Association of Hospitalist Years of Experience With Mortality in the Hospitalized Medicare Population

Exploring Clinical Lessons Learned by Experienced Hospitalists from Diagnostic Errors and Successes

BACKGROUND

Diagnostic errors cause significant patient harm. The clinician's ultimate goal is to achieve diagnostic excellence in order to serve patients safely. This can be accomplished by learning from both errors and successes in patient care. However, the extent to which clinicians grow and navigate diagnostic errors and successes in patient care is poorly understood. Clinically experienced hospitalists, who have cared for numerous acutely ill patients, should have great insights from their successes and mistakes to inform others striving for excellence in patient care.

OBJECTIVE

To identify and characterize clinical lessons learned by experienced hospitalists from diagnostic errors and successes.

DESIGN

A semi-structured interview guide was used to collect qualitative data from hospitalists at five independently administered hospitals in the Mid-Atlantic area from February to June 2022.

PARTICIPANTS

12 academic and 12 community-based hospitalists with ≥ 5 years of clinical experience.

APPROACH

A constructivist qualitative approach was used and "reflexive thematic analysis" of interview transcripts was conducted to identify themes and patterns of meaning across the dataset.

RESULTS

Five themes were generated from the data based on clinical lessons learned by hospitalists from diagnostic errors and successes. The ideas included appreciating excellence in clinical reasoning as a core skill, connecting with patients and other members of the health care team to be able to tap into their insights, reflecting on the diagnostic process, committing to growth, and prioritizing self-care.

CONCLUSIONS

The study identifies key lessons learned from the errors and successes encountered in patient care by clinically experienced hospitalists. These findings may prove helpful for individuals and groups that are authentically committed to moving along the continuum from diagnostic competence towards excellence.

Comparison of Hospital Mortality and Readmission Rates by Physician and Patient Sex

BACKGROUND

Little is known as to whether the effects of physician sex on patients' clinical outcomes vary by patient sex.

OBJECTIVE

To examine whether the association between physician sex and hospital outcomes varied between female and male patients hospitalized with medical conditions.

DESIGN

Retrospective observational study.

SETTING

Medicare claims data.

PATIENTS

20% random sample of Medicare fee-for-service beneficiaries hospitalized with medical conditions during 2016 to 2019 and treated by hospitalists.

MEASUREMENTS

The primary outcomes were patients' 30-day mortality and readmission rates, adjusted for patient and physician characteristics and hospital-level averages of exposures (effectively comparing physicians within the same hospital).

RESULTS

Of 458 108 female and 318 819 male patients, 142 465 (31.1%) and 97 500 (30.6%) were treated by female physicians, respectively. Both female and male patients had a lower patient mortality when treated by female physicians; however, the benefit of receiving care from female physicians was larger for female patients than for male patients (difference-in-differences, -0.16 percentage points [pp] [95% CI, -0.42 to 0.10 pp]). For female patients, the difference between female and male physicians was large and clinically meaningful (adjusted mortality rates, 8.15% vs. 8.38%; average marginal effect [AME], -0.24 pp [CI, -0.41 to -0.07 pp]). For male patients, an important difference between female and male physicians could be ruled out (10.15% vs. 10.23%; AME, -0.08 pp [CI, -0.29 to 0.14 pp]). The pattern was similar for patients' readmission rates.

LIMITATION

The findings may not be generalizable to younger populations.

CONCLUSION

The findings indicate that patients have lower mortality and readmission rates when treated by female physicians, and the benefit of receiving treatments from female physicians is larger for female patients than for male patients.

PRIMARY FUNDING SOURCE

Gregory Annenberg Weingarten, GRoW @ Annenberg.

Perceptions of Clinical Experience and Scientific Evidence in Medical Decision Making: A Survey of a Stratified Random Sample of Swedish Health Care Professionals

BACKGROUND

Evidence-based medicine recognizes that clinical expertise gained through experience is essential to good medical practice. However, it is not known what beliefs clinicians hold about how personal clinical experience and scientific knowledge contribute to their clinical decision making and how those beliefs vary between professions, which themselves vary along relevant characteristics, such as their evidence base.

DESIGN

We investigate how years in the profession influence health care professionals' beliefs about science and their clinical experience through surveys administered to random samples of Swedish physicians, nurses, occupational therapists, dentists, and dental hygienists. The sampling frame was each profession's most recent occupational registry.

RESULTS

Participants (N = 1,627, 46% response rate) viewed science as more important for decision making, more certain, and more systematic than experience. Differences among the professions were greatest for systematicity, where physicians saw the largest gap between the 2 types of knowledge across all levels of professional experience. The effect of years in the profession varied; it had little effect on assessments of importance across all professions but otherwise tended to decrease the difference between assessments of science and experience. Physicians placed the greatest emphasis on science over clinical experience among the 5 professions surveyed.

CONCLUSIONS

Health care professions appear to share some attitudes toward professional knowledge, despite the variation in the age of the professions and the scientific knowledge base available to practitioners. Training and policy making about clinical decision making might improve by accounting for the ways in which knowledge is understood across the professions.

HIGHLIGHTS

Study participants, representing 5 health care professions-medicine, nursing, occupational therapy, dentistry, and dental hygiene-viewed science as more important for decision making, more certain, and more systematic than their personal clinical experience.Of all the professions represented in the study, physicians saw the greatest differences between the 2 types of knowledge.The effect of years of professional experience varied but tended to be small, attenuating the differences seen between science and clinical experience.

Missing Voices: What Early Career Hospitalists View as Essential in Hospital Medicine-Focused Education

OBJECTIVES

Acknowledging that a successful career in hospital medicine (HM) requires specialized skills, residency programs have developed hospital medicine-focused education (HMFE) programs. Surveys of Internal Medicine residency leaders have described HMFE curricula but are limited to that specialty and lack perspectives from early career hospitalists (ECHs) who recently completed this training. As such, we surveyed multispecialty ECHs to evaluate their preferences for HMFE and to identify gaps in standard residency training and career development that HMFE can bridge. The objectives of our study were to describe multispecialty ECH needs and preferences for HMFE and to identify gaps in standard residency training and career development that HMFE can bridge.

METHODS

From February to March 2021, ECHs (defined as hospitalists within 0-5 years from residency) were surveyed using the Society of Hospital Medicine's listserv. Respondents identified as having participated in HMFE or not during residency (defining them as HMFE participants or non-HMFE participants).

RESULTS

From 257 respondents, 84 (33%) ECHs met inclusion criteria. Half (n = 42) were HMFE participants. ECHs ranked clinical hospitalist career preparation (86%) and mentorship from HM faculty (85%) as the most important gaps in standard residency training and career development that HMFE can bridge. Other key components of HMFE included exposure to quality improvement, patient safety, and high-value care (67%); provision of autonomy through independent rounding (54%); and preparation for the job application process (70%).

CONCLUSIONS

Multispecialty ECHs describe HMFE as positively influencing their decision to pursue a hospitalist career and increasing their preparedness for practice. HMFE may be particularly well suited to foster advanced clinical skills such as independent rounding, critical thinking, and self-reflection. We propose an organizing framework for HMFE in residency that may assist in the implementation and innovation of HMFE programs nationwide and in the development of standardized HMFE competencies.

Retrospective evaluation of factors associated with emergency frequency and survival in equids presenting for emergency care (2019-2020): 3071 cases

OBJECTIVE

To determine factors associated with frequency and outcome of equid emergencies in private practice.

DESIGN

Retrospective study from February 2019 to January 2020.

SETTING

Private practice large animal hospital.

ANIMALS

A total of 3071 equids of various breeds and ages presenting for emergency care.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Variables included for analysis of daily emergency frequency included day of the week, month, and daily climate data. A Poisson regression model found the maximum temperature (P = 0.05), average barometric pressure (P = 0.005), and decreases in barometric pressure (P = 0.05) were associated with an increasing daily number of emergencies. Overall survival for all emergencies was 89% (2748/3071). Variables included for analysis of nonsurvival for emergencies included signalment, body system, clinical examination findings, laboratory data, and experience of the veterinarian. A logistic regression model for primary emergencies (nonreferral) found that increasing age, increasing heart rate, and decreased gastrointestinal sounds were associated with an increase in nonsurvival. Body system and experience of the veterinarian affected nonsurvival. A logistic regression model for all emergencies (primary and referral) found that absent gastrointestinal sounds and an increasing PCV were associated with increased nonsurvival.

CONCLUSIONS

The number of daily emergencies in this practice was affected by the month of the year and day of the week. Additionally, hotter days, increased barometric pressure, or drops in barometric pressure are likely to be associated with a higher emergency caseload. Nonsurvival of primary equid emergencies in private practice increases with age, higher heart rates, and decreased gastrointestinal sounds.

Association Between Emergency Physician's Age and Mortality of Medicare Patients Aged 65 to 89 Years After Emergency Department Visit

STUDY OBJECTIVE

To determine the association between emergency physicians' ages and patient mortality after emergency department visits.

METHODS

This observational study used a 20% random sample of Medicare fee-for-service beneficiaries aged 65 to 89 years treated by emergency physicians at EDs from 2016 to 2017. We investigated whether 7-day mortality after ED visits differed by the age of the emergency physician, adjusting for patient and physician characteristics and hospital fixed effects.

RESULTS

We observed 2,629,464 ED visits treated by 32,570 emergency physicians (mean age 43.5). We found that patients treated by younger emergency physicians had lower mortality rates compared with those treated by older physicians. Adjusted 7-day mortality was 1.33% for patients treated by emergency physicians aged less than 40 years, 1.36% (adjusted difference, 0.03%; 95% confidence interval [CI], -0.001% to 0.06%) for physicians ages 40 to 49, 1.40% (0.08%; 95% CI 0.04% to 0.12%) for physicians ages 50 to 59, and 1.43% (0.11%; 95% CI 0.06% to 0.16%) for those with a physician age of 60 years and more. Similar patterns were observed when stratified by the patient's disposition (discharged vs admitted), and the association was more pronounced for patients with higher severity of illness.

CONCLUSIONS

Medicare patients aged 65 to 89 years treated by emergency physicians aged under 40 years had lower 7-day mortality rates than those treated by physicians aged 50 to 59 years and 60 years or older within the same hospital. Potential mechanisms explaining the association between emergency physician age and patient mortality (eg, differences in training received and other unobservable patient/physician characteristics) are uncertain and require further study.

Does Hospitalist Care Enhance Palliative Care and Reduce Aggressive Treatments for Terminally Ill Patients? A Propensity Score-Matched Study

BACKGROUND

Information on the use of palliative care and aggressive treatments for terminally ill patients who receive care from hospitalists is limited.

METHODS

This three-year, retrospective, case-control study was conducted at an academic medical center in Taiwan. Among 7037 patients who died in the hospital, 41.7% had a primary diagnosis of cancer. A total of 815 deceased patients who received hospitalist care before death were compared with 3260 patients who received non-hospitalist care after matching for age, gender, catastrophic illness, and Charlson comorbidity score. Regression models with generalized estimating equations were performed.

RESULTS

Patients who received hospitalist care before death, compared to those who did not, had a higher probability of palliative care consultation (odds ratio (OR) = 3.41, 95% confidence interval (CI): 2.63-4.41), and a lower probability to undergo invasive mechanical ventilation (OR = 0.13, 95% CI: 0.10-0.17), tracheostomy (OR = 0.14, 95% CI: 0.06-0.31), hemodialysis (OR = 0.70, 95% CI: 0.55-0.89), surgery (OR = 0.25, 95% CI: 0.19-0.31), and intensive care unit admission (OR = 0.11, 95% CI: 0.08-0.14). Hospitalist care was associated with reductions in length of stay (coefficient (B) = -0.54, 95% CI: -0.62--0.46) and daily medical costs.

CONCLUSIONS

Hospitalist care is associated with an improved palliative consultation rate and reduced life-sustaining treatments before death.

Comparison of Hospital Outcomes for Patients Treated by Allopathic Versus Osteopathic Hospitalists : An Observational Study

BACKGROUND

The United States has 2 types of degree programs that educate physicians: allopathic and osteopathic medical schools.

OBJECTIVE

To determine whether quality and costs of care differ between hospitalized Medicare patients treated by allopathic or osteopathic physicians.

DESIGN

Retrospective observational study.

SETTING

Medicare claims data.

PATIENTS

20% random sample of Medicare fee-for-service beneficiaries hospitalized with a medical condition during 2016 to 2019 and treated by hospitalists.

MEASUREMENTS

The primary outcome was 30-day patient mortality. The secondary outcomes were 30-day readmission, length of stay (LOS), and health care spending (Part B spending). Multivariable regression models adjusted for patient and physician characteristics and their hospital-level averages (to effectively estimate differences within hospitals) were estimated.

RESULTS

Of 329 510 Medicare admissions, 253 670 (77.0%) and 75 840 (23.0%) received care from allopathic and osteopathic physicians, respectively. The results can rule out important differences in quality and costs of care between allopathic versus osteopathic physicians for patient mortality (adjusted mortality, 9.4% for allopathic physicians vs. 9.5% [reference] for osteopathic hospitalists; average marginal effect [AME], -0.1 percentage point [95% CI, -0.4 to 0.1 percentage point]; P = 0.36), readmission (15.7% vs. 15.6%; AME, 0.1 percentage point [CI, -0.4 to 0.3 percentage point; P = 0.72), LOS (4.5 vs. 4.5 days; adjusted difference, -0.001 day [CI, -0.04 to 0.04 day]; P = 0.96), and health care spending ($1004 vs. $1003; adjusted difference, $1 [CI, -$8 to $10]; P = 0.85).

LIMITATION

Data were limited to elderly Medicare patients hospitalized with medical conditions.

CONCLUSION

The quality and costs of care were similar between allopathic and osteopathic hospitalists when they cared for elderly patients and worked as the principal physician in a team of health care professionals that often included other allopathic and osteopathic physicians.

PRIMARY FUNDING SOURCE

National Institutes of Health/National Institute on Aging.

Factors Associated With Inpatient Subspecialty Consultation Patterns Among Pediatric Hospitalists

IMPORTANCE

Subspecialty consultation is a frequent, consequential practice in the pediatric inpatient setting. Little is known about factors affecting consultation practices.

OBJECTIVES

To identify patient, physician, admission, and systems characteristics that are independently associated with subspecialty consultation among pediatric hospitalists at the patient-day level and to describe variation in consultation utilization among pediatric hospitalist physicians.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study of hospitalized children used electronic health record data from October 1, 2015, through December 31, 2020, combined with a cross-sectional physician survey completed between March 3 and April 11, 2021. The study was conducted at a freestanding quaternary children's hospital. Physician survey participants were active pediatric hospitalists. The patient cohort included children hospitalized with 1 of 15 common conditions, excluding patients with complex chronic conditions, intensive care unit stay, or 30-day readmission for the same condition. Data were analyzed from June 2021 to January 2023.

EXPOSURES

Patient (sex, age, race and ethnicity), admission (condition, insurance, year), physician (experience, anxiety due to uncertainty, gender), and systems (hospitalization day, day of week, inpatient team, and prior consultation) characteristics.

MAIN OUTCOMES AND MEASURES

The primary outcome was receipt of inpatient consultation on each patient-day. Risk-adjusted consultation rates, expressed as number of patient-days consulting per 100, were compared between physicians.

RESULTS

We evaluated 15 922 patient-days attributed to 92 surveyed physicians (68 [74%] women; 74 [80%] with ≥3 years' attending experience) caring for 7283 unique patients (3955 [54%] male patients; 3450 [47%] non-Hispanic Black and 2174 [30%] non-Hispanic White patients; median [IQR] age, 2.5 ([0.9-6.5] years). Odds of consultation were higher among patients with private insurance compared with those with Medicaid (adjusted odds ratio [aOR], 1.19 [95% CI, 1.01-1.42]; P = .04) and physicians with 0 to 2 years of experience vs those with 3 to 10 years of experience (aOR, 1.42 [95% CI, 1.08-1.88]; P = .01). Hospitalist anxiety due to uncertainty was not associated with consultation. Among patient-days with at least 1 consultation, non-Hispanic White race and ethnicity was associated with higher odds of multiple consultations vs non-Hispanic Black race and ethnicity (aOR, 2.23 [95% CI, 1.20-4.13]; P = .01). Risk-adjusted physician consultation rates were 2.1 times higher in the top quartile of consultation use (mean [SD], 9.8 [2.0] patient-days consulting per 100) compared with the bottom quartile (mean [SD], 4.7 [0.8] patient-days consulting per 100; P < .001).

CONCLUSIONS AND RELEVANCE

In this cohort study, consultation use varied widely and was associated with patient, physician, and systems factors. These findings offer specific targets for improving value and equity in pediatric inpatient consultation.

Does experience matter? The relationship between nephrologist characteristics and end stage kidney disease patient outcomes

BACKGROUND

Nephrology offers the unique opportunity to directly link patients to providers, allowing the study of patient outcomes at the provider level. The purpose of this analysis was to determine whether nephrologist experience, defined as years in nephrology practice, was associated with clinical outcomes.

DESIGN

Physician data contained within the American Medical Association (AMA) Physician Masterfile was combined with patient and Medicare claims data from the United States Renal Data System (USRDS) for the calendar year 2012, with follow up extending through June 30, 2014. Associations with important healthcare outcomes including mortality in patients receiving maintenance renal replacement therapy (RRT), waitlisting for kidney transplantation, and receipt of a kidney transplant were determined with broad adjustment for both patient and provider level variables, with attention on tertile of provider time in practice.

RESULTS

We identified 256,324 patients on maintenance RRT cared for by 6193 nephrologists. Nephrologists with the least experience were more likely to be female, reside in a region with ≥1,000,000 people, have a Doctor of Osteopathic Medicine degree, and have a listed maintenance of certification status as "yes." Overall, 30.2% of the cohort died at a mean follow up of 1.99 years. Compared to those with the 0-10 years of experience, receipt of care from nephrologists with more experience was associated with lower mortality (AHR 0.97 CI 0.94-0.99 for nephrologists with 11-20 years) and increased listing for kidney transplantation (AHR 1.10; CI 1.01-1.21 for nephrologists with >21 years experience). Experience level did not result in a difference in kidney transplantation rates.

CONCLUSIONS

Receipt of maintenance RRT from nephrologists with greater experience was associated with decreased mortality and increased listing for kidney transplantation, an effect that remained significant after multiple adjustments for important patient and nephrologist variables.

Physicians' clinical experience and its association with healthcare quality: a systematised review

BACKGROUND AND PURPOSE

There is conflicting evidence regarding whether physicians' clinical experience affects healthcare quality. Knowing whether an association exists and which dimensions of quality might be affected can help healthcare services close quality gaps by tailoring improvement initiatives according to physicians' clinical experience. Here, we present a systematised review that aims to assess the potential association between physicians' clinical experience and different dimensions of healthcare quality.

METHODS

We conducted a systematised literature review, including the databases MEDLINE, Embase, PsycINFO and PubMed. The search strategy involved combining predefined terms that describe physicians' clinical experience with terms that describe different dimensions of healthcare quality (ie, safety, clinical effectiveness, patient-centredness, timeliness, efficiency and equity). We included relevant, original research published from June 2004 to November 2020.

RESULTS

Fifty-two studies reporting 63 evaluations of the association between physicians' clinical experience and healthcare quality were included in the final analysis. Overall, 27 (43%) evaluations found a positive or partially positive association between physicians' clinical experience and healthcare quality; 22 (35%) found no association; and 14 (22%) evaluations reported a negative or partially negative association. We found a proportional association between physicians' clinical experience and quality regarding outcome measures that reflect safety, particularly in the surgical fields. For other dimensions of quality, no firm evidence was found.

CONCLUSION

We found no clear evidence of an association between measures of physicians' clinical experience and overall healthcare quality. For outcome measures related to safety, we found that physicians' clinical experience was proportional with safer care, particularly in surgical fields. Our findings support efforts to secure adequate training and supervision for early-career physicians regarding safety outcomes. Further research is needed to reveal the potential subgroups in which gaps in quality due to physicians' clinical experience might exist.

Rates and Characteristics of Medical Malpractice Claims Against Hospitalists

BACKGROUND

Hospitalists practice in high-stakes and litigious settings. However, little data exist about the malpractice claims risk faced by hospitalists.

OBJECTIVE

To characterize the rates and characteristics of malpractice claims against hospitalists.

DESIGN, SETTING, AND PARTICIPANTS

An analysis was performed of malpractice claims against hospitalists, as well as against select other specialties, using data from a malpractice claims database that includes approximately 31% of US malpractice claims.

MAIN OUTCOMES AND MEASURES

For malpractice claims against hospitalists (n = 1,216) and comparator specialties (n = 18,644): claims rates (using a data subset), percentage of claims paid, median indemnity payment amounts, allegation types, and injury severity.

RESULTS

Hospitalists had an annual malpractice claims rate of 1.95 claims per 100 physician-years, similar to that of nonhospitalist general internal medicine physicians (1.92 claims per 100 physician-years), and significantly greater than that of internal medicine subspecialists (1.30 claims per 100 physician-years) (P < .001). Claims rates for hospitalists nonsignificantly increased during the study period (2009-2018), whereas claims rates for four of the five other specialties examined significantly decreased over this period. The median indemnity payment for hospitalist claims was $231,454 (interquartile range, $100,000-$503,015), significantly higher than the amounts for all the other specialties except neurosurgery. The greatest predictor of a hospitalist case closing with payment (compared with no payment) was an error in clinical judgment as a contributing factor, with an adjusted odds ratio of 5.01 (95% CI, 3.37-7.45).

CONCLUSION

During the study period, hospitalist claims rates did not drop, whereas they fell for other specialties. Hospitalists' claims had relatively high injury severity and median indemnity payment amounts. The malpractice environment for hospitalists is becoming less favorable.

Ready to Go Home? Assessment of Shared Mental Models of the Patient and Discharging Team Regarding Readiness for Hospital Discharge

BACKGROUND

A critical task of the inpatient interprofessional team is readying patients for discharge. Assessment of shared mental model (SMM) convergence can determine how much team members agree about patient discharge readiness and how their mental models align with the patient's self-assessment.

OBJECTIVE

Determine the convergence of interprofessional team SMMs of hospital discharge readiness and identify factors associated with these assessments.

DESIGN

We surveyed interprofessional discharging teams and each team's patient at time of hospital discharge using validated tools to capture their SMMs.

PARTICIPANTS

Discharge events (N = 64) from a single hospital consisting of the patient and their team (nurse, coordinator, physician).

MEASURES

Clinician and patient versions of the validated Readiness for Hospital Discharge Scales/Short Form (RHDS/SF). We measured team convergence by comparing the individual clinicians' scores on the RHDS/SF, and we measured team-patient convergence as the absolute difference between the Patient-RHDS/SF score and the team average score on the Clinician-RHDS/SF.

RESULTS

Discharging teams assessed patients as having high readiness for hospital discharge (mean score, 8.5 out of 10; SD, 0.91). The majority of teams had convergent SMMs with high to very high interrater agreement on discharge readiness (mean r*wg(J), 0.90; SD, 0.10). However, team-patient SMM convergence was low: Teams overestimated the patient's self-assessment of readiness for discharge in 48.4% of events. We found that teams reporting higher-quality teamwork (P = .004) and bachelor's level-trained nurses (P < .001) had more convergent SMMs with the patient.

CONCLUSION

Measuring discharge teams' SMM of patient discharge readiness may represent an innovative assessment tool and potential lever to improve the quality of care transitions.

Using Peer Feedback to Promote Clinical Excellence in Hospital Medicine

Hospitalists provide a significant amount of direct clinical care in both academic and community hospitals. Peer feedback is a potentially underutilized and low resource method for improving clinical performance, which lends itself well to the frequent patient care handoffs that occur in the practice of hospital medicine. We review current literature on peer feedback to provide an overview of this performance improvement tool, briefly describe its incorporation into multi-source clinical performance appraisals across disciplines, highlight how peer feedback is currently used in hospital medicine, and present practical steps for hospital medicine programs to implement peer feedback to foster clinical excellence among their clinicians.

Association between surgeon case volume and years of practice experience with open abdominal aortic aneurysm repair outcomes

BACKGROUND

Widespread adoption of endovascular aneurysm repair has led to a consequential decline in the use of open aneurysm repair (OAR). This evolution has had significant ramifications on vascular surgery training paradigms and contemporary practice patterns among established surgeons. Despite being the subject of previous analyses, the surgical volume-outcome relationship has remained a focus of controversy. At present, little is known about the complex interaction of case volume and surgeon experience with patient selection, procedural characteristics, and postoperative complications of OAR. The purpose of the present analysis was to examine the association between surgeon annual case volume and years of practice experience with OAR.

METHODS

All infrarenal OARs (n = 11,900; elective, 70%; nonelective, 30%) included in the Society for Vascular Surgery Vascular Quality Initiative from 2003 to 2019 were examined. Surgeon experience was defined as years in practice after training. The experience level at repair was categorized chronologically (≤5 years, n = 1667; 6-10 years, n = 1887; 11-15 years, n = 1806; ≥16 years, n = 6540). The annual case volume was determined by the number of OARs performed by the surgeon annually (median, five cases). Logistic regression was used to perform risk adjustment of the outcomes across surgeon experience and volume (five or fewer vs more than five cases annually) strata for in-hospital major complications and 30-day and 1-year mortality.

RESULTS

Practice experience had no association with unadjusted mortality (30-day death: elective, P = .2; nonelective, P = .3; 1-year death: elective, P = .2; nonelective, P = .2). However, more experienced surgeons had fewer complications after elective OAR (25% with ≥16 years vs 29% with ≤5 years; P = .004). A significant linear correlation was identified between increasing surgeon experience and performance of a greater proportion of elective OAR (P-trend < .0001). Risk adjustment (area under the curve, 0.776) revealed that low-volume (five or fewer cases annually) surgeons had inferior outcomes compared with high-volume surgeons across the experience strata for all presentations. In addition, high-volume, early career surgeons (≤5 years' experience) had outcomes similar to those of older, low-volume surgeons (P > .1 for all pairwise comparisons). Early career surgeons (≤5 years) had operated on a greater proportion of elective patients with American Society of Anesthesiologists class ≥4 (35% vs 30% [≥16 years' experience]; P = .0003) and larger abdominal aortic aneurysm diameters (mean, 62 vs 59 mm [≥16 years' experience]; P < .0001) compared with all other experience categories. Similarly, the use of a suprarenal cross-clamp occurred more frequently (26% vs 22% [≥16 years' experience]; P = .0009) but the total procedure time, estimated blood loss, and renal and/or visceral ischemia times were all greater for less experienced surgeons (P-trend < .0001).

CONCLUSIONS

Annual case volume appeared to be more significantly associated with OAR outcomes compared with the cumulative years of practice experience. To ensure optimal OAR outcomes, mentorship strategies for "on-boarding" early career, as well as established, low-volume, aortic aneurysm repair surgeons should be considered. These findings have potential implications for widespread initiatives surrounding regulatory oversight and credentialing paradigms.

The Role of Physician and Practice Characteristics in the Quality of Diabetes Management in Primary Care: Systematic Review and Meta-analysis

BACKGROUND

Despite evidence-based guidelines, high-quality diabetes care is not always achieved. Identifying factors associated with the quality of management in primary care may inform service improvements, facilitating the tailoring of quality improvement interventions to practice needs and resources.

METHODS

We searched MEDLINE, EMBASE, CINAHL and Web of Science from January 1990 to March 2019. Eligible studies were cohort studies, cross-sectional studies and randomised controlled trials (baseline data) conducted among adults with diabetes, which examined the relationship between any physician and/or practice factors and any objective measure(s) of quality. Studies which examined patient factors only were ineligible. Where possible, data were pooled using random-effects meta-analysis.

RESULTS

In total, 82 studies were included. The range of individual quality measures and the construction of composite measures varied considerably. Female physicians compared with males ((odds ratio (OR) = 1.07, 95% CI: 1.04, 1.10), 8 studies), physicians with higher diabetes volume compared with lower volume (OR = 1.24, 95% CI: 1.05-1.47, 4 studies) and practices with Electronic Health Records (EHR) versus practices without (OR = 1.43, 95% CI: 1.11-1.84, 4 studies) were associated with a higher quality of care. There was no association between physician experience, practice location and type of practice and quality. Based on the narrative synthesis, increasing physician age and higher practice socio-economic deprivation may be associated with lower quality of care.

DISCUSSION

Identification of physician- and practice-level factors associated with the quality of care (female gender, younger age, physician-level diabetes volume, practice deprivation and EHR use) may explain differences across practices and physicians, provide potential targets for quality improvement interventions and indicate which practices need specific supports to deliver improvements in diabetes care.

Provider-Level and Hospital-Level Factors and Process Measures of Quality Care Delivered in Pediatric Emergency Departments

OBJECTIVE

Differences in the quality of emergency department (ED) care are often attributed to nonclinical factors such as variations in the structure, systems, and processes of care. Few studies have examined these associations among children. We aimed to determine whether process measures of quality of care delivered to patients receiving care in children's hospital EDs were associated with physician-level or hospital-level factors.

METHODS

We included children (<18 years old) who presented to any of the 12 EDs participating in the Pediatric Emergency Care Applied Research Network (PECARN) between January 2011 and December 2011. We measured quality of care from medical record reviews using a previously validated implicit review instrument with a summary score ranging from 5 to 35, and examined associations between process measures of quality and physician- and hospital-level factors using a mixed-effects linear regression model adjusted for patient case-mix, with hospital site as a random effect.

RESULTS

Among the 620 ED encounters reviewed, we did not find process measures of quality to be associated with any physician-level factors such as physician sex, years since medical school graduation, or physician training. We found, however, that process measures of quality were positively associated with delivery at freestanding children's hospitals (1.96 points higher in quality compared to nonfreestanding status, 95% confidence interval: 0.49, 3.43) and negatively associated with higher annual ED patient volume (-0.03 points per thousand patients, 95% confidence interval: -0.05, -0.01).

CONCLUSION

Process measures of quality of care delivered to children were higher among patients treated at freestanding children's hospitals but lower among patients treated at higher volume EDs.

Evaluating the Outcome of Multi-Morbid Patients Cared for by Hospitalists: a Report of Integrated Medical Model in Korea

BACKGROUND

The lack of medical personnel has led to the employment of hospitalists in Korean hospitals to provide high-quality medical care. However, whether hospitalists' care can improve patients' outcomes remains unclear. We aimed to analyze the outcome in patients cared for by hospitalists.

METHODS

A retrospective review was conducted in 1,015 patients diagnosed with pneumonia or urinary tract infection from March 2017 to July 2018. After excluding 306 patients, 709 in the general ward who were admitted via the emergency department were enrolled, including 169 and 540 who were cared for by hospitalists (HGs) and non-hospitalists (NHGs), respectively. We compared the length of hospital stay (LOS), in-hospital mortality, readmission rate, comorbidity, and disease severity between the two groups. Comorbidities were analyzed using Charlson comorbidity index (CCI).

RESULTS

HG LOS (median, interquartile range [IQR], 8 [5-12] days) was lower than NHG LOS (median [IQR], 10 [7-15] days), (P < 0.001). Of the 30 (4.2%) patients who died during their hospital stay, a lower percentage of HG patients (2.4%) than that of NHG patients (4.8%) died, but the difference between the two groups was not significant (P = 0.170). In a subgroup analysis, HG LOS was shorter than NHG LOS (median [IQR], 8 [5-12] vs. 10 [7-16] days, respectively, P < 0.001) with CCI of ≥ 5 points.

CONCLUSION

Hospitalist care can improve the LOS of patients, especially those with multiple comorbidities. Further studies are warranted to evaluate the impact of hospitalist care in Korea.

[Introduction of Hospitalists and Their Role in Gastroenterology]

A hospitalist system in Korea began in August 2016. Patient safety issues, resident law, and reduction of resident numbers in Korea are leading to an increase in the demand for hospitalist in Korea. The roles and responsibilities of GI hospitalists have not been established. Therefore, cooperation among the Korean society of gastroenterology, each hospital, and government is necessary. In particular, it is important to prepare an education program for gastroenterology hospitalists.

Postacute care outcomes and medicare payments for patients treated by physicians and advanced practitioners who specialize in nursing home practice

OBJECTIVE

To measure the association between clinician specialization in nursing home (NH) practice and outcomes of patients who received postacute care in skilled nursing facilities (SNFs).

DATA SOURCES

Medicare claims and NH assessments for 2 118 941 hospital discharges to 14 526 SNFs in January 2012-October 2014 and MD-PPAS data for 52 379 clinicians.

STUDY DESIGN

Generalist physicians and advanced practitioners with ≥ 90 percent of claims for NH-based care were considered NH specialists. The primary clinician during each SNF stay was determined based on plurality of claims during that stay. We estimated the effect of being treated by a NH specialist on 30-day rehospitalizations, successful discharge to community, and 60-day episode-of-care Medicare payments (Parts A and B). All models included patient demographics, clinical variables, and SNF fixed effects.

PRINCIPAL FINDINGS

Nursing home specialists' patients were less likely to be rehospitalized (14.71 percent vs 16.23 percent; adjusted difference, -1.51 percent, 95% CI -1.78 to -1.24), more likely to be successfully discharged to community (56.33 percent vs 55.49 percent; adjusted difference, 0.84 percent, 95% CI 0.54 to 1.14), but had higher 60-day Medicare payments ($31 628 vs $31 292; adjusted difference, $335; 95% CI $242 to $429).

CONCLUSIONS

Clinicians who specialize in NH practice may achieve better postacute care outcomes at slightly higher costs.

Association Between Clinician Specialization in Nursing Home Care and Nursing Home Clinical Quality Scores

IMPORTANCE

While the number of prescribing clinicians (physicians and nurse practitioners) who provide any nursing home care remained stable over the past decade, the number of clinicians who focus their practice exclusively on nursing home care has increased by over 30%.

OBJECTIVES

To measure the association between regional trends in clinician specialization in nursing home care and nursing home quality.

DESIGN

Retrospective cross-sectional study.

SETTING AND PARTICIPANTS

Patients treated in 15,636 nursing homes in 305 US hospital referral regions between 2013 and 2016.

MEASURES

Clinician specialization in nursing home care for 2012-2015 was measured using Medicare fee-for-service billings. Nursing home specialists were defined as generalist physicians (internal medicine, family medicine, geriatrics, and general practice) or advanced practitioners (nurse practitioners and physician assistants) with at least 90% of their billings for care in nursing homes. The number of clinicians was aggregated at the hospital referral region level and divided by the number of occupied Medicare-certified nursing home beds. Nursing Home Compare quality measure scores for 2013-2016 were aggregated at the HHR level, weighted by occupied beds in each nursing home in the hospital referral region. We measured the association between the number of nursing home specialists per 1000 beds and the clinical quality measure scores in the subsequent year using linear regression.

RESULTS

An increase in nursing home specialists per 1000 occupied beds in a region was associated with lower use of long-stay antipsychotic medications and indwelling bladder catheters, higher prevalence of depressive symptoms, and was not associated with urinary tract infections, use of restraints, or short-stay antipsychotic use.

CONCLUSIONS AND IMPLICATIONS

Higher prevalence of nursing home specialists was associated with regional improvements in 2 of 6 quality measures. Future studies should evaluate whether concentrating patient care among clinicians who specialize in nursing home practice improves outcomes for individual patients. The current findings suggest that prescribing clinicians play an important role in nursing home care quality.

Impact of Mobile Device-Based Clinical Decision Support Tool on Guideline Adherence and Mental Workload

OBJECTIVE

To evaluate the individual-level impact of an electronic clinical decision support (ECDS) tool, PedsGuide, on febrile infant clinical decision making and cognitive load.

METHODS

A counterbalanced, prospective, crossover simulation study was performed among attending and trainee physicians. Participants performed simulated febrile infant cases with use of PedsGuide and with standard reference text. Cognitive load was assessed using the NASA-Task Load Index (NASA-TLX), which determines mental, physical, temporal demand, effort, frustration, and performance. Usability was assessed with the System Usability Scale (SUS). Scores on cases and NASA-TLX scores were compared between condition states.

RESULTS

A total of 32 participants completed the study. Scores on febrile infant cases using PedsGuide were greater compared with standard reference text (89% vs 72%, P = .001). NASA-TLX scores were lower (ie, more optimal) with use of PedsGuide versus control (mental 6.34 vs 11.8, P < .001; physical 2.6 vs 6.1, P = .001; temporal demand 4.6 vs 8.0, P = .003; performance 4.5 vs 8.3, P < .001; effort 5.8 vs 10.7, P < .001; frustration 3.9 vs 10, P < .001). The SUS had an overall score of 88 of 100 with rating of acceptable on the acceptability scale.

CONCLUSIONS

Use of PedsGuide led to increased adherence to guidelines and decreased cognitive load in febrile infant management when compared with the use of a standard reference tool. This study employs a rarely used method of assessing ECDS tools using a multifaceted approach (medical decision-making, assessing usability, and cognitive workload,) that may be used to assess other ECDS tools in the future.

Incorporating Continuity in a 7-On 7-Off Hospitalist Model and the Correlation With Patient Handoffs and Length of Stay

Little research in hospital medicine examines the effects of hospitalist continuity on patient outcomes. This study implemented a novel staffing model with approximately half of rounding teams starting their 7-day workweek on Monday and the others on Friday. Teams admitted their own patients on their first 4 days with additional nighttime admissions handed off to those teams. No admissions were given to teams on their last 3 days. Length of stay was significantly reduced from 6.34 days in 2015 to 5.7 days in 2016 (P < .002) with a significant decrease in handoffs. There was an increase in odds ratio of death (1.37, SE = .128) with each additional hospitalist involved in a patient's care while adjusting for year and number of patient diagnoses (P < .001). There was no statistical difference in charges, 30-day readmissions, or mortality between years.

Adverse Events and Patient Outcomes Among Hospitalized Children Cared for by General Pediatricians vs Hospitalists

IMPORTANCE

Pediatric hospital medicine is a relatively new and growing specialty. However, research remains inconclusive on outcomes for inpatients cared for by pediatric hospitalists compared with those cared for by general pediatricians.

OBJECTIVE

To analyze outcomes, adverse events (AEs), and types of AEs associated with care provided for pediatric patients by hospitalists vs general pediatricians.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the medical records of a US urban academic children's hospital comprising 1423 hospitalizations between January 1, 2009, and August 31, 2015, for 57 diagnoses of patients cared for by either a hospitalist or general pediatrician. General pediatricians worked primarily in the hospital's outpatient clinic, serving a few inpatient weeks per year, and were not the patients' primary care physician. Data analysis was performed from July 1, 2017, to October 10, 2018.

MAIN OUTCOMES AND MEASURES

Outcomes were length of stay, total costs, 30-day readmission rates, and AEs. Adverse events were documented by International Classification of Diseases, Ninth Revision, Clinical Modification codes determined by review of medical records. Adverse event categories were drug events, infections, and device-related AEs. Generalized linear models were used to analyze patient outcomes, with standard errors clustered by physician. Models were adjusted for patient characteristics, including Chronic Condition Indicators. Models were estimated with and without adjustment for physician characteristics.

RESULTS

The data set contained 1423 hospitalizations among 726 female patients and 697 male patients (mean [SD] age, 6.1 [6.3] years). Hospitalists cared for 870 patients, and general pediatricians cared for 553 patients. Among the physicians, there were 57 women and 38 men; physicians were a mean (SD) 11.1 (8.1) years out of medical school. Patients cared for by general pediatricians were younger than those cared for by hospitalists (mean [SD] age, 5.4 [6.0] vs 6.5 [6.4] years; P = .001) but had similar mean (SD) Chronic Condition Indicator scores (1.5 [1.0] vs 1.5 [1.0]). A total of 33 of 56 general pediatricians (58.9%) and 24 of 39 hospitalists (61.5%) were women (P = .006), and general pediatricians were in practice twice as long as hospitalists on average (mean [SD], 16.0 [10.3] vs 7.9 [3.8] years out of medical school; P < .001). In multivariate models adjusting for patient-level features, there were no significant differences between general pediatricians and hospitalists for mean length of stay (4.7 vs 4.6 days), total costs ($14 490 vs $15 200), and estimated 30-day readmission rate (8.9% vs 6.4%), and results were similar with adjustments for physician characteristics. Device-related AEs were higher among hospitalists (3.0% vs 1.1%; odds ratio, 0.34; 95% CI, 0.12-1.00); this association became nonsignificant after adjusting for physician experience.

CONCLUSIONS AND RELEVANCE

General pediatrician and hospitalist inpatient care had similar length of stay, total costs, and readmission rates. However, AEs differed between hospitalists and general pediatricians, with device-related AEs more common among hospitalists, which may be associated with hospitalists' fewer years in practice. Such findings can inform hospitals in planning their inpatient staffing and patient safety oversight.

Physician-related determinants of medical end-of-life decisions - A mortality follow-back study in Switzerland

Background

Medical end-of-life decisions (MELD) and shared decision-making are increasingly important issues for a majority of persons at the end of life. Little is known, however, about the impact of physician characteristics on these practices. We aimed at investigating whether MELDs depend on physician characteristics when controlling for patient characteristics and place of death.

Methods and findings

Using a random sample (N = 8,963) of all deaths aged 1 year or older registered in Switzerland between 7 August 2013 and 5 February 2014, questionnaires covering MELD details and physicians' demographics, life stance and medical formation were sent to certifying physicians. The response rate was 59.4% (N = 5,328). Determinants of MELDs were analyzed in binary and multinomial logistic regression models. MELDs discussed with the patient or relatives were a secondary outcome. A total of 3,391 non-sudden nor completely unexpected deaths were used, 83% of which were preceded by forgoing treatment(s) and/or intensified alleviation of pain/symptoms intending or taking into account shortening of life. International medical graduates reported forgoing treatment less often, either alone (RRR = 0.30; 95% CI: 0.21–0.41) or combined with the intensified alleviation of pain and symptoms (RRR = 0.44; 0.34–0.55). The latter was also more prevalent among physicians who graduated in 2000 or later (RRR = 1.60; 1.17–2.19). MELDs were generally less frequent among physicians with a religious affiliation. Shared-decision making was analyzed among 2,542 decedents. MELDs were discussed with patient or relatives less frequently when physicians graduated abroad (OR = 0.65, 95% CI: 0.50–0.87) and more frequently when physicians graduated more recently; physician's sex and religion had no impact.

Conclusions

Physicians' characteristics, including the country of medical education and time since graduation had a significant effect on the likelihood of an MELD and of shared decision-making. These findings call for additional efforts in physicians' education and training concerning end-of-life practices and improved communication skills.