May 25, 2017

Teaching hospitals may cost more—but their Medicare patients are less likely to die, study finds

Daily Briefing

    Teaching hospitals have a lower 30-day mortality rate for older patients than community hospitals, challenging some insurers' belief that teaching hospitals charge more for care without providing better results, according to a new study in JAMA.

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    Teaching hospitals are typically considered more costly than community hospitals, the researchers wrote. In turn, some insurers have excluded major teaching hospitals from their coverage network as a means of cost control—under the assumption that community hospitals and teaching hospitals are comparable in quality.

    Methods

    For the study, the researchers looked at records on 21.4 million hospitalizations of Medicare beneficiaries at 4,483 hospitals throughout the country. The sample included:

    • 250 major teaching hospitals;
    • 894 minor teaching hospitals; and
    • 3,339 community hospitals.

    Key findings

    After accounting for differences in patient and hospital characteristics, the researchers found that:

    • Major teaching hospitals had an adjusted 30-day patient mortality rate of 8.3 percent;
    • Minor teaching hospitals had an adjusted 30-day patient mortality rate of 9.2 percent; and
    • Community hospitals had an adjusted 30-day patient mortality rate of 9.5 percent.  

    The researchers observed similar results when it came to seven-day and 90-day mortality rates, STAT News reports. Moreover, when the researchers dug into the data to assess specific conditions and surgical procedures, they found similar results: Major teaching hospitals had lower 90-day morality rates than community hospitals for 13 out of 15 common conditions and two out of six surgical procedures.

    When the researchers looked at hospital size, they found that teaching hospitals had lower mortality 30-day rates than non-teaching hospitals among large facilities—those with at least 400 beds—and medium facilities—those with 100 to 399 beds. Among small facilities—those with fewer than 100 beds—minor teaching hospitals had lower mortality rates than non-teaching hospitals.

    Discussion

    The study looked only at data from Medicare beneficiaries, so it's unclear whether the findings apply to younger patients, according to the researchers. James Robinson—a health economist at the University of California, Berkeley, who was not involved with the study—pointed out that mortality might not be as strong of a quality measure for younger patients, who are less likely to die overall and more likely to go to the hospital for services such as delivery or gall bladder removal.

    Laura Burke, one of the study's authors and an instructor at the Harvard T.H. Chan School of Public Health, also argued that while "teaching hospitals are largely considered to be more expensive," overall cost considerations need to take "into account [patient] outcomes." She said that while the study did not explore the reason for the difference in mortality rates—an area the researchers plan to assess in a follow-up study—"excluding teaching hospitals ... could have some implications for quality."

    A spokesperson for America's Health Insurance Plans in an email to STAT News declined to discuss the study specifically, but she said that "health plans focus on building innovative, high quality, and cost-effective networks that best serve the varying needs of their customers, including academic and non-academic hospitals" (Punke, Becker's Infection Control & Clinical Quality, 5/23; Rapaport, Reuters, 5/23; Joseph, STAT News, 5/23; Lagasse, Healthcare Finance News, 5/23; Burke et al., JAMA, 5/23).

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    Electronic medical records (EMR) have a role to play in mortality reduction. Computerized practitioner order entry (CPOE) and electronic order sets are the key EMR capabilities that can help reduce hospital mortality, but changes in process, culture, and individual behavior are also necessary.

    In this report, we present six hospital case studies to illustrate the impact of EMR on mortality, identify the mechanisms by which EMRs could help reduce hospital mortality, and zero in on the specific functionality that might have the greatest impact.

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