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Hospital teaching intensity, patient race, and surgical outcomes.
Silber JH, Rosenbaum PR, Romano PS, Rosen AK, Wang Y, Teng Y, Halenar MJ, Even-Shoshan O, Volpp KG. Hospital teaching intensity, patient race, and surgical outcomes. Archives of surgery (Chicago, Ill. : 1960). 2009 Feb 1; 144(2):113-20; discussion 121.
OBJECTIVES: To determine if the lower mortality often observed in teaching-intensive hospitals is because of lower complication rates or lower death rates after complications (failure to rescue) and whether the benefits at these hospitals accrue equally to white and black patients, since black patients receive a disproportionate share of their care at teaching-intensive hospitals. DESIGN: A retrospective study of patient outcomes and teaching intensity using logistic regression models, with and without adjusting for hospital fixed and random effects. SETTING: Three thousand two hundred seventy acute care hospitals in the United States. PATIENTS: Medicare claims on general, orthopedic, and vascular surgery admissions in the United States for 2000-2005 (N = 4,658,954 unique patients). MAIN OUTCOME MEASURES: Thirty-day mortality, in-hospital complications, and failure to rescue (the probability of death following complications). RESULTS: Combining all surgeries, compared with nonteaching hospitals, patients at very major teaching hospitals demonstrated a 15% lower odds of death (P < .001), no difference in complications, and a 15% lower odds of death after complications (failure to rescue) (P < .001). These relative benefits associated with higher resident-to-bed ratio were not experienced by black patients, for whom the odds of mortality and failure to rescue were similar at teaching and nonteaching hospitals, a pattern that is significantly different from that of white patients (P < .001). CONCLUSIONS: Survival after surgery is higher at hospitals with higher teaching intensity. Improved survival is because of lower mortality after complications (better failure to rescue) and generally not because of fewer complications. However, this better survival and failure to rescue at teaching-intensive hospitals is seen for white patients, not for black patients.