The Association Between Health Care Quality and Cost
Although there is broad policy consensus that both cost containment and quality improvement are critical, the association between costs and quality is poorly understood.
To systematically review evidence of the association between health care quality and cost.
Electronic literature search of PubMed, EconLit, and EMBASE databases for U.S.-based studies published between 1990 and 2012.
Title, abstract, and full-text review to identify relevant studies.
Two reviewers independently abstracted data with differences reconciled by consensus. Studies were categorized by level of analysis, type of quality measure, type of cost measure, and method of addressing confounders.
Of 61 included studies, 21 (34%) reported a positive or mixed-positive association (higher cost associated with higher quality); 18 (30%) reported a negative or mixed-negative association; and 22 (36%) reported no difference, an imprecise or indeterminate association, or a mixed association. The associations were of low to moderate clinical significance in many studies. Of 9 studies using instrumental variables analysis to address confounding by unobserved patient health status, 7 (78%) reported a positive association, but other characteristics of these studies may have affected their findings.
Studies used widely heterogeneous methods and measures. The review is limited by the quality of underlying studies.
Evidence of the direction of association between health care cost and quality is inconsistent. Most studies have found that the association between cost and quality is small to moderate, regardless of whether the direction is positive or negative. Future studies should focus on what types of spending are most effective in improving quality and what types of spending represent waste.
Robert Wood Johnson Foundation.
Available from: Corinne Chmiel
- "The relationship between healthcare costs and quality of care is under debate and evidence is inconsistent.20 21 Some authors argue, that improvements in quality of care are associated with raised costs (eg, due to costly medical innovations).22 "
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ABSTRACT: Emergency departments (EDs) are increasingly overcrowded by walk-in patients. However, little is known about health-economic consequences resulting from long waiting times and inefficient use of specialised resources. We have evaluated a quality improvement project of a Swiss urban hospital: In 2009, a triage system and a hospital-associated primary care unit with General Practitioners (H-GP-unit) were implemented beside the conventional hospital ED. This resulted in improved medical service provision with reduced process times and more efficient diagnostic testing. We now report on health-economic effects.
From the hospital perspective, we performed a cost comparison study analysing treatment costs in the old emergency model (ED, only) versus treatment costs in the new emergency model (triage plus ED plus H-GP-unit) from 2007 to 2011. Hospital cost accounting data were applied. All consecutive outpatient emergency contacts were included for 1 month in each follow-up year.
The annual number of outpatient emergency contacts increased from n=10 440 (2007; baseline) to n=16 326 (2011; after intervention), reflecting a general trend. In 2007, mean treatment costs per outpatient were €358 (95% CI 342 to 375). Until 2011, costs increased in the ED (€423 (396 to 454)), but considerably decreased in the H-GP-unit (€235 (221 to 250)). Compared with 2007, the annual local budget spent for treatment of 16 326 patients in 2011 showed cost reductions of €417 600 (27 200 to 493 600) after adjustment for increasing patient numbers.
From the health-economic point of view, our new service model shows 'dominance' over the old model: While quality of service provision improved (reduced waiting times; more efficient resource use in the H-GP-unit), treatment costs sustainably decreased against the secular trend of increase.
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Postmarketing reports have linked exenatide use with acute pancreatitis and pancreatic cancer, but a definitive relationship has yet to be established.
Subjects and methods:
We conducted a retrospective cohort analysis of patients with type 2 diabetes with employer-provided health insurance from 2007 to 2009. Multivariate models estimated the association between exenatide use and acute pancreatitis and pancreatic cancer. We required at least 1 year of exenatide exposure in the pancreatic cancer analysis. Sensitivity analyses were conducted that quasirandomized exenatide use based on patient out-of-pocket costs.
Among 268,561 patients included in the acute pancreatitis analysis, only 2.6% used exenatide. Hospitalization for acute pancreatitis was rare (0.247% of patients). In unadjusted and adjusted analyses, patients who did not use exenatide were more likely to be hospitalized for acute pancreatitis (0.249% vs. 0.196% in unadjusted analysis), but the difference was not statistically significant in either analysis (P = 0.22 and P = 0.70, respectively). Among 209,306 patients in the pancreatic cancer analysis, 0.070% were diagnosed with pancreatic cancer, and 0.88% had at least 1 year of continuous exenatide exposure prior to the diagnosis. Those with exenatide exposure had higher rates of pancreatic cancer compared with those without (0.081% vs. 0.070% in unadjusted analysis). In both unadjusted and adjusted analyses, the difference was not statistically significant (P = 0.80 and P = 0.46, respectively). In sensitivity analyses, results were similar.
We found no association between exenatide use and either hospitalization for acute pancreatitis or pancreatic cancer in a large sample of privately insured U.S. patients.
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