Is more care better?
Hospitals providing a higher intensity of care did not generally score higher on measures of patient experience, patient safety, or processes of care. Table 4 shows the relationship between each of the variables studied and the intensity of care delivered at 236 teaching hospitals around the country, as captured by the HCI index (a measure of the intensity of inpatient care). There were no significant positive relationships between hospital intensity and patient recommendations, pain control, whether medicines were explained before being given, whether information was given about recovery, or three of the five safety measures. Lower adverse events were found with higher care intensity for two of the safety measures—urinary catheter infection and uncontrolled blood sugar. There were also no significant relationships between the intensity of care provided at each hospital and the three measures of effective care for pneumonia patients. A graph of the relationship between care intensity and whether medicines were explained to patients is shown in Figure 9.
Table 4. Relationships between patient experience and quality and hospital care intensity
| Variable vs. Hospital Care Intensity |
Correlation
Coefficient |
R-Squared |
P-Value |
| % rating hospital "highly" |
-0.326 |
0.106 |
< 0.01 |
| % who recommend hospital |
-0.301 |
0.091 |
< 0.01 |
| % with pain controlled |
-0.253 |
0.064 |
< 0.01 |
| % with medicines explained |
-0.434 |
0.188 |
< 0.01 |
| % given info about recovery |
-0.542 |
0.294 |
< 0.01 |
| Severe pressure sores per 1,000 |
0.194 |
0.038 |
< 0.01 |
| Falls and injuries per 1,000 |
-0.006 |
0.000 |
n/s |
| Blood infection from large vein catheter per 1,000 |
0.058 |
0.003 |
n/s |
| Infection from urinary catheter per 1,000 |
-0.250 |
0.063 |
< 0.01 |
| Signs of uncontrolled blood sugar per 1,000 |
-0.181 |
0.033 |
< 0.01 |
| % given pneumonia vaccine (in pneumonia patients) |
0.100 |
0.010 |
n/s |
| % given influenza vaccine (in pneumonia patients) |
0.120 |
0.014 |
n/s |
| % given smoking cessation counseling (in pneumonia patients) |
-0.053 |
0.003 |
n/s |
Figure 9. Relationship between the HCI index and the percentage of patients to whom medicines were explained
Additional research studies done at the Dartmouth Institute for Health Policy and Clinical Practice have shown that higher spending and greater volume of services per patient do not necessarily improve either survival or quality of care. In a cohort study, Dr. Elliott Fisher and his colleagues studied whether patients with similar baseline health status experienced better quality, access, outcomes, or satisfaction in areas with high versus low end-of-life spending. The patient population studied consisted of patients hospitalized between 1993 and 1995 for hip fracture, colorectal cancer, or acute myocardial infarction (AMI), along with a sample of the general population from the Medicare Current Beneficiary Survey. The researchers found that patients in higher-spending regions were provided more care in the form of physician visits, hospital days, specialist consultations, and procedures. However, the quality of care, measured by aspirin use for an AMI and rate of influenza immunization, was the same or worse in higher-spending regions compared to lower-spending regions. Similarly, outcomes—measured by the five-year mortality rate—were slightly worse in higher-spending regions for both the colorectal cancer and AMI cohorts. Access and satisfaction with care were found to be the same between high- and low-spending regions. [12,13] Still other studies have shown Medicare spending to be inversely related to patient satisfaction. [14,15] Finally, quality and satisfaction are positively correlated, meaning that, in those hospitals with low quality measures, patient ratings are also low, and vice versa. [16]
Why do these measures of outcomes, quality, access, and satisfaction often worsen as spending and care intensity increase? A plausible hypothesis is that, as spending increases because of higher utilization of resources and the involvement of multiple physicians, care becomes more disorganized. Patients may receive more services than they need and be exposed to more medical errors, simply because they are getting more care. In addition, without effective coordination of care and informed patient choice, patient preferences may not be followed. These patterns of care are hard to see in the hospital wards and physician offices, but they are part of the learning environment for residents.