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Jeffrey H. Silber, MD, PhD; Paul R. Rosenbaum, PhD; Patrick S. Romano, MD; Amy K. Rosen, PhD; Yanli Wang, MS; Yun Teng, MS; Michael J. Halenar, BA; Orit Even-Shoshan, MS; Kevin G. Volpp, MD, PhD

Arch Surg. 2009;144(2):113-120.

Objectives  To determine if the lower mortality often observed in teaching-intensive hospitals is because of lower complication rates or lower death rates after complications (failure to rescue) and whether the benefits at these hospitals accrue equally to white and black patients, since black patients receive a disproportionate share of their care at teaching-intensive hospitals.

Design  A retrospective study of patient outcomes and teaching intensity using logistic regression models, with and without adjusting for hospital fixed and random effects.

Setting  Three thousand two hundred seventy acute care hospitals in the United States.

Patients  Medicare claims on general, orthopedic, and vascular surgery admissions in the United States for 2000-2005 (N = 4 658 954 unique patients).

Main Outcome Measures  Thirty-day mortality, in-hospital complications, and failure to rescue (the probability of death following complications).

Results  Combining all surgeries, compared with nonteaching hospitals, patients at very major teaching hospitals demonstrated a 15% lower odds of death (P < .001), no difference in complications, and a 15% lower odds of death after complications (failure to rescue) (P < .001). These relative benefits associated with higher resident-to-bed ratio were not experienced by black patients, for whom the odds of mortality and failure to rescue were similar at teaching and nonteaching hospitals, a pattern that is significantly different from that of white patients (P < .001).

Conclusions  Survival after surgery is higher at hospitals with higher teaching intensity. Improved survival is because of lower mortality after complications (better failure to rescue) and generally not because of fewer complications. However, this better survival and failure to rescue at teaching-intensive hospitals is seen for white patients, not for black patients.

Author Affiliations: Center for Outcomes Research, The Children's Hospital of Philadelphia (Dr Silber and Mss Wang, Teng, and Even-Shoshan), Departments of Pediatrics and Anesthesiology and Critical Care (Dr Silber) and Medicine (Mr Halenar and Dr Volpp), School of Medicine, Departments of Health Care Systems (Dr Silber) and Statistics (Dr Rosenbaum), the Wharton School, and the Leonard Davis Institute of Health Economics (Drs Silber and Volpp and Ms Even-Shoshan), University of Pennsylvania, and Center for Health Equity Research and Promotion, Veteran's Administration Hospital (Mr Halenar and Dr Volpp), Philadelphia; Division of General Medicine and Center for Healthcare Policy and Research, University of California Davis School of Medicine, Sacramento (Dr Romano); and Department of Health Policy and Management, Boston University School of Public Health, Boston (Dr Rosen), and Center for Health Quality, Outcomes and Economic Research, Veteran's Administration Hospital, Bedford (Dr Rosen), Massachusetts.

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