Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
JAMA Netw Open. 2018 Nov 2;1(7):e184852. doi: 10.1001/jamanetworkopen.2018.4852.
Clinical experience suggests that there are substantial differences in patient complexity across medical specialties, but empirical data are lacking.
To compare the complexity of patients seen by different types of physician in a universal health care system.
DESIGN, SETTING, AND PARTICIPANTS: Population-based retrospective cohort study of 2 597 127 residents of the Canadian province of Alberta aged 18 years and older with at least 1 physician visit between April 1, 2014 and March 31, 2015. Data were analyzed in September 2018.
Type of physician seeing each patient (family physician, general internist, or 11 types of medical subspecialist) assessed as non-mutually exclusive categories.
Nine markers of patient complexity (number of comorbidities, presence of mental illness, number of types of physicians involved in each patient's care, number of physicians involved in each patient's care, number of prescribed medications, number of emergency department visits, rate of death, rate of hospitalization, rate of placement in a long-term care facility).
Among the 2 597 127 participants, the median (interquartile range) age was 46 (32-59) years and 54.1% were female. Over 1 year of follow-up, 21 792 patients (0.8%) died, the median (range) number of days spent in the hospital was 0 (0-365), 8.1% of patients had at least 1 hospitalization, and the median (interquartile range) number of prescribed medications was 3 (1-7). When the complexity markers were considered individually, patients seen by nephrologists had the highest mean number of comorbidities (4.2; 95% CI, 4.2-4.3 vs [lowest] 1.1; 95% CI, 1.0-1.1), highest mean number of prescribed medications (14.2; 95% CI, 14.2-14.3 vs [lowest] 4.9; 95% CI, 4.9-4.9), highest rate of death (6.6%; 95% CI, 6.3%-6.9% vs [lowest] 0.1%; 95% CI, <0.1%-0.2%), and highest rate of placement in a long-term care facility (2.0%; 95% CI, 1.8%-2.2% vs [lowest] <0.1%; 95% CI, <0.1%-0.1%). Patients seen by infectious disease specialists had the highest complexity as assessed by the other 5 markers: rate of a mental health condition (29%; 95% CI, 28%-29% vs [lowest] 14%; 95% CI, 14%-14%), mean number of physician types (5.5; 95% CI, 5.5-5.6 vs [lowest] 2.1; 95% CI, 2.1-2.1), mean number of physicians (13.0; 95% CI, 12.9-13.1 vs [lowest] 3.8; 95% CI, 3.8-3.8), mean days in hospital (15.0; 95% CI, 14.9-15.0 vs [lowest] 0.4; 95% CI, 0.4-0.4), and mean emergency department visits (2.6; 95% CI, 2.6-2.6 vs [lowest] 0.5; 95% CI, 0.5-0.5). When types of physician were ranked according to patient complexity across all 9 markers, the order from most to least complex was nephrologist, infectious disease specialist, neurologist, respirologist, hematologist, rheumatologist, gastroenterologist, cardiologist, general internist, endocrinologist, allergist/immunologist, dermatologist, and family physician.
Substantial differences were found in 9 different markers of patient complexity across different types of physician, including medical subspecialists, general internists, and family physicians. These findings have implications for medical education and health policy.
临床经验表明，不同医学专业的患者复杂性存在很大差异，但缺乏经验数据。
在全民医疗保健系统中比较不同类型的医生所看患者的复杂性。
设计、设置和参与者：这是一项基于人群的回顾性队列研究，研究对象为加拿大艾伯塔省年龄在 18 岁及以上的 2597127 名居民，他们在 2014 年 4 月 1 日至 2015 年 3 月 31 日期间至少有一次看医生的就诊记录。数据分析于 2018 年 9 月进行。
评估了 9 种患者复杂性标志物（共病数量、精神疾病存在情况、参与每位患者治疗的医生类型数量、参与每位患者治疗的医生数量、开处的药物数量、急诊就诊次数、死亡率、住院率、长期护理机构安置率），这些标志物均为非互斥类别。
在 2597127 名参与者中，中位数（四分位距）年龄为 46（32-59）岁，54.1%为女性。在 1 年的随访期间，21792 名患者（0.8%）死亡，中位（范围）住院天数为 0（0-365）天，8.1%的患者至少有 1 次住院，中位数（四分位距）开处的药物数量为 3（1-7）。当考虑到个别复杂性标志物时，肾脏病专家所看患者的共病数量平均最高（4.2；95%CI，4.2-4.3 比 [最低] 1.1；95%CI，1.0-1.1），开处的药物数量平均最高（14.2；95%CI，14.2-14.3 比 [最低] 4.9；95%CI，4.9-4.9），死亡率最高（6.6%；95%CI，6.3%-6.9%比 [最低] 0.1%；95%CI，<0.1%-0.2%），安置到长期护理机构的比例最高（2.0%；95%CI，1.8%-2.2%比 [最低] <0.1%；95%CI，<0.1%-0.1%）。传染病专家所看患者的其他 5 种标志物（精神健康状况的发生率、参与患者治疗的医生类型数量、参与患者治疗的医生数量、住院天数、急诊就诊次数）的复杂性评估最高：精神健康状况发生率最高（29%；95%CI，28%-29%比 [最低] 14%；95%CI，14%-14%），参与患者治疗的医生类型数量最多（5.5；95%CI，5.5-5.6 比 [最低] 2.1；95%CI，2.1-2.1），参与患者治疗的医生数量最多（13.0；95%CI，12.9-13.1 比 [最低] 3.8；95%CI，3.8-3.8），住院天数最长（15.0；95%CI，14.9-15.0 比 [最低] 0.4；95%CI，0.4-0.4），急诊就诊次数最多（2.6；95%CI，2.6-2.6 比 [最低] 0.5；95%CI，0.5-0.5）。根据 9 项标志物评估的所有患者的复杂性对医生类型进行排序，从最复杂到最不复杂的顺序是肾脏病专家、传染病专家、神经病专家、呼吸病专家、血液科专家、风湿病专家、胃肠病专家、心脏病专家、普通内科医生、内分泌专家、过敏/免疫专家、皮肤科医生和家庭医生。
在不同类型的医生（包括医学专科医生、普通内科医生和家庭医生）中，发现了 9 种不同的患者复杂性标志物存在显著差异。这些发现对医学教育和卫生政策具有重要意义。
