Extensive debate exists in the healthcare community over whether outcomes of medical care at teaching hospitals and other healthcare units are better or worse than those at the respective nonteaching ones. Thus, our goal was to systematically evaluate the evidence pertaining to this question.
Methods and Findings
We reviewed all studies that compared teaching versus nonteaching healthcare structures for mortality or any other patient outcome, regardless of health condition. Studies were retrieved from PubMed, contact with experts, and literature cross-referencing. Data were extracted on setting, patients, data sources, author affiliations, definition of compared groups, types of diagnoses considered, adjusting covariates, and estimates of effect for mortality and for each other outcome. Overall, 132 eligible studies were identified, including 93 on mortality and 61 on other eligible outcomes (22 addressed both). Synthesis of the available adjusted estimates on mortality yielded a summary relative risk of 0.96 (95% confidence interval [CI], 0.93–1.00) for teaching versus nonteaching healthcare structures and 1.04 (95% CI, 0.99–1.10) for minor teaching versus nonteaching ones. There was considerable heterogeneity between studies (I2 = 72% for the main analysis). Results were similar in studies using clinical and those using administrative databases. No differences were seen in the 14 studies fully adjusting for volume/experience, severity, and comorbidity (relative risk 1.01). Smaller studies did not differ in their results from larger studies. Differences were seen for some diagnoses (e.g., significantly better survival for breast cancer and cerebrovascular accidents in teaching hospitals and significantly better survival from cholecystectomy in nonteaching hospitals), but these were small in magnitude. Other outcomes were diverse, but typically teaching healthcare structures did not do better than nonteaching ones.
The available data are limited by their nonrandomized design, but overall they do not suggest that a healthcare facility's teaching status on its own markedly improves or worsens patient outcomes. Differences for specific diseases cannot be excluded, but are likely to be small.
Published data do not suggest that the teaching status of a hospital or other healthcare facility alone influences the outcome of patients treated in that facility.
When people need medical treatment they may be given it in a “teaching hospital.” This is a place where student doctors and other trainee healthcare workers are receiving part of their education. They help give some of the treatment that patients receive. Teaching hospitals are usually large establishments and in most countries they are regarded as being among the very best hospitals available, with leading physicians and surgeons among the staff. It is usually assumed that patients who are being treated in a teaching hospital are lucky, because they are getting such high-quality healthcare. However, it has sometimes been suggested that, because some of the people involved in their care are still in training, the patients may face higher risks than those who are in nonteaching hospitals.
Why Was This Study Done?
The researchers wanted to find out which patients do best after treatment—those who were treated in teaching hospitals or those who were in nonteaching hospitals. This is a difficult issue to study. The most reliable way of comparing two types of treatment would be to decide at random which treatment each patient should receive. (For more on this see the link below for “randomized controlled trials.”) In practice, it would be difficult to set up a study where the decision on which hospital a patient should go to was made at random. One problem is that, because of the high reputation of teaching hospitals, the patients whose condition is the most serious are often sent there, with other patients going to nonteaching hospitals. It would not be a fair test to compare the “outcome” for the most seriously ill patients with the outcome for those whose condition was less serious.
What Did the Researchers Do and Find?
The researchers conducted a thorough search for studies that had already been done, which met criteria which the researchers had specified in advance. This type of research is called a “systematic review.” They found 132 studies that had compared the outcomes of patients in teaching or nonteaching hospitals. None of these studies was a trial. (They were “observational studies” where researchers had gathered information on what was already taking place, rather than setting up an experiment.) However, in 14 studies, extensive allowances had been made for differences in such factors as the severity of the patients' condition, and whether or not they had more than one type of illness when they were treated. There was a great deal of variability in the results between the studies but, overall, there was no major difference in the effectiveness of treatment provided by the two types of hospital.
What Do These Findings Mean?
There is no evidence to support that it is better to be given treatment in a teaching or a nonteaching hospital. The authors do note that a limitation in their analysis is that it was based on studies that were not randomized controlled trials. They also raise the question that differences might be found if considering specific diseases one by one, rather than putting information on all conditions together. However, they believe that any such difference would be small. Their findings will be useful in the continuing debate on the most effective ways to train doctors, while at the same time providing the best possible care for patients.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030341.
Wikipedia entry on teaching hospitals (note: Wikipedia is a free online encyclopedia that anyone can edit)
Information on randomized clinical trials from the US National Institutes of Health
A definition of systematic reviews from the Cochrane Collaboration, an organization which produces systematic reviews
All of the above include links to other Web sites where more detailed information can be found.