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[JAMA Intern Med在线发表]:由第一年医院医生(hospitalist)负责诊治的患者病死率较高
2018年01月10日 时讯速递, 进展交流 暂无评论

Original Investigation

December 26, 2017

Association of Hospitalist Years of Experience With Mortality in the Hospitalized Medicare Population

James S. Goodwin, Habeeb Salameh, Jie Zhou, et al.

JAMA Intern Med. Published online December 26, 2017.

doi:10.1001/jamainternmed.2017.7049

Abstract

Importance 背景

Substantial numbers of hospitalists are fresh graduates of residency training programs. Current data about the effect of hospitalist years of experience on patient outcomes are lacking.

相当数量的医院医生刚刚完成住院医师的培训。现有资料缺乏医院医生工作年限对患者预后的影响。

Objective 目的

To describe the association of hospitalist years of experience with 30-day mortality and hospital mortality of their patients.

描述医院医生工作年限与其患者30天病死率及住院病死率的相关性。

Design, Setting, and Participants 设计,场景和研究人群

We used a 5% sample of national Medicare data of patient and hospital characteristics to build a multilevel logistic regression model to predict mortality as a function of years of experience of the hospitalists. We created 2 cohorts. The first was 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 assess their years of prior experience as a hospitalist, and the second was 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.

我们从全国Medicare患者及医院特征数据中抽样5%,建立了多层次logistic回归模型,用于预测病死率与医院医生工作年限的关系。我们建立了两个队列。第一个队列为横断面研究,2013年7月1日至2014年6月30日间工作的21612名医院医生,并回顾此前5年间其作为医院医生的工作。第二个队列为纵向队列,纳入2008年7月1日至2011年6月30日间开始执业的3860名医院医生,这些医院医生继续工作至少4年。

Main Outcomes and Measures 主要预后指标

Thirty-day postadmission mortality adjusted for patient and hospital characteristics in a 3-level logistic regression model. Hospital mortality was a secondary outcome.

3层logistic回归模型中对患者及医院特征进行校正后30天病死率。住院病死率为次要指标。

Results 结果

Among 21 612 hospitalists caring for Medicare inpatients from July 1, 2013, to June 30, 2014, 5445 (25%) had 1 year of experience or less, while 11 596 (54%) had 4 years of experience or more. We then identified 3860 physicians in their first year as hospitalists who continued to practice as hospitalists for 4 years. There was a significant association between hospitalist experience and mortality. Observed 30-day mortality was 10.50% for patients of first-year hospitalists vs 9.97% for patients of hospitalists in their second year. The mortality odds for patients of second-year hospitalists were 0.90 (95% CI, 0.84-0.96) compared with patients of first-year hospitalists. Observed hospital mortality was 3.33% for patients cared for by first-year hospitalists vs 2.96% for second-year hospitalists. (odds ratio, 0.84; 95% CI, 0.75-0.95). For both 30-day and hospital mortality, there was little change in odds of mortality between the second year and subsequent years of experience.

2013年7月1日至2014年6月30日间,负责Medicare患者诊治的21612名医院医生中,5445名 (25%) 工作年限不超过1年,11596名 (54%) 工作年限至少为4年。此后,我们确定了3860名开始第一年执业的医院医生,这些医院医生继续工作4年。医院医生工作年限与病死率密切相关。第一年医院医生负责诊治患者30天病死率为10.50%,第二年为9.97%。与第一年医院医生相比,第二年医院医生负责诊治患者死亡比数比为0.90 (95% CI, 0.84-0.96)。第一年医院医生负责诊治患者住院病死率为3.33%,第二年医院医生为 2.96% (比数比0.84; 95% CI, 0.75-0.95)。无论30天病死率抑或住院病死率,第二年医院医生与更高工作年限医生负责患者死亡比数比无显著改变。

Conclusions and Relevance 结论与意义

Patients cared for by hospitalists in their first year of practice experience higher mortality. Early-career hospitalists may require additional support to ensure optimal outcomes for their patients.

第一年医院医生负责诊治患者病死率较高。年资较低的医院医生可能需要额外的支持,以保证其患者良好预后。

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