Variation In Resource Use Research Articles

Physician Professionalism and Accountability: The Role of Collaborative Improvement Networks

The medical profession is facing an imperative to deliver more patient-centered care, improve quality, and reduce unnecessary costs and waste. With significant unexplained variation in resource use and outcomes, even physicians and health care organizations with "the best" reputations cannot assume they always deliver the best care possible. Going forward, physicians will need to demonstrate professionalism and accountability in a different way: to their peers, to society in general, and to individual patients. The new accountability includes quality and clinical outcomes but also resource utilization, appropriateness and patient-centeredness of recommended care, and the responsibility to help improve systems of care. The pediatric collaborative improvement network model represents an important framework for helping transform health care. For individual physicians, participation in a multisite network offers the opportunity to demonstrate accountability by measuring and improving care as part of an approach that addresses the problems of small sample size, attribution, and unnecessary variation in care by pooling patients from individual practices and requiring standardization of care to participate. For patients and families, the model helps ensure that they are likely to receive the current best evidence-based recommendation. Finally, this model aligns with payers' goals of purchasing value-based care, rewarding quality and improvement, and reducing unnecessary variation around current best evidenced-based, effective, and efficient care. In addition, within the profession, the American Board of Pediatrics recognizes participation in a multisite quality improvement network as one of the most rigorous and meaningful approaches for a diplomate to meet practice performance maintenance of certification requirements.

A year in an ant's life: Opportunism and seasonal variation in the foraging ecology of Aphaenogaster senilis

Ants are important consumers in most terrestrial ecosystems. They show a great diversity of diets and foraging strategies. Here, we analyzed how circannual variation in resource use by the Mediterranean species Aphaenogaster senilis is related to colony life cycle and resource availability. In southwestern Spain, this species is active almost year-round, but foraging intensity decreases 10-fold between March and November, following larval production. In the summer, ants refrain from foraging at midday to avoid high temperatures. We hypothesized that diet and foraging plasticity could also explain the ecological success of this species. There are several techniques for assessing the diet of ants. Combining isotope analyses with conventional methods can provide better taxonomic resolution of resource utilization. Using a combination of classic and isotopic analyses, we found that 1) the proportion of plant and animal-derived items collected by foragers did not vary significantly from March to November, and 2) isotope analyses indicated a decrease in the trophic level of A. senilis between June and September, suggesting a difference between collected material and items assimilated. Interestingly, most animal prey were collected by individual ants, and many were retrieved alive. Therefore, A. senilis is not only a scavenger, but also a non-negligible predator, particularly of aphids. The abundance of the most common animal-derived items in the diet was proportional to their abundance in the study area. We conclude that A. senilis is an opportunistic species that is able to feed on a variety of resources, which may be key to its ecological success.

Individual variation in resource use by opossums leading to nested fruit consumption

Despite recent findings on the ecological relevance of within population diet variation far less attention has been devoted to the role diet variation for ecological services. Seed dispersal is a key ecological service, affecting plant fitness and regeneration based on foraging by fruit‐eating vertebrates. Here we used a network approach, widely used to understand how seed‐dispersal is organized at the species level, to gain insights into the patterns that emerge at the individual‐level. We studied the individual fruit consumption behavior of a South American didelphid Didelphis albiventris, during the cool–dry and warm–wet seasons. In species–species networks the heterogeneity in specialization levels generates patterns such as nestedness and asymmetry. Because generalist populations may be comprised of specialized individuals, we hypo thesized that network structural properties, such as nestedness, should also emerge at the individual level. We detected variation in fruit consumption that was not related to resource availability, ontogenetic or sexual factors or sampling biases. Such variation resulted in the structural patterns often found in species–species seed‐dispersal networks: low connectance, a high degree of nestedness and the absence of modules. Moreover structure varied between the warm–wet and cool–dry seasons, presumably as a consequence of seasonal fluctuation in fruit availability. Our findings suggest individuals may differ in selectivity causing asymmetries in seed dispersal efficiency within the population. In this sense the realized dispersal would differ from the expected dispersal estimated from their average dispersal potential. Additionally the results suggest possible frequency‐dependent effects on seed dispersal that might affect individual plant performance and plant community composition.

Between-individual variation drives the seasonal dynamics in the trophic niche of a Neotropical marsupial

The dynamics of population niches result from the variation in resource use within individuals and also from the variation between individuals. The prevalence of one mechanism or the other leads to competing hypotheses about the major mechanisms underlying the empirical observations of the contraction/expansion dynamics of the trophic niche in natural populations. In this study, we investigated how within- and between-individual variation in resource use shapes the food niche dynamics of the woolly mouse opossum, Marmosa paraguayana (Didelphimorphia: Didelphidae), in a remnant of the highly seasonal Cerrado in south-eastern Brazil. To do so, we analysed the faecal samples of live-trapped individuals to determine their diets within the wet and dry seasons. In addition to a seasonal shift in the composition of the diet, the population trophic niche was significantly wider during the dry season than the wet season. This expansion resulted from larger between-individual variation in the dry season that was not related to sex preferences, whereas the individual niche widths did not significantly increase from the wet to the dry seasons. Our findings add to the growing list of animal populations that show individual-level variation in resource use. Furthermore, these results represent a pattern of individual-level response to seasonal changes that is different from patterns reported for other organisms. We suggest that a pathway to build more realistic foraging models and produce more accurate predictions on population and community dynamics is to consider between-individual variation and short-term niche dynamics.

HOW WELL DO DIAGNOSIS‐RELATED GROUPS EXPLAIN VARIATIONS IN COSTS OR LENGTH OF STAY AMONG PATIENTS AND ACROSS HOSPITALS? METHODS FOR ANALYSING ROUTINE PATIENT DATA

We set out an analytical strategy to examine variations in resource use, whether cost or length of stay, of patients hospitalised with different conditions. The methods are designed to evaluate (i) how well diagnosis-related groups (DRGs) capture variation in resource use relative to other patient characteristics and (ii) what influence the hospital has on their resource use. In a first step, we examine the influence of variables that describe each individual patient, including the DRG to which the patients are assigned and a range of personal and treatment-related characteristics. In a second step, we explore the influence that hospitals have on the average cost or length of stay of their patients, purged of the influence of the variables accounted for in the first stage. We provide a rationale for the variables used in both stages of the analysis and detail how each is defined. The analytical strategy allows us (i) to identify those factors that explain variation in resource use across patients, (ii) to assess the explanatory power of DRGs relative to other patient and treatment characteristics and (iii) to assess relative hospital performance in managing resources and the characteristics of hospitals that explain this performance.

DIAGNOSIS RELATED GROUPS AND VARIATIONS IN RESOURCE USE FOR CHILD DELIVERY ACROSS 10 EUROPEAN COUNTRIES

Childbirth is one of the main causes of hospitalisation for women, accounting for about 5% of hospital activity in most Organisation for Economic Co-operation and Development countries. We analysed the factors that explain variations in resource use for child delivery in ten European countries. We compared the performance of three models for explaining the variations in resource use (log cost or length of inpatient stay) at patient and hospital level. The first model used only the DRGs to which child deliveries were coded (M(D) ), the second used a set of 'patient-level' and delivery specific explanatory variables (M(P) ), and the third model combined both sets of variables (M(F) ). Countries vary both in the number of DRGs and the criteria used to classify cases of child delivery (range: 3-8) and in the percentage of deliveries classified as 'delivery without complication' (range: 53-90%). The capacity of DRGs and patient level variables to explain cost variation for child birth ranges from 48% in Sweden to over 70% in Spain. There is room for improving current DRG classification in most countries, but this does not necessary imply multiplying the groups and/or complicating criteria. Countries with a higher number of DRGs do not always perform better.

DO DIAGNOSIS‐RELATED GROUPS APPROPRIATELY EXPLAIN VARIATIONS IN COSTS AND LENGTH OF STAY OF HIP REPLACEMENT? A COMPARATIVE ASSESSMENT OF DRG SYSTEMS ACROSS 10 EUROPEAN COUNTRIES

This paper assesses the variations in costs and length of stay for hip replacement cases in Austria, England, Estonia, Finland, France, Germany, Ireland, Poland, Spain and Sweden and examines the ability of national diagnosis-related group (DRG) systems to explain the variation in resource use against a set of patient characteristic and treatment specific variables. In total, 195,810 cases clustered in 712 hospitals were analyzed using OLS fixed effects models for cost data (n=125,698) and negative binominal models for length-of-stay data (n=70,112). The number of DRGs differs widely across the 10 European countries (range: 2-14). Underlying this wide range is a different use of classification variables, especially secondary diagnoses and treatment options are considered to a different extent. In six countries, a standard set of patient characteristics and treatment variables explain the variation in costs or length of stay better than the DRG variables. This raises questions about the adequacy of the countries' DRG system or the lack of specific criteria, which could be used as classification variables.

Factors affecting resource use variation for an abundant coastal fish predator, Lutjanus apodus, in a bahamian wetland system

Studies of fishes' resource use reflect important ecological interactions, and provide insight into the structure of aquatic food webs. Individuals within species are often assumed to have an equivalent ecological role despite increasing evidence that among-individual variation in resource use within populations is common. Such intraspecific variation in resource use can be a result of ontogenetic-based diet shifts, differences in individual feeding behavior within age groups (i.e., individual specialization), and temporal variation in resource pools. We examined trophic interactions in schoolmaster, Lutjanus apodus (Walbaum, 1972), over multiple seasons and across size classes in a Bahamian wetland system. Using combined stable isotope and stomach content analyses, we found that, as with many other fishes, subadults fed at higher trophic levels than juveniles, likely because of a shift from feeding predominantly on lower trophic-level prey taxa (e.g., crabs) to higher trophic-level prey taxa (e.g., teleosts). Despite a considerable overlap in stable isotope values between subadults and juveniles, stable isotope and stomach content data suggest a switch from feeding predominantly within mangrove prop roots as juveniles to foraging increasingly in adjacent seagrass beds as subadults. Niche width and degree of individual dietary specialization varied among years, suggesting important levels of temporal variation. In sum, individual snapper do not use resources homogeneously, and we outline some of the factors, including predation risk, increase piscivory, and temporal differences in resource use, that underlie this variation.

Structure and mechanism of diet specialisation: testing models of individual variation in resource use with sea otters

Studies of consumer-resource interactions suggest that individual diet specialisation is empirically widespread and theoretically important to the organisation and dynamics of populations and communities. We used weighted networks to analyze the resource use by sea otters, testing three alternative models for how individual diet specialisation may arise. As expected, individual specialisation was absent when otter density was low, but increased at high-otter density. A high-density emergence of nested resource-use networks was consistent with the model assuming individuals share preference ranks. However, a density-dependent emergence of a non-nested modular network for 'core' resources was more consistent with the 'competitive refuge' model. Individuals from different diet modules showed predictable variation in rank-order prey preferences and handling times of core resources, further supporting the competitive refuge model. Our findings support a hierarchical organisation of diet specialisation and suggest individual use of core and marginal resources may be driven by different selective pressures.

Stable isotope series from elephant ivory reveal lifetime histories of a true dietary generalist

Longitudinal studies have revealed how variation in resource use within consumer populations can impact their dynamics and functional significance in communities. Here, we investigate multi-decadal diet variations within individuals of a keystone megaherbivore species, the African elephant (Loxodonta africana), using serial stable isotope analysis of tusks from the Kruger National Park, South Africa. These records, representing the longest continuous diet histories documented for any extant species, reveal extensive seasonal and annual variations in isotopic--and hence dietary--niches of individuals, but little variation between them. Lack of niche distinction across individuals contrasts several recent studies, which found relatively high levels of individual niche specialization in various taxa. Our result is consistent with theory that individual mammal herbivores are nutritionally constrained to maintain broad diet niches. Individual diet specialization would also be a costly strategy for large-bodied taxa foraging over wide areas in spatio-temporally heterogeneous environments. High levels of within-individual diet variability occurred within and across seasons, and persisted despite an overall increase in inferred C(4) grass consumption through the twentieth century. We suggest that switching between C(3) browsing and C(4) grazing over extended time scales facilitates elephant survival through environmental change, and could even allow recovery of overused resources.

Geographic variation in resource use by specialist versus generalist butterflyfishes

Localised patterns of resource use can be constrained by multiple factors. Comparison of resource use at multiple locations with differing resource availability can allow fundamental specialists to be distinguished from species that simply feed predominantly on prey types that are locally abundant. This study investigates geographic variation in the feeding ecology of coral‐feeding butterflyfishes to examine whether patterns of resource use and levels of dietary specialisation vary among distinct locations, corresponding with changes in resource availability. Our specific aims were to investigate whether the dietary niche breadth of four butterflyfishes varies among five geographically separated locations and assess whether each species utilises similar resources in each location. Resource availability and dietary composition of four butterflyfishes were quantified at three sites across each of five geographic locations throughout the Pacific. Niche breadth, niche overlap, and resource selection functions were calculated for each species at each site and compared among locations. Availability of dietary resources varied significantly among locations and sites. Chaetodon vagabundus, C. citrinellus and C. lunulatus had low levels of dietary specialisation and used different resources in each location. Chaetodon trifascialis had high levels of dietary specialisation and used the same few resources in each location. Our results indicate that relative levels of dietary specialisation among different butterflyfishes do hold at larger spatial scales, however, geographical variation in the dietary composition of all butterflyfishes indicates that prey availability has a fundamental influence on dietary composition. Highly specialised species such as C. trifascialis will be highly vulnerable to coral loss as they appear to be largely inflexible in their dietary composition. However, the increased feeding plasticity observed here for C. trifascialis suggests this species may have a greater capacity to respond to coral loss than previously assumed.

Designing Payment for Collaborative Care for Depression in Primary Care

To design a bundled case rate for Collaborative Care for Depression (CCD) that aligns incentives with evidence-based depression care in primary care. A clinical information system used by all care managers in a randomized controlled trial of CCD for older primary care patients. We conducted an empirical investigation of factors accounting for variation in CCD resource use over time and across patients. CCD resource use at the patient-episode and patient-month levels was measured by number of care manager contacts and direct patient contact time and analyzed with count data (Poisson or negative binomial) models. Episode-level resource use varies substantially with patient's time in the program. Monthly use declines sharply in the first 6 months regardless of treatment response or remission status, but it remains stable afterwards. An adjusted episode or monthly case rate design better matches payment with variation in resource use compared with a fixed design. Our findings lend support to an episode payment adjusted by number of months receiving CCD and a monthly payment adjusted by the ordinal month. Nonpayment tools including program certification and performance evaluation and reward systems are needed to fully align incentives.

The nested assembly of individual-resource networks

1. Much of the current understanding of ecological systems is based on theory that does not explicitly take into account individual variation within natural populations. However, individuals may show substantial variation in resource use. This variation in turn may be translated into topological properties of networks that depict interactions among individuals and the food resources they consume (individual-resource networks). 2. Different models derived from optimal diet theory (ODT) predict highly distinct patterns of trophic interactions at the individual level that should translate into distinct network topologies. As a consequence, individual-resource networks can be useful tools in revealing the incidence of different patterns of resource use by individuals and suggesting their mechanistic basis. 3. In the present study, using data from several dietary studies, we assembled individual-resource networks of 10 vertebrate species, previously reported to show interindividual diet variation, and used a network-based approach to investigate their structure. 4. We found significant nestedness, but no modularity, in all empirical networks, indicating that (i) these populations are composed of both opportunistic and selective individuals and (ii) the diets of the latter are ordered as predictable subsets of the diets of the more opportunistic individuals. 5. Nested patterns are a common feature of species networks, and our results extend its generality to trophic interactions at the individual level. This pattern is consistent with a recently proposed ODT model, in which individuals show similar rank preferences but differ in their acceptance rate for alternative resources. Our findings therefore suggest a common mechanism underlying interindividual variation in resource use in disparate taxa.

P51 Surviving intensive care: a systematic review of health care resource use after hospital discharge

BackgroundIntensive care units (ICUs) are an expensive resource. However, this expense does not end at hospital discharge. ICU survivors continue to experience significant morbidity. As the demand for ICU is...

Seasonal diet and feeding habits of juvenile fishes foraging along a subtropical marine ecotone

AB Aquatic Biology Contact the journal Twitter RSS Mailing List Subscribe to our mailing list via Mailchimp HomeLatest VolumeAbout the JournalEditorsTheme Sections AB 9:279-290 (2010) - DOI: https://doi.org/10.3354/ab00251 Seasonal diet and feeding habits of juvenile fishes foraging along a subtropical marine ecotone Neil Hammerschlag1,2,*, Dan Ovando1,4, Joseph E. Serafy1,3 1Rosenstiel School of Marine and Atmospheric Science, University of Miami, 4600 Rickenbacker Causeway, Miami, Florida 33149, USA 2Leonard and Jayne Abess Center for Ecosystem Science and Policy, University of Miami, PO Box 248203, Coral Gables, Florida 33124, USA 3National Oceanic and Atmospheric Administration, National Marine Fisheries Service, Southeast Fisheries Science Center, 75 Virginia Beach Drive, Miami, Florida 33149, USA 4Present address: Donald Bren School of Environmental Science and Management, University of California Santa Barbara, 2400 Bren Hall, Santa Barbara, California 93106-5131, USA *Email: nhammerschlag@rsmas.miami.edu ABSTRACT: Few studies have examined seasonal diet variation and trophic relationships among fishes in shallow subtropical waters. We sampled consecutive wet and dry seasons within Biscayne Bay, Florida, USA, to examine seasonal diet and feeding habit variation in juvenile gray snapper Lutjanus griseus (GS), bluestriped grunt Haemulon sciurus (BSG), seabream Archosargus rhomboidalis (SB) and great barracuda Sphyraena barracuda (GB). We found significantly lower feeding intensity during the dry season compared to the wet, which is likely related to lower water temperatures during the former season. GS fed on a variety of fishes and crustaceans, while BSG fed primarily on caridean shrimps. SB fed on vegetation and GB was piscivorous. Seasonal shifts in major food resources generally did not correspond with changes in relative abundance of food supply. Seasonal population niche breadth differences were evident for GS, GB and BSG, but for SB niche breadth was similar between seasons. Based on seasonal food supply, population niche breadth values did not match basic foraging theory predictions, which state that niche breadth should expand as preferred food items become scarce. In GS, BSG and GB, individuals fed on a narrow subset of prey consumed by the population, revealing the existence of individual specialization. For these species, seasonal expansion in population niche breadth did not correspond to increased individual specialization, but rather via increased within-individual variation in resource use. Given the seasonal differences in feeding habits, it is important to incorporate seasonal variation when modeling trophodynamics of shallow subtropical systems or characterizing them as essential fish habitats. KEY WORDS: Diet · Niche breadth · Resource use · Habitat use · Snapper · Grunt · Barracuda · Food availability · Feeding intensity · Individual specialization Full text in pdf format PreviousNextCite this article as: Hammerschlag N, Ovando D, Serafy JE (2010) Seasonal diet and feeding habits of juvenile fishes foraging along a subtropical marine ecotone. Aquat Biol 9:279-290. https://doi.org/10.3354/ab00251Export citation RSS - Facebook - Tweet - linkedIn Cited by Published in AB Vol. 9, No. 3. Online publication date: June 10, 2010 Print ISSN: 1864-7782; Online ISSN: 1864-7790 Copyright © 2010 Inter-Research.

Measuring efficiency in Australian and New Zealand paediatric intensive care units

To develop a measure of paediatric intensive care unit (PICU) efficiency and compare the efficiency of PICUs in Australia and New Zealand. Separate outcome prediction models for estimating clinical performance and resource usage were constructed using patient data from 20,742 admissions between 2005 and 2007. A standardised mortality ratio was calculated using a recalibrated Paediatric Index of Mortality 2 model. A random effects length of stay (LoS) prediction model was used to provide an indicator of unit-level variation in resource use. A modified Rapoport-Teres plot of risk-adjusted mortality versus unit mean LoS provided a visual representation of efficiency. To account for potential differences in admission threshold, the calculation of performance measures was repeated on patients receiving mechanical respiratory support and compared to those estimated for all patients. The modified plot provides a useful tool for visualising ICU efficiency. Two units were identified as potentially inefficient with higher SMR and risk-adjusted mean LoS at the 95% level. One unit had a significantly lower SMR and significantly higher risk-adjusted mean LoS. The measures for both SMR and risk-adjusted mean LoS showed good agreement between all patients and those who received mechanical respiratory support. There is significant variation in efficiency among PICUs in Australia and New Zealand. Two units were designated as inefficient and one unit was considered to be effective at the expense of high resource use. Application of these methods may help to identify inefficiencies in units located in other countries or regions.

Individual specialists in a generalist population: results from a long-term stable isotope series

Individual variation in resource use has often been ignored in ecological studies, but closer examination of individual patterns through time may reveal significant intrapopulation differences. Adult loggerhead sea turtles (Caretta caretta) are generalist carnivores with a wide geographical range, resulting in a broad isotopic niche. We microsampled scute, a persistent and continuously growing tissue, to examine long-term variation in resource use (up to 12 years) in 15 nesting loggerhead turtles. Using stable isotopes of nitrogen and carbon, we examined the resource use patterns (integration of diet, habitat and geographical location) and demonstrate that individual loggerheads are long-term specialists within a generalist population. We present our results in the context of a conceptual model comparing isotopic niches in specialist and generalist populations. Individual consistency may have important ecological, evolutionary and conservation consequences, such as the reduction of intraspecific competition.

Niche Occupancy and the Relative Role of Micro-Habitat and Diet in Resource Partitioning Among Pond Dwelling Tadpoles

ABSTRACT. We determined microhabitat and diet niche for tadpoles from two ponds in an agricultural landscape. Additionally, we verified the intraspecific variation in resource use, and if diet and microhabitat use were correlated. Tadpoles found in the two ponds differed in microhabitat use, because in the larger pond they explored deeper places far from the margin. There were three groups with high microhabitat niche overlap. In both ponds, plant cover was the best descriptor to explain interspecific variation in microhabitat use. Tadpoles of all species ingested mainly Bacillariophyceae and Trachellomonas however the diet differed intraspecifically in the species from the two ponds. Ten items in the temporary pond and 15 items in the permanent one were ingested by all species; however, the relative abundance of each item differed. Diet similarity was not correlated to similarity in microhabitat use. In this study, diet was as important as microhabitat use to explain resource partitioning.

Pediatric Hospital Adherence to the Standard of Care for Acute Gastroenteritis

Adherence to published care guidelines for the management of acute gastroenteritis (AGE) is unknown. To evaluate the association of AGE guideline adherence with outcomes and resource use at pediatric hospitals. We studied children aged 6 months to 6 years with an International Classification of Diseases, Ninth Edition (ICD-9) discharge code indicative of AGE and without comorbid conditions in the emergency department, observation setting, or hospital. Laboratory studies, antiemetic use, and antibiotic use were evaluated, and the length of stay, mean adjusted total charges, and readmission proportion were documented. Multiple analysis of variance determined if the variance of adjusted charges, length of stay, and diagnostic studies were hospital-related. A regression analysis determined the association between guideline adherence and outcomes. There were a total of 188873 patients; 174594 (92.4%) were not admitted, and 14279 (7.6%) were admitted. There was substantial variation in resource use among hospitals. The mean adjusted total charge for all patients was $863 (SD: 1336). The mean adjusted total charge for nonadmitted patients was $591 (SD: 636). Individual hospitals contributed to the variance of mean length of stay, total adjusted charges, and use of diagnostic studies after controlling for covariates (P < .001). Guideline adherence was associated with a mean decrease in the average adjusted cost ($591) for nonadmitted patients of $296 (95% confidence interval: -399 to -193). Guideline-adherent hospitals demonstrated 50% lower charges for emergency department or observation patients with uncomplicated AGE without adversely affecting outcomes. Use of resources not routinely recommended by published AGE guidelines remains common in pediatric hospitals.

Looking Forward, Looking Back

Recent studies have found substantial variation in hospital resource use by expired Medicare beneficiaries with chronic illnesses. By analyzing only expired patients, these studies cannot identify differences across hospitals in health outcomes like mortality. This study examines the association between mortality and resource use at the hospital level, when all Medicare beneficiaries hospitalized for heart failure are examined. A total of 3999 individuals hospitalized with a principal diagnosis of heart failure at 6 California teaching hospitals between January 1, 2001, and June 30, 2005, were analyzed with multivariate risk-adjustment models for total hospital days, total hospital direct costs, and mortality within 180-days after initial admission ("Looking Forward"). A subset of 1639 individuals who died during the study period were analyzed with multivariate risk-adjustment models for total hospital days and total hospital direct costs within 180-days before death ("Looking Back"). "Looking Forward" risk-adjusted hospital means ranged from 17.0% to 26.0% for mortality, 7.8 to 14.9 days for total hospital days, and 0.66 to 1.30 times the mean value for indexed total direct costs. Spearman rank correlation coefficients were -0.68 between mortality and hospital days, and -0.93 between mortality and indexed total direct costs. "Looking Back" risk-adjusted hospital means ranged from 9.1 to 21.7 days for total hospital days and 0.91 to 1.79 times the mean value for indexed total direct costs. Variation in resource use site ranks between expired and all individuals were attributable to insignificant differences. California teaching hospitals that used more resources caring for patients hospitalized for heart failure had lower mortality rates. Focusing only on expired individuals may overlook mortality variation as well as associations between greater resource use and lower mortality. Reporting values without identifying significant differences may result in incorrect assumption of true differences.