L ki Forward,
Looking
F
d Looking
L ki
Back:
B k
Assessing Variations in Hospital
Resource Use and Outcomes
f Elderly
for
Eld l Patients
P ti t with
ith Heart
H
t Failure
F il
M.K.
M
K Ong1, C.M.
C M Mangione1, P.S.
P S Romano2, Q.
Q Zhou1, A.D.
A D Auerbach3,
A. Chun4, B. Davidson4, T.G. Ganiats5, S. Greenfield6, M. Gropper3,
S. Malik6, J.T. Rosenthal1, J.J. Escarce1,7
1University of California, Los Angeles; 2University of California, Davis;
3University of California, San Francisco; 4Cedars
Cedars--Sinai Medical Center;
5University of California, San Diego; 6University of California, Irvine;
7RAND
Health
Funded by the California Health Care Foundation and the National Institute of
Aging
g g
Published in Circulation: Cardiovascular Quality and Outcomes, Nov 2009
Why study heart failure patients
hospitalized at six hospitals?
Six hospitals interested in understanding and
acting on identified variation
– Includes all 5 University of California hospitals and
Cedars--Sinai Medical Center
Cedars
– Identified by the Dartmouth Atlas as hospitals with
high (Cedars(Cedars-Sinai, UCLA) and low (UCD, UCSF)
resource use by patients at the end of life
St di d hospitalized
Studied
h
it li d elderly
ld l M
Medicare
di
beneficiaries with heart failure
– heart failure is a common cause of hospitalization in
this population
Research Questions
Do
health
D h
lth outcomes
t
((mortality)
t lit ) ffor chronically
h i ll ill
patients vary across hospitals?
– Studies using only patients at the end of life
Force health outcomes to be identical across hospitals
(100% mortality)
Identify resourceresource-intensive care as inherently inefficient by
ignoring the possibility that resourceresource-intensive care may
improve survival
Do patterns of hospital resource use variation
observed among patients at the end of life
accurately reflect the patterns among all patients?
– including patients who survived
“Looking
Looking Forward
Forward, Looking Back”
Back
Examined resource use and mortality
– Looking
g Forward: 180180-days
y from admission
– Looking Back: 180
180--days prior to death
180-days
hospitalization
Looking
L
ki
Forward
Looking Back
180-days
Outcomes & Statistical Models
“Looking Forward”
Total Hospital
p
Days
y
– Zero
Zero--truncated Poisson
Total Hospital Direct
Costs
– Zero
Zero--truncated
negative
g
binomial
Mortality
– Logistic models
“Looking Back”
Total Hospital
p
Days
y
– Overdispersed Poisson
Total Hospital Direct
Costs
– Ordinary Least Squares
Risk Adjustment Approaches
“Looking Forward”
Age,
g g
gender, ethnicity
y
Comorbidities
– 21 comorbidities used
byy AHRQ
Q HCUP
Additional covariates
– Medicaid dual
eligibility, surgical
DRG, admit year
“Looking Back”
Age,
g g
gender, ethnicity
y
Comorbidities
– 12 chronic illnesses
used in 2006
Dartmouth Atlas report
on hospitals
Sample characteristics
Characteristics
LF
LB
N
3,999
,
1,639
,
Mean age (years)
80.3
82.0
Male gender
48.1%
50.8%
Caucasian ethnicityy
71.9%
74.6%
Medicaid dual eligibility
33.9%
31.3%
S i l DRG
Surgical
3 5%
3.5%
9 3%
9.3%
Total Hospital Days
30
6
25
20
3
2
2
5
4
3
1 1
5
D
E
4
15
10
5
0
A
B
C
Looking Back
Looking Forward
F
6
Total Indexed Direct Hospital Costs
2.0
6
1.8
2
3
4
5
5
16
1.6
1.4
4
3 2
1 1
1.2
1.0
0.8
0.6
0.4
02
0.2
0.0
A
B
C
Looking Back
D
E
Looking Forward
F
6
Mortality Rates
30%
A
D
B
E
C
F
26.0%
25%
20%
15%
10%
17.0%
5%
0%
% index
stays
Inpatient Mortality
A
30-Day Mortality
B
C
D
180-Day Mortality
E
F
Spearman Correlations:
180--Day Resource Use Outcomes
180
and 180
180--Day Mortality
Outcomes
Coefficient
p-value
Total Hospital Days
-0.68
0.12
Total Indexed Direct Costs
-0.93
<0.01
Limitations
Cannot
between
C
t identify
id tif causall relationship
l ti
hi b
t
resource use and mortality
– Further study needed to determine relationship
Administrative data riskrisk-adjustment
j
methods are
subject to potential biases
– Similar to chartchart-validated HF risk adjustment methods
Si il results
lt with
ith clinical
li i l llaboratory
b t
l
dd d
– Similar
values
added
St d does
Study
d
nott accountt for
f outpatient
t ti t utilization
tili ti
– Rank ordering of hospitals on resource use could change
with inclusion of outpatient care
Conclusions
Variation
V i ti exists
i t
– but both on resource use and mortality
1 5 ffold
1.5
ld diff
difference ffor 180
180--day
d mortality
t lit
– is less when looking at all patients “Looking Forward”
27--44% less variation compared to patients “Looking
27
Looking Back”
Back
Potential association between g
greater resource use
and lower mortality
– Studying only expired individuals ignores the possibility
that
h resources iinfluence
fl
outcomes
– Moving Forward ….