A Dissertation Proposal Presented to the Faculty of the Heller ...

ABSTRACT
Efficiency of Cardiac Care in US Hospitals
A Dissertation Proposal Presented to the Faculty of the Heller School of Social Policy and
Management
Brandeis University, Waltham, Massachusetts
By
Taroon Amin, MPH, MA
A central aim of United States health policy is to improve health care system efficiency by
simultaneously achieving high quality care while reducing the rate of health care cost growth. However,
this policy objective of increased US health care efficiency is not a recent phenomenon. US health care
expenditure has been double the median expenditure of countries in the Organization for Economic
Cooperation and Development (OECD) since the 1960s (Rosko 2001). The premium paid by Americans
for their health care has not broadly resulted in higher quality outcomes compared to their international
peers; for instance, the US continues to achieve below average performance on infant mortality and life
expectancy at birth (Rosko 2001). Increasing pressure to restrain the growth of health expenditures in the
US has made the ability to make meaningful comparisons of resource utilization, and ultimately
efficiency between hospitals an urgent priority.
While increased cost pressure is present broadly across the health system, cost growth in the
Medicare program is particularly acute. Increased Medicare spending will continue to strain services for
beneficiaries and taxpayers, with increasing pressure to crowd-out other public and private sector
activities. Per-beneficiary spending in high-spending regions exceeds that in low-spending regions by
one third with no signals of higher quality care (Hackbarth, Reischauer et al. 2008).
The theory underlying this study is based in the microeconomic theory of efficiency. Pareto
efficiency claims markets are perfectly competitive and the firm (in this case the hospital) will always
make optimal decisions on the use of inputs, thus any inefficiency within a market is allocated across
hospitals not within hospitals (Leibenstein 1966). Traditional economic theory posits that any inefficiency
within hospitals is only temporary as hospitals adjust toward optimization. However, existing literature
challenges the traditional economic notion that hospitals will seek to minimize the cost of producing a
healthcare outcome since there is inefficiency in the form of non-random cost and quality variation within
hospitals (Zuckerman, Hadley et al. 1994; Chirikos and Sear 2000; Rosko 2001; McKay and Deily 2005;
McKay and Deily 2008). This study seeks to examine this non-random risk-adjusted cost and quality
variation as an indicator of systematic inefficiency when paired with patient-level mortality quality
indicators.
The proposed study will employ a quantitative approach using a retrospective observational
design. The study will consist of four study aims which seek to examine the relationship between
resource use and quality in the Medicare program. The first aim seeks to validate the
PACES/Complications measure by examining its relationship to AMI mortality. Hospitals will be ranked
into deciles of performance based on their AMI mortality performance to examine the relationship
between mortality and inpatient complications. The second aim of this study will be to examine the total
cost of an episode for AMI, PCI and CABG across tiers of hospital performance defined by AMI
mortality. The third and fourth aim will explore a more nuanced evaluation of the total cost of the
episode. The third aim will deconstruct the total cost of the episodes into only those costs representing
typical or best practice care and examine its relationship across tiers of quality performance. The final
aim will deconstruct the total cost of the episodes into only those costs representing complications and

examine its relationship across tiers of quality performance. This dissertation will use the Patient-
Centered Episode System (PACES) methodology recently developed for the Medicare program to define
episodes of cardiac care.
This study will generate new knowledge on the relationship between resource use and quality for
cardiac care in US hospitals. It will provide insight into how policy can be developed to improve quality
while reducing overall costs for cardiac services. This study posits that a trade-off between cost
minimization and quality maximization exists in health care markets, however this trade-off may not be
apparent at all levels of cost and quality. At the lowest levels of quality, investments in quality
improvement may actually reduce overall costs. This analysis will inform value-based purchasing
program development in the private and public sector.
Dissertation Committee:
Christopher Tompkins, PhD, Chair, Brandeis University
Jennifer Perloff, PhD, Brandeis University
John Chapman, PhD, Brandeis University
Helen Burstin, MD, MPH, School of Medicine and Public Health, The George Washington
University School of Medicine & Senior Vice President, National Quality Forum (NQF)
Proposal Hearing:
Wednesday, April 25, 2012 at 1:00pm – 3:00pm.
Heller School
Room G55