post by Bill Gardner
From JAMA, a group of researchers from the University of Toronto and Dartmouth report that in a group of Ontario hospitals, "higher spending intensity was associated with lower mortality, readmissions, and cardiac event rates."
As noted in an accompanying editorial, this finding appears to contradict some previous research by the same group suggesting that large differences in US spending on health care had little effect on medical outcomes. In many cases, it seems that the intensity of medical spending reflects the interest of the provider more than the patient.
In large data sets of Ontarian patients, however, it appears that patients did benefit from more intensive medical services. The Figure plots mortality rates as a function of the End of Life Expenditure Index (EoL-EI), which is the amount that a hospital typical spent on patients in their last years of life, adjusted for the age and sex of the patient. Being to the left in this plot meant that patients were more likely to survive. What the results showed was that across several important conditions, Ontario hospitals that typically spent more on patients at the end of life had better survival rates. The authors are carefully to note that the observational design of the study means that one cannot infer that spending more money actual causes better health outcomes.
So why do we find this association in Canada, but not the US?
Canadian hospitals, with fewer specialized resources, selective access to medical technology, and global budgets, are using these resources more efficiently, especially during the inpatient episode for care-sensitive conditions. Canada's health care expenditures per capita are about 57% of those in the United States. At this spending level, there might still be a positive association between spending and outcomes.
That is, US hospitals spend more intensively, to a point where additional spending in the US no longer brings additional patient benefit. Canadian hospitals spend much less, and are at a point where an additional loonie is associated with additional benefit for patients. There is no evidence here about whether Canadian care is better than US care, but it is almost certainly more cost-effective.