Comparing outcomes and charges for patients with acute myocardial infarction in three community hospitals: an approach for assessing "value".

OBJECTIVE

To assess the value of care (i.e. outcomes in relation to charges) for acute myocardial infarction (Acute MI) patients in three community hospitals after controlling for patient mix differences.

DESIGN

An observational study of a cohort of acute MI patients admitted to hospital for care were studied based on medical record review and on patient-completed questionnaires at 8 weeks post-discharge.

SETTING

Three community hospitals located in urban areas in the southeastern region of the United States.

PATIENTS

A consecutive sample of 133 non-transfer Acute MI patients were entered into the study based on EKG results, enzyme tests and chest pain characteristics. Hospital medical record and charge data were available on all patients and patient-reports on 86% of survivors.

MAIN OUTCOME MEASURES

Data were gathered on clinical outcomes (death, angina, dyspnea), functional outcomes (physical and psychosocial), satisfaction, and resource intensity (length of stay, total hospital charges, ancillary charges). Because of patient mix differences across hospitals, outcomes were adjusted for severity of Acute MI, comorbidity and demographics.

RESULTS

There were important patient mix differences across hospitals. For example, Hospital C had more comorbidity than Hospital B (57.78% of Hospital C patients vs 15.00% of Hospital B patients were rated moderate or severe using a well tested index, p < 0.0001). After adjusting for patient mix differences, Hospital C scored significantly better on four of six outcome measures (i.e. angina, dyspnea, physical functioning, psychosocial functioning). For example, Hospital C's patients' mean scores on physical functioning at 8 week follow-up averaged 75.19 (on a 0-100 scale), while Hospital A's was 63.03 and Hospital B's was 48.57 (F-ratio = 4.95; p < 0.05). However, Hospital A scored significantly lower on all three resource intensity indicators (length of stay, ancillary charges, and total charges). For example, Hospital A's ancillary charges averaged $10,752 while Hospital B's and C's averaged $11,432 and $16,598 respectively. Between-hospital comparisons on adjusted mortality and satisfaction did not differ significantly.

CONCLUSION

The "value" profiles (i.e. outcomes related to charges) produced by these three hospitals were substantially different. Studies that simultaneously measure outcomes, costs, patient mix and processes have potential to: (a) enable clinical teams to improve the measurable value of clinical care; and (b) enable purchasers to better evaluate which providers to select as preferred sources of care.