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Jeroan J. Allison, MD, MS; Catarina I. Kiefe, PhD, MD; Norman W. Weissman, PhD; Sharina D. Person, PhD; Matthew Rousculp, MPH; John G. Canto, MD, MSPH; Sejong Bae, PhD; O. Dale Williams, PhD; Robert Farmer; Robert M. Centor, MD

JAMA. 2000;284:1256-1262.

Context  Issues of cost and quality are gaining importance in the delivery of medical care, and whether quality of care is better in teaching vs nonteaching hospitals is an essential question in this current national debate.

Objective  To examine the association of hospital teaching status with quality of care and mortality for fee-for-service Medicare patients with acute myocardial infarction (AMI).

Design, Setting, and Patients  Analysis of Cooperative Cardiovascular Project data for 114,411 Medicare patients from 4361 hospitals (22,354 patients from 439 major teaching hospitals, 22,493 patients from 455 minor teaching hospitals, and 69,564 patients from 3467 nonteaching hospitals) who had AMI between February 1994 and July 1995.

Main Outcome Measures  Administration of reperfusion therapy on admission, aspirin during hospitalization, and -blockers and angiotensin-converting enzyme inhibitors at discharge for patients meeting strict inclusion criteria; mortality at 30, 60, and 90 days and 2 years after admission.

Results  Among major teaching, minor teaching, and nonteaching hospitals, respectively, administration rates for aspirin were 91.2%, 86.4%, and 81.4% (P<.001); for angiotensin-converting enzyme inhibitors, 63.7%, 60.0%, and 58.0% (P<.001); for -blockers, 48.8%, 40.3%, and 36.4% (P<.001); and for reperfusion therapy, 55.5%, 58.9%, and 55.2% (P = .29). Differences in unadjusted 30-day, 60-day, 90-day, and 2-year mortality among hospitals were significant at P<.001 for all time periods, with a gradient of increasing mortality from major teaching to minor teaching to nonteaching hospitals. Mortality differences were attenuated by adjustment for patient characteristics and were almost eliminated by additional adjustment for receipt of therapy.

Conclusions  In this study of elderly patients with AMI, admission to a teaching hospital was associated with better quality of care based on 3 of 4 quality indicators and lower mortality.

Author Affiliations: Divisions of General Internal Medicine (Drs Allison, Kiefe, Weissman, and Centor), Preventive Medicine (Drs Kiefe, Person, Bae, and Williams), and Cardiovascular Medicine (Dr Canto), Department of Medicine, Department of Health Services Administration, School of Related Health Professions (Dr Weissman), Center for Outcomes and Effectiveness Research and Education (Drs Allison, Kiefe, Weissman, Person, Canto, Bae, Williams, and Centor and Mr Rousculp), Informatics Core, Pittman General Clinical Research Center (Dr Allison), and Lister Hill Center for Health Policy (Drs Kiefe and Weissman and Mr Rousculp), University of Alabama at Birmingham; Veterans Affairs Medical Center (Dr Kiefe); and Alabama Quality Assurance Foundation (Mr Farmer), Birmingham.

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RELATED LETTER

Quality of Care at Teaching and Nonteaching Hospitals
David R. Thiemann, Josef Coresh, Neil R. Powe, Jeroan J. Allison, Catarina I. Kiefe, Norman Weissman, John G. Canto, Sharina D. Person, O. Dale Williams, and Robert M. Centor
JAMA. 2000;284(23):2994-2995.
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