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

Finlay A. McAlister; Erik Youngson; Jeffrey A. Bakal; Jayna Holroyd-Leduc; Narmin Kassam

doi:10.1503/cmaj.150316

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Figure 1:
Derivation of the study cohort.
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Figure 2:
Patient outcomes across quartiles of physician experience. Referent group for each comparison are patients cared for by the physician quartile with the least experience (quartile 1). Odds ratios less than 1 favour physicians with more experience. Adjusted odds ratios were obtained using logistic generalized linear mixed models, with physician as a random effect and fixed effects being patient age, sex, hospital and LACE score (except death during index admission, which instead used Charlson Comorbidity Index score). CI = confidence interval; LACE = length of stay, acuity of admission, comorbidities and emergency department (ED) visits; OR = odds ratio.

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Table 1:

Characteristics of study participants, by quartile of physician experience

Characteristic	Overall (149 physicians)	Physician experience quartile				p value^*
Characteristic	Overall (149 physicians)	1, 4–10 yr (40 physicians)	2, 11–17 yr (38 physicians)	3, 18–22 yr (33 physicians)	4, ≥ 23 yr (38 physicians)	p value^*
No. of patients	10046	2394	2471	2720	2461
Age, yr, mean ± SD	63.4 ± 19.5	64.1 ± 19.1	62.8 ± 19.5	62.3 ± 19.7	64.5 ± 19.6	< 0.001
Male sex	5153 (51.3)	1192 (49.8)	1271 (51.4)	1428 (52.5)	1262 (51.3)	0.3
Top 5 most responsible diagnoses, no. (%)	2506 (24.9)	648 (27.1)	612 (24.8)	656 (24.1)	590 (24.0)	0.045^†
COPD	766 (7.6)	221 (9.2)	187 (7.6)	176 (6.5)	182 (7.4)
Pneumonia	512 (5.1)	135 (5.6)	118 (4.8)	148 (5.4)	111 (4.5)
Heart failure	517 (5.1)	120 (5.0)	120 (4.9)	130 (4.8)	147 (6.0)
Urinary tract infection	364 (3.6)	104 (4.3)	98 (4.0)	92 (3.4)	70 (2.8)
Venous thromboembolism	347 (3.5)	68 (2.8)	89 (3.6)	110 (4.0)	80 (3.3)
Diagnosis fields populated in Discharge Abstract Database, no. (%)	7.4 (4.6)	7.7 (4.8)	7.7 (4.8)	7.0 (4.5)	7.4 (4.4)	< 0.001
Charlson Comorbidity Index score, mean ± SD	2.6 ± 3.2	2.7 ± 2.9	2.7 ± 3.3	2.6 ± 3.5	2.6 ± 3.1	0.4
Features of index admission, mean ± SD
Resource intensity weight^‡	1.4 ± 1.2	1.4 ± 1.2	1.3 ± 1.3	1.4 ± 1.1	1.4 ± 1.2	0.5
LACE score	10.4 ± 3.1	10.6 ± 3.1	10.2 ± 3.1	10.4 ± 3.1	10.6 ± 3.0	< 0.001
Expected length of stay, d	7.3 ± 5.2	7.6 ± 5.8	7.2 ± 5.3	7.3 ± 5.0	7.2 ± 4.6	0.03
Actual length of stay, d	7.6 ± 6.2	7.6 ± 6.2	7.1 ± 6.1	7.6 ± 6.0	8.2 ± 6.3	< 0.001
Discharge disposition, no. (%)						0.2^§
Death	541 (5.4)	133 (5.6)	135 (5.5)	137 (5.0)	136 (5.5)
Transferred to facility with inpatient care	241 (2.4)	66 (2.8)	47 (1.9)	60 (2.2)	68 (2.8)
Transferred to long-term care facility	700 (7.0)	169 (7.1)	163 (6.6)	190 (7.0)	178 (7.2)
Transferred to hospice	32 (0.3)	4 (0.2)	9 (0.4)	8 (0.3)	11 (0.4)
Discharged home with support services	1688 (16.8)	388 (16.2)	419 (17.0)	428 (15.7)	453 (18.4)
Discharged home	6645 (66.1)	1581 (66.0)	1655 (67.0)	1846 (67.9)	1563 (63.5)
Left against medical advice	199 (2.0)	53 (2.2)	43 (1.7)	51 (1.9)	52 (2.1)

Note: COPD = chronic obstructive pulmonary disease, LACE = length of stay, acuity of admission, comorbidities and emegency department visits, SD = standard deviation.
↵* Calculated using analysis of variance (continuous variables) or χ² test (binary and categorical variables).
↵† p value comparing overall proportion of discharges (binary) that were a “Top 5 diagnoses” across physician experience groups.
↵‡ Resource intensity weight values provide a measure of a patient’s relative resource consumption compared with an average typical inpatient cost and are generated by the Canadian Institute of Health Information for each case mix group.
↵§ Overall p value for discharge disposition (categorical) across physician experience groups.

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Table 2:

Outcomes during the index admission and during the first 30 days postdischarge

Outcome	Overall, %	Physician experience quartile, %^*				p value
Outcome	Overall, %	1, 4–10 yr	2, 11–17 yr	3, 18–22 yr	4, ≥ 23 yr	p value
Death during index admission, or death or readmission within 30 d postdischarge	17.3	18.8	16.5	16.6	17.4	0.2
Death during index admission	5.4	5.6	5.5	5.0	5.5	0.8
Death or readmission within 30 d for any cause^†^‡	12.8	14.2	11.9	12.5	12.9	0.2
Readmission within 30 d for any cause^‡	11.2	11.9	11.0	11.1	10.9	0.7
Death within 30 d postdischarge^†^‡	3.0	3.6	2.3	3.1	2.9	0.1
Emergency department visit within 30 d postdischarge^‡	16.6	17.2	15.6	16.9	16.7	0.5
Discharged back to same level of care as preadmission^‡	93.1	92.8	94.1	93.2	92.5	0.2
Outpatient physician visit within 30 d of discharge^†	72.2	72.9	71.1	72.1	72.6	0.6
No. of outpatient physician visits in the first 30 d postdischarge, mean ± SD^‡	2.53 ± 1.98	2.57 ± 2.02	2.53 ± 2.03	2.51 ± 1.89	2.53 ± 1.97	0.8
Length of stay, d (95% CI)
Mean actual	7.62 (7.50–7.74)	7.62 (7.37–7.87)	7.10 (6.86–7.34)	7.55 (7.33–7.78)	8.22 (7.97–8.47)	< 0.001
Physician-adjusted actual^§		7.30 (6.64–7.95)	7.53 (6.88–8.19)	7.53 (6.84–8.22)	8.04 (7.37–8.71)	0.5
Patient- and physician-adjusted actual^¶		7.63 (7.13–8.14)	7.71 (7.21–8.22)	7.82 (7.30–8.34)	7.90 (7.39–8.42)	0.9

↵* Unless otherwise stated.
↵† Mortality data postdischarge are not available for patients discharged after Dec. 1, 2011; thus, these patients are excluded from this calculation.
↵‡ Denominator excludes patients who died during index admission to hospital.
↵§ Physician-adjusted length of stay obtained from generalized linear mixed model containing physician experience group (fixed effect) and controlling for physician as a random effect.
↵¶ Patient- and physician-adjusted length of stay obtained from same generalized linear mixed model with physician as a random effect, but also including age, sex, Charlson Comorbidity Index score, hospital, time period (2011–2012 v. 2009–2010) and hospital × time period interaction.