February 22, 2010
Lower Cost Hospitals Achieve Equivalent Quality

W. Edwards Deming would not be surprised. Lower cost hospitals are not lower quality - at least for congestive heart failure treatment.

The costs that hospitals incur in treating patients vary widely and do not appear to be strongly associated either with the quality of care patients receive or their risk of dying within 30 days, according to a report in the February 22 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

"Hospitals face increasing pressure to lower cost of care while improving quality of care," the authors write as background information in the article. However, critics have expressed concerns about the trade-off between the two goals. "In particular, might hospitals with lower cost of care and lower expenditures devote less effort to improving quality of care? Might the pursuit of lower cost of care drive hospitals to be 'penny wise and pound foolish,' discharging patients sooner, only to increase re-admission rates and incur greater inpatient use over time?"

Lena M. Chen, M.D., M.S., of the University of Michigan, Ann Arbor, and colleagues conducted a national study of hospitals that discharged Medicare patients who were hospitalized for congestive heart failure or pneumonia in 2006. For each condition, the researchers used data from national databases to examine the association between hospital cost of care and several variables: 30-day death rates, readmission rates, six-month inpatient cost of care and a quality score based on several performance indicators for each condition.

Costs of care for each condition varied widely. Care for a typical patient with congestive heart failure averaged $7,114 and could range from $1,522 to $18,927, depending on which of the 3,146 hospitals discharged the patient. Cost of care for a typical patient with pneumonia averaged $7,040 and varied from $1,897 to $15,829 per hospitalization among 3,152 facilities.

"Compared with hospitals in the lowest-cost quartile [one-fourth] for congestive heart failure care, hospitals in the highest-cost quartile had higher quality-of-care scores (89.9 percent vs. 85.5 percent) and lower mortality [death] for congestive heart failure (9.8 percent vs. 10.8 percent)," the authors write. "For pneumonia, the converse was true. Compared with low-cost hospitals, high-cost hospitals had lower quality-of-care scores (85.7 percent vs. 86.6 percent) and higher mortality for pneumonia (11.7 percent vs. 10.9 percent)."

This makes sense in the United States especially because providers and consumers of health care services both lack sufficient incentives for lower costs. The payers aren't the receivers of medical treatments. The overall system encourages massive spending. So there's lots of potential for cost cutting. Also, the pursuit of higher quality can cut costs in lots of ways. Achieving higher quality requires better understanding of a process and correction of flaws in the process. In a hospital that includes cutting infections, cutting surgical mistakes, cutting drug dosage mistakes, and other improvements that lead to better outcomes at lower cost.

Better practices for handling catheters developed at Johns Hopkins eliminates almost all bloodstream infections in ICUs.

The state of Michigan, which used a five-step checklist developed at Johns Hopkins to virtually eliminate bloodstream infections in its hospitals' intensive care units , has been able to keep the number of these common, costly and potentially lethal infections near zero even three years after first adopting the standardized procedures. A report on the work is being published in the February 20 issue of BMJ (British Medical Journal).

Peter Pronovost, M.D., Ph.D., a professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine and a patient safety expert, says the widely heralded success in Michigan the first state system to tackle in a wholesale fashion infections in central-line catheters ubiquitous in intensive-care units has significantly changed the way physicians think about these infections.

A checklist for inserting catheters saves money and lives. This is not high tech.

The checklist contains five basic steps for doctors to follow when placing a central-line catheter: wash their hands; clean a patient's skin with chlorhexidine; wear a mask, hat, gown, and gloves and put sterile drapes over the patient; avoid placing a catheter in the groin where infection rates are higher and remove the catheter as soon as possible, even if there's a chance it might be needed again at some point.

Central lines are used regularly for patients in the ICU to administer medication or fluids, obtain blood tests, and directly gauge cardiovascular measurements such as central venous blood pressure. Each year roughly 80,000 patients become infected and 30,000 to 60,000 die at a cost of $3 billion nationally. Before heading to Michigan, Pronovost tested the checklist at Johns Hopkins Hospital, where catheter infections have also been virtually eliminated.

That these practices aren't already practiced in every hospital tells us there's probably still plenty of low hanging fruit in the area of medical quality improvement. Oh, and Johns Hopkins is also trying to boost herd immunity of their employees. Good idea.

One can try to spend larger sums of money to prevent very few deaths (more here). But if the goal is really to save lives then a relentless pursuit of process improvements to achieve higher quality will save more lives and save money at the same time.

Share |      Randall Parker, 2010 February 22 10:07 PM  Policy Medical


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