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Teaching Intensity, Race and Surgical Outcomes Jeffrey H. Silber The University of Pennsylvania The Children’s Hospital of Philadelphia

Teaching Intensity, Race and Surgical Outcomes

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Teaching Intensity, Race and Surgical Outcomes. Jeffrey H. Silber The University of Pennsylvania The Children’s Hospital of Philadelphia. Acknowledgments. Jeffrey H. Silber, M.D., PhD Paul R. Rosenbaum, PhD Patrick S. Romano, MD Amy K. Rosen, PhD Yanli Wang, MS Michael J. Halenar, BA - PowerPoint PPT Presentation

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Page 1: Teaching Intensity, Race and Surgical Outcomes

Teaching Intensity, Race and Surgical Outcomes

Jeffrey H. Silber

The University of PennsylvaniaThe Children’s Hospital of Philadelphia

Page 2: Teaching Intensity, Race and Surgical Outcomes

AcknowledgmentsJeffrey H. Silber, M.D., PhDPaul R. Rosenbaum, PhDPatrick S. Romano, MD

Amy K. Rosen, PhDYanli Wang, MS

Michael J. Halenar, BAOrit Even-Shoshan, MS

Kevin G. Volpp, MD, PhD

The University of Pennsylvania School of Medicine; The Wharton School, The Children’s Hospital of Philadelphia,

The University of California, Davis, and Boston University; The U.S.Veterans Administration Hospitals in

Philadelphia and Boston.Funding: NHLBI (R01 HL082637) and VA (IIR 04-202)

Page 3: Teaching Intensity, Race and Surgical Outcomes

Background• Teaching hospitals often show better

surgical outcomes for mortality based measures than non-teaching hospitals

• At the same time, it is well known that blacks obtain a disproportionate share of their care at teaching hospitals, yet do not generally display better adjusted outcomes than whites

Page 4: Teaching Intensity, Race and Surgical Outcomes

Background• While black patients have generally been

observed to have worse outcomes, some studies [see Polsky and Volpp HSR 2008 and Volpp and Polsky HSR 2007], report that 30-day mortality may actually be lower in blacks than whites, with this lower mortality rate switching to higher mortality over a longer time horizon.

Page 5: Teaching Intensity, Race and Surgical Outcomes

Background

• In our recent work [Anesthesiology 2007], we reported a clear difference in length of procedures by race, especially at teaching hospitals.

• Using Medicare anesthesiologist billing data in Pennsylvania, controlling for procedure and patient comorbidities, surgery on black patients took on average 30 minutes longer than similar surgery on white patients. After controlling for the hospital, there remained a significant 7 to 9 minute difference, with some teaching hospitals displaying racial differences of 15 minutes.

Page 6: Teaching Intensity, Race and Surgical Outcomes

Motivation• Given:

– (1) the differences observed in outcomes between teaching-intensive and non-teaching hospitals

– (2) the high proportion of black patients at teaching-intensive hospitals

– (3) Differential procedure time between black and white patients (potentially reflecting differential attending involvement)

• Any analysis of differential outcomes across hospitals with different teaching intensity must include an analysis that examines the interaction of teaching intensity and race.

Page 7: Teaching Intensity, Race and Surgical Outcomes

Aims

• To determine whether there are improved mortality outcomes at teaching intensive hospitals, and if so was this based on lower complication rates or lower death rates after complications (failure-to-rescue)

• To determine whether differential outcomes for black patients observed between teaching-intensive and non-teaching hospitals is similar to those of white patients

Page 8: Teaching Intensity, Race and Surgical Outcomes

Study Population

• MEDPAR data from 2000-2005 for the entire US

• Include General Surgery, Orthopedics and Vascular Surgery

• Exclude patients in Managed Care plans

• Choose the first admission for each patient

• 3270 Acute Care Hospitals

• 4.6 million patients

Page 9: Teaching Intensity, Race and Surgical Outcomes

The Resident to Bed Ratio• We utilized the Resident-to-Bed Ratio as our

measure of teaching intensity

• The RB ratio is defined as the total number of residents at a hospital divided by the hospital’s average daily census (ADC), as reported to Medicare using Medicare Cost Reports

• RB ratios are classified as follows:– RB = 0 (non-teaching)

– 0<RB<0.05 (very minor teaching)

– .05<RB<0.25 (minor teaching)

– 0.25<RB<0.6 (major teaching hospitals)

– RB > 0.6 (very major teaching hospitals).

Page 10: Teaching Intensity, Race and Surgical Outcomes

Statistical Methods

• Risk Adjustment – Procedures, Elixhauser Comorbidities, Age,

Sex– Interactions: comorbidities, procedures

• Models – Logistic regression with and without fixed

effects for hospital– Random effects model (SAS GLIMMIX)

clustering by hospital

Page 11: Teaching Intensity, Race and Surgical Outcomes

RESULTS

Page 12: Teaching Intensity, Race and Surgical Outcomes

RB Ratio and Hospital Characteristics Non- Very Very

Hospital Variable Teaching Minor Minor Major Major

RB Ratio 0 0<RB<0.05 .05<RB<.25 .25<RB<.6 .6<RB<1.1

_________________________________________________________________________

N. Hospitals (%) 2251 307 409 194 109

(68.83%) (9.38%) (12.51%) (5.93%) (3.33%)

N. Patients (%) 2,247,368 693,023 999,633 450,695 240,489

(48.53%) (14.96%) (21.58%) (9.73%) (5.19%)

Hosp Beds: Median 118 260 295 383 477

Hosp Surg Vol: Median 1192 3423 4058 4681 7429

Technology Index (%) 19 51 62 59 83

NTB Ratio Median 1.29 1.38 1.48 1.60 2.02

Nurse Mix: Median 0.85 0.90 0.92 0.94 0.95

Page 13: Teaching Intensity, Race and Surgical Outcomes

Patient Characteristics by Race and RB RatioVariable RB = 0 RB > 0.6 RB = 0 RB > 0.6

Black Black White White

# Patients 114,448 28,899 2,080,165 199,686

Age (mean) 75.68 74.91 76.66 75.43

Male % 33.83 34.98 37.66 44.30

# Comorbids (mean) 2.76 2.60 2.07 2.02

HBP % 72.87 73.49 57.52 57.17

COPD % 16.38 15.40 19.40 16.46

Diabetes % 28.57 26.40 16.24 14.90

CHF % 15.82 14.13 11.89 9.70

PeripheralVasc Dis % 11.91 11.30 6.95 9.18

Renal Failure % 8.38 6.58 2.81 2.36

Page 14: Teaching Intensity, Race and Surgical Outcomes

Patient Characteristics by Race and RB Ratio

Variable RB = 0 RB > 0.6 RB = 0 RB > 0.6 Black Black White White

N. Patients 114,448 28,899 2,080,165 199,686

Death Rate (%) 5.06 5.21 4.23 3.94

Comp. Rate (%) 51.5 50.2 42.9 41.9

Failure Rate (%) 9.84 10.37 9.91 9.40

Page 15: Teaching Intensity, Race and Surgical Outcomes

The Resident-to-Bed Ratio and its Association with Mortality, Complication and Failure-to-Rescue

RB Ratio 95% CI P-value N (millions) Rate (%) C-Stat

Mortality 0.86 (0.85, 0.88) p<0.0001 4.66 4.23% 0.850

Mortality (RE) 0.92 (0.89, 0.95) p<0.0001 4.66 4.23% 0.853

Complications 1.00 (0.99, 1.00) p=0.141 4.66 43.39% 0.764

Compl. (RE) 0.99 (0.97, 1.01) p=0.60 4.66 43.39% 0.775

FTR 0.86 (0.85, 0.88) p<0.0001 2.02 9.75% 0.775

FTR (RE) 0.91 (0.88, 0.94) p<0.0001 2.02 9.75% 0.781

Adjustments included patient covariates but not race or income. Results including income adjustment yielded almost identical results. RB ratio reported as RB = 0 versus RB = 0.6

Page 16: Teaching Intensity, Race and Surgical Outcomes

Influence of RB Ratio and Race on the Odds of 30-day Mortality

Model 1 Model 2 Model 3 Model 4 Fixed Effects Random Effects

Black Vs. White 0.94 0.94 0.92 0.92(RB=0) (0.92, 0.96) (0.92, 0.96) (0.90, 0.94) (0.91, 0.94)

p<0.0001 p<0.0001 p<0.0001 p<0.0001

RB Ratio x 1.05 1.26 1.13 1.18Black (1.00, 1.10) (1.20, 1.31) (1.08, 1.20) (1.13, 1.24)

p=0.03 p<0.0001 p<0.0001 p<0.0001

RB Ratio x 0.84White (0.82, 0.85) ------ ------ ------

p<0.0001

RB Ratio 0.84 0.89 ------ (0.83, 0.84) ------ (0.87, 0.90)

p<0.0001 p<0.0001

Note: In these tables we report models for the combined surgery group only. Separate models usinggeneral surgery, orthopedics or vascular surgery without and with adjustment for the individual hospital(a fixed effects approach) produced mostly similar results. Note also, RB change is 0 vs. 0.6

Page 17: Teaching Intensity, Race and Surgical Outcomes

Influence of RB Ratio and Race on the Odds of Complications

Model 1 Model 2 Model 3 Model 4 Fixed Effects Random Effects

Black Vs. White 1.26 1.26 1.27 1.27(RB=0) (1.24, 1.27) (1.24, 1.27) (1.26, 1.29) (1.26, 1.28)

p<0.0001 p<0.0001 p<0.0001 p<0.0001

RB Ratio x 0.97 0.99 0.98 0.98Black (0.95, 0.99) (0.97, 1.01) (0.96, 1.00) (0.95, 1.02)

p=0.004 p=0.25 p=0.09 p=0.13

RB Ratio x 0.98White (0.98, 0.99) ------ ------ ------

p<0.0001

RB Ratio 0.98 0.98 ------ (0.98, 0.99) ------ (0.96, 1.00)

p<0.0001 p=0.94

Note: In these tables we report models for the combined surgery group only. Separate models usinggeneral surgery, orthopedics or vascular surgery without and with adjustment for the individual hospital(a fixed effects approach) produced mostly similar results. Note also, RB change is 0 vs. 0.6

Page 18: Teaching Intensity, Race and Surgical Outcomes

Influence of RB Ratio and Race on the Odds of Failure-to-Rescue

Model 1 Model 2 Model 3 Model 4 Fixed Effects Random Effects

Black Vs. White 0.87 0.87 0.84 0.85(RB=0) (0.85, 0.89) (0.85, 0.89) (0.82, 0.86) (0.84, 0.86)

p<0.0001 p<0.0001 p<0.0001 p<0.0001

RB Ratio x 1.04 1.24 1.14 1.18Black (1.00, 1.09) (1.18, 1.30) (1.08, 1.20) (1.12, 1.24)

p=0.06 p<0.0001 p<0.0001 p<0.0001

RB Ratio x 0.84White (0.83, 0.86) ------ ------ ------

p<0.0001

RB Ratio 0.84 0.89 ------ (0.84, 0.85) ------ (0.87, 0.91)

p<0.0001 p<0.0001

Note: In these tables we report models for the combined surgery group only. Separate models usinggeneral surgery, orthopedics or vascular surgery without and with adjustment for the individual hospital(a fixed effects approach) produced mostly similar results. Note also, RB change is 0 vs. 0.6

Page 19: Teaching Intensity, Race and Surgical Outcomes

Unadjusted Mortality

0

1

2

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Black White

Race

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rtal

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RB=0

RB=0.6

Page 20: Teaching Intensity, Race and Surgical Outcomes

Figure 1A: Standardized Mortality Rates

0

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White Black

Race

Mo

rta

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RB=0

RB=0.6

Page 21: Teaching Intensity, Race and Surgical Outcomes

Unadjusted Complications

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10

20

30

40

50

60

White Black

Race

Co

mp

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ion

Rat

e

RB=0

RB=0.6

Page 22: Teaching Intensity, Race and Surgical Outcomes

Figure 1B: Standardized Complication Rates

0

10

20

30

40

50

60

White Black

Race

Co

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n R

ate

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Page 23: Teaching Intensity, Race and Surgical Outcomes

Unadjusted Failure-to-Rescue

0

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4

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8

10

12

White Black

Race

FT

R R

ate

RB=0

RB=0.6

Page 24: Teaching Intensity, Race and Surgical Outcomes

Figure 1C: Standardized Failure-to-Rescue Rates

0

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White Black

Race

FT

R R

ate

RB=0

RB=0.6

Page 25: Teaching Intensity, Race and Surgical Outcomes

Summary

• Higher teaching intensity is associated with lower mortality

• This better mortality is due to better failure-to-rescue and not lower complications

• However, when blacks are treated at teaching-intensive hospitals they do not experience the same relative benefits as their white counterparts when each group is compared to their outcomes at less teaching-intensive hospitals

Page 26: Teaching Intensity, Race and Surgical Outcomes

Conclusions

• Teaching intensive hospitals must seek to better understand why blacks do not seem to reap the same relative benefits of teaching hospitals as their white counterparts

• These findings are especially concerning, as all patients in this report have Medicare

• These findings may aid in explaining why blacks may sometimes avoid admission to teaching hospitals, despite close proximity