Hospital Spending and Inpatient Mortality: Evidence From California. An Observational Study

Study Questions:

Is hospital spending associated with risk-adjusted inpatient mortality?


This was a retrospective cohort study using discharge records from 1999 to 2008 for California hospitals (n = 208) included in The Dartmouth Atlas of Health Care. Diagnoses which were examined included acute myocardial infarction (AMI), congestive heart failure, acute stroke, gastrointestinal hemorrhage, hip fracture, and pneumonia. Hospital costs included inpatient physician visits, hospital room charges, medication administration, and procedures for two periods: 1999 to 2003, and 2004 to 2008, for each of the six medical conditions examined. For 1999 to 2003, overall hospital spending during the last 2 years of life of Medicare fee-for-service beneficiaries was used to estimate costs. For the years 2004 to 2008, when diagnosis-specific hospital spending was not available, these costs were computed on the basis of patients who died while hospitalized. Models were created at the patient level to examine associations between hospital spending and inpatient hospital mortality.


A total of 2,545,352 patients hospitalized during 1999 to 2008 with one of six major medical conditions was included in this analysis. The average age ranged from 72.5 years for AMI to 81.4 years for hip fracture. Number of hospitalizations ranged from 98,208 for hip fracture to 345,449 for pneumonia. Mortality rates ranged from 2.97% for hip fracture to 10.25% for AMI, and 11.71% for stroke. For each of six diagnoses at admission, patient admission to higher-spending hospitals was associated with lower risk-adjusted inpatient mortality. During 1999 to 2003, for example, patients admitted with AMI to California hospitals in the highest quintile of hospital spending had lower inpatient mortality than did those admitted to hospitals in the lowest quintile (odds ratio, 0.86; 95% confidence interval, 0.74-0.98). Predicted inpatient deaths would increase by 1,831 if all patients admitted with AMI were cared for in hospitals in the lowest quintile of spending rather than the highest. The association between hospital spending and inpatient mortality did not vary by region or hospital size.


The authors concluded that hospital spending was associated with inpatient mortality. Those hospitals that spent more had lower inpatient mortality for the six common medical conditions examined.


Regional variation in spending is well known and in several studies does not appear to be associated with better care. However, this study suggests that for certain specific diagnoses or specific events such as hospitalization for AMI, increased spending is associated with better care. Further study to determine specific costs related to quality of care is warranted.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Risk, Stroke, Myocardial Infarction, Hospital Mortality, Pneumonia, Health Facility Size, Gastrointestinal Hemorrhage, Inpatients, Hospital Costs, California, Heart Failure, Hospitalization, United States

< Back to Listings