DURHAM, N.C. -- A study conducted by Duke University researchers has found that while it costs more to treat people for hip fractures and other conditions at major teaching hospitals, the survival rate is also higher among people initially treated at these facilities.
The study findings, published in the Jan. 28 issue of The New England Journal of Medicine, examines the survival rates among patients initially treated in five different types of hospitals: major teaching, minor teaching, government-run, for-profit and nonprofit. The researchers compared the survival rates for four conditions -- hip fractures, stroke, coronary heart disease and congestive heart failure -- and found that "survival is better for these common conditions for those initially treated in major teaching hospitals."
The Duke researchers used data from Medicare and the 1982, 1984, 1989 and 1994 National Long Term Care Surveys -- longitudinal surveys of the nation's elderly population that were sponsored by the government's National Institute on Aging -- to measure the costs and survival rates. Adjustments were made for about 20 variables, including age and the health of the patient prior to having a stroke or one of the other three health conditions.
"Basically what we found is that, not surprisingly, major teaching hospitals, primarily those located at universities, cost the Medicare program more than non-teaching hospitals do," said Donald Taylor Jr., an assistant research professor of public policy studies at Duke and one of the study's authors, in an interview. "But we did find evidence that such teaching hospitals did deliver better results."
To calculate costs, the Duke researchers looked at Medicare payments for the initial hospital treatment as well as the first six months of after-care, including home health care and outpatient visits. The study found that:
for hip fractures, the six-month cost at major teaching hospitals came
to $17,501, compared to $14,917 at minor teaching hospitals, $14,586 at for-profit
hospitals, $14,569 at nonprofit facilities and $13,266 at government hospitals.
for strokes, the cost at minor teaching hospitals was $14,216, compared
to $13,874 at major teaching hospitals, $12,681 at nonprofits, $11,840 at
for-profits, and $9,097 at government facilities.
for coronary heart disease, the six-month cost was $14,220 at major
teaching hospitals, $11,679 at for-profits, $11,046 at minor teaching
facilities, $10,484 at non-profits, and $8,205 at government-run hospitals.
for congestive heart failure, the cost was $14,161 at for-profits,
$12,756 at major teaching facilities, $10,596 at minor teaching, $9,453 at
nonprofits, and $8,343 at government hospitals.
The study also found major teaching hospitals "had the highest crude survival rate for hip fractures, stroke, and congestive heart failure, and were second to minor teaching hospitals for coronary heart disease.
"Overall, controlling for other determinants of survival, Medicare patients at major teaching hospitals had lower mortality than those admitted to other hospitals," the authors wrote. "Compared to for-profit non-teaching hospitals, mortality was 25 percent lower among patients initially treated in a major teaching hospital."
The researchers defined major teaching hospitals as those with more than one physician resident for every 10 beds; minor teaching hospitals had fewer than one physician resident per 10 beds, but did have some residents.
Frank Sloan, director of the Center for Health Policy, Law & Management at Duke and one of the study's authors, said the three-year study, funded by the National Institute on Aging, adds to the debate about whether Medicare funds are being well-spent.
"Medicare is under substantial financial strain, and one of the subsidies that is on the table is the payment to teaching hospitals for indirect medical education and possibly the disproportionate share subsidies for treating an unusually high number of Medicare and Medicaid patients," Sloan said in an interview. "These are the subsidies for many teaching institutions that are going to make the difference between possibly surviving and not surviving, or at least having financial health and not having financial health.
"Some people say we have too many specialists in this country, maybe we shouldn't have so many of these facilities. But here we're seeing in this case there is a reason that a Medicare beneficiary should care about where they go; that at a teaching facility they seem to do better."
Taylor said the results raise an important question that this study cannot answer: "What is it about what these major teaching hospitals that produce these better outcomes?" Taylor said the Duke researchers, which included Dr. David Whellan of Duke's cardiology division, hope to answer that question in the near future.
In a related study that was presented at a meeting this month of the American Association for the Advancement of Science (AAAS) in Anaheim, Calif., researchers compared Medicare payments, survival rates and quality-of-life issues for patients admitted to for-profit, nonprofit and public hospitals. Teaching hospitals were not part of this study.
Medicare payments for the initial treatment as well as the first six months of after-care for patients with a stroke, hip fracture, coronary heart disease or congestive heart failure were about 6 percent to 8 percent higher at for-profit hospitals than non-profits, and about 20 percent to 25 percent higher than public hospitals, which include city-, county- and state-run hospitals but not federally operated hospitals.
The researchers also wrote that "when quality was measured in terms of survival, the non-profits were better than the for-profits. However, conditional on surviving, patients admitted to for-profit facilities did as well or slightly better in terms of staying out of nursing homes and cognitive and functional status following major health shocks."
The researchers who worked on this study were Sloan, Taylor, Gabriel Picone of the University of South Florida and Duke graduate student Shin-Yi Chou.
Sloan noted in an interview that for-profit companies are becoming increasingly involved in services that were once handled exclusively by government and nonprofit entities, including prisons, schools and medical clinics.
"The argument for for-profits has been, "Let's bring in efficient business practices. The nonprofits and the public facilities are inefficient, people haven't been given the incentives to be efficient, and we're going to bring in modern methods to this very old and important but not-yet- up-to-date industry.' But what you see here is that the for-profits brought in good methods for getting higher reimbursements, but they didn't necessarily bring in the methods that would save the public programs money."
Sloan said the data from these two studies could help Congress decide on ways to keep Medicare solvent. "This and Social Security are two issues that a president and Congress, if they could figure out what to do, would put them in history as very effective public servants," Sloan noted.
Journal
New England Journal of Medicine