Variations in how hospital resources are used across the United States have been a central component of the current discussion on health care reform. A new study by the University of California’s five medical centers and Cedars-Sinai Medical Center in Los Angeles that examined variations in medical treatment, cost and patient outcomes between hospitals has some surprising new findings to add to the debate.
The study, "Looking Forward, Looking Back: Assessing Variations in Hospital Resource Use and Outcomes for Elderly Patients With Heart Failure," takes a more in-depth look into the wide variation documented by recent studies on hospital utilization among chronically ill Medicare beneficiaries at the end of life. The findings appear in the early online edition of the journal Circulation: Cardiovascular Quality and Outcomes.
Among the six California teaching hospitals, researchers found lower mortality rates at six months for elderly Medicare heart failure patients hospitalized at hospitals that used more health care resources, compared with those at hospitals that used fewer resources. This finding suggests that more resource-intensive care may improve outcomes among certain patients with heart failure, the most frequent cause of hospitalization and death among Medicare beneficiaries.
The study used a "looking forward" approach that examined all hospitalized heart failure patients; this approach was compared with the "looking back" approach used in prior studies of variation among hospitals — an approach that examined only hospitalized individuals in the last six months of life.
"Two major concerns with the ’looking back’ approach are that, one, it cannot identify differences across hospitals in health outcomes, and it ignores the possibility that resource-intensive care may influence survival; and two, it assumes that patterns of resource use among deceased individuals accurately reflect patterns of resource use among all individuals," said Dr. Michael Ong, the study’s lead investigator and an assistant professor in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA.
"This positive association between increased resource use and reduced mortality would not be observed with a ’looking back’ approach," said Dr. J. Thomas Rosenthal, chief medical officer at Ronald Reagan UCLA Medical Center and one of the study’s authors. "In addition, changing to the ’looking forward’ approach resulted in nearly half the amount of variation in resource use generated by the ’looking back’ approach."
The researchers suggest that focusing only on deceased individuals may overlook important associations between resource utilization and mortality. They believe that acting on variation will require a careful balance between trying to reduce resource use and improving health outcomes. The researchers feel that essential efforts to reduce inefficient use of resources must safeguard against inadvertent reductions of beneficial resources as well.
The study was designed to further examine variations among hospitals and is not a comment on the many studies that have examined variations among geographic areas. However, it highlights the potential complications of ignoring health outcomes in discussions about reducing health care utilization at hospitals.
The study focused on elderly Medicare beneficiaries hospitalized from 2001 to 2005 for heart failure. The six hospitals included UCLA Medical Center (now known as Ronald Reagan UCLA Medical Center); UC San Francisco Medical Center; Cedars-Sinai Medical Center, Los Angeles; UC San Diego Medical Center, UC Irvine Medical Center and UC Davis Medical Center.
The study was funded by the California HealthCare Foundation; in-kind support from the six medical centers included in the study; the Resource Centers for Minority Aging Research/Center for Health Improvement of Minority Elderly (RCMAR/CHIME), which is funded by the National Institutes of Health/National Institute on Aging; and the UCLA Older Americans Independence Center, which is funded by the National Institutes of Health/National Institute on Aging.
Other authors were Carol M. Mangione (UCLA), Patrick S. Romano (UCD), Qiong Zhou (UCLA), Andrew D. Auerbach (UCSF), Alein Chun (Cedars-Sinai), Bruce Davidson (Cedars-Sinai), Theodore G. Ganiats (UCSD), Sheldon Greenfield (UCI), Michael A. Gropper (UCSF), Shaista Malik (UCI), J. Thomas Rosenthal (UCLA) and Jose J. Escarce (UCLA/RAND). The authors report no conflicts of interest.