- Email: [email protected]
Teaching: Tips and Costs
Air Medical Journal 36 (2017) 226–228
Contents lists available at ScienceDirect
Air Medical Journal j o u r n a l h o m e p a g e : h t t p : / / w w w. a i r m e d i c a l j o u r n a l . c o m /
Critical Care Update
Teaching: Tips and Costs David J. Dries, MSE, MD
Szostek J. Being an effective teacher. Five tips for busy clinicians. Minn Med. 2016;99:42-44. Chi J, Artandi M, Kugler J, et al. The five-minute moment. Am J Med. 2016; 129:792-795. Multiple studies show that most of the characteristics of effective teaching are not related to specific expertise. Effective teaching transcends the mastery of knowledge, skills, and attitudes. Unfortunately, most physicians receive little formal training in teaching and may be unaware of effective practices and techniques. Below I summarize some basic tips and present a comment on the “five-minute moment.” As a former air medical program director, I find that these comments are relevant to flight crewmembers as well. First, and perhaps most important, is the creation of a learning environment. Learners must comfortably engage with teachers and be willing to ask questions and admit when they “don’t know or are uncomfortable.” This could include encouraging learner participation in conversation, avoiding dogmatism, showing respect, and conveying enthusiasm for both the learner and the topic. Perhaps a good start is encouraging the students to state what they want to learn. Upon the creation of a learning environment, goals and expectations for both the learner and teacher must be articulated. Frequently, this is an explicit expectation about training that will be received and the revelation that questions regarding the goal of clinical competence in a particular area should be expected. For example, how is a patient presented? How long should presentations be? What are the elements of effective case presentation? How is a diag-
nostic and therapeutic plan developed? Communicated expectations allow the teacher to assess and give effective feedback to the learner. When goals are unclear, both teachers and students may experience confusion and frustration. Third is the communication of digestible information across the content domain. Providing a vast amount of information makes it easy to lose the learner and the point of a presentation because learners have a limited span of attention. Teaching points should be limited to 1 or 2 per case or episode. Fourth, and a difficult item for this writer, is the evaluation of the performance of the learner. Evaluating a learner’s performance is essential to providing effective feedback and should be based on goals and expectations set early in the teaching relationship. A variety of formal metrics have been developed such as Bloom’s Taxonomy and a framework based on proposals such as that by the Accreditation Council of Graduate Medical Education Core Competencies. Finally, in a positive learning environment with established goals, systematic feedback will be less painful to both the individual delivering and the individual receiving the communication. In addition to providing feedback, this is an opportunity to reinforce initial goals and the structure of the learning environment. This is particularly helpful if the teacher will have a longterm relationship with the learner (as with a flight crewmember). Emphasis on productivity and efficiency has made it increasingly common for trainees and attendings to see patients separately. Attending rounds, a historic teaching opportunity, vary considerably in audience, content, and duration. As a result, physical examination skills are de-emphasized. For junior staff
1067-991X/$36.00 Copyright © 2017 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amj.2017.07.002
members, diminished confidence in their own skills or a lack of faith in the notion of bedside assessment (often because they were not instructed sufficiently) poses additional barriers to teaching bedside examination and decision making. Some commentators indicate that the increase in physician burnout seen recently (very prominent in critical care) may be related to hours of physician time in front of the computer rather than at the bedside. A recent work by Chi et al, who describe the “five-minute moment,” examined oversight and consequences when simple physical findings are overlooked, which include expensive testing, diagnostic delay, therapeutic misadventure, and, occasionally, surgical misadventure. As the teaching landscape in the United States continues to change, it is crucial to maintain basic teaching of time-honored, bedside skills. To enhance teaching, this group recommends a technique known as the “fiveminute bedside moment.” The “five-minute bedside moment” consists of 2 simple elements. First is a narrative to explain the context and usefulness of a clinical maneuver based either on technology or physical findings. A case vignette or historical anecdote facilitates learning in this setting. Second is demonstration of the physical finding or outcome of a particular intervention. The interpretation of findings and common errors in a clinical approach should also be presented. As these writers point out, there remain compelling reasons to be at the beside and teach at the bedside. The most important reason is that the patient is at the bedside. Saliba AN, Taher AT, Tamim H, et al. Impact of resident involvement in surgery (IRIS-NSQIP): looking at the bigger picture based on the American College of Surgeons-NSQIP database. J Am Coll Surg. 2016;222:30-40.
D.J. Dries / Air Medical Journal 36 (2017) 226–228
Pradarelli JC, Scally CP, Nathan H, et al. Hospital teaching status and Medicare expenditures for complex surgery. Ann Surg. 2017;265:502-513. Burke LG, Frakt AB, Khullar D, et al. Association between teaching status and mortality in US hospitals. JAMA. 2017;317:2105-2113. What is the impact of teaching programs? Three recent reports provide important contemporary insight into the answer to this question. Saliba et al examine the massive National Surgical Quality Improvement Program of the American College of Surgeons to determine whether patients having operations involving residents were at risk of postoperative mortality or morbidity similar to patients having operations performed by attending surgeons alone. A wide range of surgical procedures were examined. The recent institution of resident work hour restrictions and continuous changes in the medical/legal system as well as the evolution of subspecialized surgical training have put acknowledged strain on the traditional surgical training model. These data examine the implications of these and other forces. In reviewing over 100,000 different types of procedures stored in the database, the authors emphasize postoperative mortality and morbidity at 30 days including cardiac events, respiratory complications such as pneumonia, central nervous system events such as stroke or coma, acute kidney injury, wound complications, sepsis, and venous thromboembolic disorders. Composite morbidity was defined in this study as the presence of 1 or more of these major complications. The primary outcome measure was mortality within 30 days of the index operative procedure in the group of patients with any resident involvement compared with cases in the data set marked as “attending alone.” Secondary outcomes were morbidity within 30 days of the index operative procedure in the group of patients with resident involvement compared with the “attending alone” group. Across the data set of over 1.3 million total operative encounters, cases with resident involvement had lower mortality than attending alone procedures. The adjusted odds of 30-day composite morbidity suggest no difference in 30-day morbidity between patients with any level of resident involvement compared with the attending alone group across age and sex categories. These findings held true for emergent and nonemergent cases. By surgical subspecialty, there was not a statistically significant difference in morbidity between the group
of patients with any level of resident involvement compared with the procedures performed by the attending surgeon in all surgical subspecialties except neurosurgery and orthopedics. In neurosurgery and orthopedics, there was a slight but statistically significant increase in the risk of morbidity in the patient group with resident involvement compared with procedures performed by attendings alone. When specific morbidities were examined, there was no statistically significant difference in neurologic, genitourinary, wound, sepsis, and venous thromboembolic morbidities between the 2 study groups. There was a slight but statistically significant higher risk of cardiac and respiratory morbidity in patients with resident involvement compared with attending alone procedures. When all results were summarized, resident involvement had a positive impact on mortality and comparable morbidity outcome. Potential positive effects of resident participation in the operating room rather than a scrub nurse or other first assistant could reflect additional safety and quality checkpoints. Surgical procedures in which residents participate were more likely to be at teaching hospitals, usually academic medical centers, where attending surgeons may have more advanced experience and surgical expertise and where postoperative care may be of better quality. This study also shows a low level of independent resident involvement in the operating room. Residents were involved in over 55% of 1.3 million surgical procedures. However, only .3% of cases were performed with a limited presence of an attending surgeon in the operating room. Two areas of higher morbidity in procedures featuring resident participation were cardiac complications and respiratory events such as pneumonia and prolonged ventilator support. Specific reasons for these findings cannot be delineated from this work. The obvious strength of this project is the inclusion of a large multicenter, multidisciplinary database from the American College of Surgeons that uses standardized definitions for clinical outcomes and patient characteristics. Resident involvement in surgery is associated with good outcomes, which should reassure patients, staff surgeons, and surgical educators. If the provision of procedural training is safe, is it cost-effective? Dimick and coworkers from the University of Michigan examine the extent to which teaching hospitals provide cost-effective care in patients undergoing complex operative procedures. These investigators used Medicare Provider and Analysis Review files to examine beneficiaries who underwent abdominal
227
aortic aneurysm repair, pulmonary resection, or colectomy from 2009 to 2012. In all, over 4,000 cases were reviewed. After examining Medicare reimbursement for these high-risk patients, risk-adjusted Medicare payments were not statistically different between major teaching hospitals and nonteaching hospitals for abdominal aortic aneurysm repair and pulmonary resection. A statistically significant but small difference in cost persisted for colon resections. Major teaching hospitals had higher risk-adjusted rates of serious complications and readmissions but lower riskadjusted rates of failure to rescue from complications and overall lower 30-day mortality than nonteaching hospitals. These writers qualified their results by showing that risk-adjusted Medicare payments were higher for teaching hospitals for the 3 operations evaluated. However, by studying standardized Medicare episode payments allowing for the comparison of Medicare resource use for surgery across a spectrum of care at hospitals with differing levels of teaching intensity, Medicare spending was roughly equivalent between teaching and nonteaching hospitals for an episode of surgical care. One potential explanation for these observations is that better quality of care is delivered in teaching hospitals, and, therefore, hospital mortality is lower. These data suggest that postoperative complications were more common in hospitals in which residents participated in surgical care, but the treatment of complications was more effective, contributing to lower overall 30day mortality. This work is limited in that the generalizability of these findings to younger patients with insurers other than Medicare may not be possible. In addition, the operations studied are common in elderly patients and less frequently seen in other age groups. Finally, add-on Medicare payments for teaching hospitals were not reflected in this economic analysis. Despite considerations including social subsidies and regional variation in Medicare payment, teaching hospitals were no more costly than nonteaching hospitals in providing surgical care for 3 important inpatient procedures. Despite more frequent perioperative complications, mortality rates were lower in teaching hospitals than nonteaching facilities. The first 2 articles briefly reflect the impact of training on surgical outcomes. A large recent study by Burke and colleagues examines the implication of teaching status on mortality in a wide range of hospitals. Major teaching (university or major affiliate) hospitals were compared with hospitals having medical school affiliation without
228
major teaching commitment and nonteaching hospitals. Again, Medicare data were used to evaluate 30-day mortality for all hospitalizations involving 15 common medical and 6 surgical conditions. Secondary outcomes include 30-day mortality stratified by hospital size and 7-day mortality and 90-day mortality for all hospitalizations as well as for individual medical and surgical conditions. This work was conducted by the Department of Health Policy and Management at the Harvard School of Public Health. This study used Medicare data to answer 3 questions. First, what are the overall outcomes in teaching versus nonteaching hospitals? Second, are the benefits of receiving care at a teaching hospital focused on a small number of conditions or are they present broadly across multiple types of conditions and procedures? Third, are differences present even among large hospitals in which high volume could reduce any advantage of being a teaching institution? Over 21 million total hospitalizations were studied at approximately 4,500 hospitals. Only 2% of hospitalizations were excluded because of missing data. Two hundred fifty of the hospitals (5.6%) studied were major teaching hospitals and accounted for 16.7% of admissions in the sample; 19.9% of hospitals were minor teaching hospitals and accounted for 33.6% of admissions, and the remaining 3,300 hospitals were nonteaching hospitals, accounting for nearly 50% of hospitalizations. In the unadjusted analysis of overall 30day mortality, the mortality rates for major teaching, minor teaching, and nonteaching hospitals were 8.1%, 9.2%, and 9.6%, respectively, with major teaching hospitals having a 1.5% lower mortality relative to nonteaching hospitals. This pattern persisted after adjustment for patient characteristics between major teaching and nonteaching hospitals. For common medical admissions, unadjusted 30-day mortality was 11.1% at major teaching hospitals and
D.J. Dries / Air Medical Journal 36 (2017) 226–228
11.8% at minor teaching and nonteaching hospitals. This pattern persisted after adjustment for patient and hospital characteristics. For six surgical procedures examined, unadjusted mortality rates for major teaching, minor teaching, and nonteaching hospitals were 3%, 3.7%, and 4.3%, respectively. The finding of lower mortality at major teaching hospitals compared with nonteaching hospitals persisted after adjusting for patient and hospital characteristics. The surgical procedures evaluated included open abdominal aortic aneurysm repair, colon resection, pulmonary resection, coronary artery bypass grafting, hip replacement, and endovascular abdominal aortic aneurysm repair. In 1 subanalysis, there was no statistically significant difference in mortality for surgical procedures between small minor teaching hospitals and small nonteaching hospitals. It remains unclear why teaching status was associated with lower mortality in this work. The difference in outcomes may reflect greater experience in treating particular conditions at teaching hospitals, but accounting for hospital volume did not substantially explain the differences. Teaching hospitals also tend to be early adopters of new technologies, which could yield better outcomes for conditions that are technologically complex or require specialized knowledge. Other studies have found that teaching intensity was associated with higher performance on process measures in a variety of conditions, suggesting that superior processes may explain lower average mortality found at teaching hospitals. One interesting observation is that for sepsis and stroke, outcomes were no better at teaching hospitals compared with nonteaching facilities. Some investigators suggest that differential changes in coding between academic and nonacademic hospitals may lead academic facilities to be falsely penalized when administrative data are used for risk-adjusted quality investigation. Different strategies for coding by teaching hospitals could tend to bias against
finding lower mortality. In addition, there is some evidence that teaching hospitals may be misclassified as poorer performers on stroke mortality using traditional adjustment models that do not fully reflect stroke severity. Other limitations of this important article must be noted. Again, these investigators use Medicare data, and it is not possible to determine whether these findings can be generalized to nonelderly patients. Second, only mortality was used as an indicator of quality of care. Finally, this work did not account for patient preference in end-oflife care. Lower mortality, in theory, could reflect the reduced use of palliative care services for appropriate patients at teaching hospitals. However, in summary, using some of the best administrative data available, the role of teaching hospitals as a public health asset is reinforced.
Summary Points
•
• •
Effective teaching must be placed in the proper context. Openness to questions and admission of uncertainty must be allowed. Expectations for learners and timely feedback driven by performance relative to expectations are vital. Using episodes of care with focused teaching points is a concise, effective bedside tool. Despite limitations of available data, major studies to date support the clinical and economic product of programs emphasizing teaching.
Acknowledgment The author gratefully acknowledges the assistance of Ms. Sherry Willett in preparation of this series for Air Medical Journal. David J. Dries, MSE, MD, is division medical director at HealthPartners Medical Group and professor or surgery and emergency medicine at the University of Minnesota in Minneapolis, MN, and can be reached at [email protected].
Contents lists available at ScienceDirect
Air Medical Journal j o u r n a l h o m e p a g e : h t t p : / / w w w. a i r m e d i c a l j o u r n a l . c o m /
Critical Care Update
Teaching: Tips and Costs David J. Dries, MSE, MD
Szostek J. Being an effective teacher. Five tips for busy clinicians. Minn Med. 2016;99:42-44. Chi J, Artandi M, Kugler J, et al. The five-minute moment. Am J Med. 2016; 129:792-795. Multiple studies show that most of the characteristics of effective teaching are not related to specific expertise. Effective teaching transcends the mastery of knowledge, skills, and attitudes. Unfortunately, most physicians receive little formal training in teaching and may be unaware of effective practices and techniques. Below I summarize some basic tips and present a comment on the “five-minute moment.” As a former air medical program director, I find that these comments are relevant to flight crewmembers as well. First, and perhaps most important, is the creation of a learning environment. Learners must comfortably engage with teachers and be willing to ask questions and admit when they “don’t know or are uncomfortable.” This could include encouraging learner participation in conversation, avoiding dogmatism, showing respect, and conveying enthusiasm for both the learner and the topic. Perhaps a good start is encouraging the students to state what they want to learn. Upon the creation of a learning environment, goals and expectations for both the learner and teacher must be articulated. Frequently, this is an explicit expectation about training that will be received and the revelation that questions regarding the goal of clinical competence in a particular area should be expected. For example, how is a patient presented? How long should presentations be? What are the elements of effective case presentation? How is a diag-
nostic and therapeutic plan developed? Communicated expectations allow the teacher to assess and give effective feedback to the learner. When goals are unclear, both teachers and students may experience confusion and frustration. Third is the communication of digestible information across the content domain. Providing a vast amount of information makes it easy to lose the learner and the point of a presentation because learners have a limited span of attention. Teaching points should be limited to 1 or 2 per case or episode. Fourth, and a difficult item for this writer, is the evaluation of the performance of the learner. Evaluating a learner’s performance is essential to providing effective feedback and should be based on goals and expectations set early in the teaching relationship. A variety of formal metrics have been developed such as Bloom’s Taxonomy and a framework based on proposals such as that by the Accreditation Council of Graduate Medical Education Core Competencies. Finally, in a positive learning environment with established goals, systematic feedback will be less painful to both the individual delivering and the individual receiving the communication. In addition to providing feedback, this is an opportunity to reinforce initial goals and the structure of the learning environment. This is particularly helpful if the teacher will have a longterm relationship with the learner (as with a flight crewmember). Emphasis on productivity and efficiency has made it increasingly common for trainees and attendings to see patients separately. Attending rounds, a historic teaching opportunity, vary considerably in audience, content, and duration. As a result, physical examination skills are de-emphasized. For junior staff
1067-991X/$36.00 Copyright © 2017 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amj.2017.07.002
members, diminished confidence in their own skills or a lack of faith in the notion of bedside assessment (often because they were not instructed sufficiently) poses additional barriers to teaching bedside examination and decision making. Some commentators indicate that the increase in physician burnout seen recently (very prominent in critical care) may be related to hours of physician time in front of the computer rather than at the bedside. A recent work by Chi et al, who describe the “five-minute moment,” examined oversight and consequences when simple physical findings are overlooked, which include expensive testing, diagnostic delay, therapeutic misadventure, and, occasionally, surgical misadventure. As the teaching landscape in the United States continues to change, it is crucial to maintain basic teaching of time-honored, bedside skills. To enhance teaching, this group recommends a technique known as the “fiveminute bedside moment.” The “five-minute bedside moment” consists of 2 simple elements. First is a narrative to explain the context and usefulness of a clinical maneuver based either on technology or physical findings. A case vignette or historical anecdote facilitates learning in this setting. Second is demonstration of the physical finding or outcome of a particular intervention. The interpretation of findings and common errors in a clinical approach should also be presented. As these writers point out, there remain compelling reasons to be at the beside and teach at the bedside. The most important reason is that the patient is at the bedside. Saliba AN, Taher AT, Tamim H, et al. Impact of resident involvement in surgery (IRIS-NSQIP): looking at the bigger picture based on the American College of Surgeons-NSQIP database. J Am Coll Surg. 2016;222:30-40.
D.J. Dries / Air Medical Journal 36 (2017) 226–228
Pradarelli JC, Scally CP, Nathan H, et al. Hospital teaching status and Medicare expenditures for complex surgery. Ann Surg. 2017;265:502-513. Burke LG, Frakt AB, Khullar D, et al. Association between teaching status and mortality in US hospitals. JAMA. 2017;317:2105-2113. What is the impact of teaching programs? Three recent reports provide important contemporary insight into the answer to this question. Saliba et al examine the massive National Surgical Quality Improvement Program of the American College of Surgeons to determine whether patients having operations involving residents were at risk of postoperative mortality or morbidity similar to patients having operations performed by attending surgeons alone. A wide range of surgical procedures were examined. The recent institution of resident work hour restrictions and continuous changes in the medical/legal system as well as the evolution of subspecialized surgical training have put acknowledged strain on the traditional surgical training model. These data examine the implications of these and other forces. In reviewing over 100,000 different types of procedures stored in the database, the authors emphasize postoperative mortality and morbidity at 30 days including cardiac events, respiratory complications such as pneumonia, central nervous system events such as stroke or coma, acute kidney injury, wound complications, sepsis, and venous thromboembolic disorders. Composite morbidity was defined in this study as the presence of 1 or more of these major complications. The primary outcome measure was mortality within 30 days of the index operative procedure in the group of patients with any resident involvement compared with cases in the data set marked as “attending alone.” Secondary outcomes were morbidity within 30 days of the index operative procedure in the group of patients with resident involvement compared with the “attending alone” group. Across the data set of over 1.3 million total operative encounters, cases with resident involvement had lower mortality than attending alone procedures. The adjusted odds of 30-day composite morbidity suggest no difference in 30-day morbidity between patients with any level of resident involvement compared with the attending alone group across age and sex categories. These findings held true for emergent and nonemergent cases. By surgical subspecialty, there was not a statistically significant difference in morbidity between the group
of patients with any level of resident involvement compared with the procedures performed by the attending surgeon in all surgical subspecialties except neurosurgery and orthopedics. In neurosurgery and orthopedics, there was a slight but statistically significant increase in the risk of morbidity in the patient group with resident involvement compared with procedures performed by attendings alone. When specific morbidities were examined, there was no statistically significant difference in neurologic, genitourinary, wound, sepsis, and venous thromboembolic morbidities between the 2 study groups. There was a slight but statistically significant higher risk of cardiac and respiratory morbidity in patients with resident involvement compared with attending alone procedures. When all results were summarized, resident involvement had a positive impact on mortality and comparable morbidity outcome. Potential positive effects of resident participation in the operating room rather than a scrub nurse or other first assistant could reflect additional safety and quality checkpoints. Surgical procedures in which residents participate were more likely to be at teaching hospitals, usually academic medical centers, where attending surgeons may have more advanced experience and surgical expertise and where postoperative care may be of better quality. This study also shows a low level of independent resident involvement in the operating room. Residents were involved in over 55% of 1.3 million surgical procedures. However, only .3% of cases were performed with a limited presence of an attending surgeon in the operating room. Two areas of higher morbidity in procedures featuring resident participation were cardiac complications and respiratory events such as pneumonia and prolonged ventilator support. Specific reasons for these findings cannot be delineated from this work. The obvious strength of this project is the inclusion of a large multicenter, multidisciplinary database from the American College of Surgeons that uses standardized definitions for clinical outcomes and patient characteristics. Resident involvement in surgery is associated with good outcomes, which should reassure patients, staff surgeons, and surgical educators. If the provision of procedural training is safe, is it cost-effective? Dimick and coworkers from the University of Michigan examine the extent to which teaching hospitals provide cost-effective care in patients undergoing complex operative procedures. These investigators used Medicare Provider and Analysis Review files to examine beneficiaries who underwent abdominal
227
aortic aneurysm repair, pulmonary resection, or colectomy from 2009 to 2012. In all, over 4,000 cases were reviewed. After examining Medicare reimbursement for these high-risk patients, risk-adjusted Medicare payments were not statistically different between major teaching hospitals and nonteaching hospitals for abdominal aortic aneurysm repair and pulmonary resection. A statistically significant but small difference in cost persisted for colon resections. Major teaching hospitals had higher risk-adjusted rates of serious complications and readmissions but lower riskadjusted rates of failure to rescue from complications and overall lower 30-day mortality than nonteaching hospitals. These writers qualified their results by showing that risk-adjusted Medicare payments were higher for teaching hospitals for the 3 operations evaluated. However, by studying standardized Medicare episode payments allowing for the comparison of Medicare resource use for surgery across a spectrum of care at hospitals with differing levels of teaching intensity, Medicare spending was roughly equivalent between teaching and nonteaching hospitals for an episode of surgical care. One potential explanation for these observations is that better quality of care is delivered in teaching hospitals, and, therefore, hospital mortality is lower. These data suggest that postoperative complications were more common in hospitals in which residents participated in surgical care, but the treatment of complications was more effective, contributing to lower overall 30day mortality. This work is limited in that the generalizability of these findings to younger patients with insurers other than Medicare may not be possible. In addition, the operations studied are common in elderly patients and less frequently seen in other age groups. Finally, add-on Medicare payments for teaching hospitals were not reflected in this economic analysis. Despite considerations including social subsidies and regional variation in Medicare payment, teaching hospitals were no more costly than nonteaching hospitals in providing surgical care for 3 important inpatient procedures. Despite more frequent perioperative complications, mortality rates were lower in teaching hospitals than nonteaching facilities. The first 2 articles briefly reflect the impact of training on surgical outcomes. A large recent study by Burke and colleagues examines the implication of teaching status on mortality in a wide range of hospitals. Major teaching (university or major affiliate) hospitals were compared with hospitals having medical school affiliation without
228
major teaching commitment and nonteaching hospitals. Again, Medicare data were used to evaluate 30-day mortality for all hospitalizations involving 15 common medical and 6 surgical conditions. Secondary outcomes include 30-day mortality stratified by hospital size and 7-day mortality and 90-day mortality for all hospitalizations as well as for individual medical and surgical conditions. This work was conducted by the Department of Health Policy and Management at the Harvard School of Public Health. This study used Medicare data to answer 3 questions. First, what are the overall outcomes in teaching versus nonteaching hospitals? Second, are the benefits of receiving care at a teaching hospital focused on a small number of conditions or are they present broadly across multiple types of conditions and procedures? Third, are differences present even among large hospitals in which high volume could reduce any advantage of being a teaching institution? Over 21 million total hospitalizations were studied at approximately 4,500 hospitals. Only 2% of hospitalizations were excluded because of missing data. Two hundred fifty of the hospitals (5.6%) studied were major teaching hospitals and accounted for 16.7% of admissions in the sample; 19.9% of hospitals were minor teaching hospitals and accounted for 33.6% of admissions, and the remaining 3,300 hospitals were nonteaching hospitals, accounting for nearly 50% of hospitalizations. In the unadjusted analysis of overall 30day mortality, the mortality rates for major teaching, minor teaching, and nonteaching hospitals were 8.1%, 9.2%, and 9.6%, respectively, with major teaching hospitals having a 1.5% lower mortality relative to nonteaching hospitals. This pattern persisted after adjustment for patient characteristics between major teaching and nonteaching hospitals. For common medical admissions, unadjusted 30-day mortality was 11.1% at major teaching hospitals and
D.J. Dries / Air Medical Journal 36 (2017) 226–228
11.8% at minor teaching and nonteaching hospitals. This pattern persisted after adjustment for patient and hospital characteristics. For six surgical procedures examined, unadjusted mortality rates for major teaching, minor teaching, and nonteaching hospitals were 3%, 3.7%, and 4.3%, respectively. The finding of lower mortality at major teaching hospitals compared with nonteaching hospitals persisted after adjusting for patient and hospital characteristics. The surgical procedures evaluated included open abdominal aortic aneurysm repair, colon resection, pulmonary resection, coronary artery bypass grafting, hip replacement, and endovascular abdominal aortic aneurysm repair. In 1 subanalysis, there was no statistically significant difference in mortality for surgical procedures between small minor teaching hospitals and small nonteaching hospitals. It remains unclear why teaching status was associated with lower mortality in this work. The difference in outcomes may reflect greater experience in treating particular conditions at teaching hospitals, but accounting for hospital volume did not substantially explain the differences. Teaching hospitals also tend to be early adopters of new technologies, which could yield better outcomes for conditions that are technologically complex or require specialized knowledge. Other studies have found that teaching intensity was associated with higher performance on process measures in a variety of conditions, suggesting that superior processes may explain lower average mortality found at teaching hospitals. One interesting observation is that for sepsis and stroke, outcomes were no better at teaching hospitals compared with nonteaching facilities. Some investigators suggest that differential changes in coding between academic and nonacademic hospitals may lead academic facilities to be falsely penalized when administrative data are used for risk-adjusted quality investigation. Different strategies for coding by teaching hospitals could tend to bias against
finding lower mortality. In addition, there is some evidence that teaching hospitals may be misclassified as poorer performers on stroke mortality using traditional adjustment models that do not fully reflect stroke severity. Other limitations of this important article must be noted. Again, these investigators use Medicare data, and it is not possible to determine whether these findings can be generalized to nonelderly patients. Second, only mortality was used as an indicator of quality of care. Finally, this work did not account for patient preference in end-oflife care. Lower mortality, in theory, could reflect the reduced use of palliative care services for appropriate patients at teaching hospitals. However, in summary, using some of the best administrative data available, the role of teaching hospitals as a public health asset is reinforced.
Summary Points
•
• •
Effective teaching must be placed in the proper context. Openness to questions and admission of uncertainty must be allowed. Expectations for learners and timely feedback driven by performance relative to expectations are vital. Using episodes of care with focused teaching points is a concise, effective bedside tool. Despite limitations of available data, major studies to date support the clinical and economic product of programs emphasizing teaching.
Acknowledgment The author gratefully acknowledges the assistance of Ms. Sherry Willett in preparation of this series for Air Medical Journal. David J. Dries, MSE, MD, is division medical director at HealthPartners Medical Group and professor or surgery and emergency medicine at the University of Minnesota in Minneapolis, MN, and can be reached at [email protected].