We compared rates of hospital use and mortality in fiscal year 1985 among Medicare enrollees in Boston and New Haven, Connecticut. Adjusted rates of discharge, readmission, length of stay, and reimbursement were 47, 29, 15, and 79 percent higher, respectively, in Boston; 40 percent of Boston's deaths occurred in hospitals as compared with 32 percent of New Haven's. High-variation medical conditions (those for which there is little consensus about the need for hospitalization) accounted for most of these differences. By contrast, discharge rates for low-variation medical conditions (which tend to reflect the incidence of disease) were similar. Inpatient case-fatality rates were lower in Boston than in New Haven (RR = 0.85; 95 percent confidence interval, 0.78 to 0.92), but when all deaths (regardless of place of death) were measured, the mortality rates in Boston and New Haven were nearly identical (RR = 0.99; 95 percent confidence interval, 0.93 to 1.05). We conclude that the lower rate of hospital use by Medicare enrollees in New Haven was not associated with a higher overall mortality rate. Population-based as well as hospital-based statistics are needed to evaluate differences in hospital mortality rates for high-variation medical conditions. (N Engl J Med 1989; 321:1168–73.), PREVIOUS studies showed that residents of the Boston hospital-service area used about 4.5 beds per thousand population, as compared with less than 3 per thousand for residents of the New Haven, Connecticut, hospital-service area1,2 and raised questions about the possible withholding of care in New Haven.2,3 In 1982 the total number of days in the hospital and expenditures per capita were 44 and 100 percent higher, respectively, in Boston than in New Haven.2 The higher rate of hospital use among Boston residents was largely due to higher discharge rates involving high-variation medical conditions, such as pneumonia, gastroenteritis, and chronic obstructive….
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