending found that more expensive care there was sometimes wasteful and ineffective.

Lead author Therese Stukel, a Toronto-based health services and health policy analyst, said there is such a thing as spending too much on health care, which is what happens at times in the United States. She said this study suggests Ontario hospitals may be striking a better balance, using specialized care — high-tech diagnostic testing and quick access to specialists — for the people who need them most.

"The take-home message is it's not how much you spend, it's what you do with the money," Stukel said.

"In Canada, in this context, we are using our health-care resources efficiently — and that's a good news story. Everybody wants to know they're getting return on investment, bang for the buck. That when you spend you're actually getting outcomes."

But she was quick to note the study does not say adding more money would lead to even better outcomes for patients.

"This study doesn't tell you where to spend the next health-care dollar," said Stukel, who is a senior scientist at the Institute for Clinical Evaluative Sciences (ICES) in Toronto.

The study is published in this week's issue of the Journal of the American Medical Association. Stukel's coauthors come from ICES, the University of Toronto and Dartmouth College in Lebanon, N.H.

They used a formula to calculate spending by hospitals, dividing them into high-, medium- and low-spending institutions. They then compared rates of deaths, readmissions and repeat events for people who went to hospital for four reasons — a first heart attack, congestive heart failure, colon cancer surgery (when the cancer hadn't spread) and hip fractures.

Hospitals that spend the most are typically, but not always, larger teaching hospitals with many specialists, more nurses and lots of high-tech medical equipment. They are also the hospitals that generally get the sickest of the sick patients, a factor which — if not adjusted for — could actually make the study outcomes for hospitals that spend a lot look worse, not better.

After adjusting for patient distribution, the researchers found that heart attack patients were seven per cent less likely to die within 30 days if they were treated in a high-spending facility.

For the other conditions, the benefit was more striking. There was a 19 per cent difference in deaths due to congestive heart failure, a 26 per cent decrease in deaths due to hip fractures and a 22 per cent decrease in the patients who had colon cancer surgery.

The study wasn't designed in such a way as to prove that one thing caused another — in this case that better outcomes were due to higher spending. It can only suggest the two may be linked.

Stukel said a basket of factors are probably responsible — higher nursing staff ratios, more on-site medical technology, a higher proportion of specialist doctors, more insistence on care that is based on the best medical evidence.

Hip fracture patients were more likely to get more rehabilitation in higher-spending hospitals, the cancer patients were more likely to have their cancer staged before surgery using a CT scan and cardiac patients to get higher rates of evidence-based medications at discharge.

"So it's not just one thing. It's a collection of things," she said.

Steven Lewis, a health policy consultant from Saskatoon, praised the study as being well done. But he stressed one can't draw too many lines between the findings and conclusions, tempting as that might be.

"This finding ought not to be ignored. It may suggest that with a system that is considerably cheaper than the American system, that we may be spending money in hospitals fairly efficiently," Lewis said.

"But it's not proven. And nobody in the quality movement would suggest that Canadian hospitals are, across the board, higher quality than American hospitals."

He noted that because the study compares two types of hospitals — those that spend more versus those that spend less — the findings can only illuminate a difference between the two. They cannot say whether higher-spending hospitals are the best they can be.

"If you only had this study, you would be inclined to conclude that spending more gets you more. I wouldn't conclude that. But it doesn't refute the argument that spending more or spending less gets you either better or worse care," Lewis said.

"And I think it would be particularly inappropriate to conclude that the system by and large is first rate and spending a little more makes it first rate plus. This study doesn't tell us whether Ontario hospitals are performing either very well or not very well, compared to the best possible hospitals."

He said it would be useful to look at outliers — hospitals that perform well, yet spend less money. That would help analysts home in on why some hospitals have better outcomes than others, he said.

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