Making Sense of How Better Quality Can Be Achieved with Less Money

Janice Simmons, for HealthLeaders Media , June 4, 2009

Eleven process measures provided at least 25 observations for a majority of hospitals: aspirin at arrival and at discharge and beta blocker prescription at arrival and at discharge (for AMI); assessment of left ventricular function, the provision of discharge instructions, and angiotensin converter enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) prescription for patients with left ventricular systolic dysfunction (LVSD) (congestive heart failure); blood culture performed before receiving the first antibiotic in the hospital, first dose of antibiotic within four hours of admission, initial antibiotic selected appropriately, and assessment of arterial oxygenation within twenty four hours of arrival (pneumonia).

The researchers constructed a measure of spending that reflected only the specific use of services to explain a large amount of hospital spending: number of hospital days, total physician visits, intensive care unit (ICU) days, and the ratio of specialist to primary care physician visits at the end of life. (This means that the influence of varying reimbursements linked to graduate medical education, Medicare disproportionate share payments, and geographical price adjustments were removed.)

What they found after all this is that by examining process of care measures, hospitals that provide more intensive and costly care do not necessarily provide better quality care—as measured by the percentage of patients who are given evidence based treatments.

In more concrete figures, the study found that among a fifth of hospitals that spent the least, the cost of end of life care was $16,059 on average. In comparison, the cost of end of life care at the top 20% bracket of highest spending hospitals was $34,742 on average.

The researchers noted that the results might be skewed because the quality indicators they used might penalize hospitals that treat sicker patients. In addition, the study used process of care measures instead of patient outcomes which could yield different results if they were used. However, it helps demonstrate how differences in costs—and care—can be more carefully observed hospital by hospital.

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Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at

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