Association of Hospital Spending Intensity With Mortality and Readmission Rates in Ontario Hospitals

Study Questions:

What is the association between higher spending in hospitals with mortality and readmissions?


The study population was comprised of adults (>18 years) in Ontario, Canada, with a first admission for acute myocardial infarction (AMI) (n = 179,139), congestive heart failure (CHF) (n = 92,377), hip fracture (n = 90,046), or colon cancer (n = 26,195) during 1998-2008, with follow-up to 1 year. The exposure measure was the index hospital’s end-of-life expenditure index for hospital, physician, and emergency department services. The primary outcomes were 30-day and 1-year mortality, and readmissions and major cardiac events (readmissions for AMI, angina, CHF, or death) for AMI and CHF.


Patients’ baseline health status was similar across hospital expenditure groups. Patients admitted to hospitals in the highest- versus lowest-spending intensity terciles had lower rates of all adverse outcomes. In the highest- versus lowest-spending hospitals, respectively, the age- and sex-adjusted 30-day mortality rate was 12.7% versus 12.8% for AMI, 10.2% versus 12.4% for CHF, 7.7% versus 9.7% for hip fracture, and 3.3% versus 3.9% for CHF; fully adjusted relative 30-day mortality rates were 0.93 (95% confidence interval [CI], 0.89-0.98) for AMI, 0.81 (95% CI, 0.76-0.86) for CHF, 0.74 (95% CI, 0.68-0.80) for hip fracture, and 0.78 (95% CI, 0.66-0.91) for colon cancer. Results for 1-year mortality, readmissions, and major cardiac events were similar. Higher spending hospitals had higher nursing staff ratios, and their patients received more inpatient medical specialist visits, interventional (AMI cohort) and medical (AMI and CHF cohorts) cardiac therapies, preoperative specialty care (colon cancer cohort), and post-discharge collaborative care with a cardiologist and primary care physician (AMI and CHF cohorts).


The authors concluded that among Ontario hospitals, higher spending intensity was associated with lower mortality, readmissions, and cardiac event rates.


The current study reports that higher hospital spending intensity was associated with better survival, lower readmission rates, and better quality of care for seriously ill, hospitalized patients in a universal health care system with more selective access to medical technology. It would be simplistic to interpret this study as suggesting that higher spending is causally related to better outcomes and that providing more money to lower-spending hospitals would automatically improve their outcomes. Higher spending hospitals differed in many ways, such as greater use of evidence-based care, skilled nursing and critical care staff, more intensive inpatient specialist services, and high technology, all of which are more expensive. It is critical to understand not only how much money is spent, but whether it is spent on effective procedures and services.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Myocardial Infarction, Hospital Mortality, Follow-Up Studies, Colonic Neoplasms, Canada, Physicians, Primary Care, Ontario, Emergency Service, Hospital, Critical Care, Inpatients, Patient Readmission, Delivery of Health Care, Heart Failure, Health Expenditures, Confidence Intervals, Health Status

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