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Original Articles

Looking Forward, Looking Back

Assessing Variations in Hospital Resource Use and Outcomes for Elderly Patients With Heart Failure

Michael K. Ong, MD, PhD; Carol M. Mangione, MD, MSPH; Patrick S. Romano, MD, MPH; Qiong Zhou, MA; Andrew D. Auerbach, MD, MPH; Alein Chun, PhD, MSPH; Bruce Davidson, PhD, MPH; Theodore G. Ganiats, MD; Sheldon Greenfield, MD; Michael A. Gropper, MD, PhD; Shaista Malik, MD, PhD; J. Thomas Rosenthal, MD and José J. Escarce, MD, PhD

From the Departments of Medicine (M.K.O., C.M.M., Q.Z., J.T.R., J.J.E.) and Health Services (C.M.M.), University of California, Los Angeles; Department of Medicine (P.S.R.), University of California, Davis; Department of Medicine (A.D.A., M.A.G.), University of California, San Francisco; Department of Resource and Outcomes Management (A.C., B.D.), Cedars-Sinai Medical Center, Los Angeles; Department of Family and Preventive Medicine (T.G.G.), University of California, San Diego; Department of Medicine (S.G., S.M.), University of California, Irvine; and RAND Health (J.J.E.), Santa Monica, Calif.

Correspondence to Michael K. Ong, MD, PhD, David Geffen School of Medicine at the University of California, Los Angeles, Department of Medicine, Division of General Internal Medicine & Health Services Research, 911 Broxton Ave, 1st Floor, Los Angeles, CA 90024. E-mail michael.ong{at}ucla.edu

Received October 3, 2008; accepted September 1, 2009.

Background— Recent studies have found substantial variation in hospital resource use by expired Medicare beneficiaries with chronic illnesses. By analyzing only expired patients, these studies cannot identify differences across hospitals in health outcomes like mortality. This study examines the association between mortality and resource use at the hospital level, when all Medicare beneficiaries hospitalized for heart failure are examined.

Methods and Results— A total of 3999 individuals hospitalized with a principal diagnosis of heart failure at 6 California teaching hospitals between January 1, 2001, and June 30, 2005, were analyzed with multivariate risk-adjustment models for total hospital days, total hospital direct costs, and mortality within 180-days after initial admission ("Looking Forward"). A subset of 1639 individuals who died during the study period were analyzed with multivariate risk-adjustment models for total hospital days and total hospital direct costs within 180-days before death ("Looking Back"). "Looking Forward" risk-adjusted hospital means ranged from 17.0% to 26.0% for mortality, 7.8 to 14.9 days for total hospital days, and 0.66 to 1.30 times the mean value for indexed total direct costs. Spearman rank correlation coefficients were –0.68 between mortality and hospital days, and –0.93 between mortality and indexed total direct costs. "Looking Back" risk-adjusted hospital means ranged from 9.1 to 21.7 days for total hospital days and 0.91 to 1.79 times the mean value for indexed total direct costs. Variation in resource use site ranks between expired and all individuals were attributable to insignificant differences.

Conclusions— California teaching hospitals that used more resources caring for patients hospitalized for heart failure had lower mortality rates. Focusing only on expired individuals may overlook mortality variation as well as associations between greater resource use and lower mortality. Reporting values without identifying significant differences may result in incorrect assumption of true differences.

Key Words: heart failure • delivery of health care • outcome assessment • healthcare costs • healthcare economics • organizations

The online-only Data Supplement is available at http://circoutcomes.ahajournals.org/cgi/content/full/CIRCOUTCOMES.108.825612/DC1.