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AcademyHealth Honors Research Papers Challenging 'Aggressive' Hospital Assumptions

Contradict Previous Claims About Cost and Care Quality

SEATTLE -- AcademyHealth, the country's largest professional organization of health service researchers, has given its highest annual publishing award to two studies contradicting
Jeffrey Silber
Photo: Hoag Levins

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Jeffrey H. Silber, MD, explains his team's findings to an AcademyHealth audience. (1:22 sec.)
claims previously cited by the White House, The Dartmouth Institute for Health Policy & Clinical Practice, Consumer Reports, and health-care journalism superstar Atul Gawande.

Throughout the ongoing national debate over health care reform, those respected offices, institutions and authors have maintained that "aggressive" hospital procedures that cost more don't actually improve the outcome for patients. Some have characterized the higher spending as ineffective "waste." One policy inference of this belief is that Medicare payments for hospital stays could be cut without causing harm to patients.

But at its annual three-day research conference, AcademyHealth gave its Article-of-the-year Award to two companion research articles detailing how aggressive hospital care is associated with fewer deaths in a Medicare patient population.

Previous findings challenged
The findings challenge previous research papers associated with the Dartmouth Institute that have been prominently cited by President Obama and prestigious magazines such as The New Yorker and Consumer Reports.

For twenty years, the Dartmouth Atlas of Health Care Project has analyzed and mapped various levels of costs, care and outcomes in hospitals across the country. Its recent issue brief on the subject says "Studies that have looked carefully at the additional services provided in high-spending [hospitals] have shown that the higher volume of care does not produce better outcomes for patients."

In a June, 2009, speech to the American Medical Association, President Obama referred to these studies. Consumer Reports used Dartmouth data as the basis of an article headlined, "Too Much Treatment? Aggressive Medical Care Can Lead to More Pain With No Gain." And in his widely acclaimed "Cost Conundrum" article in The New Yorker, Atul Gawande likewise cited Dartmouth data.

Increase in survival
But in their new studies, AcademyHealth award-winning lead researchers Jeffrey Silber, MD, and Robert Kaestner, PhD, looked at Medicare patients who underwent serious surgeries in both "aggressive" and non-aggressive hospital facilities across the country. They found in many types of surgeries, aggressive procedures resulted in a decrease of from 3.1 to 11.3 percent in the number of patients who died during the first 30 days after surgery.

Explaining his charted data, Silber told the AcademyHealth audience, "If you talk about a 10 percent increase in spending, which is roughly about $2,000 to $5,000, what does that buy you in terms of a percentage of improvement in your thirty-day mortality? Well, for general surgery it's about 4 to 11 percent; vascular surgery, 3 to 10 percent; orthopedic surgery, 3 to 11 percent. So, we do get a benefit."

Both of Silber and Kaestner's studies used Medicare data from more than 3,000 hospitals and defined "aggressive" facilities according to the Dartmouth Index measure of hospital spending intensity.

'A world of difference'
"From a policy perspective," Silber told the AcademyHealth audience, "it makes a world of difference to suggest that aggressiveness buys no improvement in health or is detrimental, versus the alternative statement that, on average, aggressiveness is beneficial. And while reducing or eliminating care that is wasteful is always a good thing, we should not delude ourselves into believing that substantial cuts in Medicare will not have deleterious effects on quality."

Silber is a professor of pediatrics and anesthesiology and critical care at the University of Pennsylvania Perelman School of Medicine, director of the Center for Outcomes Research at The Children's Hospital of Philadelphia, professor of health care management at the Wharton School, and a senior fellow at the Leonard Davis Institute of Health Economics. Kaestner is a professor at the Institute of Government and Public Affairs of the University of Illinois, and a research associate of the National Bureau of Economic Research.

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The two awarded papers are:
- Aggressive Treatment Style and Surgical Outcomes, by Jeffrey H. Silber, Robert Kaestner, Orit Even-Shoshan, Yanbli Wang and Laura J. Bressler, HSR: Health Services Research, Dec., 2010.
- Evidence on the Efficacy of Inpatient Spending on Medicare Patients, by Robert Kaestner and Jeffrey H. Silber, The Milbank Quarterly, Vol. 88, No. 4, 2010.

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