Teaching Hospitals and Quality of Care: A Review of the Literature


John Z. Ayanian, M.D., M.P.P., Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave., Boston, MA 02115 (e-mail: ayanian@hcp.med.harvard.edu).


Teaching hospitals are widely reputed to provide high-quality care, eliciting very positive public opinions in surveys across the United States (Boscarino 1992). The U.S. News and World Report's listing of “America's Best Hospitals” (2000), based in part on the opinions of academic and community physicians, highly ranks many major teaching hospitals. These public and professional views may reflect features of teaching hospitals that are perceived to foster a higher quality of care, including the treatment of rare diseases and complex patients, the provision of specialized services and advanced technology, and the conduct of biomedical research (Neely and McInturff 1998). Some services, such as specialized surgery and bone marrow transplants, are provided predominantly at teaching hospitals (Levin, Moy, and Griner 2000). Other distinctive missions of teaching hospitals include medical education and training, innovations in clinical care, and treatment of indigent patients, particularly at public teaching hospitals (Blumenthal, Weissman, and Campbell 1997).

Because teaching hospitals face increasing pressure to justify their higher charges for clinical care, the quality of care in teaching and nonteaching hospitals is an important policy question. The most rigorous peer-reviewed studies published between 1985 and 2001 that assessed quality of care by hospital-teaching status in the United States provide moderately strong evidence of better quality and lower risk-adjusted mortality in major teaching hospitals for elderly patients with common conditions such as acute myocardial infarction, congestive heart failure, and pneumonia. A few studies, however, found nursing care, pediatric intensive care, and some surgical outcomes to be better in nonteaching hospitals. Some factors related to teaching status, such as organizational culture, staffing, technology, and volume, may lead to higher-quality care.