Spending More Won’t Necessarily Improve Acute MI Outcomes

Mortality rates have declined over time for Medicare beneficiaries hospitalized for acute MI, and that trend is more strongly associated with greater uptake of cost-effective care, like early PCI, rather than increases in overall spending, a new analysis shows.

“Increased adoption of cost-effective care at the hospital level could improve patient outcomes and, if accompanied by cuts in cost-ineffective care (whether in the acute care or postacute care setting), may also reduce expenditures,” researchers led by Donald Likosky, PhD (University of Michigan, Ann Arbor), write in a study published online December 20, 2017, ahead of print in JAMA Cardiology.

In the current study, “hospitals that increased early PCI use experienced improvements in health outcomes but did not experience large overall cost increases,” they point out. “Policies encouraging hospitals to adopt early PCI, while supporting hospital-based and non-hospital-based reductions in spending on less cost-effective services (perhaps through newly designed bundled payment programs), may help improve patient outcomes without increasing costs.”

Likosky told TCTMD that this information needs to be shared more broadly with frontline providers to spur positive changes to practice.

“Absent giving them this information it’s likely very difficult for them to know what their practice looks like, as well its overall impact,” he said. “Many of these things may be a function of the way we traditionally take care of patients, and while well-meaning, may actually not have the intended benefit.”

Weak Association Between Overall Spending and Mortality

Many prior studies have examined overall spending in the setting of acute MI, but looking only at the aggregate amount can hide important information about how that money is spent, Likosky said.

For this study, Likosky and his colleagues looked at the association between Medicare expenditure growth and mortality rates in 479,893 fee-for-service beneficiaries admitted for acute MI between 1999 and 2014. The analysis incorporated spending on testing, imaging, physician visits, PCI, other cardiac and noncardiac procedures, outpatient care, and postacute care, including skilled nursing facilities, home health agencies, hospice, and durable medical equipment.

During the study period, the risk-adjusted 180-day mortality rate declined from 26.9% to 21.5%. At the same time, 180-day mean expenditures per patient—adjusted for price differences and inflation—climbed by 13.9% (from $32,182 to $36,668), taking into account a slight decline after 2008. The change in spending varied widely across hospitals, with mean expenditures rising by 44.1% in centers with the most rapid growth and falling by 18.7% in those with the slowest growth.

Changes in spending were only weakly associated with risk-adjusted mortality, however. A stronger relationship was seen with use of early PCI (on the day of admission), which increased from 17.3% to 35.1% over time.

Looking at types of spending, increased expenditure for cardiac procedures was associated with elevated 180-day mortality (P = 0.007), whereas greater postacute care spending was tied to lower mortality (P < 0.001); the latter type of spending was moderately cost-effective at $455,000 per life saved after 180 days.

A sensitivity analysis picking apart the different aspects of postacute care revealed that spending on skilled nursing facilities—but not on home health agencies, hospice, and durable medical equipment—was associated with a lower mortality rate.

“We previously argued that when different components of healthcare spending exhibit higher or lower cost-effectiveness, total expenditures and growth are poor predictors of overall health benefits,” the authors write. “Our results are consistent with this hypothesis. Factors leading to improved outcomes have little impact on spending, while the factors leading to the highest impact on spending have a modest impact on health outcomes.”

Potential Role of Bundled Payments

The researchers found that much of the increase in spending over time occurred beyond 30 days; there was a 6.1% increase in expenditures up to 30 days after the index admission over time compared with a 31% jump in spending from 31 to 180 days after admission.

The fact that short-term spending has not changed much indicates that the traditional way of reimbursing hospitals through a fixed diagnosis-related group payment has been largely effective for reining in spending, Likosky said, adding, “What it masks, though, is that there’s quite a bit of increase in spending beyond that time period where policies actually have not been targeted but perhaps should be.”

Thus, he and co-authors write in their paper, “bundling payments to include services occurring beyond 30 days could further moderate expenditure growth.”

In an accompanying editorial, Jason Wasfy, MD (Massachusetts General Hospital, Boston), and Robert Yeh, MD (Beth Israel Deaconess Medical Center, Boston), note that “incentives both for research on optimal care pathways after AMI and for implementation of care proven to improve clinical outcomes” would have been boosted by a plan floated by the US Department of Health & Human Services to bundle Medicare payments for MI care.

“This would have created strong incentives for the index hospital to improve specific quality benchmarks and reduce costs, not only during the index hospitalization but also after discharge,” Wasfy and Yeh say.

Nevertheless, the Centers for Medicare & Medicaid Services ditched the plan this fall.

In that context, “the importance of the findings by Likosky et al become clearest,” the editorialists say. “Both from the perspective of individual patients and the healthcare system, we know very little about the optimal way to care for patients with AMI, particularly after the index hospitalization. In most cases, intensification of different types of care for AMI has not led to reduced mortality. Whether the delivery of these services improves clinical outcomes other than mortality remains unknown.

“Given the substantial spending without clear benefit demonstrated here, reintroducing strong incentives to improve quality and value seems urgent to best help our patients now and improve the sustainability of the healthcare system,” they conclude.