Hospitalized Medicare patients faced worse mortality when physicians had fewer clinic days

Hospitalized Medicare patients had better 30-day mortality when they were treated by physicians who worked more clinical days, according to results from a cross-sectional study.

In recent years, more and more physicians work in their clinical practice part time in order to participate in academic research, conduct administrative and management work, and stem the tide of physician burnout—almost 25% of physicians are estimated to work part time, an 11% increase from 1993, Hirotaka Kato, PhD, of Keio University in Tokyo, Japan, and colleagues explained in JAMA Internal Medicine. However, as the ranks of part-time health care workers continue to swell, the quality of care provided by these physicians remains unclear.

For their analysis, Kato and colleagues pulled nationally representative data on hospitalized Medicare beneficiaries treated by a hospitalist from 2011 through 2016 to assess the association between physicians’ number of days worked clinically per year and 30-day patient mortality/hospital readmission rates.

While readmission rates were not linked to number of days hospitalists worked, the study authors found that “patients treated by physicians who worked fewer days clinically experienced higher patient mortality compared with patients treated by physicians who worked full time clinically. Given that physicians with reduced clinical time must often balance clinical and nonclinical obligations, better support by institutions may be necessary to maintain the clinical performance of those physicians.”

Kato and colleagues pointed to several factors that may explain why physicians who work fewer days in the clinic might have worse patient outcomes:

  • Physicians with limited clinical time may face difficulty keeping up with the latest evidence and clinical guidelines.
  • Physician skills and knowledge may decline if they do not see patients frequently.
  • Part-time clinicians may be less familiar with other clinical staff (nurses, medical assistants, etc.), leading to worse teamwork that can impact patient outcomes.
  • Part-time physicians may have to balance non-clinical responsibilities with providing inpatient care.
  • It is possible that physicians with less clinical knowledge or skills choose to work part-time, while physicians with superior performance choose full-time work.

And, in an editorial accompanying the study, James S. Goodwin, MD, of the University of Texas Medical Branch at Galveston, Texas, noted that these results make sense in the context of specialization. In the study, all of the workers specialized in hospital medicine, “but the assumption is that some also have other roles, such as teaching, administration, research, or roles outside of the workplace,” he explained. “A hospitalist devoting 20% effort to clinical care, 20% to administration, and 60% to teaching is not as specialized as one with 90% effort in patient care. It makes sense that such physicians might have worse outcomes.”

However, he added that there are two aspects of the study that do not immediately make sense, the first of which is that there was an association of number of days worked with mortality but not with readmission rates.

“Readmission rates should be a more sensitive indicator of quality than post-discharge mortality,” he wrote. “Readmissions are more common than mortality and often are a more proximal step on the path to mortality after hospital discharge. I could not find other studies examining hospital quality where a particular process was associated with elevated mortality with no change in readmissions, while the converse—elevated readmissions with no change in mortality—is more common.”

The second finding that Goodwin found puzzling was that “the association of hospitalist workdays with mortality is independent of the total number of episodes of care provided by hospitalists to their patients. In other words, it is not the total number of patients who are seen in a year that is important to outcomes, it is the total number of days on which they are seen… The total workload of the hospitalist does not appear to be important.”

If clinical volume is not the relevant factor, it is possible that hospitalist schedules explain the association between number of working days and patient outcomes, Goodwin hypothesized.

Hospitalists’ schedules vary widely,” he wrote. “Some work 8-hour shifts each day while others work 24- or 48-hour shifts. Thus, hospitalists with similar total patient volumes can differ in total working days, depending on their schedules. In a previous article I coauthored, we showed that patients cared for by hospitalists who usually worked every day for several days in a row had lower mortality than hospitalists with discontinuous schedules such as 24 hours on and 48 hours off. In the study by Kato et al, the group of hospitalists with the fewest total working days per year presumably includes more hospitalists who worked 24- or 48-hour shifts.”

For their analysis, the study authors analyzed a 20% random sample of Medicare fee-for-service beneficiaries 65 years of age and older admitted to hospitals for an emergency medical condition and treated by hospitalists from 2011-2016. Number of days worked clinically was defined as unique days with any physician claims found in the 20% carrier file.

The primary outcome was 30-day patient mortality; the secondary outcome was 30-day patient readmission. The final analysis consisted of 392,797 patient hospitalizations treated by 19,170 hospitalists (7,482 female [39.0%], 11,688 male [61.0%]; mean [SD] age, 41.1 [8.8] years).

Kato and colleagues found that “patients treated by physicians with more days worked clinically exhibited lower mortality. Adjusted 30-day mortality rates were 10.5% (reference), 10.0% (adjusted risk difference [aRD], −0.5%; 95% CI, −0.8% to −0.2%; P=0.002), 9.5% (aRD, −0.9%; 95% CI, −1.2% to −0.6%; P<0.001), and 9.6% (aRD, −0.9%; 95% CI, −1.2% to −0.6%; P<0.001) for physicians in the first (bottom), second, third, and fourth (top) quartile of days worked clinically, respectively. Readmission rates were not associated with the numbers of days a physician worked clinically (adjusted 30-day readmissions for physicians in the bottom quartile of days worked clinically per year versus those in the top quartile, 15.3% vs 15.2%; aRD, −0.1%; 95% CI, −0.5% to 0.3%; P=0.61).”

“We found no evidence that patients’ severity of illness, as defined by expected mortality, or reason for admission differed in a clinically meaningful way between physicians with varying numbers of days worked clinically, indicating that these findings were unlikely to be explained by differences in patient factors,” they added.

“The findings of Kato et al could and should cause policy makers some consternation,” Goodwin wrote. “…The absolute differences in mortality reported by Kato et al between the lowest quartile versus the highest 2 quartiles in working days of hospitalists is close to 1%, which, if generalizable, translate into many thousands of deaths each year.”

So, should hospitals discourage physicians from working part time?

If the association of total working days with mortality holds for each of these different groups, that would be evidence that the number of working days may indeed be the causal factor,” he wrote. “In contrast, if only 1 or some of the subtypes of part-time hospitalists are associated with higher mortality, that might suggest that their lower total working days was a marker for some other factor that led to higher mortality. More importantly, it will give hospitals and hospitalist groups a more specific target to focus on to improve patient outcomes.”

Study limitations included the potential for unmeasured confounders; the analysis couldn’t capture hospitalists’ care that was not billed, and they didn’t count days when hospitalists may have exclusively treated non-Medicare patients or patients not included in the 20% random sample; the researchers were unable to determine the reason for part-time clinical work; and the findings may not be generalizable to younger or surgical patient populations.

  1. Results from a cross-sectional, observational study found that hospitalized Medicare beneficiaries treated by hospitalists had improved 30-day mortality if their physician worked more days in the clinic, while those whose physician worked fewer days had worse mortality.
  2. Note that number of clinical days was not associated with 30-day hospital readmissions.

John McKenna, Associate Editor, BreakingMED™

Kato reported support from a Japan Society for the Promotion of Science fellowship.

Goodwin had no relevant relationships to disclose.


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