Teaching hospitals and quality of care: a review of the literature

A time of accelerated change in academic cardiovascular medicine

With the vast epidemic of vascular disease predicted to be the leading cause of death and disability by a growing margin over the next 30 years, academic medical centers with cardiology training programs have a special responsibility. Given the dramatic advances of biotechnology in producing highly effective but expensive strategies of prevention and treatment, cardiovascular specialists should assist their academic centers in envisioning the future to prepare trainees for a different environment. Cardiologists of the future must be able to adapt to a societal need for patient-oriented, team-based clinical care and rapidly evolving technology, while maintaining the fundamental skills and knowledge required for individual patient interaction. Academic programs should benchmark their activities to ensure responsible resource allocation so that cardiologists of the future will be trained in an environment stimulating excellence and creativity.

Effects of weekend admission and hospital teaching status on in-hospital mortality

PURPOSE

The effect of reduced hospital staffing during weekends on in-hospital mortality is not known. We compared mortality rates between patients admitted on weekends and weekdays and whether weekend-weekday variation in rates differed between patients admitted to teaching and nonteaching hospitals in California.

METHODS

The sample comprised patients admitted to hospitals from the emergency department with any of 50 common diagnoses (N = 641,860). Mortality between patients admitted on weekends and those admitted on weekdays (the "weekend effect") was compared. The magnitude of the weekend effect was also compared among patients admitted to major teaching, minor teaching, and nonteaching hospitals.

RESULTS

The adjusted odds of death for patients admitted on weekends when compared with weekdays was 1.03 (95% confidence interval [CI]: 1.01 to 1.06; P = 0.0050). Three diagnoses (cancer of the ovary/uterus, duodenal ulcer, and cardiovascular symptoms) were associated with a statistically significant weekend effect. None of the 50 diagnoses demonstrated a statistically significant reduction in mortality for weekend admissions as compared with weekday admissions. Mortality was similar among patients admitted to major (odds ratio [OR] = 1.06; 95% CI: 0.94 to 1.19) and minor (OR = 1.03; 95% CI: 0.97 to 1.09) teaching hospitals, compared with nonteaching hospitals. However, the weekend effect was larger in major teaching hospitals compared with nonteaching hospitals (OR =1.13 vs. 1.03, P = 0.03) and minor teaching hospitals (OR = 1.05, P = 0.11).

CONCLUSION

Patients admitted to hospitals on weekends experienced slightly higher risk-adjusted mortality than did patients admitted on weekdays. While overall mortality was similar for patients admitted to all hospital categories, the weekend effect was larger in major teaching hospitals and is cause for concern.

Hospital-level performance improvement: beta-blocker use after acute myocardial infarction

BACKGROUND

National surveys indicate improvement in beta-blocker use after acute myocardial infarction (AMI) over time; however, these data could obscure important variation in improvement at individual hospitals. Our objective was to characterize the hospital-level variation in the improvements in beta-blocker prescription rates after AMI and to identify hospital characteristics that were associated with hospital improvement rates after adjustment for patient demographic and clinical characteristics.

METHODS AND RESULTS

We used data (n = 335,244 patients with AMI discharged from 682 hospitals) from the National Registry of Myocardial Infarction (NRMI) and from the American Hospital Association Annual Survey of Hospitals and hierarchical modeling to examine the associations between hospital characteristics and hospital-level rates of change in beta-blocker use during 1996-1999. On average, hospital rates of beta-blocker use for patients with AMI increased 5.9 percentage points (standard deviation, 9.7 percentage points) from the premidpoint time period (April 1996-February 1998) to the postmidpoint time period (March 1998-September 1999) of the study. The range in hospital-level changes in beta-blocker rates was substantial, from a decline of -50.0 percentage points to an increase of +35.7 percentage points. AMI volume and teaching status, geographic region, and initial beta-blocker use rates were associated with rate of improvement, but the magnitude of these effects was modest.

CONCLUSIONS

The study reveals marked hospital-level variation in improvement in beta-blocker use after AMI. Several hospital characteristics were associated with this improvement, but they are weak predictors of hospital-based improvement in the use of beta-blockers.

The evolving science of quality measurement for hospitals: implications for studies of competition and consolidation

The literature on hospital competition and quality is young; most empirical studies have focused on few conditions and outcomes. Measures of in-hospital mortality and complications are susceptible to bias from unmeasured severity and transfer/discharge practices. Only one research team has evaluated related process and outcome measures, and none has exploited chart-review or patient survey-based data. Prior studies have generated inconsistent findings, suggesting the need for additional research. We describe the strengths and limitations of various approaches to quality measurement, summarize how quality has been operationalized in studies of hospital competition, outline three mechanisms by which competition may affect hospital quality, and propose measures appropriate for testing each mechanism.

Use of physician extenders in surgical pathology practice

CONTEXT

Use of a variety of nonphysician personnel for surgical pathology gross examination is generally known to be increasing, although detailed information regarding nonphysician use is currently unavailable.

OBJECTIVE

To measure and describe the use of nonphysician personnel for surgical pathology gross examination in order to gain a better understanding of the current surgical pathology workforce.

DESIGN

A voluntary, mailed questionnaire containing items related to the use of multiple nonphysician personnel types in surgical pathology was distributed to (1) a cross-sectional sample (n = 968) of US pathologists and (2) a purposive sample of pathologist directors of surgical and/or anatomic pathology (n = 77) located at teaching institutions. Responses were analyzed using descriptive statistics, correlation analyses, the chi2 test, and 1-way analysis of variance. Staffing ratios were calculated for multiple nonphysician personnel types.

RESULTS

The overall response rate was 22% (n = 225). Of the US sample, 56% of respondents reported using nonphysician laboratory personnel to perform gross examinations, compared with 91% of the directors' sample. The most frequently reported personnel type for both samples was pathologists' assistants, but multiple other personnel types were used as well. Significant associations existed between certain practice types and personnel types used, as well as differences in the scope of responsibilities between personnel types. Calculated staffing ratios were variable across personnel types and were highest for pathologists' assistants.

CONCLUSIONS

The use of a variety of nonphysician laboratory personnel for surgical pathology gross examination is common, particularly in academic pathology practice. Further studies are needed to examine the impact of physician extenders on laboratory efficiency and quality of care.

The imperative for quality: a call for action to medical schools and teaching hospitals

Patient safety and quality improvement are critical clinical and research endeavors supported by the federal government, accrediting bodies, regulatory agencies, and patient-advocacy groups. The Boston-based Institute for Healthcare Improvement has led in educating physicians, nurses, and other health professionals to improve the effectiveness and efficiency of their delivery systems. Recently, academic medical institutions have come together to improve patient outcomes by participating in the institute's IMPACT network. Each participating institution works in one or more of five improvement domains: patient safety, intensive care, patient flow, office practice, and workforce development. In addition, the chief executive officer of each participating organization focuses on leadership. The infrastructure for raising the bar of performance is improving at medical schools and teaching hospitals in this country. Important trends include interdisciplinary centers of excellence, improved faculty practice plan governance and management, leadership recruitment and development, and a commitment to quality as a high educational priority at a number of medical schools. Quality improvement efforts are intellectual activities that are consistent with the values of academic medicine and discovery. Academic medical centers are well positioned to lead the way in the improvement of quality of care. As institutions entrusted with the education of future health professionals and charged with developing new knowledge, the authors call for a complete commitment to the highest level of quality in patient care.

What Will Become Of The Medical Mecca? Health Care Spending In Massachusetts

Massachusetts has been called a "medical mecca." It has also been called the world's most expensive health care market. This paper concludes that claims of excess costs in Massachusetts are overstated. Massachusetts hospitals have lower inpatient costs than peer institutions in other states, yet the state's concentration of academic hospitals tilts the system toward higher spending. In markets like Massachusetts, there is growing pressure to demonstrate tangible benefits to justify the additional costs of academic health centers (AHCs). Applying new information technologies to proactively manage patients with expensive chronic illnesses is a critical area for future collaboration between payers and AHCs.

Evaluation of the quality of care in the clinical care centers of the National Centers of Excellence in Women's Health

This study evaluated the quality of primary care services provided in 15 National Centers of Excellence in Women's Health (CoE) clinical sites in operation in 2001 using self-reported clinical preventive services and patient satisfaction as indicators of quality of care. A sample of 3,111 women served by the CoE program was surveyed and compared with quality of care benchmarks from national and local community surveys. The benchmark surveys were: a nationally representative sample of 2,075 women from the 1998 Commonwealth Fund Survey of Women's Health; a community sample of women who lived within a geographical catchment area for three CoEs; and a sample of 71,438 women in the 1999 Consumer Assessment of Health Plans Study (CAHPS) of commercial managed care plans. Adjusting for region, age, education, perceived health status, and managed care enrollment, women in the CoEs were more satisfied with their care and had received significantly more screening tests and counseling services than women in the benchmark samples. The largest effects among primary care services were for physical breast examination, mammogram (ages 50+), and counseling for smoking, domestic violence, and sexually transmitted diseases.