Burke Laura G, Frakt Austin B, Khullar Dhruv, Orav E John, Jha Ashish K
Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts2Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System, Boston, Massachusetts4Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts.
JAMA. 2017 May 23;317(20):2105-2113. doi: 10.1001/jama.2017.5702.
Few studies have analyzed contemporary data on outcomes at US teaching hospitals vs nonteaching hospitals.
To examine risk-adjusted outcomes for patients admitted to teaching vs nonteaching hospitals across a broad range of medical and surgical conditions.
DESIGN, SETTING, AND PARTICIPANTS: Use of national Medicare data to compare mortality rates in US teaching and nonteaching hospitals for all hospitalizations and for common medical and surgical conditions among Medicare beneficiaries 65 years and older.
Hospital teaching status: major teaching hospitals (members of the Council of Teaching Hospitals), minor teaching hospitals (other hospitals with medical school affiliation), and nonteaching hospitals (remaining hospitals).
Primary outcome was 30-day mortality rate for all hospitalizations and for 15 common medical and 6 surgical conditions. Secondary outcomes included 30-day mortality stratified by hospital size and 7-day mortality and 90-day mortality for all hospitalizations as well as for individual medical and surgical conditions.
The sample consisted of 21 451 824 total hospitalizations at 4483 hospitals, of which 250 (5.6%) were major teaching, 894 (19.9%) were minor teaching, and 3339 (74.3%) were nonteaching hospitals. Unadjusted 30-day mortality was 8.1% at major teaching hospitals, 9.2% at minor teaching hospitals, and 9.6% at nonteaching hospitals, with a 1.5% (95% CI, 1.3%-1.7%; P < .001) mortality difference between major teaching hospitals and nonteaching hospitals. After adjusting for patient and hospital characteristics, the same pattern persisted (8.3% mortality at major teaching vs 9.2% at minor teaching and 9.5% at nonteaching), but the difference in mortality between major and nonteaching hospitals was smaller (1.2% [95% CI, 1.0%-1.4%]; P < .001). After stratifying by hospital size, 187 large (≥400 beds) major teaching hospitals had lower adjusted overall 30-day mortality relative to 76 large nonteaching hospitals (8.1% vs 9.4%; 1.2% difference [95% CI, 0.9%-1.5%]; P < .001). This same pattern of lower overall 30-day mortality at teaching hospitals was observed for medium-sized (100-399 beds) hospitals (8.6% vs 9.3% and 9.4%; 0.8% difference between 61 major and 1207 nonteaching hospitals [95% CI, 0.4%-1.3%]; P = .003). Among small (≤99 beds) hospitals, 187 minor teaching hospitals had lower overall 30-day mortality relative to 2056 nonteaching hospitals (9.5% vs 9.9%; 0.4% difference [95% CI, 0.1%-0.7%]; P = .01).
Among hospitalizations for US Medicare beneficiaries, major teaching hospital status was associated with lower mortality rates for common conditions compared with nonteaching hospitals. Further study is needed to understand the reasons for these differences.
很少有研究分析美国教学医院与非教学医院的当代结局数据。
研究在广泛的内科和外科疾病中，入住教学医院与非教学医院患者的风险调整后结局。
设计、背景和参与者：利用国家医疗保险数据，比较美国教学医院和非教学医院中65岁及以上医疗保险受益人的所有住院治疗以及常见内科和外科疾病的死亡率。
医院教学状况：主要教学医院（教学医院理事会成员）、次要教学医院（其他附属于医学院的医院）和非教学医院（其余医院）。
主要结局是所有住院治疗以及15种常见内科疾病和6种外科疾病的30天死亡率。次要结局包括按医院规模分层的30天死亡率、所有住院治疗以及个别内科和外科疾病的7天死亡率和90天死亡率。
样本包括4483家医院的21451824次住院治疗，其中250家（5.6%）是主要教学医院，894家（19.9%）是次要教学医院，3339家（74.3%）是非教学医院。主要教学医院未调整的30天死亡率为8.1%，次要教学医院为9.2%，非教学医院为9.6%，主要教学医院与非教学医院之间的死亡率差异为1.5%（95%CI，1.3%-1.7%；P＜0.001）。在对患者和医院特征进行调整后，相同的模式仍然存在（主要教学医院死亡率为8.3%，次要教学医院为9.2%，非教学医院为9.5%），但主要教学医院与非教学医院之间的死亡率差异较小（1.2%[95%CI，1.0%-1.4%]；P＜0.001）。按医院规模分层后，187家大型（≥400张床位）主要教学医院相对于76家大型非教学医院调整后的总体30天死亡率较低（8.1%对9.4%；差异1.2%[95%CI，0.9%-1.5%]；P＜0.001）。在中型（100-399张床位）医院中也观察到教学医院总体30天死亡率较低的相同模式（61家主要教学医院与1207家非教学医院相比，分别为8.6%对9.3%和9.4%；差异0.8%[95%CI，0.4%-1.3%]；P = 0.003）。在小型（≤99张床位）医院中，187家次要教学医院相对于2056家非教学医院的总体30天死亡率较低（9.5%对9.9%；差异0.4%[95%CI，0.1%-0.7%]；P = 0.01）。
在美国医疗保险受益人的住院治疗中，主要教学医院状况与常见疾病的较低死亡率相关。需要进一步研究以了解这些差异的原因。
