Comparing Outcomes and Costs of Medical Patients Treated at Major Teaching and Non-teaching Hospitals: A National Matched Analysis

Silber, Jeffrey H.; Rosenbaum, Paul R.; Niknam, Bijan A.; Ross, Richard N.; Reiter, Joseph G; Hill, Alexander S.; Hochman, Lauren L.; Brown, Sydney E. S.; Arriaga, Alexander F.; Fleisher, Lee A.

doi:10.1007/s11606-019-05449-x

Cited by 39 publications

(64 citation statements)

References 44 publications

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“…No explanation was provided for why small hospitals had better survival experiences than medium‐size hospitals. Teaching hospitals’ better performance in treating pneumonia is consistent with Silber et al.’s finding 36 in spite of the appreciable differences in study methods, sample, and follow‐up periods.…”

Section: Qualitysupporting

confidence: 84%

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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: Qualitysupporting

confidence: 84%

“…or Taylor et al., Silber et al. assessed mortality 30 days post admission for AMI, CHF, and pneumonia using Medicare claims data 36 . Since the study relied on Medicare claims data, risk adjustment was probably less precise than in studies that supplemented claims with medical records abstraction or household survey data.…”

Section: Qualitymentioning

confidence: 99%

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

Sloan

2021

Milbank Quarterly

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“…A recent study found good value among major teaching hospitals by demonstrating lower mortality at slightly higher cost for medical patients in teaching hospitals as compared with similar patients in non-teaching hospitals. 1 Only 13% of US hospitals are major teaching hospitals with medical residents. 1 In contrast, every hospital employs nurses, yet we know little about the comparative value of investments in nursing resources, which are undertaken to different extents by all hospitals.…”

Section: Introductionmentioning

confidence: 99%

“…1 Only 13% of US hospitals are major teaching hospitals with medical residents. 1 In contrast, every hospital employs nurses, yet we know little about the comparative value of investments in nursing resources, which are undertaken to different extents by all hospitals. In this study, we examine hospitals that have made substantial versus limited investments in nursing, comparing the costs of those investments relative to the outcomes for medical patients.…”

Section: Introductionmentioning

confidence: 99%

Evaluating the Costs and Outcomes of Hospital Nursing Resources: a Matched Cohort Study of Patients with Common Medical Conditions

et al. 2020

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BACKGROUND: Nursing resources, such as staffing ratios and skill mix, vary across hospitals. Better nursing resources have been linked to better patient outcomes but are assumed to increase costs. The value of investments in nursing resources, in terms of clinical benefits relative to costs, is unclear. OBJECTIVE: To determine whether there are differential clinical outcomes, costs, and value among medical patients at hospitals characterized by better or worse nursing resources. DESIGN: Matched cohort study of patients in 306 acute care hospitals. PATIENTS: A total of 74,045 matched pairs of fee-forservice Medicare beneficiaries admitted for common medical conditions (25,446 sepsis pairs; 16,332 congestive heart failure pairs; 12,811 pneumonia pairs; 10,598 stroke pairs; 8858 acute myocardial infarction pairs). Patients were also matched on hospital size, technology, and teaching status. MAIN MEASURES: Better (n = 76) and worse (n = 230) nursing resourced hospitals were defined by patient-tonurse ratios, skill mix, proportions of bachelors-degree nurses, and nurse work environments. Outcomes included 30-day mortality, readmission, and resource utilization-based costs. KEY RESULTS: Patients in hospitals with better nursing resources had significantly lower 30-day mortality (16.1% vs 17.1%, p < 0.0001) and fewer readmissions (32.3% vs 33.6%, p < 0.0001) yet costs were not significantly different ($18,848 vs 18,671, p = 0.133). The greatest outcomes and cost advantage of better nursing resourced hospitals were in patients with sepsis who had lower mortality (25.3% vs 27.6%, p < 0.0001). Overall, patients with the highest risk of mortality on admission experienced the greatest reductions in mortality and readmission from better nursing at no difference in cost. CONCLUSIONS: Medicare beneficiaries with common medical conditions admitted to hospitals with better nursing resources experienced more favorable outcomes at almost no difference in cost.

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“…This finding was replicated in specialty-specific studies focusing primarily on general surgery admissions, vascular surgery admissions, acute myocardial infarction, heart failure, and pneumonia. [32,33] These studies also found significant reductions in re-admissions and ICU utilization, but length of stay was marginally longer, resulting in an estimate that total admission cost was increased by 427 USD for each 1% mortality improvement in a teaching hospital [33]. The authors of that study concluded that the effort of teaching returns excellent value for the extra resources utilized [32,33].…”

Section: Cost Reduction With Improved Patient Outcomesmentioning

confidence: 98%

Benefits of developing graduate medical education programs in community health systems

Alweis

Donato

Terry

et al. 2021

Journal of Community Hospital Internal Medicine Perspectives

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The creation of new CMS-funded Graduate Medical Education (GME) cap positions by the Consolidated Appropriations Act 2021 offers a unique opportunity for systems in community and rural settings to develop and expand their training programs. This article provides a review of the evidence behind the value proposition for system administrators to foster the growth of GME in community health systems. The infrastructure needed to accredit GME programs may reduce the cost of care for both the patients and the system through improved patient outcomes and facilitation of system efforts to recognize and mitigate social determinants of health. Residents, fellows and medical students expand the capacity of the current healthcare workforce of a system by providing coverage during healthcare emergencies and staffing services in difficult-to-recruit specialties. Those trainees are the nucleus of succession planning for the current medical staff, can facilitate the creation and expansion of service lines, and may elevate the profile of the system through scholarly work and equity and quality improvement activities. While creating GME programs in a community health system may, at first glance, be perceived as cost-prohibitive, there are robust advantages to a system for their creation.

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Comparing Outcomes and Costs of Medical Patients Treated at Major Teaching and Non-teaching Hospitals: A National Matched Analysis

Cited by 39 publications

References 44 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?

Evaluating the Costs and Outcomes of Hospital Nursing Resources: a Matched Cohort Study of Patients with Common Medical Conditions

Benefits of developing graduate medical education programs in community health systems

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