Patient outcomes in teaching versus nonteaching general internal medicine services: a systematic review and meta-analysis

Outcomes of Upper Gastrointestinal Bleeding at United States Teaching and Non-teaching Hospitals: A National Inpatient Sample Analysis

BACKGROUND/AIMS

Studies have varied results regarding the impact of the teaching and non-teaching status of hospitals on the outcomes for hospitalized patients with upper gastrointestinal bleeding (UGIB). To evaluate these outcomes, we conducted a retrospective cohort study using the 2014 National Inpatient Sample (NIS) database.

METHODS

We included all adult patients who were admitted with the principal diagnosis of UGIB. Patients admitted to rural and urban non-teaching hospitals were classified as non-teaching, whereas those admitted to urban teaching hospitals were classified as teaching. The main outcomes of interest were in-hospital mortality, percentage of patients requiring inpatient endoscopy, and endoscopic therapy, packed red blood cell (PRBC) transfusion, length of stay (LOS), and total hospitalization charges.

RESULTS

The study included 132,085 (97%) with nonvariceal UGIB (NVUGIB) and 4,200 (3%) with variceal UGIB (VUGIB). Of them, 62% were managed at teaching hospitals. Compared with admitted patients at non-teaching hospitals, patients with nonvariceal UGIB admitted at teaching hospitals had similar adjusted in-hospital mortality rates (adjusted odds ratio (OR): 0.97, 95% confidence interval (CI): 0.79-1.19), inpatient endoscopy rates (OR: 0.98, 95% CI: 0.91-1.1), and early endoscopy rates (within 24 hours) (OR: 0.98, 95% CI: 0.91-1.1) and lower PRBC transfusion rates (OR: 0.87, 95% CI: 0.79-0.97) but higher endoscopic therapy rates (OR: 1.3, 95% CI: 1.2-1.4), length of stay (mean increase of 0.43 days) (P<0.01), and total hospital charges (mean increase of $4,369) (P<0.01). Patients with variceal UGIB had similar adjusted in-hospital mortality rates (OR: 1.2, 95% CI: 0.61-2.3), inpatient endoscopy rates (OR: 0.97, 95% CI: 0.67-1.4), early endoscopy rates (within 24 hours) (OR: 0.97, 95% CI: 0.67-1.4), endoscopic therapy rates (OR: 2.5, 95% CI: 0.54- 11.2), and total hospital charges (P=0.45), and lower PRBC transfusion rates (OR: 0.63, 95% CI: 0.45-0.88) but higher length of stay (mean increase of 0.69 days) (P=0.02).

CONCLUSIONS

Patients with nonvariceal UGIB treated at US teaching hospitals and non-teaching hospitals have similar mortality, rates of in-hospital endoscopy, and early endoscopy, but teaching hospitals have higher rates of in-hospital therapeutic endoscopy, length of stay, and total hospital charges. There was no difference in any of the outcomes for variceal gastrointestinal (GI) bleeding treated at teaching hospitals compared with those treated at non-teaching hospitals, except for length of stay, which was higher among patients admitted to teaching hospitals compared to those admitted to non-teaching hospitals.

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.

Performance management of generalist care for hospitalised multimorbid patients-a scoping review for value-based care

Objectives

Given the shift towards value-based healthcare and the increasing recognition of generalist care, enacting value-based healthcare for generalist care is critical. This work aims to shed light on how to conduct performance management of generalist care to facilitate value-based care, with a focus on medical care of hospitalised patients.

Design and setting

A scoping review of published literature was conducted. 30 publications which were relevant to performance management of generalist medical inpatient care were included in the review.

Outcome measures

The performance measures used across the studies were analysed and other qualitative findings were also obtained.

Results

We report an overall lack of research on performance management methods for generalist inpatient care. Relevant performance measures found include both outcome and process of care measures and both clinical and reported measures, with clinical outcome measures the most frequently reported. Length of stay, readmission rates and mortality were the most frequently reported. The insights from the papers emphasise the relevance of process of care measures for performance management, the advantages and disadvantages of types of measures and provide suggestions relevant for performance management of generalist inpatient care.

Conclusion

The findings of this scoping review outline a variety of performance measures valuable for generalist inpatient care including clinical outcome measures, reported outcome measures and process of care measures. The findings also suggest directions for implementation of such performance management, including emphasis on physician level performance management and the importance of documentation training. Further research for selecting and operationalising the measures for specific contexts and developing a comprehensive performance management system involving these measures will be important for achieving value-based healthcare for generalist inpatient care.

The effect of early follow-up after open cardiac surgery in a student clinic

Objectives. Readmission rates following open cardiac surgery are high, affecting patients and the cost of care. This study aimed to investigate the effect of early additional follow-up after open cardiac surgery when 5th-year medical students conducted follow-ups under the supervision of physicians. The primary endpoint was unplanned cardiac-related readmissions within one year. The secondary outcomes were the detection of impending complications and health-related quality of life (HRQOL). Methods. Patients undergoing open cardiac surgery were prospectively included. For intervention, additional follow-up visits, including point-of-care ultrasound, were conducted by supervised 5th-year medical students on postoperative days 3, 14 and 25. Unplanned cardiac-related readmissions, including emergency department visits, were registered within the first year of surgery. Danish National Health Survey 2010 questionnaire was used for HRQOL. In standard follow-up, all patients were seen 4-6 weeks postoperative. Results. For data analysis, 100 of 124 patients in the intervention group and 319 of 335 patients in the control group were included. The 1-year unplanned readmission rates did not differ; 32% and 30% in the intervention and control groups, respectively (p = 0.71). After discharge, 1% of patients underwent pericardiocentesis. The additional follow-up initiated scheduled drainage, contrary to more unscheduled/acute drainages in the control group. Pleurocentesis was more common in the intervention group (17% (n = 17) vs 8% (n = 25), p = 0.01) and performed earlier. There was no difference between groups on HRQOL. Conclusion. Supervised student-led follow-up of newly cardiac-operated patients did not alter readmission rates or HRQOL but may detect complications earlier and initiate non-emergent treatment of complications.

The Association Between Federally Qualified Health Centers' Medical Training Programs and Clinical Outcomes

This study examined whether an association exists between federally qualified health centers' (FQHCs') provision of medical training programs and clinical outcomes. Employing a cross-sectional data analysis of the sample FQHCs in the year 2019, the study found that FQHCs with medical training programs provided higher rates of immunization, screenings for cervical cancer, tobacco, statin use, and colorectal cancer. The FQHCs with medical training programs also reported a higher percentage of hypertensive patients properly managing blood pressure level. The results indicated that an FQHC providing medical training, as part of its organizational structure, has a positive influence on patient outcomes.

Beyond Training the Next Generation of Physicians: The Unmeasured Value Added by Residents to Teaching Hospitals and Communities

Following medical school, most newly graduated physicians enter residency training. This period of graduate medical education (GME) is critical to creating a physician workforce with the specialized skills needed to care for the population. Completing GME training is also a requirement for obtaining medical licensure in all 50 states. Yet, crucial federal and state funding for GME is capped, creating a bottleneck in training an adequate physician workforce to meet future patient care needs. Thus, additional GME funding is needed to train more physicians. When considering this additional GME funding, it is imperative to take into account not only the future physician workforce but also the value added by residents to teaching hospitals and communities during their training. Residents positively affect patient care and health care delivery, providing intrinsic and often unmeasured value to patients, the hospital, the local community, the research enterprise, and undergraduate medical education. This added value is often overlooked in decisions regarding GME funding allocation. In this article, the authors underscore the value provided by residents to their training institutions and communities, with a focus on current and recent events, including the global COVID-19 pandemic and teaching hospital closures.

Hospitalization and Post-hospitalization Outcomes Among Teaching Internal Medicine, Employed Hospitalist, and Locum Tenens Hospitalist Services in a Tertiary Center: a Prospective Cohort Study

BACKGROUND

There are no prospective studies comparing hospitalization and post-hospitalization outcomes between teaching internal medicine services and non-teaching hospitalists, and no prospective studies comparing these outcomes between locum and employed hospitalists.

OBJECTIVE

To compare the length of stay, hospital costs readmission rate, and mortality rate in patients treated by teaching internal medicine services vs. hospitalists and among patients treated by locum vs. employed hospitalists.

DESIGN

Prospective cohort study. Propensity score was used to obtain weighted estimates.

SETTING

Referral center.

PATIENTS

All patients 18 years and older admitted to internal medicine services.

INTERVENTION

Treatment by teaching internal medicine services vs. hospitalists. Treatment by locum hospitalists vs. employed hospitalists.

MAIN MEASURES

Primary outcome was adjusted length of stay and secondary outcomes included hospital cost, inpatient mortality, 30-day all-cause readmission, and 30-day mortality.

KEY RESULTS

A total of 1273 patients were admitted in the study period. The mean patient age was 61 ± 19 years, and the sample was 52% females. Teaching internal medicine physicians admitted 526 patients and non-teaching hospitalists admitted 747 patients. Being seen exclusively by teaching internal medicine physicians comports with a shorter adjusted hospital stay by 0.6 days (95% CI - 1.07 to - 0.22, P = .003) compared to non-teaching hospitalists. Adjusted length of stay was 1 day shorter in patients seen exclusively by locums compared to patients seen exclusively by employed services (95% CI - 1.6 to - 0.43, P < .001) with an adjusted average hospital cost saving of 1339 dollars (95% CI - 2037 to - 642, P < .001). There was no statistically significant difference in other outcomes.

CONCLUSIONS

Teaching internal medicine services care was associated with a shorter stay but not with increased costs, readmission, or mortality compared to non-teaching services. In contrary to the "expected," patients treated by locums had shorter stays and decreased hospital costs but no increase in readmissions or mortality.

Outcomes of Non-Variceal Upper Gastrointestinal Bleed Stratified by Hospital Teaching Status: Insights From the National Inpatient Sample

BACKGROUND

Non-variceal upper gastrointestinal bleeding (NVUGIB) is a significant cause of mortality and morbidity in the USA. Currently, there are limited data on the inpatient outcomes of patients admitted with a diagnosis of NVUGIB stratified according to teaching hospital status. We analyzed data from the National Inpatient Sample (NIS) intending to evaluate these outcomes.

METHODS

We queried the NIS 2016 and 2017 databases for NVUGIB hospitalizations by teaching hospital status. The primary outcome was inpatient mortality while secondary outcomes were rate of endoscopy for hemostasis, rate of early endoscopy (endoscopy in 1 day or less), mean time to endoscopy, rate of complications including acute kidney injury (AKI), acute respiratory failure (ARF), need for blood transfusion, development of sepsis, need for endotracheal intubation and mechanical ventilation as well as healthcare utilization.

RESULTS

There were over 71 million weighted discharges in the combined 2016 and 2017 NIS database. A total of 94,900 NVUGIB cases were identified with 63.4% admitted in teaching hospitals. The in-hospital mortality for patients admitted with an NVUGIB in teaching hospitals was 1.98% compared to 1.5% in non-teaching hospitals (adjusted odds ratio (aOR): 1.38, 95% confidence interval (CI): 1.08 - 1.77, P = 0.010) when adjusted for biodemographic and hospital characteristics as well as comorbidities. Patients admitted with a diagnosis of NVUGIB in teaching hospitals had a 10% adjusted increased odds of getting endoscopy for hemostasis (27.0% vs. 24.5%, aOR: 1.10, 95% CI: 1.02 - 1.19, P = 0.016) compared to patients in non-teaching hospitals. There was, however, no difference in early endoscopy between the two groups.

CONCLUSION

Patients admitted at teaching hospitals for an NVUGIB had worse outcomes during hospitalizations including mortality, median length of stay, and total hospital charges when compared to NVUGIB patients managed at non-teaching hospitals.

Differences in length of stay by teaching team status in an academic medical center in the Midwestern United States

Background: Given the high cost of inpatient stays, hospital systems are investigating ways to decrease lengths of stay while ensuring high-quality care. The goal of this study was to determine if patients in teaching teams (hospitalist teams with residents and interns) had a higher length of stay after adjusting for relevant confounders compared to hospitalist-only teams (staffed only by attending physicians).Methods: Using a retrospective design, we investigated differences in length of stay for 17,577 inpatient encounters over a 2-year period. Length of stay was calculated based on the time between hospital admission and hospital discharge with no removal of outliers. Encounters were assigned to teams based on the discharge provider. Teams were grouped based on whether they were teaching teams or nonteaching teams. Since the length of stay was not normally distributed, it was modeled first using generalized linear models with gamma distribution and log link, and secondly by quantile regression. Models were adjusted for age, gender, race, medicine vs. non-medicine unit, MS-DRGs, and comorbidities.Results: Using gamma models to account for the skewed nature of the data, the length of stay for encounters assigned to teaching teams was 0.56 days longer (β = 0.10 95% CI 0.06 0.14) than for nonteaching teams after adjustment. Using quantile regression, teaching teams had encounters on average 0.63 days longer (95% CI 0.44 0.81) than nonteaching teams at the 75^th percentile and 1.19 days longer (95% CI 0.77 1.61) compared to nonteaching teams at the 90^th percentile after adjustment.Conclusions: After adjusting for demographics and clinical factors, teaching teams on average had lengths of stay that were over half day longer than nonteaching teams. In addition, for the longest encounters, differences between teaching and nonteaching teams were over 1-day difference. Given these results, process improvement opportunities exist within teaching teams regarding length of stay, particularly for longer encounters.

Defining the Essential Components of a Teaching Service

OBJECTIVES

A large portion of residency education occurs in inpatient teaching services without widely accepted consensus regarding the essential components that constitute a teaching service. We sought to generate consensus around this topic, with the goal of developing criteria programs that can be used when creating, redesigning, or evaluating teaching services.

METHODS

A list of potential components of teaching services was developed from a literature search, interviews, and focus groups. Eighteen pediatric medical education experts participated in a modified Delphi method, responding to a series of surveys rating the importance of the proposed components. Each iterative survey was amended on the basis of the results of the previous survey. A final survey evaluating the (1) effort and (2) impact of implementing components that had reached consensus as recommended was distributed.

RESULTS

Each survey had 100% panelist response. Five survey rounds were conducted. Fourteen attending physician characteristics and 7 system characteristics reached consensus as essential components of a teaching service. An additional 25 items reached consensus as recommended. When evaluating the effort and impact of these items, the implementation of attending characteristics was perceived as requiring less effort than system characteristics but as having similar impact.

CONCLUSIONS

Consensus on the essential and recommended components of a resident teaching service was achieved by using the modified Delphi method. Although the items that reached consensus as essential are similar to those proposed by the Accreditation Council for Graduate Medical Education, those that reached consensus as recommended are less commonly discussed and should be strongly considered by institutions.

Hospital teaching status on the outcomes of patients with esophageal variceal bleeding in the United States

BACKGROUND

Acute variceal bleeding is a major complication of portal hypertension and is a leading cause of death in patients with cirrhosis. There is limited data on the outcomes of patients with esophageal variceal bleeding in teaching versus nonteaching hospitals. Because esophageal variceal bleeding requires complex management, it may be hypothesized that teaching hospitals have lower mortality.

AIM

To assess the differences in mortality, hospital length of stay (LOS) and cost of admission for patients admitted for variceal bleed in teaching versus nonteaching hospitals across the US.

METHODS

The National Inpatient Sample is the largest all-payer inpatient database consisting of approximately 20% of all inpatient admissions to nonfederal hospitals in the United States. We collected data from the years 2008 to 2014. Cases of variceal bleeding were identified using the International Classification of Diseases, Ninth Edition, Clinical Modification codes. Differences in mortality, LOS and cost were evaluated for patients with esophageal variceal bleed between teaching and nonteaching hospitals and adjusted for patient characteristics and comorbidities.

RESULTS

Between 2008 and 2014, there were 58362 cases of esophageal variceal bleeding identified. Compared with teaching hospitals, mortality was lower in non-teaching hospitals (8.0% vs 5.3%, P < 0.001). Median LOS was shorter in nonteaching hospitals as compared to teaching hospitals (4 d vs 5 d, P < 0.001). A higher proportion of non-white patients were managed in teaching hospitals. As far as procedures in nonteaching vs teaching hospitals, portosystemic shunt insertion (3.1% vs 6.9%, P < 0.001) and balloon tamponade (0.6% vs 1.2%) were done more often in teaching hospitals while blood transfusions (64.2% vs 59.9%, P = 0.001) were given more in nonteaching hospitals. Using binary logistic regression models and adjusting for baseline patient demographics and comorbid conditions the mortality, LOS and cost in teaching hospitals remained higher.

CONCLUSION

In patients admitted for esophageal variceal bleeding, mortality, length of stay and cost were higher in teaching hospitals versus nonteaching hospitals when controlling for other confounding factors.

Readmissions on Teaching Versus Non-Teaching Services: Are They Any Different?

Introduction There is a paucity of comparative data on readmissions between teaching services (TS) and nonteaching services (NTS). Therefore, we designed this study to determine if there are any differences in readmissions between the two services. Materials and methods A unique cohort of 384 readmissions during one year was retrospectively examined at Hunter Holmes McGuire Veterans Medical Center. The data on patient demographics, baseline characteristics, comorbid illnesses, length of stay (LOS), and reasons for readmission within 30 days were extracted. Results There were no differences in readmission rates (8.2% vs. 10.2%; P = .135), LOS during index admission (4.2 ± 4.8 vs. 4.1 ± 3.5; P = .712), and age-adjusted Charlson Comorbid Index Score (6.1 ± 3.0 vs. 6.8 ± 2.8; P = .037) between the TS and NTS groups. However, the reasons for readmissions between the two groups were statistically significantly different (P < .01). Specifically, these differences were found between system issues and new diagnoses. The NTS showed higher rates of readmissions secondary to new diagnoses and systems issues, whereas the TS showed higher rates of secondary to clinician issues and disease progression. Conclusions We have a new understanding of the difference in reasons for readmissions between TS and NTS; it possibly results from the different structures of the two teams, which may help us address readmissions in a different light to improve overall readmission rate.

Effect of hospital teaching status on endoscopic retrograde cholangiopancreatography mortality and complications in the USA

BACKGROUND

Our aim was to assess the differences in outcomes of cholecystitis, pancreatitis, gastrointestinal (GI) bleed, GI perforation, and mortality in teaching versus nonteaching hospitals nationwide among therapeutic and diagnostic ERCPs. We hypothesized that complication rates would be higher in teaching hospitals given greater patient complexity.

METHODS

Inpatient diagnostic and therapeutic ERCPs were identified from the National Inpatient Sample (NIS) from 2008 to 2012. The presence of ACGME-approved residency programs is required to qualify as a teaching hospital. Nonteaching urban and rural hospitals were grouped together. We identified hospital stays complicated by pancreatitis, cholecystitis, GI hemorrhage, perforation, and mortality. Logistic regression propensity-matched analysis was performed in SPSS to compare differences in complication rates between teaching and nonteaching hospitals.

RESULTS

A total of 1,466,356 weighted cases of inpatient ERCPs were included in this study: of those, 367 and188 were diagnostic, 1,099,168 were therapeutic, 766,230 were at teaching hospitals, and 700,126 were at nonteaching hospitals. Mortality rates were higher in teaching hospitals when compared to nonteaching hospitals for diagnostic (OR 1.266, p < 0.001) and therapeutic ERCPs (OR 1.157, p = 0.001). There was no significant difference in rates of post-ERCP cholecystitis, pancreatitis, or perforation between the two groups. Among diagnostic ERCPs, GI hemorrhage was higher in teaching compared to nonteaching hospitals (OR 1.181, p = 0.003). Likewise, length of stay was increased in teaching hospitals (7.9 vs 6.9 days, p < 0.001, for diagnostic and 6.5 vs 5.8 days, p < 0.001, for therapeutic ERCPs).

CONCLUSIONS

In conclusion, teaching hospitals were noted to have a higher mortality rate associated with inpatient ERCPs as well as higher rates of GI hemorrhage in diagnostic ERCPs, which may be due to a higher comorbidity index in those patients admitted to teaching hospitals.

Readmissions Are Not What They Seem: Incidence and Classification of 30-Day Readmissions After Orthopedic Trauma Surgery

OBJECTIVES

To evaluate the causes of 30-day readmissions after orthopedic trauma surgery and classify them based on their relation to the index admission.

DESIGN

Retrospective chart review.

SETTING

One large, academic, medical center.

PARTICIPANTS

Patients admitted to a large, academic, medical center for a traumatic fracture injury over a 9-year period.

INTERVENTION

Assignment of readmission classification.

MAIN OUTCOME MEASURES

Readmissions within 30 days of discharge were identified and classified into orthopedic complications, medical complications, and noncomplications. A χ test was performed to assess any difference in the proportion of readmissions between the hospital-reported readmission rate and the orthopedic complication readmission rate.

RESULTS

One thousand nine hundred fifty-five patients who were admitted between 2011 and 2018 for an acute orthopedic trauma fracture injury were identified. Eighty-nine patients were readmitted within 30 days of discharge with an overall readmission rate of 4.55%. Within the 30-day readmission cohort, 30 (33.7%) were the direct result of orthopedic treatment complications, 36 (40.4%) were unrelated medical conditions, and 23 (25.8%) were noncomplications. Thus, the readmission rate directly due to orthopedic treatment complications was 1.53%. A χ test of homogeneity revealed a statistically significant difference between the hospital-reported readmission rate and the orthopedic-treatment complication readmission rate (P < 0.0005).

CONCLUSION

The use of 30-day readmissions as a measure of hospital quality of care overreports the number of preventable readmissions and penalizes surgeons and hospitals for caring for patients with less optimal health.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Association of Type of Treatment Facility With Overall Survival After a Diagnosis of Head and Neck Cancer

IMPORTANCE

Patients with head and neck cancer receive care at academic comprehensive cancer programs (ACCPs), integrated network cancer programs (INCPs), comprehensive community cancer programs (CCCPs), and community cancer programs (CCPs). The type of treatment facility may be associated with overall survival.

OBJECTIVE

To examine whether type of treatment facility is associated with overall survival after a diagnosis of head and neck cancer.

DESIGN, SETTING, AND PARTICIPANTS

This population-based retrospective cohort study included patients from the National Cancer Database, a prospectively maintained, hospital-based cancer registry of patients treated at more than 1500 US hospitals. Participants were diagnosed with malignant tumors of the head and neck from January 1, 2004, through December 31, 2016. Data were analyzed from May 1 through November 30, 2019.

EXPOSURES

Treatment at facilities classified as ACCPs, INCPs, CCCPs, or CCPs.

MAIN OUTCOMES AND MEASURES

Overall survival after diagnosis and treatment of head and neck cancer was the primary outcome. The secondary outcome was the odds of receiving treatment at ACCPs and INCPs vs CCCPs and CCPs. Multivariable Cox proportional hazards regression and univariable and multivariable logistic regression models were used for analysis.

RESULTS

A total of 525 740 patients (368 821 men [70.2%]; mean [SD] age, 63.3 [14.0] years) were diagnosed with malignant tumors of the head and neck during the study period. Among them, 36 595 patients (7.0%) were treated at CCPs; 174 658 (33.2%), at CCCPs; 232 867 (44.3%), at ACCPs; and 57 857 (11.0%), at INCPs. The median survival for patients with aerodigestive cancers was 69.2 (95% CI, 68.6-69.8) months; salivary gland cancers, 107.2 (95% CI, 103.9-110.2) months; and skin cancers, 113.2 (95% CI, 111.4-114.6) months. Improved overall survival was associated with treatment at ACCPs (hazard ratio [HR], 0.89; 95% CI, 0.88-0.91), INCPs (HR, 0.94; 95% CI, 0.92-0.96), and CCCPs (HR, 0.94; 95% CI, 0.92-0.95) compared with CCPs. Compared with patients with private insurance, those with government insurance (odds ratio [OR], 1.35; 95% CI, 1.29-1.41), no insurance (OR, 1.12; 95% CI, 1.09-1.16), or Medicaid (OR, 1.17; 95% CI, 1.14-1.20) were more likely to receive treatment at ACCPs and INCPs, whereas patients with Medicare were less likely to receive treatment at ACCPs and INCPs (OR, 0.95; 95% CI, 0.94-0.97). Compared with white patients, black (OR, 1.55; 95% CI, 1.52-1.59) and Asian (OR, 1.56; 95% CI, 1.49-1.63) patients were more likely to receive care at ACCPs and INCPs. Compared with patients from lower-income areas, patients from high-income areas were more likely to receive treatment at ACCPs and INCPs (OR, 1.25; 95% CI, 1.22-1.28).

CONCLUSIONS AND RELEVANCE

These findings suggest that treatment at ACCPs and INCPs was associated with a better overall survival rate in patients with head and neck cancer. Key social determinants of health such as race/ethnicity, socioeconomic status, and type of insurance were associated with receiving treatment at ACCPs and INCPs.

Holiday Discharges Are Associated with Higher 30-Day General Internal Medicine Hospital Readmissions at an Academic Medical Center

OBJECTIVE

Academic medical centers face unique challenges in educating physician trainees in effective discharge practices to prevent readmissions. Meanwhile, residents must handle high workloads coupled with frequent rotations to different services. This study aimed to determine whether daily service census, service turnover, time of discharge, and day of discharge increase the risk of 30-day readmission.

METHODS

All of the discharges from two academic general internal medicine teaching services between October 1, 2013 and September 30, 2014 were included in this observational data analysis. Variables were fit to a 30-day, all-cause readmission outcome using multiple logistic regression with inverse probability of treatment weighting and multiple imputations with chained equations. The following potential confounding variables were included in the model: health system utilization, demographics, laboratory values, and comorbidities.

RESULTS

Among 1935 total discharges, 258 patients (13.3%) were readmitted within 30 days of the index discharge. Turnover, service census, weekend discharge, and time of discharge were not significantly associated with the risk of readmission. Patients discharged during holiday periods had higher odds of readmission (odds ratio 2.56, 95% confidence interval 2.01-3.25), whereas patients discharged on an intern switch day had lower odds of readmission (odds ratio 0.33, 95% confidence interval 0.27-0.41).

CONCLUSIONS

Patients who are discharged during holiday periods are at a higher risk of readmission after adjusting for potential confounders. These results also suggest that discharge on an intern switch day had a protective effect on readmission. Further work is needed to examine whether these findings can be replicated, and, if confirmed, to determine to what extent these associations are causal.

The impact of teaching status on trauma center clinical outcomes in the United States

Teaching status/academic ranking may play a role in the variations in trauma center (TC) outcomes. Our study aimed to determine the relationship between TC teaching status and injury-adjusted, all-cause mortality in a national sampling.Retrospective review of the National Sample Program (NSP) from the National Trauma Data bank (NTDB). TCs were categorized based on teaching status. Adjusted mortality was determined by observed/expected (O/E) mortality ratios, derived using TRauma Injury Severity Score methodology from the Injury Severity Score and Revised Trauma Score. Chi-square and t test analyses were utilized with a statistical significance defined as P <.05.Of the 94 TCs in the NSP, 46 were university, 38 were community teaching, and 10 were community nonteaching. For the University TCs, 62.8% were American College of Surgeons (ACS) level 1 and 81.2% state level 1. Of the community teaching TCs, 39.0% was ACS level 1 and 35.1% was state level 1. Of the community nonteaching TCs, 0% was ACS level 1 and 11.1% was state level 1. University TCs had a significantly higher O/E mortality rate than community teaching (0.75 vs 0.71; P = .04). There were no differences in O/E between community teaching and nonteaching TCs (0.71 vs 0.70; P = .70).Community teaching and nonteaching TCs have lower injury-adjusted, all-cause mortality rates than University Centers. Future studies should further investigate key differences between University TCs and community teaching TC to evaluate possible quality and performance improvement measures.

Differences in healthcare outcomes between teaching and non teaching hospitals for patients with delirium: a retrospective cohort study

BACKGROUND

The physician workforce at teaching hospitals differs compared to non-teaching hospitals, and data suggest that patient outcomes may also be dissimilar. Delirium is a common, costly disorder among hospitalized patients and approaches to care are not standardized.

OBJECTIVE

This study set out to explore differences in healthcare outcomes between teaching and non-teaching hospitals for patients admitted with delirium.

DESIGN

Retrospective cohort analysis.

SETTING AND PARTICIPANTS

We used the 2014 Nationwide Inpatient Sample database. Adult patients (≥18 years of age) hospitalized in acute-care hospitals in the USA with delirium (defined with ICD-9 code) were studied.

MAIN OUTCOME MEASURES

The primary outcome was in-hospital all-cause mortality. Secondary outcomes were discharge status and several measures of healthcare resource utilization: length of stay, total hospitalization costs and multiple procedures performed.

RESULTS

In 2014, out of 57 460 adult patients admitted to hospitals with delirium, 58.4% were hospitalized at teaching hospitals and the remainder 41.6% at non-teaching hospitals. The in-hospital mortality of delirium patients in teaching hospitals was 1.33% (95% CI 1.08%-1.63%), and 1.26% (95% CI 0.97%-1.63%) in non-teaching hospitals. The mean total hospital costs were $7642 (95% CI 7384-7900) in teaching hospitals, and $6650 (95% CI 6460-6840) in non-teaching hospitals. After adjustment for confounders, total hospitalization costs were statistically significantly different between the hospitals types-with non-teaching providing less expensive care.

CONCLUSIONS

Patients with delirium admitted to non-teaching hospitals had comparable clinical and process outcomes achieved at lower costs. Further research can be conducted to explore the contextual issues and reasons for these differences in healthcare costs.

Readmission and mortality in patients treated by interprofessional student teams at a training ward compared with patients receiving usual care: a retrospective cohort study

OBJECTIVE

This study aimed to compare the rate of patient readmissions and mortality between care provided at an orthopaedic interprofessional training ward (IPTW) and usual care.

DESIGN

Retrospective cohort study.

SETTING

Orthopaedic wards at a level II trauma centre at a Swedish university teaching hospital between 2006 and 2011.

PARTICIPANTS

Two cohorts were identified: (1) a control cohort that had not received care at the IPTW, and (2) patients who had been treated for at least 1 day at the IPTW.

MAIN OUTCOME MEASURES

Readmission at 90 days and 1-year mortality.

RESULTS

We included 4652 controls and 1109 in the IPTW group. The mean age was 63 years, and 58% were women. The groups did not differ in any of the outcomes: the readmission rate in the control and IPTW groups was 13.5% and 14.0%, respectively, while mortality was 5.2% and 5.3%, respectively. This lack of difference remained after adjusting for confounders.

CONCLUSION

Interprofessional undergraduate training in patient-based settings can be performed in a level II trauma hospital with satisfactory patient safety.

On measuring the quality of hospitals

PURPOSE

Researchers, policymakers and hospital managers often encounter numerous quality measures when assessing hospital quality. The purpose of this paper is to address the challenge of summarising, interpreting and comparing multiple quality measures across different quality dimensions by proposing a simple method of constructing a composite quality index. The method is applied to hospital administrative data to demonstrate its use in analysing hospital performance.

DESIGN/METHODOLOGY/APPROACH

Logistic and fixed effects regression analyses are applied to secondary admitted patient data from all hospitals in the state of Victoria, Australia for the period 2000/2001-2011/2012.

FINDINGS

The derived composite quality index was used to rank hospital performance and to assess changes in state-wide average hospital quality over time. Further regression analyses found private hospitals, day hospitals and non-acute hospitals were associated with higher composite quality, while small hospitals were associated with lower quality.

PRACTICAL IMPLICATIONS

The method will enable policymakers and hospital managers to better monitor the performance of hospitals. It allows quality to be related to other attributes of hospitals such as size and volume, and enables policymakers and managers to focus on hospitals with relevant characteristics such that quantity and quality changes can be better understood, monitored and acted upon.

ORIGINALITY/VALUE

A simple method of constructing a composite quality is an indispensable practical tool in tracking the quality of hospitals when numerous measures are used to capture different aspects of quality. The derived composite quality can be used to summarise hospital performance and to identify factors associated with quality via regression analyses.

A Comparative Analysis of Academic and Nonacademic Hospitals on Outcome Measures and Patient Satisfaction

Academic hospitals contribute to health care through patient care, research, and teaching; however, their outcomes may not be equivalent to nonacademic hospitals. Multivariate analysis of variance is used to compare publicly reported data on patient satisfaction, readmission rates, mortality rates, and hospital-acquired injury scores between 1906 academic and nonacademic hospitals, while controlling for hospital-level covariates. Results show that academic hospitals have higher levels of patient satisfaction on 7 of the 11 measures and are equivalent to nonacademic hospitals on the remaining 4 measures. Academic hospitals have lower pneumonia mortality rates than nonacademic hospitals, with no difference for other mortality or disease-specific readmissions. However, academic hospitals have a slightly higher overall readmission rate. Infection rates were equivalent between academic and nonacademic hospitals for central line-associated bloodstream infections, pressure ulcers, and wound dehiscence for abdominal and pelvic injuries, but academic hospitals have higher catheter-associated urinary tract infection rates.

What the "Nonteaching" Service Can Teach Us

"Teaching" services usually incorporate a cadre of learners such as resident physicians and medical students as part of the care team, led by a faculty physician. "Nonteaching" services, in contrast, are usually defined by the absence of resident physicians on the care team. The care for patients on a nonteaching service is frequently managed directly by a faculty or nonfaculty physician. Nonteaching services have grown in number and size at academic medical centers (AMCs) in response to regulatory requirements, operational demands, and efforts to improve clinical education. The allocation of patients to teaching and nonteaching services is frequently based on perceived teaching value of hospitalized patients, which can potentially lead to a number of unintended consequences for medical education, professional satisfaction, and patient care. Through a series of four lessons, the authors describe how the structure of nonteaching services can result in curricular gaps, devalue attending physicians, and undermine the educational and clinical missions of AMCs. Anticipating the continued expansion and evolution of nonteaching services, the authors propose seven design principles for nonteaching services to ensure robust education for students and resident physicians, advance quality of care, and enhance attending physician and patient experience.

Discharge service as a determinant of 30-day readmission in a cohort of maintenance hemodialysis patients: a retrospective cohort study

Background

End stage renal disease (ESRD) patients on maintenance hemodialysis, are high utilizers of inpatient services. Because of data showing improved outcomes in medical patients admitted to hospitalist-run, non-teaching services, we hypothesized that discharge from a hospitalist-run, non-teaching service is associated with lower risk of 30-day re-hospitalization in a cohort of patients on hemodialysis.

Methods

One thousand and 84 consecutive patients with ESRD on maintenance hemodialysis who were admitted to Montefiore, a tertiary care center, in 2014 were analyzed using the electronic medical records. We evaluated factors associated with 30-day readmission in multivariable regression models. We then tested the association of care by a hospitalist-run, non-teaching service with 30-day readmission in a propensity score matched analysis.

Results

Patients cared for on the hospitalist-run, non-teaching service had lower socio-economic scores (SES) and had longer lengths of stay (LOS), as compared to a standard teaching service, but otherwise the populations were similar. In multivariable testing, severity of illness, (OR 2.40, (95%CI: 1.43–4.03) for highest quartile) number of previous hospitalizations (OR 1.22 (95%CI:1.16–1.28) for each admission), and discharge to a skilled nursing facility (SNF)(OR 1.56 (95%CI:1.01–2.43) were significantly associated with 30-day re-admissions. Care by the non-teaching service was associated with a lower risk of 30-day readmission, even after adjusting for clinical factors and matching based on propensity score (OR 0.65(95%CI:0.46–0.91) and 0.71(95%CI:0.66–0.77) respectively).

Conclusions

Patients with ESRD on hemodialysis discharged from a hospitalist-run, non-teaching medicine service had lower odds of readmission as compared to those patients discharged from a standard teaching service.

Financial, Resource Utilization and Mortality Impacts of Teaching Hospital Status on Pediatric Patients Admitted for Sepsis

BACKGROUND

With the changing healthcare landscape in the United States, teaching hospitals face increasing pressure to provide medical education as well as cost-effective care. Our study investigated the financial, resource utilization and mortality impact of teaching hospital status on pediatric patients admitted with sepsis.

METHODS

We conducted a retrospective, weighted statistical analysis of hospitalized children with the diagnosis of sepsis. The Agency for Healthcare Research and Quality 2009 Kids' Inpatient Database provided the data for analysis. Diagnosis of sepsis and severity of illness levels were based on All Patient Refined Diagnosis-Related Groups of 720: Septicemia and Disseminated Infections. Teaching hospital status was based on presence of training programs. Statistical analysis was conducted using STATA 12.1 (Stata Corporation, College Station, TX).

RESULTS

Weighted analysis revealed 17,461 patients with sepsis-9982 in teaching and 7479 in nonteaching hospitals. When comparing all patients, length of stay (8.2 vs. 4.8, P < 0.001), number of procedures received (2.03 vs. 0.87, P < 0.001), mortality (4.7% vs. 1.6%, P < 0.001), costs per day ($2326 vs. $1736, P < 0.001) and total costs ($20,428 vs. $7960, P < 0.001) were higher in teaching hospitals. Even when stratified by severity classes, length of stay, number of procedures received and total costs were higher in teaching hospitals with no difference in mortality.

CONCLUSIONS

Our study suggested that teaching hospitals provide pediatric inpatient care for sepsis at greater costs and resource utilization without a clear improvement in overall mortality rates in comparison with nonteaching hospitals.

RECALMIN: The association between management of Spanish National Health Service Internal Medical Units and health outcomes

Objective

To investigate the association between management of Internal Medical Units (IMUs) with outcomes (mortality and length of stay) within the Spanish National Health Service.

Design

Data on management were obtained from a descriptive transversal study performed among IMUs of the acute hospitals. Outcome indicators were taken from an administrative database of all hospital discharges from the IMUs.

Setting

Spanish National Health Service.

Participants

One hundred and twenty-four acute general hospitals with available data of management and outcomes (401 424 discharges).

Main Outcome Measures

IMU risk standardized mortality rates were calculated using a multilevel model adjusted by Charlson Index. Risk standardized myocardial infarction and heart failure mortality rates were calculated using specific multilevel models. Length of stay was adjusted by complexity.

Results

Greater hospital complexity was associated with longer average length of stays (r: 0.42; P < 0.001). Crude in-hospital mortality rates were higher at larger hospitals, but no significant differences were found when mortality was risk adjusted. There was an association between nurse workload with mortality rate for selected conditions (r: 0.25; P = 0.009). Safety committee and multidisciplinary ward rounds were also associated with outcomes.

Conclusions

We have not found any association between complexity and intra-hospital mortality. There is an association between some management indicators with intra-hospital mortality and the length of stay. Better disease-specific outcomes adjustments and a larger number of IMUs in the sample may provide more insights about the association between management of IMUs with healthcare outcomes.

Comparison of hospital outcomes and resource use in acute COPD exacerbation patients managed by teaching versus nonteaching services in a community hospital

RATIONALE, AIMS, AND OBJECTIVES

The impact of teaching versus nonteaching services on outcomes and resource use in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is unknown. The aim of the study is to evaluate the impact of an internal medicine teaching service compared to a nonteaching service on outcomes and resource use in patients admitted with AECOPD in a community teaching hospital.

METHODS

A retrospective cohort study of patients admitted for a primary diagnosis of chronic obstructive pulmonary disease exacerbation to Florida Hospital Orlando, a large community teaching hospital, between January 1, 2011, and December 31, 2014. Data were extracted from Premier administrative database. Risk adjusted length of stay (LOS), cost of hospitalization, 30-day readmissions, and mortality rate were measured. Risk adjustment for outcomes was based on Premier CareScience methodology.

RESULTS

A total of 1419 patients were included, 306 in the teaching group and 1113 in the nonteaching group. Risk adjusted cost and LOS were significantly lower in the teaching group compared to the nonteaching group (observed/expected cost 0.66 vs 1.06, P < .001) and (observed/expected LOS 0.93 vs 1.69, P < .001), respectively. No significant difference was found between the 2 groups in risk adjusted mortality and readmissions (P = .48 and .89, respectively). Use of consults was significantly lower in the teaching groups with 73% vs 31% of the patient in the teaching group had no consults compared to the nonteaching group (P < .001). The teaching service was significantly associated with decreased use of consults after adjustment for other variables (odds ratio, 0.17, 95% CI, 0.15-0.23, P < .001).

CONCLUSION

The teaching service had more favorable outcomes compared to nonteaching services in patients hospitalized for AECOPD. The physician practice model has a major impact on the cost, LOS, and use of consults in patients with AECOPD.

Surgeon Characteristics Supersede Hospital Characteristics in Mortality After Urgent Colectomy

BACKGROUND

Urgent colectomy is a common procedure with a high mortality rate that is performed by a variety of surgeons and hospitals. We investigated patient, surgeon, and hospital characteristics that predicted mortality after urgent colectomy.

METHODS

The University HealthSystem Consortium was queried for adults undergoing urgent or emergent colectomy between 2009 and 2013 (n = 50,707). Hospitals were grouped into quartiles according to risk-adjusted observed-to-expected (O/E) mortality ratios and compared using the 2013 American Hospital Association Annual Survey. Multiple logistic regression was used to determine patient and provider characteristics associated with in-hospital mortality.

RESULTS

The overall mortality rate after urgent colectomy was 9 %. Mortality rates were higher for patients with extreme severity of illness (27.6 %), lowest socioeconomic status (10.6 %), weekend admissions (10.7 %), and open (10.5 %) and total (15.8 %) colectomies. Hospitals with the lowest O/E ratios were smaller and had lower volume and less teaching intensity, but there were no significant trends with regard to financial (expenses, payroll, capital expenditures per bed) or personnel characteristics (physicians, nurses, technicians per bed). On multivariate analysis, mortality was associated with patient age (10 years: OR 1.31, p < 0.01), severity of illness (extreme: OR 34.68, p < 0.01), insurance status (Medicaid: OR 1.24, p < 0.01; uninsured: OR 1.40, p < 0.01), and weekend admission (OR 1.09, p = 0.04). Surgeon volume was associated with reduced mortality (per 10 cases: OR 0.99, p < 0.01), but hospital volume was not (per case: OR 1.00, p = 0.84).

CONCLUSIONS

Mortality is common after urgent colectomy and is associated with patient characteristics. Surgeon volume and practice patterns predicted differences in mortality, whereas hospital factors did not. These data suggest that policies focusing solely on hospital volume ignore other more important predictors of patient outcomes.

Health care setting and severity, symptom burden, and complications in patients with Philadelphia-negative myeloproliferative neoplasms (MPN): a comparison between university hospitals, community hospitals, and office-based physicians

Philadelphia-negative myeloproliferative neoplasms (MPN) comprise a heterogeneous group of chronic hematological malignancies with significant variations in clinical characteristics. Due to the long survival and the feasibility of oral or subcutaneous therapy, these patients are frequently treated outside of larger academic centers. This analysis was performed to elucidate differences in MPN patients in three different health care settings: university hospitals (UH), community hospitals (CH), and office-based physicians (OBP). The MPN registry of the Study Alliance Leukemia is a non-interventional prospective study including adult patients with an MPN according to WHO criteria (2008). For statistical analysis, descriptive methods and tests for significant differences were used. Besides a different distribution of MPN subtypes between the settings, patients contributed by UH showed an impaired medical condition, a higher comorbidity burden, and more vascular complications. In the risk group analyses, the majority of polycythemia vera (PV) and essential thrombocythemia (ET) patients from UH were classified into the high-risk category due to previous vascular events, while for PV and ET patients in the CH and OBP settings, age was the major parameter for a high-risk categorization. Regarding MPN-directed therapy, PV patients from the UH setting were more likely to receive ruxolitinib within the framework of a clinical trial. In summary, the characteristics and management of patients differed significantly between the three health care settings with a higher burden of vascular events and comorbidities in patients contributed by UH. These differences need to be taken into account for further analyses and design of clinical trials.

Epidemiology and resource utilization in pediatric facial fractures

BACKGROUND

Pediatric facial fractures, although uncommon, have a significant impact on public health and the US economy by the coexistence of other injuries and developmental deformities. Violence is one of the most frequent mechanisms leading to facial fracture. Teaching hospitals, while educating future medical professionals, have been linked to greater resource utilization in differing scenarios. This study was designed to compare the differences in patient characteristics and outcomes between teaching and non-teaching hospitals for violence-related pediatric facial fractures.

METHODS

Using the 2000-2009 Kids' Inpatient Database, 3881 patients younger than 18 years were identified with facial fracture and external cause of injury code for assault, fight, or abuse. Patients admitted at teaching hospitals were compared to those admitted at non-teaching hospitals in terms of demographics, injuries, and outcomes.

RESULTS

Overall, 76.2% of patients had been treated at teaching hospitals. Compared to those treated at non-teaching hospitals, these patients were more likely to be younger, non-white, covered by Medicaid, from lower income zip codes, and have thoracic injuries; but mortality rate was not significantly different. After adjusting for potential confounders, teaching status of the hospital was not found as a predictor of either longer lengths of stay (LOS) or charges.

CONCLUSIONS

There is an insignificant difference between LOS and charges at teaching and non-teaching hospitals after controlling for patient demographics. This suggests that the longer LOS observed at teaching hospitals is related to these institutions being more often involved in the care of underserved populations and patients with more severe injuries.

Thirty-day readmission rates in spine surgery: systematic review and meta-analysis

OBJECT

The rate of 30-day readmissions is rapidly gaining significance as a quality metric and is increasingly used to evaluate performance. An analysis of the present 30-day readmission rate in the spine literature is needed to aid the development of policies to decrease the frequency of readmissions. The authors examine 2 questions: 1) What is the 30-day readmission rate as reported in the spine literature? 2) What study factors impact the rate of 30-day readmissions?

METHODS

This study was registered with Prospera (CRD42014015319), and 4 electronic databases (PubMed, Cochrane Library, Web of Science, and Google Scholar) were searched for articles. A systematic review and meta-analysis was performed to assess the current 30-day readmission rate in spine surgery. Thirteen studies met inclusion criteria. The readmission rate as well as data source, time from enrollment, sample size, demographics, procedure type and spine level, risk factors for readmission, and causes of readmission were extrapolated from each study.

RESULTS

The pooled 30-day readmission rate was 5.5% (95% CI 4.2%–7.4%). Studies from single institutions reported the highest 30-day readmission rate at 6.6% (95% CI 3.8%–11.1%), while multicenter studies reported the lowest at 4.7% (95% CI 2.3%–9.7%). Time from enrollment had no statistically significant effect on the 30-day readmission rate. Studies including all spinal levels had a higher 30-day readmission rate (6.1%, 95% CI 4.1%–8.9%) than exclusively lumbar studies (4.6%, 95% CI 2.5%–8.2%); however, the difference between the 2 rates was not statistically significant (p = 0.43). The most frequently reported risk factors associated with an increased odds of 30-day readmission on multivariate analysis were an American Society of Anesthesiology score of 4+, operative duration, and Medicare/Medicaid insurance. The most common cause of readmission was wound complication (39.3%).

CONCLUSIONS

The 30-day readmission rate following spinal surgery is between 4.2% and 7.4%. The range, rather than the exact result, should be considered given the significant heterogeneity among studies, which indicates that there are factors such as demographics, procedure types, and individual institutional factors that are important and affect this outcome variable. The pooled analysis of risk factors and causes of readmission is limited by the lack of reporting in most of the spine literature.

Physician experience and outcomes among patients admitted to general internal medicine teaching wards

BACKGROUND

Physician scores on examinations decline with time after graduation. However, whether this translates into declining quality of care is unknown. Our objective was to determine how physician experience is associated with negative outcomes for patients admitted to hospital.

METHODS

We conducted a retrospective cohort study involving all patients admitted to general internal medicine wards over a 2-year period at all 7 teaching hospitals in Alberta, Canada. We used files from the Alberta College of Physicians and Surgeons to determine the number of years since medical school graduation for each patient's most responsible physician. Our primary outcome was the composite of in-hospital death, or readmission or death within 30 days postdischarge.

RESULTS

We identified 10 046 patients who were cared for by 149 physicians. Patient characteristics were similar across physician experience strata, as were primary outcome rates (17.4% for patients whose care was managed by physicians in the highest quartile of experience, compared with 18.8% in those receiving care from the least experienced physicians; adjusted odds ratio [OR] 0.88, 95% confidence interval [CI] 0.72-1.06). Outcomes were similar between experience quartiles when further stratified by physician volume, most responsible diagnosis or complexity of the patient's condition. Although we found substantial variability in length of stay between individual physicians, there were no significant differences between physician experience quartiles (mean adjusted for patient covariates and accounting for intraphysician clustering: 7.90 [95% CI 7.39-8.42] d for most experienced quartile; 7.63 [95% CI 7.13-8.14] d for least experienced quartile).

INTERPRETATION

For patients admitted to general internal medicine teaching wards, we saw no negative association between physician experience and outcomes commonly used as proxies for quality of inpatient care.

Thirty-day readmission rates in orthopedics: a systematic review and meta-analysis

Background

Hospital readmission rates are being used to evaluate performance. A survey of the present rates is needed before policies can be developed to decrease incidence of readmission. We address three questions: What is the present rate of 30-day readmission in orthopedics? How do factors such as orthopedic specialty, data source, patient insurance, and time of data collection affect the 30-day readmission rate? What are the causes and risk factors for 30-day readmissions?

Methods/Findings

A review was first registered with Prospero (CRD42014010293, 6/17/2014) and a meta-analysis was performed to assess the current 30-day readmission rate in orthopedics. Studies published after 2006 were retrieved, and 24 studies met the inclusion criteria. The 30-day readmission rate was extrapolated from each study along with the orthopedic subspecialty, data source, patient insurance, time of collection, patient demographics, and cause of readmission. A sensitivity analysis was completed on the stratified groups. The overall 30-day readmission rate across all orthopedics was 5.4 percent (95% confidence interval: 4.8,6.0). There was no significant difference between subspecialties. Studies that retrieved data from a multicenter registry had a lower 30-day readmission rate than those reporting data from a single hospital or a large national database. Patient populations that only included Medicare patients had a higher 30-day readmission rate than populations of all insurance. The 30-day readmission rate has decreased in the past ten years. Age, length of stay, discharge to skilled nursing facility, increased BMI, ASA score greater than 3, and Medicare/Medicaid insurance showed statistically positive correlation with increased 30-day readmissions in greater than 75 percent of studies. Surgical site complications accounted for 46 percent of 30-day readmissions.

Conclusions

This meta-analysis shows the present rate of 30-day readmissions in orthopedics. Demonstrable heterogeneity between studies underlines the importance of uniform collection and reporting of readmission rates for hospital evaluation and reimbursement.