Department of Internal Medicine, Dell Medical School at The University of Texas at Austin.
Department of Medicine and Graduate Medical Education, University of Chicago, Chicago, Illinois.
JAMA Intern Med. 2018 Jan 1;178(1):39-47. doi: 10.1001/jamainternmed.2017.6032.
Robust laboratory use data are lacking to support the general assumption that teaching hospitals with trainees routinely order more laboratory tests for inpatients than do nonteaching hospitals.
To quantify differences in the use of laboratory tests between teaching and nonteaching hospitals.
DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study was performed using a statewide database to identify hospitalizations with a primary diagnosis of bacterial pneumonia or cellulitis from January 1, 2014, to June 30, 2015, at teaching and nonteaching hospitals with 100 or more hospitalizations of each condition. Patients included were adult inpatients with a primary diagnosis of bacterial pneumonia (n = 24 118) or cellulitis (n = 19 211); patients excluded were those with an intensive care unit stay, transfer from another hospital, or a length of stay that was 2 SDs or more of the condition's mean length of stay.
Mean laboratory tests per day stratified by illness severity, as well as factors associated with laboratory use rates.
A total of 43 329 hospitalized patients (20493 women and 22836 men) had a principal diagnosis of bacterial pneumonia or cellulitis across 11 major teaching hospitals, 12 minor teaching hospitals, and 73 nonteaching hospitals in Texas. Mean number of laboratory tests per day varied significantly by hospital type and was highest for major teaching hospitals for both conditions (bacterial pneumonia: major teaching hospitals, 13.21; 95% CI, 12.91-13.51; nonteaching hospitals, 8.92; 95% CI, 8.84-9.00; P < .001; cellulitis: major teaching hospitals, 10.43; 95% CI, 10.16-10.70; nonteaching hospitals, 7.29; 95% CI, 7.22-7.36; P < .001). This association held for all levels of illness severity for both conditions, except for patients with cellulitis with the highest illness severity level. In generalized mixed linear regression models, controlling for additional patient and encounter covariates, there was a significant difference in the marginal effect of hospital teaching status on mean number of laboratory tests per day between major teaching and nonteaching hospitals (difference in marginal mean laboratory tests per day for bacterial pneumonia, 3.58; 95% CI, 2.61-4.55; P < .001; for cellulitis, 2.61; 95% CI, 1.76-3.47; P < .001).
Compared with nonteaching hospitals, patients in Texas admitted to major teaching hospitals with bacterial pneumonia or cellulitis received significantly more laboratory tests after controlling for illness severity, length of stay, and patient demographics. These results support the need to examine how the culture of training environments may contribute to increased use of laboratory tests.
缺乏强有力的实验室使用数据来支持这样一种普遍假设，即有培训生的教学医院通常比非教学医院为住院患者常规开更多的实验室检查。
量化教学医院和非教学医院之间实验室检查使用的差异。
设计、设置和参与者：使用全州范围内的数据库进行了一项横断面研究，以确定从 2014 年 1 月 1 日至 2015 年 6 月 30 日因细菌性肺炎或蜂窝织炎的主要诊断而住院的患者，包括在每个条件下有 100 例或更多住院患者的教学医院和非教学医院。纳入的患者为主要诊断为细菌性肺炎（n=24118）或蜂窝织炎（n=19211）的成年住院患者；排除的患者为在重症监护病房住院、从其他医院转来或住院时间比该疾病平均住院时间长 2 个标准差或更长时间的患者。
根据疾病严重程度分层的每天平均实验室检查数量，以及与实验室使用率相关的因素。
在德克萨斯州的 11 所主要教学医院、12 所次要教学医院和 73 所非教学医院中，共有 43329 名患有细菌性肺炎或蜂窝织炎的住院患者（20493 名女性和 22836 名男性）。每天的实验室检查数量因医院类型而有显著差异，对于两种疾病来说，主要教学医院的数量最高（细菌性肺炎：主要教学医院，13.21；95%CI，12.91-13.51；非教学医院，8.92；95%CI，8.84-9.00；P<0.001；蜂窝织炎：主要教学医院，10.43；95%CI，10.16-10.70；非教学医院，7.29；95%CI，7.22-7.36；P<0.001）。这种关联在两种疾病的所有严重程度水平上都成立，但对于蜂窝织炎中最严重疾病程度水平的患者除外。在广义混合线性回归模型中，控制其他患者和就诊协变量后，主要教学医院和非教学医院之间每天实验室检查的平均数量存在教学医院状态的边际效应的显著差异（细菌性肺炎的每日平均实验室检查的边际差异，3.58；95%CI，2.61-4.55；P<0.001；蜂窝织炎，2.61；95%CI，1.76-3.47；P<0.001）。
与非教学医院相比，在控制疾病严重程度、住院时间和患者人口统计学因素后，在德克萨斯州因细菌性肺炎或蜂窝织炎而住院的主要教学医院的患者接受的实验室检查明显更多。这些结果支持需要检查培训环境的文化如何导致实验室检查使用的增加。
