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For Heart Failure, Better Care Comes at a Cost

Hospitals that see a lot of heart failure cases give better care, but it also costs more, according to a new study.

That translates into about 20,000 people a year who aren't dying because they're going to the right type of hospital - and tens of millions of dollars.

"That's a lot of folks. This is just such a huge public health issue," said Dr. Karen Joynt, a cardiology fellow at Brigham and Women's Hospital and Harvard's School of Public Health, and lead author on the America Heart Association-funded study.

Congestive heart failure, in which the heart weakens and struggles to pump enough blood to the rest of the body, sends about 1.1 million adults to the hospital a year, according to the American Heart Association. It costs the health care system some $29 billion per year, and is the most common reason people 65 and older go to the hospital in the U.S.

At a low-volume hospital, where the chance of dying is two percent higher, care for heart failure costs an average of $7,200, the study in the journal Annals of Internal Medicine found. But at a high volume hospital with a lower chance of dying, it's about $8,400.

That $1,200 difference adds up, Joynt told Reuters Health. "Again, if you're looking at a million people, that's a lot of money."

In Medicare patients over 65, the risk of dying from heart failure within 30 days was 10.5 percent if the patient went to a hospital that saw nine or fewer cases per month. This rate shrunk to eight and a half percent if the patient went to a hospital that had more than 17 cases per month

Several other studies have looked at mortality rates versus volume of cases for conditions like AIDS, pneumonia, or heart attack, and also found that bigger hospitals tend to give better care. However, this is the first time that researchers have looked at the cost as well.

"It's something that's becoming increasingly important to include in these types of studies," Joynt said, especially in the light of health care reform and the need to get the best care for the least amount of money.

This study looked at the rates of death and readmission within 30 days, and costs for low, medium, and high volume hospital cases of congestive heart failure. It included just over a million patients at more than 4000 hospitals for about 2 years.

More than one-third of hospitals in the U.S. are medium to high volume hospitals for heart failure, so their death rates are relatively low. Joynt said this means the focus really needs to be on the remaining one third of hospitals that don't see a large amount of cases, and to help them improve their outcomes.

The researchers found that at a certain point, the benefits of going to a big hospital leveled off.
But this wasn't true for the cost of care. The more cases a hospital saw per month, the more each patient paid, on average.

This is actually the opposite of what's expected, says Uwe Reinhardt, professor of economics and public affairs at Princeton University in New Jersey.

A hospital that deals with more heart failure cases should run more smoothly, Reinhardt told Reuters Health. "So you'd think that costs would go down. Here they go up, which leaves you with some kind of puzzle."

One explanation might be that a hospital could spend more money on facilities, which would draw in more top-level physicians, which in turn might attract more patients, said Reinhardt. There are other possibilities, he said, but the reason isn't clear.

Joynt agrees that they don't understand why this is.

"But it does sort of call into question if you can really have your cake and eat it too," she said. "Maybe some of these chronic diseases are going to need us to spend more money to get better outcomes."

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