Norra MacReady

When it comes to improving healthcare in the United States, most discussions revolve around the twin pillars of quality and cost: Will higher expenditures result in better care, or will better clinical outcomes help to contain costs?

In a review of the evidence currently available, there was no clear relationship between the 2, leading the authors of an article published in the January 2013 issue of the Annals of Internal Medicine to conclude that the association between healthcare cost and quality is still poorly understood.

Lead author Peter S. Hussey, PhD, from RAND Health, Arlington, Virginia, and colleagues conducted a systematic review of 61 studies and “found inconsistent evidence on both the direction and the magnitude of the association between health care costs and quality,” they write. “To our knowledge, there has been no previous systematic literature review of evidence on the cost–quality association in health care.”

One problem Dr. Hussey and colleagues found was that studies varied widely in the way they defined costs and in the levels of analysis they employed. However, the findings remained inconsistent even after Dr. Hussey and colleagues controlled for these differences.

“These results are a stark reminder of how little researchers and caregivers know about the optimal allocation of scarce health care resources to achieve the best health outcomes,” Alyna T. Chien, MD, from Harvard Medical School and Boston Children’s Hospital in Massachusetts, and Meredith B. Rosenthal, PhD, from the Harvard School of Public Health, write in an accompanying editorial.

The investigators searched the PubMed, EconLit, and EMBASE databases for relevant studies published between January 1, 1990, and June 10, 2012. The search also included studies gleaned from the bibliographies of selected papers, as well as informal searches and consultations with outside experts. Two of the authors independently reviewed and abstracted the data. For each study reviewed, outcomes of interest were the magnitude and direction of the association between cost and quality as well as the statistical significance of that association.

To assess quality measures, the reviewers used 5 categories defined by the National Quality Measures Clearinghouse of the Agency for Healthcare Research and Quality: structure, process, outcome, patient experience, and access. They also added a sixth category that included composites of measures in 2 or more of those categories. Cost measures were divided into 4 categories: accounting costs, charges, expenditures, and a “care intensity index” used in some studies as a measure of resource use relative to the services provided.

Of the 61 studies that met the inclusion criteria, higher cost was associated with better quality of care in 21 (34%), indicating a positive or mixed-positive association between the 2. In 18 studies (30%), the association was negative or mixed negative (lower cost was associated with higher quality), and in 22 studies (36%), the association was nonexistent, mixed, imprecise, or indeterminate.

Imprecise or indeterminate findings “do not rule out the possibility of a real and clinically significant cost–quality association,” the authors write. “For example, a study of 22 Veterans Affairs geographic networks found that an average increase of $1000 in risk-adjusted funding was associated with nonstatistically significantly lower odds of death among male patients (odds ratio, 0.943 [(confidence interval [CI]), 0.880 to 1.010]). With a larger sample size, the study may have identified a statistically and clinically significant association.”

Still, more data are needed for clinicians and policy makers to make effective decisions that affect the clinical and fiscal health of the nation, Dr. Chien and Dr. Rosenthal state in their editorial. They urge physicians to learn more about the cost and price of the services they provide and recommend that funders of research support studies that evaluate the cost or cost-effectiveness of the interventions in question. Payers should reconsider the extent to which they shift financial risk onto provider organizations, and incentives for quality targets should be offered to promote processes of care that are well-supported by evidence or, conversely, to discourage care shown to be inappropriate or of poor value.

“Finally,” they write, “all parties should participate in ongoing monitoring of access, care processes (spending and clinical), patient experience, and outcomes to ensure that we not only detect any unforeseen problems but that we can also continue to learn what works to produce value in health care.”

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