Hospital teaching intensity, patient race, and surgical outcomes

Abstract

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.

Figure 1

Crude Mortality, Complications and Failure-to-Rescue in black and white patients at hospitals with high teaching intensity (RB = 0.6) versus non-teaching hospital (RB = 0). The relative differences between outcomes at hospitals with RB = 0 versus RB = 0.6 for blacks versus whites were significant at the P < 0.0007 level for death and P < 0.0004 for FTR comparisons; the relevance difference for complications failed to reach statistical significance (P = 0.498).

Figure 2

Standardized Mortality, Complications and Failure-to-Rescue in black and white patients at hospitals with high teaching intensity (RB = 0.6) versus those with low teaching intensity (RB = 0). These are directly standardized results derived from Model 1 of Table 5. The model was used to predict the outcomes of an artificial population in which the distribution of risk factors were the same for blacks and whites and for patients at teaching intensive and non-teaching hospitals. The relative differences between outcomes at hospitals with RB = 0.6 versus 0 for blacks versus whites were significant at the P < 0.0001 level for death and FTR comparisons; complications failed to reach statistical significance.