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Does more care mean better care?


A recent study found that Ontario hospitals that used more resources and spent more money had better outcomes for acutely ill patients than hospitals that used fewer resources. 

These findings go against a previous study that looked at the same question in the United States and found that more resources didn’t impact outcomes. 

A better understanding of what kind of health spending is of high value might help us improve the quality of care in Ontario.

A recent study published in the Journal of the American Medical Association compared the outcomes of patients hospitalized for hip fractures, colon cancer, and heart failure care in both high spending and low spending hospitals in Ontario.

The study, led by Therese Stukel, aimed to replicate a 2003 study done in the United States (US) which found that patients at resource-intensive hospitals did not have improved outcomes.

Stukel and others were interested in examining “whether these findings [from the 2003 study] would hold true in a country with universal access to hospital and physician care but a far lower supply of specialists and more selective access to medical technology.”

Watch a video of Stukel discuss the results and implications of the study here:

The Canadian health care system has one-third the amount of specialists and specialized resources (such as CT scanners) as the US. Interestingly, the Ontario findings did not replicate the US findings – in fact, patients at high spending hospitals had better outcomes.

However, it should be noted that the differences between outcomes at patients in higher and lower spending hospitals were modest but still statistically significant, at most a few percentage points when looking at deaths in the multiple patient groups included in the study after 30 days and 1 year of being admitted to hospital.

The study notes that the hospitals which had better outcomes might have been spending more because they were high volume teaching or community hospitals with specialized programs such as regional cancer centres and specialized services, such as on-site diagnostic imaging.

Stukel explains that “what needs to be clear is that the study’s results do not mean that all spending is good spending.” However, she notes that “for patients who are seriously ill and go to hospitals where care pathways and specialized services exist – there is evidence that this works.”

More is better in Canada, but not in the United States?

The original 2003 study using data from the US was motivated by the commonly-held  view that spending more in healthcare, especially on high-tech interventions, leads to clear cut health benefits.  This belief stands in contrast to increasing evidence that many patients in the US are ‘overtreated.’

The 2003 study’s results, however, defied the popular wisdom that more is better, as the patients who received more care, at much higher costs, did not have better outcomes than those who received less resource-intensive care.  The higher costs in the study were associated with an increased number of specialists involved in care and increased use of hospital-based technology.

Duminda Wijeysundera, an anesthesiologist at the University of Toronto says that there are different incentives around the application of higher intensity care in Canada and the US. He notes that in Canada, clinicians in acute care hospitals may be more selective in using resources, and are more likely to consider “which patients will benefit the most from more resources” and that “in a system [like the US] where there are incentives generated by putting people in high resource care,” clinicians are more likely to provide resource-intensive care to more patients.

Rising costs: no evidence of improved outcomes?

Health care spending in the US is nearly double that of Canada, with $7410 per capita spent on health care in 2010, as compared to Canada’s per capita health care spending at $4196 in 2010.

This is 43% less than the US, and health outcomes are equivalent or perhaps even better in Canada. Indeed, much of the additional costs of care in the US have been characterized by ‘flat of the curve’ spending – the point in which not much additional health benefit is obtained for the additional dollars.

One reason health care spending is higher in the United States is because prices are higher south of the border. Another reason is that the intensity of medical care is greater–in the US, patients are more likely to have care provided by many specialists, and have more diagnostic tests, which increase costs.  For example, the data from the Organization for Economic Cooperation and Development (OECD) found that overall Magnetic Resonance Imaging (MRI) utilization was about 90 per 1,000 people in the US, as compared to about 40 per 1,000 people in Canada.

In the context of rising health care costs in Canada, and given the findings of the recent study; there is a debate about the appropriateness of increased resource use in health care in Canada.

Mark Stabile, director of the School of Public Policy and Governance at the University of Toronto says that “one of the biggest challenges in Canadian health care settings is not figuring out how to do more with less, but rather what the right amount of care is… so where do we see inputs leading to better outcomes.”

Implications & interpretation: more is (sometimes) better in Canadian health care

Experts suggest that when interpreting the findings of the recent Ontario study, it is important to understand specifically what it was about the higher spending hospitals led to better outcomes.

Gordon Guyatt, a doctor and researcher at McMaster University notes that if the findings of this study are interpreted to suggest that “more spending leads to better outcomes, we’d be making a terrible mistake as spending money the wrong way can lead to inefficient use of resources and creation of waste. Given how expensive health care is, we cannot afford that.” However, Guyatt suggests that the study’s findings “give some hope that if we invest the money in the right ways we can improve outcomes.”

There is ongoing discussion and debate in the US about the extent of waste in health care, with research suggesting that 1 in 5 dollars spent on health care is care that adds no clinical value. While there are no similar studies around waste in Canada, the recent study adds nuance to the debate about appropriate use of resources.

There are economists on both sides of the Canada-US border who suggest that increased health care spending can sometimes add value, so long as resources are directed appropriately.

In the case of the complex care conditions considered in this study, it just may be the case.

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7 comments

  1. Mark MacLeod

    Stablie has identified the right question – in an odd sort of way – and it isn’t about what spending produces the better outcomes – it is about which patient should receive that expense. My contention is that we all can’t and shouldn’t have access to care when a resource is limited and care right now is not garnered by best outcome but by who is most acute.

    For example, the patient who presents to emergency department gets access to hospital ahead of a person who has been seen in a clinic or who is waiting for a referral to a specialist. However that patient might wait a year to see a specialist, and months more for testing and treatment. That waiting time is invisible in the system and the social cost is immense. However, the patient with an illness who presents to emerg with acute symptoms, whether or not new or acute on chronic gets immediate access to specialists, tests, drugs, surgery and so on. The social benefit might be negligible and the value of the medical expense and treatment may be immense. Where are we to made decisions about value in a system where there clearly is an inability, for dollar reason or otherwise, to provide treatment to all who need it in a timely fashion.

    I’m not proposing a solution, I’m not that capable of making the decision. But society does need to grapple with this. Until it does, the health care system will wander in the dark, doing the best it can do with out guidance, and yet subject to the examination and judgement of the chorus on the outside.

  2. John Lohrenz

    Gordon Guyatt hit the nail on the head. Perhaps it is just a devise to get the discussion going, but surely no one thinks the US and Canadian healthcare systems can be compared in the terms presented by the authors. Aside from all the population, supply and demand side issues, the impact of technology, overuse, profit driven performance and private insurance all distorting the comparison, what about marginality? Mr. Guyatt is right, the important question for Canadians’ is when do we start and stop paying for certain services, based on the cost and marginal benefits of those services? We could compare our outcomes to the Americans’ on that basis; it would be useful to understand which system is better performing in term of cost per a measurable outcome, that is usable information. To know how well we are doing is going to take more than comparing averages and percentiles from the HIT tool, and improving performance is more than mandating performance targets that are only required to be lower than the previous year. Valid and useful measures and methodologies are those that measure costs and benefits, focus on quality and performance, and can be incorporated into a sustainable funding model that respects and accounts for local differences and hospital autonomy. What are those?

  3. Dr. Bob Bell

    The recent JAMA paper is very significant in that its findings are in contradistinction to Elliot Fisher’s previously well known paper showing that quality does not necessarily correlate with cost in US health centers. The important question for further analysis is of course… What is the magic ingredient that provides value with increased cost per weighted case in the Ontario health care system?

    I believe that the differences in US and Canadian centers begin with transparency of cost attribution. Our hospital data reporting systems support transparent cost accounting practices so it is difficult to “hide” money. Centers in Canada are of course of very transparent with accounting since they are not for profit organizations. The only issue related to variability in your financial bottom line is whether you can squeeze some extra dollars into working capital for facility maintenance.

    So what accounts for variability in cost and outcomes between low cost and “higher cost” centers in this analysis?? I should note that higher cost is a relative term- as high cost Canadian centers are still operating at a much lower cost that US centers.

    My thought is that variability between low and higher cost centers is related to staffing, and my hypothesis is that it is safer to have a severe illness in a well staffed hospital than it is to have a mild illness in a poorly staffed hospital. Hospitals are intrinsically dangerous places – independent of the acuity of the illness that accompanies the patient – and if you need to be in one of these dangerous places – you should ensure that there are a reasonable number of highly skilled and trained health care workers (eg nurses) there to protect you.

  4. Andrew Holt

    Interesting article and discussion. I would attribute the cost differential between U.S. and Canadian Hospitals and health services to a number of factors.

    1.) SINGLE PAYER MODEL in Ontario allows massive administrative overhead savings versus managing hundreds of independent for profit insurance companies claims mechanisms.
    2.) THE FOR PROFIT HEALTH CARE CULTURE in the U.S. translates into the rapid investment of new technologies with the associated capital and operating costs in order to attract referrals and the associated revenues/billings. Canadian institutions tend to focus on expense controls to the detriment of having sufficient capital funds to adequately fund infrastructure. Neither approach is optimal for achieving the highest value for $ invested from the perspective of health outcomes.
    3.) HEALTH CARE AS A COMMODITY in the U.S. tends to focus on the ability to pay as the primary decision influencer when accessing services in the U.S. driving up over consumption (flat of the curve medicine) in the U.S. where as historically Canadian health professionals and tertiary clinicians tended to focus on using limited resources with an emphasis on clinical need as the ability to pay issue did not come into play to the same extent.
    4.) LESS CAPITAL FUNDING AVAILABLE clearly has been a challenge in Canada in terms of providing the most state of the art medical practice and diagnostics. On the flip side the majority of health care is not the high end capital intensive acute care. So playing a close second may in fact be more cost effective as the ‘bleeding edge’ costs are incurred for the most part outside Canada – frustrating our academic, research and innovation aspirations and carrying longer term costs in terms of our role in terms of supporting new knowledge, health care breaktrhoughs and the development of a knowledge economy.

    • Mark MacLeod

      Hi Andrew – generally I agree having worked in both systems

      On the Administrative Savings piece, although adminstrative costs are less in Canada than the US, I don’t think we should be smug about it. I don’t think less cost translates into good or effective management or leadership. In fact, we have seen a direct growth of adminstrative spending as program spending has increased – no economy of scale and no efficiency of size. As an anecdotal comment, the number of “managers” I see without real training or expertise is concerning.

      I don’t think Canadian health care professionals think much about cost – I think we tend to treat it as free and have defended our decisions about diagnostics or care by saying we are only responsible for the patient in front of us – whether or not that conveniently conicides with our own interests. We have constrained costs by budgetary mechanisms and by running up wait lists or not providing care all together.

      I’d like someone to evaluate the costs of management of chronic disease vs the management of acute disease – I think we’d see that good management of chronic disease with relatively low tech instruments has greater relative value than the management of acute disease.

      Mark

  5. Miguel Chavez

    Do not forget that:
    The standard of care is different related to the health provider and The state of the art is changing constantly.
    The outcomes in terms of Health system optimization (Cost vs Benefit) and the intensive use of health resources (Technology, Molecular Target therapy) are players in a battlefield.

    Finally considering That the health system as nonprofit organization (given a social service) Have to negotiate with Vendors of New technologies with an aggressive marketing and knowledge management trying to create the new standards of care building evidence in order to reach their goals of profit in a free market environment; the sky is the limit in health cost.

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