High costs don't necessarily correlate with high quality when it comes to health care, report Yasaitis and colleagues in one of the first nationwide analyses of quality and spending at individual hospitals. Instead, a boost in spending and procedures-and in the use of specialists, tests, and the ICU-appears to make people sicker.

To rate the quality of care offered by 2,172 hospitals between 2004 and 2007, the researchers turned to Hospital Compare, a Web site sponsored by the Department of Health and Human Services that reports on hospitals' response to pneumonia, congestive heart failure, and acute myocardial infarction. The quality measures were evidence-based treatments, such as a first dose of an antibiotic given to pneumonia patients within four hours of admission. To assess spending, which is often reflected in end-of-life charges, investigators examined the records of chronically ill Medicare recipients for two years leading up to their deaths and ranking institutions' spending accordingly. A surprising picture emerged: big spenders scored slightly lower on quality measurements than their more conservative counterparts.

Since ordering tests, scans, surgery, and the like are more costly, does this mean that more aggressive care is bad for patients' health? The researchers theorize that more intensive, expensive procedures such as angioplasty might crowd out low-cost, equally effective treatments like aspirin or [beta]-blockers. Or maybe the problem is that health risks increase when procedures do.

But Isis Montalvo, director of the American Nurses Association's National Center for Nursing Quality, has another idea: "We need to include nurses in these studies. We know that nurses make a huge difference in quality of care-therefore, not studying them is a serious limitation of this kind of research." Besides, she adds, it's difficult to isolate nursing-related information in Medicare reports. "We already know that nurses have a big effect on patient outcomes. What's needed now is more research on what specific interventions or changes will have an impact."

Bunny Wong