Blumenthal Daniel M, Olenski Andrew R, Tsugawa Yusuke, Jena Anupam B
Cardiology Division, Massachusetts General Hospital, Boston.
Harvard Medical School, Boston, Massachusetts.
JAMA. 2017 Dec 5;318(21):2119-2129. doi: 10.1001/jama.2017.17925.
Use of locum tenens physicians has increased in the United States, but information about their quality and costs of care is lacking.
To evaluate quality and costs of care among hospitalized Medicare beneficiaries treated by locum tenens vs non-locum tenens physicians.
DESIGN, SETTING, AND PARTICIPANTS: A random sample of Medicare fee-for-service beneficiaries hospitalized during 2009-2014 was used to compare quality and costs of hospital care delivered by locum tenens and non-locum tenens internal medicine physicians.
Treatment by locum tenens general internal medicine physicians.
The primary outcome was 30-day mortality. Secondary outcomes included inpatient Medicare Part B spending, length of stay, and 30-day readmissions. Differences between locum tenens and non-locum tenens physicians were estimated using multivariable logistic regression models adjusted for beneficiary clinical and demographic characteristics and hospital fixed effects, which enabled comparisons of clinical outcomes between physicians practicing within the same hospital. In prespecified subgroup analyses, outcomes were reevaluated among hospitals with different levels of intensity of locum tenens physician use.
Of 1 818 873 Medicare admissions treated by general internists, 38 475 (2.1%) received care from a locum tenens physician; 9.3% (4123/44 520) of general internists were temporarily covered by a locum tenens physician at some point. Differences in patient characteristics, demographics, comorbidities, and reason for admission between locum tenens and non-locum tenens physicians were not clinically relevant. Treatment by locum tenens physicians, compared with treatment by non-locum tenens physicians (n = 44 520 physicians), was not associated with a significant difference in 30-day mortality (8.83% vs 8.70%; adjusted difference, 0.14%; 95% CI, -0.18% to 0.45%). Patients treated by locum tenens physicians had significantly higher Part B spending ($1836 vs $1712; adjusted difference, $124; 95% CI, $93 to $154), significantly longer mean length of stay (5.64 days vs 5.21 days; adjusted difference, 0.43 days; 95% CI, 0.34 to 0.52), and significantly lower 30-day readmissions (22.80% vs 23.83%; adjusted difference, -1.00%; 95% CI -1.57% to -0.54%).
Among hospitalized Medicare beneficiaries treated by a general internist, there were no significant differences in overall 30-day mortality rates among patients treated by locum tenens compared with non-locum tenens physicians. Additional research may help determine hospital-level factors associated with the quality and costs of care related to locum tenens physicians.
美国临时替班医生的使用有所增加，但缺乏关于他们的医疗质量和成本的信息。
评估由临时替班医生与非临时替班医生治疗的住院医疗保险受益人的医疗质量和成本。
设计、设置和参与者：使用2009年至2014年期间住院的医疗保险按服务付费受益人的随机样本，比较临时替班和非临时替班内科医生提供的医院护理的质量和成本。
由临时替班普通内科医生治疗。
主要结局是30天死亡率。次要结局包括住院医疗保险B部分支出、住院时间和30天再入院率。使用针对受益人的临床和人口统计学特征以及医院固定效应进行调整的多变量逻辑回归模型估计临时替班医生和非临时替班医生之间的差异，这使得能够比较在同一医院执业的医生之间的临床结局。在预先指定的亚组分析中，在临时替班医生使用强度不同的医院中重新评估结局。
在普通内科医生治疗的1818873例医疗保险入院病例中，有38475例（2.1%）接受了临时替班医生的治疗；9.3%（4123/44520）的普通内科医生在某个时间点由临时替班医生临时替代。临时替班医生和非临时替班医生在患者特征、人口统计学、合并症和入院原因方面的差异在临床上不相关。与非临时替班医生（n = 44520名医生）治疗相比，临时替班医生治疗与30天死亡率无显著差异（8.83%对8.70%；调整差异为0.14%；95%置信区间为-0.18%至0.45%）。由临时替班医生治疗的患者B部分支出显著更高（1836美元对1712美元；调整差异为124美元；95%置信区间为93美元至154美元），平均住院时间显著更长（5.64天对5.21天；调整差异为0.43天；95%置信区间为0.34至0.52），30天再入院率显著更低（22.80%对23.83%；调整差异为-1.00%；95%置信区间为-1.57%至-0.54%）。
在由普通内科医生治疗的住院医疗保险受益人中，与非临时替班医生治疗的患者相比，临时替班医生治疗的患者总体30天死亡率无显著差异。进一步的研究可能有助于确定与临时替班医生相关的医疗质量和成本的医院层面因素。
