Mortality Higher Among Inpatients Treated by Older Physicians

Diana Swift

May 16, 2017

Inpatients treated by older physicians have a higher 30-day mortality than those cared for by younger physicians, according to a study published online May 16 in the BMJ.

The increased risk, however, did not apply to older physicians who treated high volumes of patients, report Yusuke Tsugawa, MD, MPH, PhD, a research associate in the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Cambridge, Massachusetts, and colleagues.

The authors also found that 30-day readmission rates did not vary by physician age, but costs of patient care were slightly higher among older physicians.

Dr Tsugawa and colleagues caution the results are "exploratory." However, if confirmed, the findings would mean that for every 77 patients treated by physicians age 60 years or older, one fewer patient would die if cared for by physicians younger than 40 years.

"Our findings suggest that within the same hospital, patients treated by physicians aged <40 have 0.85 times the odds of dying (1.00/1.17) or an 11% lower probability of dying (10.8/12.1), compared with patients cared for by physicians aged ≥60," Dr Tsugawa and colleagues write.

"This difference in mortality is comparable with the impact of statins for the primary prevention of cardiovascular mortality on all cause mortality (odds ratio of 0.86) or the impact of β blockers on mortality among patients with myocardial infarction (incidence rate ratio of 0.86), indicating that our observed difference in mortality is not only statistically significant but arguably clinically significant," they continue.

Quality-of-care differences between younger and older physicians is largely unstudied, and data are sparse. "Though clinical skills and knowledge accumulated by more experienced physicians could lead to improved quality of care, physicians' skills might become outdated as scientific knowledge, technology, and clinical guidelines change," Dr Tsugawa and colleagues write. They note their findings are in agreement with a 2005 systematic review by Choudhry and associates that found physicians in practice longer may provide lower-quality care and may need quality improvement interventions.

In a related editorial, Linda H. Aiken, PhD, RN, a professor of nursing at the University of Pennsylvania in Philadelphia, calls the study a "fresh and informative look at the association between physician age and patient outcomes."

Dr Aiken says it points to an inevitable need to reassess requirements for continuing physician education and develop interventions for improvement. She notes, for example, that 74% of studies in the 2005 systematic review reported some degree of negative association between physician age and adherence to treatment recommendations.

She cautions, however, that the age of hospitalists in the United States could reflect a difference in training between cohorts, as the specialty is relatively young here. Therefore, replicating the study in another country where hospitalists have been the norm for longer would be valuable.

High Volume Appears Protective

The Harvard researchers studied 30-day mortality in a 20% random sample of Medicare fee-for-service beneficiaries aged 65 years and older who were hospitalized for an acute medical condition between 2011 and 2014 and assigned to hospitalists according to scheduled hospital work blocks.

The sample comprised 736,537 admissions to US acute-care hospitals managed by 18,854 hospitalists. The median age of physicians was 41 years, with 10,177 physicians younger than 40 years, 8016 aged from 40 to 49 years, 3331 aged from 50 to 59 years, and 1086 aged 60 years and older.

The characteristics of the patients were comparable across physician age groups, with a mean age of approximately 80.5 years, 60% women, and approximately 83% white.

Overall 30-day mortality rate was 11.1%. After adjustment for patient and physician characteristics and hospital-specific fixed effects, the adjusted 30-day mortality rates across the four age categories were as follows: 10.8% for physicians younger than 40 years (95% confidence interval [CI], 10.7% - 10.9%), 11.1% for those aged 40 to 49 years (95% CI, 11.0% - 11.3%), 11.3% for those aged 50 to 59 years (95% CI, 11.1 - 11.5), and 12.1% for those aged 60 years and older (95% CI, 11.6% - 12.5%).

The outcomes were similar when the authors included patients treated by nonhospitalist general internists.

When stratified by patient volume, the association between physician age and patient mortality was positive for low volumes (<90 estimated admissions per year) and medium volumes (90 - 200 admissions per year), with each 10-year age increase associated with an adjusted odds ratio for 30-day mortality of 1.19 (95% CI, 1.14 - 1.23; P < .001) and 1.06 (95% CI, 1.03 to 1.09; P < .001), respectively.

Despite high-volume physicians' accounting for a larger number of cases (477,627 admissions), no association between age and mortality emerged: adjusted odds ratio for an additional 10 years of physician age was 1.01 (95% CI, 0.99 - 1.03; P = .29). "The interaction between physician age and patient volume was significant (P<0.001)," the authors write.

"Further research is warranted to understand exactly why low- to medium-volume older physicians have worse outcomes, and how we can solve this problem," Dr Tsugawa told Medscape Medical News.

In other study endpoints, no correlation emerged between physician age and a 30-day readmission rate of about 15% across all age groups, for an adjusted odds ratio for each additional 10 years of 1.00 (95% CI, 0.99 - 1.01; P = .82). Variations in Medicare Part B spending by physician age were significant but small, with each decade increase correlating to a cost rise of 2.4% (95% CI, 2.0% - 2.8%; P <.001). Billings ranged from $1008 for physician billings in the under-40 age category to $1071 in the 60-and-older group.

The authors point to a recent resurgence of interest in how quality of care evolves during a physician's career and how continuing medical education should be integrated into busy clinical schedules in a tolerable manner.

They note that although quality-of-care initiatives have largely focused on system-level measures, "there is increasing policy emphasis on the role of individual physicians in influencing costs and quality of care," including the value-based payment models under the Medicare Access and CHIP Reauthorization Act (MACRA).

Dr Tsugawa said these data cannot indicate whether the effect of physician age would be so pronounced among younger acute care patients. "However, it is important to note that we found that the impact of physician age was similar among patients ages 65 to 75 — relatively young patients in our sample — and among Medicare beneficiaries age 64 or younger," he told Medscape Medical News. "That suggests that similar findings may be observed if we could study a younger patient population."

In 2016, Medscape Medical News reported on another outcome study by Dr Tsugawa's group showing that elderly patients treated by female physicians had lower mortality and readmission rates than those cared for by male physicians within the same hospital. The current age-based study, however, did not tease out the gender factor, Dr Tsugawa said.

The authors and Dr Aiken have disclosed no relevant financial relationships.

BMJ. Published online May 16, 2017. Article, Editorial

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