A road less travelled

The passage of the Affordable Care Act of 2010 has created a real opportunity to advance delivery and payment system reform in the United States. The need for reform is widely recognized, not only because of the now well-established consensus that uneven quality and poorly coordinated care are endemic (IOM 2001) but also because of the growing concern that continued health care spending growth will exacerbate the federal deficit, potentially reducing U.S. Treasuries to junk bond status.

The article by Jeffrey Silber et al. (2010) in this issue of Health Services Research can contribute to a better understanding of how to improve quality and reduce costs in U.S. health care. They use data on Medicare beneficiaries undergoing major vascular, orthopedic, and general surgical procedures at U.S. acute care hospitals. Their primary results are that when a Dartmouth measure of end-of-life hospital resource use–or as they call it, “aggressiveness”–is higher, 30-day surgical mortality rates and the relative risk of failure to rescue (having a complication and dying) were lower. In other words, hospitals spending more on their chronically ill patients near death also experienced better outcomes among surgical patients.

There is much to admire in the study. The quality of the statistical analysis is very high and they do a commendable job of risk adjustment at the individual level. The failure-to-rescue quality measure is clinically meaningful and well validated. And we certainly approve of their using the Dartmouth end-of-life hospital measures.