Mortality Lower at Major Teaching Hospitals, Study Shows

Diana Phillips

May 23, 2017

Patients who receive care at major teaching hospitals have a lower risk of dying within 30 days of admission compared with patients treated at nonteaching hospitals or minor teaching hospitals, a study suggests.

The findings, which are reported in an article published online May 23 in JAMA,  add perspective to the discussion of healthcare value vs costs, according to Laura G. Burke, MD, from the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health in Boston, Massachusetts, and colleagues.

"Academic medical centers (AMCs) are often considered more expensive than community hospitals and some insurers have excluded AMCs from their networks in an attempt to control costs, assuming that quality is comparable," the authors explain. "Because evaluating the value of medical care requires consideration of quality as well as cost, understanding whether teaching hospitals provide better care is critical."

To gain insight into the cost/quality balance, the researchers compared mortality rates by hospital teaching status across approximately 21 million Medicare beneficiaries aged 65 years or older from 2012 to 2014.

Of the 4483 hospitals included in the analysis, 250 were considered major teaching hospitals according to their membership in the Council of Teaching Hospitals (COTH), 894 without COTH membership were categorized as minor teaching hospitals according to their affiliation with a medical school, and 3339 were nonteaching hospitals. The nonteaching hospitals accounted for half (49.7%) of the admissions, while the minor and major teaching hospitals accounted for 33.6% and 16.7%, respectively.

After adjustment for patient and hospital characteristics, the 30-day mortality rates for major teaching, minor teaching, and nonteaching hospitals, respectively, were 8.3%, 9.2%, and 9.5%, the authors report. The difference between major and minor teaching hospitals was significantly greater in both unadjusted and adjusted analyses (P < .001 for both).

When the researchers restricted their analysis to the 15 most common medical causes of hospitalizations and 6 common surgical procedures, they saw similar patterns. After adjustment for patient and hospital characteristics, the 30-day mortality rates for medical hospitalizations were 11.0, 11.6, and 11.9, respectively, for major teaching, minor teaching, and nonteaching. The 0.9 difference between major teaching and nonteaching was statistically significant, the authors report. Further, significant differences between the two groups were observed for 11 of the 15 individual medical conditions.

The differences in the adjusted 30-day mortality rates for surgical procedures — 3.3, 3.8, and 4.0 for major teaching, minor teaching, and nonteaching, respectively — were also statistically significant for major teaching and nonteaching hospitals, the authors report. The differences between the two groups were also significant for 2 of the 6 major procedures: open abdominal aortic aneurysm repair (12.2% vs 16.9%) and colectomy (7.0% vs 7.8%).

Significant differences by teaching status were also observed after stratification of the mortality data by hospital size. Among large hospitals (400 beds or more), the 30-day mortality rates for major teaching, minor teaching, and nonteaching hospitals were 8.1%, 8.9%, and 9.4%, respectively. Similar patterns persisted after the analysis was restricted to the 15 common medical conditions and 6 surgeries.

For medium-sized hospitals (100 to 399 beds), the investigators saw significant differences in overall mortality and surgical mortality by hospital teaching status, but not for common medical conditions. For small hospitals (99 beds or fewer), the differences by teaching status were significant for overall 30-day mortality and for medical conditions, but not surgical conditions.

The authors suggest multiple possible reasons for the mortality differences, including the fact that teaching hospitals tend to be early adopters of new treatments and technologies, "which could yield better outcomes for conditions that are more technologically intensive or require specialized knowledge," the authors write.

The outcome differences could also be a function of better processes, the authors hypothesize. "A recent study found that teaching intensity was associated with higher performance on process measures for several conditions, suggesting that superior processes may explain the lower average mortality found at teaching hospitals in the present study," they write.

"These findings may be relevant to the recent changes in the broader health care delivery system," the authors write. They mention in particular the exclusion of teaching hospitals by some narrow insurance networks, as well as national pay-for-performance programs established under the Affordable Care Act, through which teaching hospitals are disproportionately penalized.

"[T]he findings of this study suggest that teaching hospitals have better outcomes, calling into question whether the national approach to measuring and rewarding on performance is working effectively," the authors write.

Teaching hospitals do not consistently get good grades across measures, however. As reported by Medscape Medical News, a recent study suggests that academic medical centers may be falling short in infection control, which is a factor in the value-based healthcare equation.

Further research is warranted to improve understanding of the reasons for the mortality differences between teaching and nonteaching hospitals and to determine whether the improved mortality outcomes seen in the former can be replicated in the latter, the authors conclude.

This study was funded by the Association of American Medical Colleges. The authors have disclosed no relevant financial relationships.

JAMA. 2017;317:2105-2113. Abstract

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