Effects of admission to a teaching hospital on the cost and quality of care for Medicare beneficiaries

A pilot study assessing the influences of charge data and group process on diagnostic test ordering by residents

PURPOSE

Providing charge data to resident physicians has been shown to reduce the amounts spent on diagnostic testing. This pilot study sought to determine the influences of charge data and group decision making on diagnostic test ordering by internal medicine residents.

METHOD

In an interactive workshop, 23 internal medicine residents received a hypothetical case. They completed an 18-item questionnaire estimating charges for diagnostic tests and then "ordered" tests. The residents were then randomly divided into groups that either received charge data, received charge data after ordering tests, or received no charge data. The groups ordered tests by consensus. Tests were weighted for appropriateness (+1 to +6) and inappropriateness (-1 to -6). Analyses compared individual and group decisions and effect of availability of charge data.

RESULTS

Residents with access to charge data spent less on tests, but also had lower appropriateness scores. The appropriateness of the diagnostic workup was better by groups than by individuals, but cost more.

CONCLUSION

Cost-containment interventions targeted towards doctors in training need to address the effect on quality of care and the influence of the group process in clinical decision making. Group diagnostic decisions may be more costly, but more appropriate.

Hospital ownership and preventable adverse events

To determine whether hospital ownership was associated with preventable adverse events, the authors reviewed the medical records of a random sample of 15,000 hospitalizations in Utah and Colorado in 1992. Hospitals were categorized as nonprofit, for-profit, major teaching government (e.g., county, state ownership), and minor or nonteaching government. Multivariate analyses adjusting for other patient and hospital characteristics found that, when compared with patients in nonprofit hospitals, patients in minor or nonteaching government hospitals were more likely to suffer a preventable adverse event of any type (odds ratio (OR), 2.46; 95 percent confidence interval (95% CI), 1.45 to 4.20); preventable operative adverse events (OR, 4.85; 95% CI, 2.44 to 9.62); and preventable adverse events due to delayed diagnoses and therapies (OR, 4.27; 95% CI, 1.48 to 12.31). Patients in for-profit hospitals were also more likely to suffer preventable adverse events of any type (OR, 1.57; 95% CI, 1.03 to 2.38); preventable operative adverse events (OR, 2.63; 95% CI, 1.42 to 4.87); and preventable adverse events due to delayed diagnoses and therapies (OR, 4.15; 95% CI, 1.84 to 9.34). Patients in major teaching government hospitals were less likely to suffer preventable adverse drug events (OR, 0.38; 95% CI, 0.16 to 0.89).

The cost of teaching total knee arthroplasty surgery to orthopaedic surgery residents

The higher costs associated with teaching hospitals have received some attention in the literature. The objective of the current study was to determine the increase in resource consumption associated with resident education in knee arthroplasty surgery. Seventy-four patients who underwent primary total knee arthroplasty in the same hospital were studied (50 private practice and 24 teaching practice). Time in the operating room and medical severity of illness were noted. Hospital charges were used as a measure of resource consumption. In addition, length of stay and in-hospital consultations and complications were observed. Kruskall-Wallis, chi square, and stepwise multiple regression analysis were performed. The mean age of the patients was 68 years. Patients who underwent surgery at the teaching service had higher charges ($30,311 +/- $3,325 versus $23,116 +/- $3,341) and longer times in the operating room (190 +/- 19 minutes versus 145 +/- 29 minutes). These patients also had a trend toward more associated comorbid medical conditions (0.71 versus 0.42). Stepwise multiple regression analysis showed that teaching was the most important predictor of charges and operating room time. The results show a 22% increase in perioperative resource consumption for patients who underwent surgery at a teaching service. The measured increase in cost is significantly lower than what has been reported in other series (82%). At the teaching institution, the anesthesia and orthopaedic surgery residents work together on all cases and perform a significant percent of the procedures under direct supervision. The increased resource consumption observed in a teaching service is most likely attributable to the hands-on approach taken to train residents.

Impact of facility size and profit status on intermediate outcomes in chronic dialysis patients

Little information is available regarding the influence of dialysis facility size or profit status on intermediate outcomes in chronic dialysis patients. We have combined data from the Health Care Financing Administration (HCFA) Core Indicators Project; the end-stage renal disease (ESRD) facility survey; and the HCFA On-Line Survey, Certification, and Reporting System to analyze trends in this area. For hemodialysis patients, larger facilities were more likely than smaller facilities to perform dialysis on patients who were younger than 65 years of age, black, or undergoing dialysis 2 years or more (P < 0.001). Nonprofit facilities were more likely to perform dialysis on patients with diabetes mellitus as a cause of ESRD and less likely to perform dialysis on patients with hypertension as a cause of ESRD compared with for-profit units (P < 0.05). By multivariate analysis, larger facility size was modestly associated with a greater Kt/V value and urea reduction ratio, but not with hematocrit or serum albumin values. Facility profit status was not associated with these intermediate outcomes. For peritoneal dialysis patients, there were no significant differences in patient demographics based on facility size. More patients in nonprofit units had been undergoing dialysis 2 or more years than patients in for-profit units (P < 0.05). By univariate analysis, patients in larger facilities were more likely to have an adequacy measure performed than patients from smaller facilities (P < 0.05). There were few substantial differences in intermediate outcomes in chronic dialysis patients based on facility size or profit status.

Results of report cards for patients with congestive heart failure depend on the method used to adjust for severity

BACKGROUND

The validity of outcome report cards may depend on the ways in which they are adjusted for risk.

OBJECTIVES

To compare the predictive ability of generic and disease-specific survival prediction models appropriate for use in patients with heart failure, to simulate outcome report cards by comparing survival across hospitals and adjusting for severity of illness using these models, and to assess the ways in which the results of these comparisons depend on the adjustment method.

DESIGN

Analysis of data from a prospective cohort study.

SETTING

A university hospital, a Veterans Affairs (VA) medical center, and a community hospital.

PATIENTS

Sequential patients presenting in the emergency department with acute congestive heart failure.

MEASUREMENTS

Unadjusted 30-day and 1-year mortality across hospitals and 30-day and 1-year mortality adjusted by using disease-specific survival prediction models (two sickness-at-admission models, the Cleveland Health Quality Choice model, the Congestive Heart Failure Mortality Time-Independent Predictive Instrument) and generic models (Acute Physiology and Chronic Health Evaluation [APACHE] II, APACHE III, the mortality prediction model, and the Chadson comorbidity index).

RESULTS

The community hospital's unadjusted 30-day survival rate (85.0%) and the VA medical center's unadjusted 1-year survival rate (60.9%) were significantly lower than corresponding rates at the university hospital (92.7% and 67.5%, respectively). No severity model had excellent ability to discriminate patients by survival rates (all areas under the receiver-operating characteristic curve < 0.73). Whether the VA medical center, the community hospital, both, or neither had worse survival rates on simulated report cards than the university hospital depended on the prediction model used for adjustment.

CONCLUSIONS

Results of simulated outcome report cards for survival in patients with congestive heart failure depend on the method used to adjust for severity.

Hospital ownership and preventable adverse events

OBJECTIVE

To determine if type of hospital ownership is associated with preventable adverse events.

DESIGN

Medical record review of a random sample of 15,000 nonpsychiatric, non-Veterans Administration hospital discharges in Utah and Colorado in 1992.

MEASUREMENTS AND MAIN RESULTS

A two-stage record review process using nurse and physician reviewers was used to detect adverse events. Preventability was then judged by 2 study investigators who were blinded to hospital characteristics. The association among preventable adverse events and hospital ownership was evaluated using logistic regression with nonprofit hospitals as the reference group while controlling for other patient and hospital characteristics. We analyzed 4 hospital ownership categories: nonprofit, for-profit, major teaching government (e.g., county or state ownership), and minor or nonteaching government.

RESULTS

When compared with patients in nonprofit hospitals, multivariate analyses adjusting for other patient and hospital characteristics found that patients in minor or nonteaching government hospitals were more likely to suffer a preventable adverse event of any type (odds ratio [OR] 2.46; 95% confidence interval [CI], 1.45 to 4.20); preventable operative adverse events (OR, 4.85; 95% CI, 2.44 to 9.62); and preventable adverse events due to delayed diagnoses and therapies (OR, 4.27; 95% CI, 1.48 to 12.31). Patients in for-profit hospitals were also more likely to suffer preventable adverse events of any type (OR, 1.57; 95% CI, 1.03 to 2.38); preventable operative adverse events (OR, 2.63; 95% CI, 1.42 to 4.87); and preventable adverse events due to delayed diagnoses and therapies (OR, 4.15; 95% CI, 1. 84 to 9.34). Patients in major teaching government hospitals were less likely to suffer preventable adverse drug events (OR, 0.38; 95% CI, 0.16 to 0.89).

CONCLUSIONS

Patients in for-profit and minor teaching or nonteaching government-owned hospitals were more likely to suffer several types of preventable adverse events. Further research is needed to determine how these events could be prevented.

The association between hospital type and mortality and length of stay: a study of 16.9 million hospitalized Medicare beneficiaries

OBJECTIVES

To examine the association between hospital type and mortality and length of stay using hospitalized Medicare beneficiaries for a 10-year period.

METHODS

The retrospective cohort study included 16.9 million hospitalized Medicare beneficiaries > or = 65 years of age admitted for 10 common medical conditions and 10 common surgical procedures from 1984 to 1993. A total of 5,127 acute-care hospitals in the United States were grouped into 6 mutually exclusive hospital types based on teaching status and financial structure (for-profit [FP], not-for-profit [NFP], osteopathic [OSTEO], public [PUB], teaching not-for-profit [TNFP], and teaching public [TPUB]) as reported in the 1988 American Hospital Association database. Logistic and linear regression methods were used to examine risk-adjusted 30-day and 6-month mortality and length of stay.

RESULTS

During the 10-year study period, 10.6 million patients were admitted with 1 of the 10 selected medical conditions, and 6.3 million patients were hospitalized for 1 of the 10 selected surgical procedures. Patients at TNFP hospitals had significantly lower risk-adjusted 30-day mortality rates than patients at other hospital types when all diagnoses or procedures were combined (combined diagnoses: RR(TNFP) = 1.00 [reference], RR(TPUB) = 1.40, RR(OSTEO) = 1.14, RR(PUB) = 1.07, RR(FP) = 1.03, RR(NFP) = 1.02; combined procedures: RR(TNFP) = 1.00 [reference], RR(OSTEO) = 1.36, RR(TPUB) = 1.30, RR(PUB) = 1.16, RR(FP) = 1.13, RR(NFP) = 1.08). The results were mostly consistent when diagnoses and procedures were examined separately. After adjustment for patient characteristics, patients at other hospital types had 10% to 20% shorter lengths of stay (LOS) than patients at TNFP hospitals for most diagnoses and procedures studied.

CONCLUSION

As measured by the risk-adjusted 30-day mortality, TNFP hospitals had an overall better performance than other hospital types. However, patients at TNFP hospitals had relatively longer LOS than patients at other hospital types, perhaps reflecting the medical education and research activities found at teaching institutions. Future research should examine the empirical evidence to help elucidate the adequate LOS for a given condition or procedure while maintaining the quality of care.

Hospital credentialing and quality of care

The purpose of this study was to evaluate the impact of hospital credentialing standards on surgical outcomes for selected procedures. The study used hospital credentialing practices from a 1996 survey of North Carolina community hospitals, with surgical outcomes derived from a statewide database of inpatient surgical discharges in 1995. Hospital mortality, complications and elevated lengths of stay were used as outcome indicators in an analysis of 6 surgical procedures. Multivariate logit analysis was used to calculate the effects of hospital credentialing stringency and nine credentialing practices on outcomes, controlling for patient demographic characteristics, type of admission, severity of illness and hospital characteristics. Teaching hospitals adopted more stringent credentialing practices, with almost no difference between metropolitan and nonmetropolitan nonteaching facilities in their use of various credentialing policies. Surgical outcomes typically were not related to stringency of the hospital credentialing environment. Generally, the effect of specific practices was inconsistent (associated with improved outcomes for certain procedures and significantly worse outcomes for others) or counterintuitive (showing worse outcomes for selected surgical procedures where effects were statistically significant). More stringent hospital credentialing does not appear likely to improve patient outcomes.

Academic health centers and the changing health care market

Academic health centers (AHCs) have supported their mission of patient care, education, and research through a complex system of cross-subsidies, many of which originate from patient care activities. The proliferation of managed care and health care reform initiatives, however, are threatening this traditional method of financing. This article begins by describing the financing of AHCs and the web of cross-subsidization that occurs at these institutions. The article then reviews the literature on the threats that AHCs are facing in the current health care market, how these threats are affecting their mission-related activities, and how they are responding to and managing these threats. The article concludes with a summary of our current understanding of AHCs and presents a research agenda of issues in need of further study.