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Hospital outcomes research named 'Article of the Year'

Health services researchers who studied controversial aspects of Medicare spending and quality of patient care received a prestigious award yesterday from the nation's largest health services research professional association.

The organization, AcademyHealth, presented its 2011 Article of the Year Award to Jeffrey H. Silber, M.D., Ph.D., director of the Center for Outcomes Research at The Children's Hospital of Philadelphia, and his collaborator, Robert Kaestner, Ph.D., of the University of Illinois at Chicago. The award presentation occurred yesterday at AcademyHealth's Annual Research Meeting in Seattle.

The Article of the Year Award recognized two companion studies by Silber and Kaestner: "Aggressive Treatment Style and Surgical Outcomes," published in the December 2010 issue of the journal Health Services Research, and "Evidence on the Efficacy of Inpatient Spending on Medicare Patients," published the same month in The Milbank Quarterly.

As an indicator of aggressive care, Silber and Kaestner used the Dartmouth Index, a prominent set of measures of inpatient spending on elderly patients. In studying over 5 million Medicare admissions for various surgeries between 2000 and 2005, they found that surgical patients in hospitals with a more aggressive treatment style were less likely to die within 30 days of admission compared to patients in less aggressive hospitals. They also found that this benefit was stable, persisting after the 30-day mark.

Silber, who is a senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, said that these findings contradicted cost-cutting arguments made by those who assert that patients would not be harmed by reductions in Medicare spending. "People have recently argued that more spending does not yield gains in quality of care," said Silber. "Our study suggests that such a belief may be incorrect, and that cutting spending through reductions in aggressiveness may lead to worse outcomes. We should not kid ourselves that the process of reducing Medicare expenditure will be a painless one."

Much of the high cost associated with surgery is the result of complications. "We studied whether more aggressive measures lead to more complications, and found there was no difference in complication rates between aggressive and less-aggressive hospitals," said Silber, adding, "However, when complications arise, patients are more likely to survive those complications if they receive aggressive treatment."

The survival rates after 30 days were important, said Silber. After that period, patients at both aggressive and less aggressive hospitals had equal survival rates one year after admission; there was just a greater initial chance of surviving at the more aggressive hospitals. "It appears," said Silber, "that the survival benefits gained at aggressive hospitals are as stable as in patients who survive at less aggressive ones, suggesting that the life saved at more aggressive hospitals is not more fragile or fleeting than a survivor in the less aggressive hospital."

The journal articles attracted some press attention earlier this year when they were described in February online articles in the New York Times. At the time, Silber said, "Most people have been saying that the health care system is too aggressive, implying that aggressiveness is bad because people are being operated on unnecessarilyBut we have to do detailed research that compares the effectiveness of different treatment approaches, because aggressiveness is not necessarily bad and may in fact be sometimes associated with better outcomes."

Ultimately, concluded Silber, his research shows that cost-cutting in health care must be done carefully and based on evidence: "It matters how we cut expenditures, because although some spending may be inefficient, our results suggest that the amount of waste is less than conventionally believed, at least for inpatient care."


Contact: John Ascenzi
Children's Hospital of Philadelphia

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