Association of Hospital Teaching Status with Neurosurgical Outcomes: An Instrumental Variable Analysis

Bekelis, Kimon; Missios, Symeon; Coy, Shannon; MacKenzie, Todd A.

doi:10.1016/j.wneu.2017.11.071

Cited by 11 publications

(7 citation statements)

References 39 publications

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“…However, this was done in only one study in this review, 44 probably because of the approach's technical complexity. A much less complex approach involves the use of instrumental variables 43 . Use of IVs is much more straightforward computationally, but IVs are only valid under specific circumstances.…”

Section: Discussionmentioning

confidence: 99%

“…In analysis of neurosurgery outcomes, Bekelis et al. reported higher rates of discharge to (nonhospital) facilities from major teaching hospitals 43 . In Pradarelli et al.’s analysis of hospitalizations for abdominal aortic aneurysm (AAA) repair, pulmonary resection, or colectomy—all three high‐risk procedures—complication rates were more common in very major than in nonteaching hospitals, but the former had higher rates of rescue from these complications, which led to lower 30‐day (post‐discharge) mortality 50 .…”

Section: Discussionmentioning

confidence: 99%

“…In analysis of neurosurgery outcomes, Bekelis et al reported higher rates of discharge to (nonhospital) facilities from major teaching hospitals. 43 In Pradarelli et al's analysis of hospitalizations for abdominal aortic aneurysm (AAA) repair, pulmonary resection, or colectomy-all three high-risk procedures-complication rates were more common in very major than in nonteaching hospitals, but the former had higher rates of rescue from these complications, which led to lower 30-day (post-discharge) mortality. 50 All analyses in the Pradarelli et al study included binary explanatory variables for basic demographic characteristics, 29 Elixhauser comorbid diseases, procedure year, and surgical approach (e.g., open versus minimally invasive).…”

Section: Discussionmentioning

confidence: 99%

“…Only one published study measuring effects of hospital teaching status on outcomes, Bekelis et al., 43 used an instrumental variable (IV) to deal with endogeneity of teaching. Endogeneity may arise in this context if patients with certain unspecified attributes such as poor health on dimensions not explicitly known by and/or considered by the analyst lead patients to select one type of hospital over another.…”

Section: Qualitymentioning

confidence: 99%

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Quality and Cost of Care by Hospital Teaching Status: What Are the Differences?

Sloan

2021

Milbank Quarterly

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In two respects, quality of care tends to be higher at major teaching hospitals: process of care and long‐term survival of cancer patients following initial diagnosis. There is also evidence that short‐term (30‐day) mortality is lower on average at such hospitals, although the quality of evidence is somewhat lower. Quality of care is mulitdimensional. Empirical evidence by teaching status on dimensions other than survival is mixed. Higher Medicare payments for care provided by major teaching hospitals are partially offset by lower payments to nonhospital providers. Nevertheless, the payment differences between major teaching and nonteaching hospitals for hospital stays, especially for complex cases, potentially increase prices other insurers pay for hospital care. Context The relative performance of teaching hospitals has been discussed for decades. For private and public insurers with provider networks, an issue is whether having a major teaching hospital in the network is a “must.” For traditional fee‐for‐service Medicare, there is an issue of adequacy of payment of hospitals with various attributes, including graduate medical education (GME) provision. Much empirical evidence on relative quality and cost has been published. This paper aims to (1) evaluate empirical evidence on relative quality and cost of teaching hospitals and (2) assess what the findings indicate for public and private insurer policy. Methods Complementary approaches were used to select studies for review. (1) Relevant studies highly cited in Web of Science were selected. (2) This search led to studies cited by these studies as well as studies that cited these studies. (3) Several literature reviews were helpful in locating pertinent studies. Some policy‐oriented papers were found in Google under topics to which the policy applied. (4) Several papers were added based on suggestions of reviewers. Findings Quality of care as measured in process of care studies and in longitudinal studies of long‐term survival of cancer patients tends to be higher at major teaching hospitals. Evidence on survival at 30 days post admission for common conditions and procedures also tends to favor such hospitals. Findings on other dimensions of relative quality are mixed. Hospitals with a substantial commitment to graduate medical education, major teaching hospitals, are about 10% to 20% more costly than nonteaching hospitals. Private insurers pay a differential to major teaching hospitals at this range's lower end. Inclusive of subsidies, Medicare pays major teaching hospitals substantially more than 20% extra, especially for complex surgical procedures. Conclusions Based on the evidence on quality, there is reason for patients to be willing to pay more for inclusion of major teaching hospitals in private insurer networks at least for some services. Medicare payment for GME has long been a controversial policy issue. The actual indirect cost of GME is likely to be far less than the amount Medicare is currently paying hospitals.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Qualitymentioning

confidence: 99%

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Quality and Cost of Care by Hospital Teaching Status: What Are the Differences?

Sloan

2021

Milbank Quarterly

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“…We [14] used the method of instrumental variables to estimate the effect of teaching vs nonteaching hospitals on outcomes in 186,483 patients from New York undergoing spine and cranial operations. They used a continuously valued geographic instrument; the proportion in each of the 62 counties of New York of surgical patients who received their surgery at a teaching hospital.…”

Section: Methodsmentioning

confidence: 99%

Reporting of Baseline Characteristics to Accompany Analysis by Instrumental Variables

2018

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A property and criticism of instrumental variable (IV) estimators is that they estimate the exposure effect in the compliers, individuals whose exposure is influenced by the instrument. It is conceivable that the exposure effect is different in individuals whose exposure is not influenced by the instrument. For that reason, it is useful to know who the compliers are. We present methods for reporting averages and other statistics and comparing them between the compliers and noncompliers, which are applicable to scenarios in which the instrument and exposure are fixed in time and dichotomous. The methods are illustrated in a comparison of outcomes between teaching and nonteaching hospitals in patients undergoing brain or spinal surgery.

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Erfassung der Versorgungsqualität und Realität

Grundmann

Debus

2020

Versorgungsqualität in Der Operativen Medizin

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Association of Hospital Teaching Status with Neurosurgical Outcomes: An Instrumental Variable Analysis

Cited by 11 publications

References 39 publications

Quality and Cost of Care by Hospital Teaching Status: What Are the Differences?

Quality and Cost of Care by Hospital Teaching Status: What Are the Differences?

Reporting of Baseline Characteristics to Accompany Analysis by Instrumental Variables

Erfassung der Versorgungsqualität und Realität

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