Feature Article

Higher Hospital Spending Does Not Necessarily Mean Better Sepsis Survival

Higher hospital expenditure is not associated with better sepsis survival, according to researchers.


Although the association between hospital spending and sepsis mortality does not appear to be significant, study results indicated that higher spending in hospitals did not improve survival outcome. In fact, some hospitals with lower hospital spending had better survival, they reported in the February 28 Archives of Internal Medicine.

The Cost of Sepsis Care
“One of the potential drivers of the costs of care may be the quality of care coordination and the overall efficiency of the hospital environment,” said Tara Lagu, MD, MPH, from Baystate Medical Center, Springfield, Massachusetts, noting that sepsis care often requires a multidisciplinary approach. “And, unlike cancer or heart failure, sepsis is an acute rather than chronic disease, so it lends itself to studies of acute care hospitalization.”

Previous studies have suggested that high-spending regions of the US do not tend to have better adherence to quality of care and may actually have poorer outcomes as well as lower patient and physician satisfaction, compared with lower-cost areas, the investigators explained. With regard to sepsis management, the cost of care has been estimated to be close to $17 billion.

“Given the imperative to improve quality of care while reducing the growth of healthcare spending, we sought to characterize variations in hospital costs and hospital mortality rates of patients with sepsis and to examine whether higher spending is associated with better outcomes,” the researchers stated.

Data Collection
As part of a cross-sectional study, the investigators identified hospitals treating at least 100 adults patients with sepsis between 2004 and 2006 using the Perspective database—a voluntary, fee-supported database created to measure quality and healthcare utilization. It includes hospitals from all regions of the US, with mostly small to mid-sized nonteaching hospitals and that serve a largely urban population.

Patients eligible for study inclusion were 18 or older and had a principal or secondary diagnosis of sepsis (ie, underwent a blood culture and received antibiotics within the first two days of hospitalization). “We restricted the analysis to patients in whom treatment for sepsis was initiated within the first two days because we sought to focus our investigation on the care of patients who present with sepsis rather than those who developed sepsis later during the hospitalization,” the researchers noted.

Overall, 309 hospitals and 166,931 patients (mean age, 70) were included in the analysis. The median expected mortality rate for all hospitals was 19.2%; among the hospitals with an expected mortality ranging from 18.5% to 19.5%, observed mortality ranged from 9.2% to 32.3%— showing a good discrimination (area under the receiver operating characteristic curve of 0.78). “More than a third (34%) of hospitals exceeded expected costs by at least 10%, with a median average excess cost per case of $5,207,” Lagu and colleagues observed.

In addition, they found that 7% of the hospitals had both significantly lower than expected costs and lower than expected mortality, while 10% had both higher than expected costs and higher than expected mortality. However, there was no significant association between hospital spending and mortality, the investigators found after adjusting for cost and hospital-level characteristics, including bed size and region of the country.

Interpreting the Data
“In a large nationwide sample of hospitals, we observed substantial variation in risk-adjusted cost and mortality rates among hospitals that cared for patients with sepsis, yet found little correlation between overall levels of spending and hospital survival, implying that, on average, additional expenditures at high-cost hospitals do not translate into better short-term clinical outcomes,” Lagu and colleagues said. “Our method of risk adjustment, which incorporated data elements not available within standard administrative data resources, increases our confidence that the observation is real and not the result of residual confounding.”

In particular, they found that higher spending hospitals did not spend proportionally more on any specific service, such as pharmacy and diagnostic imaging. In addition, while longer length of stay explained some of the differences in spending, the highest spending hospitals also had the highest cost per day. An analysis of fixed and variable costs demonstrated that higher fixed costs could not explain spending patterns.

While the study authors are encouraged that a subset of hospitals were able to achieve both a better than expected mortality rate and a lower than expected hospital costs, this finding does not offer a specific prescription for change. “Future efforts to enhance the value of sepsis care should be guided by knowledge of the organizational characteristics and practices of high-performing hospitals.”

—Frederique H. Theuvenin

Suggested Reading
Lagu T, Rothberg MB, Nathanson BH, et al. The relationship between hospital spending and mortality in patients with sepsis. Arch Intern Med. 2011;171(4):292-299.

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