Higher Patient Mortality Rates for First-Year Hospitalists

Patients who were cared for by hospitalists in their first year of practice had higher mortality rates, suggesting hospitalists early in their career may need additional support to ensure optimal outcomes for their patients, according to a study published in JAMA Internal Medicine.

With the shift to managed care and the push to reduce hospital costs there has been a growth of hospitalists, which has subsequently increased the number of Medicare beneficiaries being treated by hospitalists. However, there is a high turnover rate among hospitalists.

“The turnover leads to substantial numbers of hospitalists who are early in their careers, frequently right out of residency,” wrote the authors of the study. “This in turn raises concerns that the outcomes of care provided by inexperienced hospitalists might be different from care provided by more experienced hospitalists.”

The authors used a 5% sample of Medicare data of patient and hospital characteristics to construct a multilevel logistic regression model in order to predict mortality as a result of a hospitalist’s years of experience. They first created a cross-sectional cohort of 21,612 hospitalists working between July 1, 2013, and June 30, 2014, with a 5-year look-back period to determine their years of prior experience as a hospitalist.

They then created a longitudinal cohort of 3860 hospitalists in their first year of practice between July 1, 2008, and June 30, 2011, who continued practicing hospital medicine for at least 4 years. According to the authors, this allowed them to assess the outcomes of the same cohort of physicians as they gained experience over their first 4 years of experience.

Between July 1, 2013, and June 30, 2014, 2796 (12.9%) of the 21,612 hospitalists had no prior experience as hospitalists, and 2649 (12.2%) had 1 year of prior experience. Meanwhile, 11,596 (53.7%) had 4 or more years of experience.

Results showed a significant association between hospitalist experience and 30-day patient mortality. The 30-day mortality was 10.5% for patients of first-year hospitalists, compared to 9.97% for patients of hospitalists in their second year. In the multivariable analysis, the mortality odds for patients treated by second-year hospitalists were 0.90 (95% CI, 0.84-0.96) compared to patients treated by first-year hospitalists.

Hospital mortality was 3.33% for patients treated by first-year hospitalists compared to 2.96% for second-year hospitalists. The multivariable analysis showed that the odds of mortality was 0.84 (95% CI, 0.75-0.95) for patients being treated by second-year hospitalists compared to first-year hospitalists. For both 30-day and hospital mortality, there was little change in odds of mortality between the second year and subsequent years of experience.

“Patients cared for by physicians in their first year as hospitalists have worse 30-day and hospital mortality when compared with more experience hospitalists,” concluded the authors. “Hospitalists very early in their careers may benefit from additional support and reduced caseloads.”