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Higher mortality among patients of hospitalists who work fewest days

16/09 - For older patients admitted with an emergency condition, 30-day mortality is greater when they're treated by hospitalists who spend the least time working clinically, a new study suggests.

An analysis of U.S. data from 392,797 hospitalizations of Medicare beneficiaries treated by 19,1790 hospitalists during 2011-2016 found that 30-day mortality rates were highest among the patients treated by physicians in the bottom quartile of days worked per year as compared with the top quartile (10.5% versus 9.6%), according to the results published in JAMA Internal Medicine.

The study did not find the same association for readmissions within 30 days.

"This is the first large-scale study of hospitalized elderly patients examining the association between the number of days worked clinically per year by hospitalists and patient mortality," said lead author, Hirotaka Kato, a research associate at the Graduate School of Health Management at Keio University in Tokyo. "Our findings suggest that clinical care by physicians working part-time clinically may be associated with higher patient mortality."

Several factors may explain these results, Kato said in an email. "Part-time physicians may face challenges in keeping up with the latest evidence and cutting-edge clinical practice," he said. "Alternatively, part-time physicians may be less familiar with nurses, medical assistants, and other staff in hospitals than full-time physicians, leading to poorer teamwork."

To explore whether the number of days worked by hospitalists might impact the health of the patients in their care, Kato and his colleagues linked Medicare claims data and the Medicare Data on Physician Practice and Specialty (MD-PPAS) file provided by the Centers for Medicare and Medicaid Services.

The researchers analyzed a random 20% sample of Medicare fee-for-service beneficiaries aged 65 and older who were admitted to hospitals between 2011 and 2016 with an emergency medical condition as defined by the Medicare Severity-Diagnosis Related Group. The study team attributed each hospitalization to the hospitalist who accounted for the largest number of evaluation and management claims during the hospitalization.

Based on claims, the researchers also determined the number of days each physician worked clinically, and grouped hospitalists into quartiles based on number of days worked per year. After excluding physicians with the top and bottom 10% of days worked, the researchers found that those in the lowest quartile worked 65% fewer days than those in the highest quartile.

Among the hospitalists included in the analysis, the mean age was 41.1 years, and 7,482 (39.0%) were female.

Overall, the study found, the more days worked by physicians, the lower the mortality rate of their patients. For hospitalists in the lowest quartile of days worked, adjusted 30-day patient mortality was 10.5%, and for the second, third and highest quartiles, mortality rates were 10%, 9.5% and 9.6%, respectively.

"As the number of physicians that engage in part-time clinical work continues to increase, our findings should lead to careful consideration by health systems to reevaluate preventive measures to address potential unintended patient harm," Kato said. "However, at this point, given that evidence is still limited, we do not believe that patients need to avoid part-time physicians."

Given that physicians working part-time clinically must often balance clinical and non-clinical obligations, better support by institutions may be necessary to maintain the clinical performance of those physicians, Kato added.

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