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Many studies over the past 20 years have found an association between receiving treatment at a university or teaching hospital and decreased hospital mortality [1–3]. However, few studies have assessed this question specifically among critically ill patients [4]. Recently, a study by Raymondos and colleagues examined the relationship between care in a university hospital and mortality for patients with the acute respiratory distress syndrome (ARDS) [5]. The study was a sub-analysis of a prospective, observational cohort of patients with respiratory failure (Second VENTILA study) [6]. The authors found that, although the characteristics of ARDS patients were somewhat similar between hospitals, unadjusted hospital mortality was significantly higher in non-university hospitals compared with university hospitals (57.5 versus 39.3%; absolute difference of 18.2%, p = 0.012). This difference remained after adjustment for patient factors, as well as factors related to individual patient management, complications during ventilation, and hospital characteristics (odds ratio 2.89; 95% confidence interval 1.31–6.38). Furthermore, they found a 9.6% increase in hospital mortality for ventilated patients who were not diagnosed with ARDS. Previous studies examining the care of surgical patients have hypothesized that the presence of residents in the operating room may lead to higher mortality, but have often found either similar or better mortality [3]. Often this lower mortality is attributed to the volume of cases at these centers [3]. In the study by Raymondos et al. the university hospitals were much bigger, with more hospital beds and more ICU beds per unit, but they were not able to show a relationship between volume of ARDS patients in each hospital and outcomes. However, it is important to note that many hospitals in the study only had one or two ARDS patients during the one-month study period. In addition to case volume, other factors may be important in the care of critically ill patients. For instance, implementation of recent, accepted best practice may be different between university and non-university hospitals. In the CESAR study, a randomized controlled trial of transfer to regional extracorporeal membrane oxygenation (ECMO) centers, one hypothesis for the better outcomes for these patients was better adherence to overall best care practices, including low tidal volume ventilation [7]. However, data from Germany assessing ICU care for sepsis patients found that university hospitals had similar rates of compliance with guidelines compared with other hospitals, despite reporting higher adherence [4]. Staffing in ICUs may also be very different in university hospitals. Depending on the system, this may include an overall higher physician to patient ratio due to the presence of trainees on the team, increased access to specialists, and/or more involvement of multidisciplinary team members, such as pharmacists on rounds. While the presence of trainees and specialists will certainly be increased at academic centers worldwide, and multidisciplinary care teams are more frequent in ICUs in teaching hospitals in the US [8], their presence elsewhere is not well described. Another challenge in comparing the outcomes for patients at university and non-university settings is the practice of transferring patients who are very sick but considered salvageable to larger, academic centers [9]. In the study by Raymondos et al., it is unclear how such transfers were accounted for. However, every hospital system has either formal or informal transfer networks [10]. Such transfers to tertiary care centers may skew reported outcomes in the different locations. * Correspondence: hannah.wunsch@sunnybrook.ca Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room D1.08, Toronto, Ontario M4N 3M5, Canada Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada Full list of author information is available at the end of the article

Care at a non-university hospital: an independent risk factor for mortality in ARDS?