Effects of physician experience on costs and outcomes on an academic general medicine service: Results of a trial of hospitalists
Effects of physician experience on costs and outcomes on an academic general medicine service: Results of a trial of hospitalists
复制标题
DOI：
10.7326/0003-4819-137-11-200212030-00007
复制
发表时间：
2002-12-03
影响因子：
39.2
通讯作者：
Levinson, W
中科院分区：
文献类型：
--
作者：
Meltzer, D;Manning, WG;Levinson, W
背景资料：住院医师可能会降低住院患者的成本并改善其结局，但现有证据有限，且尚未确定此类效应的机制。目的：研究由住院医师和非住院医师领导的学术全科医学服务团队中患者的成本和结局。设计：队列研究。设置：学术全科医学服务。患者：干预：将1997年7月至1999年6月期间收治的6511例患者每隔4天分配到2名住院医生中的1名，每年6个月，或58名非住院医生中的1名，每年1至2个月。住院费用;结果：住院患者（24.8%）和非住院患者（75.2%）在年龄、种族、性别、诊断组合或Charlson指数评分方面没有差异。在第1年，住院医生治疗的患者的平均调整住院时间比非住院医生治疗的患者短0.29天（95% CI，-0.66至0.06天; P = 0.06）;在第2年，住院医生治疗的患者的平均调整住院时间短0.49天（CI，-0.79至0.15天; P = 0.01）。平均调整后的成本没有显着降低住院医生相比，非住院医生在第1年，但减少了782美元，在第2年（CI，-1313至-187美元，P = 0.01）。当合并第1年和第2年或仅分析第1年时，住院医生和非住院医生的30天死亡率无显著差异;然而，第2年住院医生的30天死亡率为4.2%，而非住院医生为6.0（差异的CI，1.8个百分点[-3.6至-0.1个百分点]; P = 0.04），调整后的相对风险为0.65（CI，0.44至0.96; P = 0.03）。在多变量分析中，资源使用随着医生在照顾患者的主要诊断方面的累积经验而减少。死亡率表现出类似的pattern.Conclusions：住院医生护理与较低的成本和短期死亡率在第二年，但不是第一年的住院医生的经验。疾病特异性的医生经验可以减少资源的使用和改善患者的结果，此外，它可能是一个重要的决定因素的有效性住院医生。
Background: Hospitalists may decrease costs and improve outcomes in hospitalized patients, but existing evidence is limited and has not identified mechanisms for such effects.Objective: To study the costs and outcomes for patients on an academic general medicine service assigned to teams led by hospitalists and non hospitalists.Design: Cohort study.Setting: Academic general medicine service.Patients: 6511 patients admitted to the hospital from July 1997 through June 1999.Intervention: All patients admitted every fourth day were assigned to 1 of 2 hospitalists caring for inpatients 6 months each year or 1 of 58 nonhospitalists caring for inpatients 1 to 2 months each year.Measurements: Length of stay; inpatient costs; and 30-, 60, and 365-day mortality.Results: Patients assigned to hospitalists (24.8%) and nonhospitalists (75.2%) did not differ in age, race, sex, diagnosis mix, or Charlson index score. In year 1, average adjusted length of stay was 0.29 day shorter for patients cared for by hospitalists than by nonhospitalists (95% Cl, -0.66 to 0.06 day; P = 0.06); in year 2, average adjusted length of stay was 0.49 day shorter for patients cared for by hospitalists (Cl, -0.79 to -0.15 day; P = 0.01). Average adjusted costs were not significantly reduced for hospitalists compared with nonhospitalists in year 1 but were reduced by $782 in year 2 (Cl, -$1313 to -$187; P = 0.01). When years 1 and 2 were combined or when year 1 was analyzed alone, 30-day mortality was not significantly different for hospitalists and non hospitalists; however, 30-day mortality was 4.2% for hospitalists compared with 6.0% for nonhospitalists in year 2 (Cl for difference, 1.8 percentage points [-3.6 to -0.1 percentage points]; P = 0.04) and the adjusted relative risk was 0.65 (Cl, 0.44 to 0.96; P = 0.03). In multivariate analyses, resource use decreased with the physician's cumulative experience in caring for a patient's primary diagnosis. Mortality showed a similar pattern.Conclusions: Hospitalist care was associated with lower costs and short-term mortality in the second but not the first year of hospitalists' experience. Disease-specific physician experience may reduce resource use and improve patient outcomes; in addition, it may be an important determinant of the effectiveness of hospitalists.