"Phenotyping" hospital value of care for patients with heart failure

Abstract

Objective: To characterize hospitals based on patterns of their combined financial and clinical outcomes for heart failure hospitalizations longitudinally.

Data source: Detailed cost and administrative data on hospitalizations for heart failure from 424 hospitals in the 2005-2011 Premier database.

Study design: Using a mixture modeling approach, we identified groups of hospitals with distinct joint trajectories of risk-standardized cost (RSC) per hospitalization and risk-standardized in-hospital mortality rate (RSMR), and assessed hospital characteristics associated with the distinct patterns using multinomial logistic regression.

Principal findings: During 2005-2011, mean hospital RSC decreased from $12,003 to $10,782, while mean hospital RSMR declined from 3.9 to 3.2 percent. We identified five distinct hospital patterns: highest cost and low mortality (3.2 percent of the hospitals), high cost and low mortality (20.4 percent), medium cost and low mortality (34.6 percent), medium cost and high mortality (6.2 percent), and low cost and low mortality (35.6 percent). Longer hospital stay and greater use of intensive care unit and surgical procedures were associated with phenotypes with higher costs or greater mortality.

Conclusions: Hospitals vary substantially in the joint longitudinal patterns of cost and mortality, suggesting marked difference in value of care. Understanding determinants of the variation will inform strategies for improving the value of hospital care.

Keywords: Cost; heart failure; mortality; trajectory; value of care.

Figure 1

Distinct Hospital Phenotypes Identified by Jointly Modeling the Longitudinal Trajectory of In-Hospital Risk-Standardized Cost (RSC) and Risk-Standardized Mortality Rate (RSMR) Dotted lines reflect confidence intervals for each trajectory, based on the 95 percent confidence intervals of the point estimates in each year Phenotype 1: Highest cost and low mortality (n = 14 hospitals, 3.2 percent of the hospitals in sample) Phenotype 2: High cost and low mortality (n = 86 hospitals, 20.4 percent of the hospitals in sample) Phenotype 3: Medium cost and low mortality (n = 147 hospitals, 34.6 percent of the hospitals in sample) Phenotype 4: Medium cost and high mortality (n = 26 hospitals, 6.2 percent of the hospitals in sample) Phenotype 5: Low cost and low mortality (n = 151 hospitals, 35.6 percent of the hospitals in sample)