BOSTON December 1, 1998 - While well known as the main treatment centers for rare diseases, teaching hospitals have recently come under scrutiny for their value in treating more common disorders. Yet comparing care at teaching and nonteaching hospitals for congestive heart failure and pneumonia, the most common causes of hospitalization in the U.S., Harvard researchers found that teaching hospitals still generally provide a higher quality of care.
"We found evidence that in teaching hospitals, physicians do better with the history, physical exam, and diagnostic tests," says John Ayanian, assistant professor of medicine and of health care policy at Harvard Medical School (HMS) and Brigham and Women's Hospital (BWH). "However, there's also evidence that certain therapies are underutilized in teaching and nonteaching hospitals."
Ayanian and his colleagues report in the November/December Health Affairs that if teaching hospitals can maintain their quality of care while containing their costs, those institutions should continue to play a prominent role in providing care for common illnesses.
"People have accepted that teaching hospitals provide a high quality of care for rare diseases, but are less certain about their value in treating common diseases," says coauthor Arnold Epstein, professor and chair of health policy and management at Harvard School of Public Health and professor of medicine at HMS and BWH. "With costs running from 25 to 35 percent higher at teaching hospitals, the pressure's on to justify the expense."
The researchers examined the quality of care in teaching and nonteaching hospitals in four states, measuring both the specifics of patient treatment and the overall quality of care. They asked a group of experts to rate teaching and nonteaching hospitals, checking to see whether physicians took specific steps to treat 883 people with congestive heart failure and 884 with pneumonia. Forty-five percent of patients with congestive heart failure and 46 percent of those with pneumonia had been treated in teaching hospitals. In a second part of the study, a group of community physicians rated the overall quality of care. The data came from the charts of Medicare patients in Massachusetts, New York, Pennsylvania, and Illinois from September 1991 through August 1992.
In the first part of the study, the researchers found that physicians in teaching hospitals met basic standards such as lung exams and measurements of potassium and creatinine levels more regularly than did those in nonteaching hospitals.
However, the report notes that physicians at both kinds of hospitals failed to prescribe ACE inhibitors for half of the patients with congestive heart failure and were slow to administer antibiotics to pneumonia patients. "There's an important need for almost all hospitals to improve their use of effective therapies," says Ayanian.
In the second part of the study, the community physicians read the charts of the patients and rated their perception of the overall quality of care. They found that for both diseases, around 65 percent of patients in teaching hospitals received care rated as "good to excellent" while only about 35 percent of patients in nonteaching hospitals scored that high.
Part of the discrepancy in the quality of care may be due to teaching hospitals having both intern and resident physicians, which means that more physicians are available for each patient, says Ayanian.
Some of the value of teaching hospitals extends beyond the cost of patient care, says Epstein. "Important points are that teaching hospitals tend to care for underserved populations and to produce new knowledge."
Comparing the quality of treatment for the two common diseases adds another dimension to the current debate over the value of teaching hospitals within the changing national health care system, says Epstein, who hopes that this study will help guide policymakers.
Journal
Health Affairs