Comparison of surgical outcomes between teaching and nonteaching hospitalsin the Department of Veterans Affairs

Objective To determine whether the investment in postgraduate education and training places patients at risk for worse outcomes and higher costs than if medical and surgical care was delivered in nonteaching settings. Summary Background Data The Veterans Health Administration (VA) plays a maj or role in the training of medical students, residents, and fellows. Methods The database of the VA National Surgical Quality Improvement Progra m was analyzed for all major noncardiac operations performed during fiscal years 1997, 1998, and 1999. Teaching status of a hospital was determined on the basis of a background and structure questionnaire that was independent ly verified by a research fellow. Stepwise logistic regression was used to construct separate models predictive of 30-day mortality and morbidity for each of seven surgical specialties and eight operations. Based on these mod els, a severity index for each patient was calculated, Hierarchical logisti c regression models were then created to examine the relationship between t eaching versus nonteaching hospitals and 30-day postoperative mortality and morbidity, after adjusting for patient severity. Results Teaching hospitals performed 81% of the total surgical workload and 90% of the major surgery workload. In most specialties in teaching hospita ls, the residents were the primary surgeons in more than 90% of the operati ons. Compared with nonteaching hospitals, the patient populations in teachi ng hospitals had a higher prevalence of risk factors, underwent more comple x operations, and had longer operation times. Risk-adjusted mortality rates were not different between the teaching and nonteaching hospitals in the s pecialties and operations studied. The unadjusted complication rate was hig her in teaching hospitals in six of seven specialties and four of eight ope rations. Risk adjustment did not eliminate completely these differences, pr obably reflecting the relatively poor predictive validity of some of the ri sk adjustment models for morbidity. Length of stay after major operations w as not consistently different between teaching and nonteaching hospitals. Conclusion Compared with nonteaching hospitals, teaching hospitals in the V A perform the majority of complex and high-risk major procedures, with comp arable risk-adjusted 30-day mortality rates. Risk-adjusted 30-day morbidity rates in teaching hospitals are higher in some specialties and operations than in nonteaching hospitals. Although this may reflect the weak predictiv e validity of some of the risk adjustment models for morbidity, it may also represent suboptimal processes and structures of care that are unique to t eaching hospitals. Despite good quality of care in teaching hospitals, as e videnced by the 30-day mortality data, efforts should be made to examine fu rther the structures and processes of surgical care prevailing in these hos pitals.