Department of Medicine, University of Toronto, Toronto, Ontario, Canada
Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.
BMJ Qual Saf. 2021 Feb;30(2):123-132. doi: 10.1136/bmjqs-2019-010425. Epub 2020 Mar 27.
Variations in inpatient medical care are typically attributed to system, hospital or patient factors. Little is known about variations at the physician level within hospitals. We described the physician-level variation in clinical outcomes and resource use in general internal medicine (GIM).
This was an observational study of all emergency admissions to GIM at seven hospitals in Ontario, Canada, over a 5-year period between 2010 and 2015. Physician-level variations in inpatient mortality, hospital length of stay, 30-day readmission and use of 'advanced imaging' (CT, MRI or ultrasound scans) were measured. Physicians were categorised into quartiles within each hospital for each outcome and then quartiles were pooled across all hospitals (eg, physicians in the highest quartile at each hospital were grouped together). We report absolute differences between physicians in the highest and lowest quartiles after matching admissions based on propensity scores to account for patient-level variation.
The sample included 103 085 admissions to 135 attending physicians. After propensity score matching, the difference between physicians in the highest and lowest quartiles for in-hospital mortality was 2.4% (95% CI 0.6% to 4.3%, p<0.01); for readmission was 3.3% (95% CI 0.7% to 5.9%, p<0.01); for advanced imaging was 0.32 tests per admission (95% CI 0.12 to 0.52, p<0.01); and for hospital length of stay was 1.2 additional days per admission (95% CI 0.5 to 1.9, p<0.01). Physician-level differences in length of stay and imaging use were consistent across numerous sensitivity analyses and stable over time. Differences in mortality and readmission were consistent across most sensitivity analyses but were not stable over time and estimates were limited by sample size.
Patient outcomes and resource use in inpatient medical care varied substantially across physicians in this study. Physician-level variations in length of stay and imaging use were unlikely to be explained by patient factors whereas differences in mortality and readmission should be interpreted with caution and could be explained by unmeasured confounders. Physician-level variations may represent practice differences that highlight quality improvement opportunities.
住院医疗的差异通常归因于系统、医院或患者因素。对于医院内医生层面的差异知之甚少。我们描述了一般内科（GIM）住院患者的临床结果和资源利用的医生层面差异。
这是一项观察性研究，对 2010 年至 2015 年间加拿大安大略省七家医院的所有急诊内科住院患者进行了研究。测量了住院死亡率、住院时间、30 天再入院率和使用“高级影像学”（CT、MRI 或超声扫描）的医生层面差异。在每个医院内，按每个结果将医生分为四分位数，然后将四分位数在所有医院中汇总（例如，每个医院的最高四分位的医生被分为一组）。我们报告了基于倾向评分匹配入院后医生之间的绝对差异，以考虑患者层面的差异。
该样本包括 103085 例患者，由 135 名主治医生治疗。在进行倾向评分匹配后，最高和最低四分位医生之间的院内死亡率差异为 2.4%（95%CI 0.6%至 4.3%，p<0.01）；再入院率差异为 3.3%（95%CI 0.7%至 5.9%，p<0.01）；高级影像学检查差异为每次入院增加 0.32 次检查（95%CI 0.12 至 0.52，p<0.01）；住院时间差异为每次入院增加 1.2 天（95%CI 0.5 至 1.9，p<0.01）。在多次敏感性分析中，住院时间和影像学使用的医生层面差异是一致的，并且随着时间的推移是稳定的。死亡率和再入院率的差异在大多数敏感性分析中是一致的，但随着时间的推移并不稳定，并且估计受到样本量的限制。
在这项研究中，患者的住院医疗结果和资源利用在医生之间存在显著差异。住院时间和影像学使用方面的医生层面差异不太可能由患者因素解释，而死亡率和再入院率的差异应谨慎解释，并且可能由未测量的混杂因素解释。医生层面的差异可能代表实践差异，突出了质量改进的机会。
