Mortality Higher for Inpatients Seen by First-Year Hospitalists

Marcia Frellick

December 26, 2017

Thirty-day mortality rates for patients treated by first-year hospitalists were significantly higher than the rates for those treated by more experienced hospitalists, according to a study published online today in JAMA Internal Medicine.

James S Goodwin, MD, from the Department of Medicine and the Sealy Center on Aging, University of Texas Medical Branch, Galveston, and colleagues set the primary outcome of 30-day postadmission deaths, adjusted for characteristics of individuals and hospitals. Death in the hospital was a secondary outcome.

Among 21,612 hospitalists caring for Medicare inpatients studied from July 1, 2013, to June 30, 2014, 5445 (25%) had 1 year of experience or less and 11,596 (54%) had at least 4 years of experience.

The researchers included 101,575 hospitalizations and found that 30-day mortality was 10.51% for patients treated by first-year hospitalists and 9.97% for patients treated by hospitalists in their second year. The mortality odds ratio for patients treated by second-year residents was 10% lower (odds ratio, 0.90; 95% confidence interval, 0.84 - 0.96) compared with that for patients of first-year hospitalists.

Inpatient mortality, was 3.33% for those treated by first-years vs 2.96% for those treated by hospitalists in their second year (odds ratio, 0.84; 95% confidence interval, 0.75 - 0.95).

In contrast, for both 30-day and hospital death rates, there was little change in the odds between the second year and the years after.

That led authors to conclude that, "Hospitalists very early in their careers may benefit from additional support and reduced caseloads."

The authors note the change from residency to the fast pace and new systems of hospital care may be overwhelming, and the current findings may indicate need for more mentoring, involving more hospitalist faculty in residency training, and even creating hospitalist tracks in residencies or hospitalist fellowships.

Most previous studies that have looked at experience vs outcomes have included a longer period of time, such as the lowest experience category being 1 to 5 years. Looking separately at individual years helped bring new information to light, Dr Goodwin and colleagues say.

This information may have heightened relevance, given the relatively high turnover of hospitalists and the large numbers who come right out of residency, the authors say.

"Many change their career by either switching to primary care medicine or starting their fellowship training. Some international medical graduates may spend 2 years as hospitalists in medically underserved areas to meet their visa requirement before pursuing other training. The turnover leads to substantial numbers of hospitalists who are early in their careers," they write.

Hospitalizations were calculated from a 5% sample of US Medicare enrollees, so the 101,575 hospitalizations represent 2,031,500 total hospitalizations of Medicare recipients during the study period.

The study was funded by the National Institutes of Health and the Agency for Healthcare Research and Quality. The authors have disclosed no relevant financial relationships.

JAMA Intern Med. Published online December 26, 2017.

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