title: Comparison of surgical outcomes between teaching and nonteaching hospitals in the Department of Veterans Affairs.
abstract: 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.
  
  
  BACKGROUND
  The Veterans Health Administration (VA) plays a major role in the training of medical students, residents, and fellows.
  
  
  METHODS
  The database of the VA National Surgical Quality Improvement Program 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 independently 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 models, a severity index for each patient was calculated. Hierarchical logistic regression models were then created to examine the relationship between teaching 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 hospitals, the residents were the primary surgeons in more than 90% of the operations. Compared with nonteaching hospitals, the patient populations in teaching hospitals had a higher prevalence of risk factors, underwent more complex operations, and had longer operation times. Risk-adjusted mortality rates were not different between the teaching and nonteaching hospitals in the specialties and operations studied. The unadjusted complication rate was higher in teaching hospitals in six of seven specialties and four of eight operations. Risk adjustment did not eliminate completely these differences, probably reflecting the relatively poor predictive validity of some of the risk adjustment models for morbidity. Length of stay after major operations was not consistently different between teaching and nonteaching hospitals.
  
  
  CONCLUSIONS
  Compared with nonteaching hospitals, teaching hospitals in the VA perform the majority of complex and high-risk major procedures, with comparable 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 predictive validity of some of the risk adjustment models for morbidity, it may also represent suboptimal processes and structures of care that are unique to teaching hospitals. Despite good quality of care in teaching hospitals, as evidenced by the 30-day mortality data, efforts should be made to examine further the structures and processes of surgical care prevailing in these hospitals.
authors.affiliation: VA Boston Healthcare System, West Roxbury, Massachusetts 02132, USA. shukri.khuri@med.va.gov
authors.forename: S F
authors.initials: SF
authors.lastname: Khuri
authors.forename: S F
authors.initials: SF
authors.lastname: Najjar
authors.forename: J
authors.initials: J
authors.lastname: Daley
authors.forename: B
authors.initials: B
authors.lastname: Krasnicka
authors.forename: M
authors.initials: M
authors.lastname: Hossain
authors.forename: W G
authors.initials: WG
authors.lastname: Henderson
authors.forename: J B
authors.initials: JB
authors.lastname: Aust
authors.forename: B
authors.initials: B
authors.lastname: Bass
authors.forename: M J
authors.initials: MJ
authors.lastname: Bishop
authors.forename: J
authors.initials: J
authors.lastname: Demakis
authors.forename: R
authors.initials: R
authors.lastname: DePalma
authors.forename: P J
authors.initials: PJ
authors.lastname: Fabri
authors.forename: A
authors.initials: A
authors.lastname: Fink
authors.forename: J
authors.initials: J
authors.lastname: Gibbs
authors.forename: F
authors.initials: F
authors.lastname: Grover
authors.forename: K
authors.initials: K
authors.lastname: Hammermeister
authors.forename: G
authors.initials: G
authors.lastname: McDonald
authors.forename: L
authors.initials: L
authors.lastname: Neumayer
authors.forename: R H
authors.initials: RH
authors.lastname: Roswell
authors.forename: J
authors.initials: J
authors.lastname: Spencer
authors.forename: R H
authors.initials: RH
authors.lastname: Turnage
mesh_terms: D004503:Education, Medical, Graduate; D006761:Hospitals / Q000592:standards; D006784:Hospitals, Teaching / Q000592:standards*; D006787:Hospitals, Veterans / Q000592:standards*; D006801:Humans; D007902:Length of Stay; D008962:Models, Theoretical; D011183:Postoperative Complications; D012044:Regression Analysis; D012307:Risk Factors; D013514:Surgical Procedures, Operative / Q000401:mortality / Q000592:standards*; D016896:Treatment Outcome