Relationship of hospital teaching status with quality of care and mortality for Medicare patients with acute MI

University of Alabama at Birmingham, 1530 Third Ave S, MEB 621, Birmingham, AL 35294-3296, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 10/2000; 284(10).
Source: OAI


Context: Issues of cost and quality are gaining importance in the delivery of medical care, and whether quality of care is better in teaching vs nonteaching hospitals is an essential question in this current national debate. Objective: To examine the association of hospital teaching status with quality of care and mortality for fee-for-service Medicare patients with acute myocardial infarction (AMI). Design, Setting, and Patients: Analysis of Cooperative Cardiovascular Project data for 114411 Medicare patients from 4361 hospitals (22354 patients from 439 major teaching hospitals, 22493 patients from 455 minor teaching hospitals, and 69564 patients from 3467 nonteaching hospitals) who had AMI between February 1994 and July 1995. Main Outcome Measures: Administration of reperfusion therapy on admission, aspirin during hospitalization, and β-blockers and angiotensin-converting enzyme inhibitors at discharge for patients meeting strict inclusion criteria; mortality at 30, 60, and 90 days and 2 years after admission. Results: Among major teaching, minor teaching, and nonteaching hospitals, respectively, administration rates for aspirin were 91.2%, 86.4%, and 81.4% (P<.001); for angiotensin-converting enzyme inhibitors, 63.7%, 60.0%, and 58.0% (P<.001); for β-blockers, 48.8%, 40.3%, and 36.4% (P<.001); and for reperfusion therapy, 55.5%, 58.9%, and 55.2% (P=.29). Differences in unadjusted 30-day, 60-day, 90-day, and 2-year mortality among hospitals were significant at P<.O01 for all time periods, with a gradient of increasing mortality from major teaching to minor teaching to nonteaching hospitals. Mortality differences were attenuated by adjustment for patient characteristics and were almost eliminated by additional adjustment for receipt of therapy. Conclusions: In this study of elderly patients with AMI, admission to a teaching hospital was associated with better quality of care based on 3 of 4 quality indicators and lower mortality.

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Available from: Robert Centor, Oct 04, 2015
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    • "Magnet hospitals have shown better patient outcomes than non-Magnet hospitals (Lake et al. 2010). Teaching hospitals may provide better quality of care than non-teaching hospitals, adjusting for patient and hospital characteristics (Allison et al. 2000; Ayanian and Weissman 2002); however, teaching hospitals typically have more beds (Allison et al. 2000). Thus, teaching status and hospital size may be confounded with each other. "
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    ABSTRACT: We examined the concurrent and lagged effects of registered nurse (RN) turnover on unit-acquired pressure ulcer rates and whether RN staffing mediated the effects. Quarterly unit-level data were obtained from the National Database of Nursing Quality Indicators for 2008 to 2010. A total of 10,935 unit-quarter observations (2,294 units, 465 hospitals) were analyzed. This longitudinal study used multilevel regressions and tested time-lagged effects of study variables on outcomes. The lagged effect of RN turnover on unit-acquired pressure ulcers was significant, while there was no concurrent effect. For every 10 percentage-point increase in RN turnover in a quarter, the odds of a patient having a pressure ulcer increased by 4 percent in the next quarter. Higher RN turnover in a quarter was associated with lower RN staffing in the current and subsequent quarters. Higher RN staffing was associated with lower pressure ulcer rates, but it did not mediate the relationship between turnover and pressure ulcers. We suggest that RN turnover is an important factor that affects pressure ulcer rates and RN staffing needed for high-quality patient care. Given the high RN turnover rates, hospital and nursing administrators should prepare for its negative effect on patient outcomes.
    Health Services Research 01/2014; 49(4). DOI:10.1111/1475-6773.12158 · 2.78 Impact Factor
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    • "Several studies find significant returns to measures of hospital treatment intensity. Allison et al. (2000) find that those treated for Acute Myocardial Infarction (AMI) at teaching hospitals had roughly 10% lower mortality than those treated at non-teaching hospitals, and that this effect persisted for two years after the incident. Most recently, Romley et al. (2011) document that those treated in California hospitals with the highest end-of-life spending have much lower inpatient mortality: inpatient mortality in hospitals at the highest quintile of spending is 10-37% lower than at the lowest quintile across a range of conditions. "
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    ABSTRACT: Endogenous patient sorting across hospitals can confound performance comparisons. This paper provides a new lens to compare hospital performance for emergency patients: plausibly exogenous variation in ambulance-company assignment. Ambulances are effectively randomly assigned to patients in the same area based on rotational dispatch mechanisms. Using Medicare data from 2002-2008, we show that ambulance company assignment importantly affects hospital choice for patients in the same zip code. Using data for New York state from 2000-2006 that matches exact patient addresses to hospital discharge records, we show that patients who live very near each other but on either side of ambulance-dispatch boundaries go to different types of hospitals. Both strategies show that higher-cost hospitals have significantly lower one-year mortality rates compared to lower-cost hospitals. We find that common indicators of hospital quality, such as indicators for "appropriate care" for heart attacks, are generally not associated with better patient outcomes. On the other hand, we find that measures of "leading edge" hospitals, such as teaching hospitals and hospitals that quickly adopt the latest technologies, are associated with better outcomes, but have little impact on the estimated mortality-hospital cost relationship. We also find that hospital procedure intensity is a key determinant of the mortality-cost relationship, suggesting that treatment intensity, and not differences in quality reflected in prices, drives much of our findings. The evidence also suggests that there are diminishing returns to hospital spending and treatment intensity.Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at
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    • "For each comparison we then used a multivariable logistic regression model to adjust mortality analyses for patient demographics, severity of illness based on work by Krumholz[28], treatment according to a schema developed by Allison[24], hospital technology index, teaching status, and hospital size. We included in each analysis any additional covariant for which there had been a significant difference among our propensity-matched cohorts. "
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