The association between hospital care intensity and surgical outcomes in medicare patients

JAMA Surg. 2014 Dec;149(12):1254-9. doi: 10.1001/jamasurg.2014.552.


Importance: Hospitals' care intensity varies widely across the United States. Payers and policy makers have become focused on promoting quality, low-cost, efficient health care.

Objective: To evaluate whether increased hospital care intensity (HCI) is associated with improved outcomes following major surgery.

Design, setting, and participants: Using national Medicare data in this retrospective cohort study, we identified 706,520 patients at 2544 hospitals who underwent 1 of 7 major cardiovascular, orthopedic, or general surgical operations.

Exposure: The HCI Index, which is validated and publicly available through the Dartmouth Atlas of Healthcare.

Main outcomes and measures: Risk- and reliability-adjusted mortality, major complication, and failure-to-rescue rates.

Results: Hospital care intensity varied 10-fold. High-HCI hospitals had greater rates of major complications when compared with low-HCI centers (risk ratio, 1.04; 95% CI, 1.03-1.05). There was a decrease in failure to rescue at high compared with low-HCI hospitals (risk ratio, 0.95; 95% CI, 0.94-0.97). Using multilevel-models, HCI reduced the variation in failure-to-rescue rates between hospitals by 2.7% after accounting for patient comorbidities and hospital resources. Patients treated at high-HCI hospitals had longer hospitalizations, more inpatient deaths, and lower hospice use during the last 2 years of life.

Conclusions and relevance: Failure-to-rescue rates were lower at high-care intensity hospitals. Conversely, care intensity explains a very small proportion of variation in failure-to-rescue rates across hospitals.

Publication types

  • Multicenter Study

MeSH terms

  • Aged
  • Female
  • Hospital Mortality / trends
  • Hospitals / standards*
  • Humans
  • Incidence
  • Male
  • Medicare / statistics & numerical data*
  • Outcome Assessment, Health Care*
  • Postoperative Care
  • Postoperative Complications / epidemiology*
  • Quality Improvement*
  • Registries*
  • Reproducibility of Results
  • Retrospective Studies
  • Surgical Procedures, Operative / standards*
  • United States / epidemiology