Article Writeup Premise: You are an MS3 on your cardiology rotation at the Cleveland Clinic.

As you are rounding with your attending, the team passes a banner proclaiming, #1 in Cardiac Care!! In order to distract your attending from noticing that your chief resident is flirting with the cute nurse in Pod #2, you ask, Do patients really receive better care at a big academic hospital like CCF, or is that just a marketing stunt? Your attending hands you a paper that came out in AJM this month regarding just that topic and asks you to present the findings on rounds tomorrow. The Study: Belle et al. Quality of care for myocardial infarction at academic and nonacademic hospitals. Am J Med. 2012 Apr;125(4):365-73. Background: Academic hospitals are widely-proclaimed for their excellence of care due to their possession of next-generation technology and being on the cutting edge of current research. However, patients are also treated by teams including medical students and residents, which have been thought to possibly decrease their quality of care. Previous studies have found no overall benefit of survival at academic hospitals, but no studies of significance have been published since the early 1990s. Question: Do patients with acute MI treated at an academic hospital have a survival advantage over patients seen at a non-academic hospital? Method: Post-hoc analysis of data from a previous prospective cohort study (the French registry of Acute ST elevation or non-ST-elevation Myocardial Infarction [FAST-MI]) Population: 3059 patients admitted to 222 hospitals with ICUs over a period of 1 month. Patients were eligible if they had (1) serum markers of cardiac ischemia more than 2x upper limit of normal and (2) symptoms consistent with acute MI or ECG changes in at least 2 contiguous leads. Risk Factor: Patients treated at academic hospitals (defined as being attached to a university with medical students and residents regularly involved in daily care) were compared with those treated at non-academic hospitals. Outcome: Estimates of all-cause mortality at 30 days, 90 days, and 1 year were 6%, 8%, and 10% (academic) and 8%, 10%, and 15% (non-academic). When adjusted for percutaneous coronary intervention capability and receipt of reperfusion and guideline-recommended drug therapies, all differences in mortality between academic and non-academic hospitals disappeared.

Academic hospitals deliver better processes of care for patients with MI than do non-academic hospitals Academic status does not confer a survival advantage (or disadvantage) in and of itself (benefit was derived entirely from the consistency of use of guideline-recommended therapies) Comments: Strengths: Large cohort. Well-controlled study accounting for differences in processes of care. Weaknesses: Patients were not randomized, so unaccounted-for variables may have influenced the outcomes (for instance, factors determining whether patients were taken to an academic vs. non-academic hospital in the first place [selection bias]). Study did not look into possible detrimental effects of involvement of students and residents (medical errors, delays in care, etc.) despite this being part of the rationale. Finally, this study was performed in France, and utilization of standards of care have been shown to vary widely between countries, so this data may be less applicable in the US. Your Answer: Ultimately, yes, patients treated at academic hospitals have a better shot at surviving an acute MI than those at non-academic hospitals. However, this is most likely because academic hospitals tend to follow treatment guideline recommendations more consistently, as well as having greater access to resources like cardiac catheterization labs and PCI capabilities. That afternoon, your attending fills out an exceptional CAS evaluation for your presentation on rounds, and your chief does the same as thanks for saving his butt on rounds the day before.