Survival after surgery appears higher at teaching hospitals than at non-teaching hospitals, but this benefit is experienced by white patients and not black patients, according to a report in the February issue of Archives of Surgery, one of the JAMA/Archives journals. While the teaching versus non-teaching setting was not associated with different rates of complications for either white or black patients, whites are less likely to die following complications at teaching hospitals, a survival benefit not seen for black patients.
Outcomes are generally better in hospitals with higher teaching intensity, but prior to this study it was unclear how this benefit was achieved, according to background information in the article. Lower death rates at teaching hospitals might result from preventing complications or preventing death after complications (preventing a failure-to-rescue). "While teaching hospitals are generally larger and have more advanced technology, greater volume and better nurse staffing (attributes that may aid in both preventing complications and successfully treating complications), it is by no means clear whether all patients benefit equally from these attributes," the authors write.
Jeffrey H. Silber, M.D., Ph.D., and colleagues from the Center for Outcomes Research at The Children's Hospital of Philadelphia and the University of Pennsylvania, analyzed Medicare claims from 4,658,954 patients ages 65 to 90 who underwent general, orthopedic or vascular surgery at 3,270 acute care hospitals in the United States between 2000 and 2005. They compared rates of death within 30 days, in-hospital complications and the probability of death following complications between hospitals based on teaching intensity (defined as the number of resident physicians per hospital bed). Among all hospitals and all surgical procedures combined, the overall 30-day mortality rate was 4.23 percent, complication rate was 43.39 percent and rate of death occurring after complications was 9.75 percent.
"Combining all surgeries, compared with non-teaching hospitals, patients at very major teaching hospitals demonstrated a 15 percent lower odds of death, no difference in complications and a 15 percent lower odds of death after complications (failure to rescue)," the authors write. The associations were adjusted for patient illness on admission and did not change even when the researchers considered income, suggesting that the differences in death after complications is not due to unequal access to teaching hospitals between patients in different economic classes.
However, the survival benefits associated with teaching intensive hospitals were not experienced by black patients, who had similar odds of death, complication and failure-to-rescue at teaching and non-teaching hospitals. Furthermore, such differences were apparent even when analyses compared white and black patients inside the same hospital. There are several possible reasons for this disparity, the authors note.
One previous study reported black patients experienced longer delays before beginning defibrillation than white patients, suggesting potential differences in levels of monitoring. "Unintentional differences in communication might lead to less appropriate or less accurate monitoring of black patients or less involvement in their care by personnel who could make a difference in reducing failure to rescue," the authors write. There could also be varying levels of involvement by physicians-in-training in the care of patients in different racial groups, they note.
This work was funded through grants from the National Heart, Lung, and Blood Institute, Department of Veterans Affairs and National Science Foundation.
- Silber et al. Hospital Teaching Intensity, Patient Race, and Surgical Outcomes. Arch Surg., 2009; 144 (2): 113-120 [link]
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