Within the same hospital, patients treated by older physicians had higher mortality than patients cared for by younger physicians, except those physicians treating high volumes of patients, finds a large Harvard exploratory analysis.
If the results are causal, they suggest that for every 77 patients treated by doctors aged 60 or over, one fewer patient would die within 30 days of admission if those patients were cared for by physicians aged less than 40. However, the researchers stress that their findings should be regarded as exploratory.
Clinical skills and knowledge accumulated by more experienced physicians can lead to improved quality of care. It is possible, however, that physicians' skills may become outdated as scientific knowledge, technology, and clinical guidelines evolve.
Whether quality of care differs between younger and older physicians remains largely unknown, so a team led by Yusuke Tsugawa at Harvard T H Chan School of Public Health in Boston, set out to investigate whether outcomes of patients who were admitted to hospital differ between those treated by younger and older physicians.
They analysed 30 day mortality, re-admissions and costs of care for a random sample of 736,537 elderly Medicare patients (aged 65 or over) managed by 18,854 hospital physicians (average age 41) at US acute care hospitals from 2011 to 2014. Patients were assigned a physician based on scheduled work shifts and patients’ characteristics were similar across physician ages.
After adjusting for patient, physician, and hospital characteristics that could have affected the results, patients’ 30 day mortality rates were 10.8% for physicians aged less than 40, 11.1% for physicians aged 40-49, 11.3% for physicians aged 50-59, and 12.1% for physicians aged 60 or over.
Among physicians with a high volume of patients, however, there was no association between physician age and patient mortality, suggesting that high volumes could be “protective” of clinical skills, say the authors.
Readmissions did not vary with physician age, while costs of care were slightly higher among older physicians. And similar patterns were observed after further analyses to test the strength of the results.
The researchers say this is an observational study, so no firm conclusions can be drawn about cause and effect, and they outline some limitations could have introduced bias. Nevertheless, they conclude that “within the same hospital, patients treated by older physicians had higher mortality than patients cared for by younger physicians, except those physicians treating high volumes of patient volumes.”
In a linked editorial, researchers at the University of Pennsylvania ask what are the options for ensuring that quality and safety of care is optimised for patients. They point out that patient outcomes research “is providing much needed evidence to inform clinical practice, educational innovation, organisational redesign, and healthcare policy.”
The challenge, they say, “is to integrate findings across multiple studies within an overarching framework of health system responsibility, as recommended by the Institute of Medicine, which holds promise of safe care and good patient outcomes despite diversity of performance by individuals.”
Abstract
Objectives: To investigate whether outcomes of patients who were admitted to hospital differ between those treated by younger and older physicians.
Design Observational study. setting US acute care hospitals.
Participants: 20% random sample of Medicare fee-for-service beneficiaries aged ≥65 admitted to hospital with a medical condition in 2011-14 and treated by hospitalist physicians to whom they were assigned based on scheduled work shifts. To assess the generalizability of findings, analyses also included patients treated by general internists including both hospitalists and non-hospitalists.
Main outcome: Measures 30 day mortality and readmissions and costs of care. results 736 537 admissions managed by 18 854 hospitalist physicians (median age 41) were included. Patients’ characteristics were similar across physician ages. After adjustment for characteristics of patients and physicians and hospital fixed effects (effectively comparing physicians within the same hospital), patients’ adjusted 30 day mortality rates were 10.8% for physicians aged <40 (95% confidence interval 10.7% to 10.9%), 11.1% for physicians aged 40-49 (11.0% to 11.3%), 11.3% for physicians aged 50-59 (11.1% to 11.5%), and 12.1% for physicians aged ≥60 (11.6% to 12.5%). Among physicians with a high volume of patients, however, there was no association between physician age and patient mortality. Readmissions did not vary with physician age, while costs of care were slightly higher among older physicians. Similar patterns were observed among general internists and in several sensitivity analyses.
Conclusions: Within the same hospital, patients treated by older physicians had higher mortality than patients cared for by younger physicians, except those physicians treating high volumes of patients.
Authors
Yusuke Tsugawa, Joseph P Newhouse, Alan M Zaslavsky, Daniel M Blumenthal, Anupam B Jena
[link url="http://www.bmj.com/company/newsroom/treatment-in-hospital-by-older-doctors-linked-to-higher-death-rates/"]BMJ material[/link]
[link url="http://press.psprings.co.uk/bmj/may/physicianageres.pdf"]BMJ abstract[/link]
[link url="http://www.bmj.com/content/357/bmj.j2286"]BMJ editorial[/link]