We categorized the 2,712 U.S. hospitals with complete data on utilization, spending, and quality performance by quintile of EOL spending; mean EOL spending ranged from $16,059 in the lowest quintile to $34,742 in the highest quintile (). Among AMCs, almost half of those reporting adequate data were in the top quintile of spending. The correlations between the condition-specific scores are somewhat weak: 0.59 for AMI and CHF, 0.32 for AMI and pneumonia, and 0.40 for CHF and pneumonia, a result found previously.13
There were significant negative relationships for performance on AMI, pneumonia, and overall quality scores (p
< 0.001 for all; ). There was no association between performance on quality measures and spending for heart failure.
Number Of Hospitals Reporting Sufficient Data For Each Clinical Condition, By Quintile Of End-Of-Life (EOL) Spending And Medical Condition, 2004–2007
Percentile Of Quality, By Quintile Of Spending, All Hospitals, 2004–2007
For AMCs (), the only significantly negative association was between performance on AMI quality measures and spending (p = 0.009). This association accounts for the negative trend seen in overall performance (p = 0.066); there is no significant relationship between performance on heart failure or pneumonia measures and spending.
Percentile Of Quality, By Quintile Of Spending, Academic Medical Centers, 2004–2007
To assess the impact of geographical differences in care intensity, we next repeated the national analysis after accounting for HRRs (). Some of the association between quality and spending is mediated by geographical differences in care intensity. In this analysis, the relationship between performance on pneumonia measures and spending remains strong (p < 0.001) and largely accounts for the relationship between spending and overall quality performance (p = 0.015).
Performance Across Quintiles Of Spending, Adjusting For Hospital Referral Regions (HRRs), 2004–2007
For individual hospitals from two major metropolitan areas (), there was no significant relationship between spending and quality within either region; both regions show wide variability on spending and quality.
Percentile Ranking And Spending For Individual Hospitals In New York (Manhattan And The Bronx) And Los Angeles, 2004–2007
To quantify the magnitude of the associations noted in the above exhibits, we performed an analysis of the change in percentile ranking associated with a $10,000 increase in EOL spending. A change of this magnitude in spending would move a hospital from the middle to the highest quintile of spending. For the entire sample (AMC and non-AMC hospitals), the associations were −5.3 percentile points for overall quality (p < 0.001), −5.2 percentile points for AMI (p < 0.001), −9.2 percentile points for pneumonia (p 0.001), and −0.3 percentile points (p = 0.687) for CHF.