Rationale and Objectives
This study aimed to characterize associations between availability of imaging services and intensity of teaching among US hospitals.
Materials and Methods
Using the American Hospital Association Annual Survey Database, we studied information regarding the availability of imaging services at general hospitals nationwide in 2007 (4102 hospitals) and in 2012 (3876). Teaching intensity was categorized as Council of Teaching Hospitals (COTH) member, non-COTH teaching hospital (non-COTH member with affiliated medical school and/or residency), and nonteaching hospital. Availability in hospitals of reported basic and advanced imaging modalities, as well as beds, number of employed physicians, and case mix index, was analyzed. Univariable and multivariable trends were assessed.
Results
All 15 assessed modalities showed significant increases in availability with increasing hospital teaching intensity ( P < 0.001). Modalities showing the largest differences between COTH and nonteaching hospitals in 2012 were image-guided radiation therapy (78% vs. 14%), positron emission tomography/computed tomography (74% vs. 17%), and single-photon emission computed tomography (88% vs. 35%). The gap between COTH and nonteaching hospitals increased from 43% in 2007 to 57% in 2012 for positron emission tomography/computed tomography, and from 34% to 48% for virtual colonoscopy. COTH status was a significant predictor, independent of beds and employed physicians, for 10 modalities ( P < 0.001–0.038). Greater case mix index was significantly associated with availability of advanced, although not basic, modalities.
Conclusions
Availability of imaging services increased with greater hospital teaching intensity. Differences were most pronounced and sustained over time for advanced modalities. Our findings reflect the greater advanced imaging resources necessary to support the complexity of care rendered at teaching hospitals. This differential must be considered when exploring adjustments to teaching hospitals’ funding levels.
Introduction
Robust graduate medical education (GME) is vital in ensuring a future supply of well-trained physicians. However, GME is a costly process. Training programs entail considerable direct costs, such as the salaries and benefits of residents and their supervising faculty, as well as the administrative and overhead costs of operating an accredited training program. In addition, teaching hospitals face greater costs relating to offering more advanced and specialized services, as well as caring for a greater fraction of sicker, more complex, and uninsured patients .
GME is largely funded by the Medicare program , which provides teaching hospitals with both a direct GME payment to cover teaching costs as well as an indirect medical education (IME) payment to cover teaching hospitals’ greater overall cost of patient care . Concerns regarding the solvency of the Medicare program have driven continual efforts to curtail Medicare’s GME funding . For instance, the Balanced Budget Act in 1997 capped the number of nationally funded GME positions and substantially reduced the IME add-on percentage . MedPAC, the National Commission on Fiscal Responsibility and Reform, the Congressional Budget Office, as well as several recent annual White House budgets have all called for further large reductions in Medicare’s GME funding, typically targeting IME payments . Some policymakers have even suggested that Medicare cease funding GME altogether .
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Methods
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Results
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TABLE 1
Characteristics of General Hospitals Included in the Study
Hospital Characteristic Nonteaching Non-COTH Teaching COTH Teaching_P_2007n 3084 733 285 Total beds \* 114 ± 114 264 ± 187 541 ± 284 <0.001 FTE physicians \* 7 ± 18 31 ± 63 142 ± 268 <0.001 Case mix index \* 1.41 ± 0.27 1.61 ± 0.27 1.85 ± 0.28 <0.0012012n 2787 822 267 Total beds \* 108 ± 109 274 ± 206 576 ± 321 <0.001 FTE physicians \* 9 ± 21 33 ± 78 189 ± 339 <0.001 Case mix index \* 1.44 ± 0.29 1.62 ± 0.24 1.92 ± 0.26 <0.001
COTH, Council of Teaching Hospitals; FTE, full-time equivalent.
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TABLE 2
Comparison of Availability of Imaging Modalities Among Hospitals with Varying Teaching Intensity in 2007 and in 2012
Modality Nonteaching Non-COTH Teaching COTH Teaching Nonteaching Non-COTH Teaching COTH Teaching Difference (COTH vs. Nonteaching) 2007 2007 2007 2012 2012 2012 2007 2012 CT 93% 98% 100% 96% 98% 99% 7% 3% Multi-slice spiral CT 57% 76% 90% 63% 81% 90% 33% 27% 64-slice spiral CT 23% 47% 72% 41% 72% 94% 49% 53% Electron-beam CT 5% 13% 25% 5% 15% 29% 20% 24% Ultrasound 90% 98% 99% 91% 97% 99% 9% 8% MRI 63% 83% 95% 71% 87% 97% 32% 26% PET 10% 26% 54% 12% 30% 60% 44% 48% PET/CT 11% 28% 54% 17% 37% 74% 43% 57% SPECT 34% 60% 87% 35% 59% 88% 53% 53% Mammography 80% 90% 90% 81% 90% 92% 10% 11% Full-field digital mammography 21% 38% 60% 57% 74% 85% 39% 28% Diagnostic radioisotope facility 56% 82% 94% 59% 84% 93% 38% 34% Intra-operative MRI 2% 6% 19% 3% 7% 21% 17% 18% Image-guided radiation therapy 9% 26% 54% 14% 41% 78% 45% 64% Virtual colonoscopy 12% 23% 46% 13% 28% 61% 34% 48%
COTH, Council of Teaching Hospitals; CT, computed tomography; MRI, magnetic resonance imaging; PET, positron emission tomography; SPECT, single-photon emission computed tomography.
TABLE 3
Comparison of Availability of Imaging Modalities in 2012 Among Hospitals with Varying Teaching Intensity, Stratified by Availability Solely at the Hospital vs. Availability Either at the Hospital or Through the Hospital System, Network, or Joint Venture
Modality Nonteaching Non-COTH Teaching COTH Teaching Nonteaching Non-COTH Teaching COTH Teaching Difference (COTH vs. Nonteaching) Hospital Hospital Hospital All All All Hospital All CT 96% 98% 99% 97% 99% 100% 3% 3% Multi-slice spiral CT 63% 81% 90% 68% 86% 92% 27% 24% 64-slice spiral CT 41% 72% 94% 48% 79% 95% 53% 47% Electron-beam CT 5% 15% 29% 10% 24% 36% 24% 26% Ultrasound 91% 97% 99% 97% 99% 100% 8% 3% MRI 71% 87% 97% 91% 98% 100% 26% 9% PET 12% 30% 60% 32% 59% 81% 48% 49% PET/CT 17% 37% 74% 37% 70% 92% 57% 55% SPECT 35% 59% 88% 43% 69% 93% 53% 50% Mammography 81% 90% 92% 88% 97% 99% 11% 11% Full-field digital mammography 57% 74% 85% 63% 83% 93% 28% 30% Diagnostic radioisotope facility 59% 84% 93% 66% 89% 97% 34% 31% Intra-operative MRI 3% 7% 21% 7% 15% 31% 18% 24% Image-guided radiation therapy 14% 41% 78% 27% 60% 88% 64% 61% Virtual colonoscopy 13% 28% 61% 19% 38% 70% 48% 51%
COTH, Council of Teaching Hospitals; CT, computed tomography; MRI, magnetic resonance imaging; PET, positron emission tomography; SPECT, single-photon emission computed tomography. “All” refers to availability of the modality through the hospital system, network, or joint venture.
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TABLE 4
P Values From Multivariable Logistic Regression to Identify Significant Independent Predictors of Availability of the Imaging Modalities, Based on the 2012 Data \*
Modality COTH Status Total Beds FTE Physicians CT0.030<0.001 0.113 Multi-slice spiral CT0.035<0.001 0.057 64-slice spiral CT 0.740<0.001<0.001 Electron-beam CT 0.150<0.001 0.989 Ultrasound0.015<0.001<0.001 MRI 0.835<0.001 0.469 PET0.038<0.001 0.105 PET/CT0.022<0.0010.003 SPECT 0.284<0.0010.003 Mammography<0.001<0.001 0.818 Full-field digital mammography 0.329<0.001 0.447 Diagnostic radioisotope facility<0.001<0.001<0.001 Intra-operative MRI0.003<0.001 0.767 Image-guided radiation therapy0.001<0.001 0.105 Virtual colonoscopy<0.001<0.0010.016
COTH, Council of Teaching Hospitals; CT, computed tomography; FTE, full-time equivalent; MRI, magnetic resonance imaging; PET, positron emission tomography; SPECT, single-photon emission computed tomography.
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TABLE 5
Comparison of CMI Between Hospitals with and without Availability of the Imaging Modalities \*
Modality Not Available Available_P_ CT 1.63 ± 0.64 1.53 ± 0.300.020 Multi-slice spiral CT 1.41 ± 0.33 1.57 ± 0.30<0.001 64-slice spiral CT 1.40 ± 0.34 1.60 ± 0.27<0.001 Electron-beam CT 1.51 ± 0.31 1.71 ± 0.29<0.001 Ultrasound 1.60 ± 0.66 1.53 ± 0.30 0.075 MRI 1.36 ± 0.39 1.56 ± 0.29<0.001 PET 1.48 ± 0.30 1.70 ± 0.28<0.001 PET/CT 1.46 ± 0.31 1.68 ± 0.27<0.001 SPECT 1.44 ± 0.34 1.60 ± 0.27<0.001 Mammography 1.54 ± 0.51 1.53 ± 0.28 0.643 Full-field digital mammography 1.46 ± 0.38 1.56 ± 0.28<0.001 Diagnostic radioisotope facility 1.40 ± 0.42 1.56 ± 0.28<0.001 Intra-operative MRI 1.52 ± 0.30 1.79 ± 0.34<0.001 Image-guided radiation therapy 1.45 ± 0.31 1.69 ± 0.26<0.001 Virtual colonoscopy 1.49 ± 0.31 1.67 ± 0.29<0.001
CMI, case mix index; CT, computed tomography; MRI, magnetic resonance imaging; PET, positron emission tomography; SPECT, single-photon emission computed tomography.
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Discussion
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