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Comparing Outcomes and Costs of Surgical Patients Treated at Major Teaching and Nonteaching Hospitals

A National Matched Analysis

Silber, Jeffrey H. MD, PhD*,†,‡,§,¶; Rosenbaum, Paul R. PhD¶,||; Niknam, Bijan A. BS*; Ross, Richard N. MS*; Reiter, Joseph G. MS*; Hill, Alexander S. BS*; Hochman, Lauren L. BA*; Brown, Sydney E. MD, PhD; Arriaga, Alexander F. MD, MPH, ScD‡,**,††; Kelz, Rachel R. MD, MSCE¶,‡‡; Fleisher, Lee A. MD‡,¶,††

doi: 10.1097/SLA.0000000000003602
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Objective: To compare outcomes and costs between major teaching and nonteaching hospitals on a national scale by closely matching on patient procedures and characteristics.

Background: Teaching hospitals have been shown to often have better quality than nonteaching hospitals, but cost and value associated with teaching hospitals remains unclear.

Methods: A study of Medicare patients at 340 teaching hospitals (resident-to-bed ratios ≥ 0.25) and matched patient controls from 2444 nonteaching hospitals (resident-to-bed ratios < 0.05).

We studied 86,751 pairs admitted for general surgery (GS), 214,302 pairs of patients admitted for orthopedic surgery, and 52,025 pairs of patients admitted for vascular surgery.

Results: In GS, mortality was 4.62% in teaching hospitals versus 5.57%, (a difference of −0.95%, <0.0001), and overall paired cost difference = $915 (P < 0.0001). For the GS quintile of pairs with highest risk on admission, mortality differences were larger (15.94% versus 18.18%, difference = −2.24%, P < 0.0001), and paired cost difference = $3773 (P < 0.0001), yielding $1682 per 1% mortality improvement at 30 days. Patterns for vascular surgery outcomes resembled general surgery; however, orthopedics outcomes did not show significant differences in mortality across teaching and nonteaching environments, though costs were higher at teaching hospitals.

Conclusions: Among Medicare patients, as admission risk of mortality increased, the absolute mortality benefit of treatment at teaching hospitals also increased, though accompanied by marginally higher cost. Major teaching hospitals appear to return good value for the extra resources used in general surgery, and to some extent vascular surgery, but this was not apparent in orthopedic surgery.

*Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA

Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA

Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA

§Department of Health Care Management, The Wharton School, The University of Pennsylvania, Philadelphia, PA

The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA

||Department of Statistics, The Wharton School, The University of Pennsylvania, Philadelphia, PA

**Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, MA

††Center for Perioperative Outcomes Research and Transformation, The University of Pennsylvania, Philadelphia, PA

‡‡Department of Surgery, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

silber@email.chop.edu.

Reprints will not be available from the authors.

This research was funded by a grant from the Association of American Medical Colleges (AAMC).

The authors report no conflicts of interest.

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