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.