Home Analysis How group structure affects outcomes

How group structure affects outcomes

July 2011

Published in the July 2011 issue of Today’s Hospitalist

THERE’S A SAYING IN HOSPITAL MEDICINE: If you’ve seen one hospitalist group, you’ve seen one hospitalist group. There’s so much variation among programs that it’s difficult to make generalizations about how they’re organized, how their physicians work and how they’re paid.

But in an era of increasingly standardized medicine, that raises an obvious question: Does variation among hospitalist groups have any measurable effect on patient care?

A new study examining variations in hospital medicine found many of the differences you’d expect to see in hospitalist groups. But the data also uncovered differences that affected patient outcomes.

The study’s final analysis, for example, showed that one of the five groups studied had mortality rates nearly three times higher than the others. While the physicians in that group weren’t seeing many more patients, they did have less experience than doctors in some of the other groups “and they didn’t offer 24/7 coverage.

What affects outcomes?
The study, which appeared in the March issue of the Journal of Clinical Outcomes Management, took a close look at the hospitalist groups working at five hospitals in the Baltimore area.

Christine Soong, MD, lead author of the study and a hospitalist at Toronto’s Mount Sinai Hospital, says that she envisioned the research as a snapshot of hospitalist groups in one area. While there’s a good body of data on the characteristics of hospitalist groups, no one has ever looked at how differences in hospitalist programs might affect outcomes.

“Studies have shown that groups within the same geographic area can vary in terms of the services they provide, the type of work they do and the people they employ,” Dr. Soong says. “We wanted to see whether there were any associations between group structure and patient care.”

In terms of demographics, researchers found both similarities and differences. When it came to gender, for example, two of the groups had an even mix of male and female physicians, but two other groups were more than three-quarters male. There were also some differences in the number of IMG physicians in the groups, but Dr. Soong says that none of those differences appeared to have an impact on outcomes.

Mortality rates and 24/7 coverage
But one factor that may have had an impact had more to do with physicians’ experience than their age or training background. Dr. Soong says that more established groups, for example, generally posted better mortality rates and lengths of stay.

That conclusion didn’t really surprise her, in part because other studies have shown that more experienced hospitalists seem to have an edge.

Dr. Soong’s team also found other clues that might explain an even bigger difference among the five groups: patient mortality rates. When researchers looked at the outcomes of the group it identified as “Hospital 5,” they found that mortality rates came in at 2.1%. That was two to three times higher than the mortality rates of the four other groups.

“On paper,” Dr. Soong says, “this group seemed to have the worst outcomes. It was also the only hospital that didn’t have an in-house hospitalist covering patients 24 hours a day, seven days a week.”

A spotlight on experience
Dr. Soong says those findings weren’t completely unexpected, particularly because similar studies looking at ICU care have shown that having intensivists in the hospital 24/7 tends to lead to better outcomes and perhaps decreased mortality.

“If you have a hospitalist on-site seven days a week and 24 hours a day,” Dr. Soong says, “you would presumably provide better care and decrease the unnecessary utilization of resources.”

Another factor that might have affected Hospital 5’s mortality rates: While the physicians at most of the other groups worked full time, many hospitalists at Hospital 5 worked part time.

But other findings proved to be more counterintuitive. The hospitalists at Hospital 5, for example, posted fewer admissions per year than any of the other groups. And overall charges for Hospital 5’s hospitalists were almost three to four times as high as in the other programs. Dr. Soong speculates that the level of physician experience likely played a factor.

Physicians at that group also had a mean of four years practicing as a hospitalist, lower than the doctors in some of the other groups. The program itself was only four years old, which was considerably younger than three of the four other programs.

“This group is one of the smaller, younger groups,” Dr. Soong says, “so maybe they were less experienced and utilized resources differently.”

Any role of turnover?
While the study raises some interesting questions about the impact of how hospitalist groups are organized, Dr. Soong cautions that it’s difficult to draw firm conclusions from her data. A case in point: While Hospital 5 fared poorly on mortality rates, that group’s length of stay and 14-day readmission rates were average. Also, the study sample size was small and the data not adjusted for possible confounders.

Data in other categories painted a decidedly mixed picture. The study found mixed evidence, for example, of the impact of hospitalist turnover. Researchers found that Hospital 1, for example, had a whopping turnover rate of 44%. (Hospital 5, by comparison, had the third-highest turnover rate of 28%.) But despite that high rate, the hospitalist group at Hospital 1 had relatively good outcomes.

By comparison, Hospitals 2 and 3 both had lower rates of turnover “and presumably more stability ” and more senior physicians. While those programs fared a little better in terms of length of stay, their 14- day readmissions were above average.

“Our results raise questions about the role that turn- over plays in the stability of a group,” Dr. Soong says, “and how it potentially affects patient care and maybe even mortality.”

Edward Doyle is Editor of Today’s Hospitalist.