December 5, 2017 / 8:12 PM / a year ago

Hospital patients are safe with substitute doctors

(Reuters Health) - Hospital patients’ survival rates don’t suffer when fill-in doctors substitute for the regular staff physicians, a U.S. study suggests.

Patients were no more likely to die within 30 days of arrival at the hospital when they were treated by so-called locum tenens physicians, who temporarily fill in for staff physicians, researchers found.

Hospital reliance on locum tenens physicians has surged in recent years, driven in part by regional physician shortages and by increasing demand for care by patients who have recently gained insurance.

Researchers examined data on more than 1.8 million Medicare beneficiaries hospitalized between 2009 and 2014 and found 8.8 percent of patients treated by locum tenens physicians died within 30 days of being admitted to the hospital, as did 8.7 percent of patients who had staff doctors. The difference was too small to rule out the possibility that it was due to chance.

“Our work indicates that locum tenens physicians caring for patients hospitalized for treatment of general medical conditions likely deliver equivalent quality care to non-locum tenens physicians,” said lead study author Dr. Daniel Blumenthal, of Massachusetts General Hospital and Harvard Medical School in Boston.

“While it is unlikely that patients would ever know whether or not their physician was a substitute physician, our work indicates that patients should not worry about whether or not their physician is a locum tenens,” Blumenthal said by email.

Locum tenens doctors generally do not have any previous relationship with their patients, are not familiar with the local community, and may never have worked with the hospital’s electronic health records system, hospital staff, or with the local network of facilities where patients may be discharged to after hospitalization, the researchers said.

Overall, about 38,000 patients in the study, or roughly 2 percent, were treated by locum tenens physicians, researchers report in JAMA.

Slightly more than 9 percent of all the general internists in the study had a locum tenens physician cover for them at some point.

Patients were hospitalized for a variety of reasons typically handled by general internists in hospitals such as pneumonia, kidney infections, lung disease, and gastrointestinal disorders.

There were no meaningful differences in patient characteristics, including reason for admission or other medical conditions, between those seen by staff doctors and substitute physicians.

Yet there were some small but statistically significant differences in other measures. Patients treated by substitute physicians had somewhat higher spending and slightly longer hospitalizations.

Patients treated by locum tenens doctors had average total charges of $1,836, compared with $1,712 for patients seen by staff doctors, the study found.

With locum tenens doctors, patients remained in the hospital an average of 6.64 days, compared with 5.21 days for staff physicians.

Readmissions, or repeat hospitalizations, occurred for about 23 percent of patients with locum tenens physicians, compared to 24 percent with staff doctors.

The study wasn’t a controlled experiment designed to prove whether or how the employment status of physicians might influence patient outcomes.

“I suspect most would hypothesize that outcomes would be significantly worse for locum tenens physicians compared to staff physicians, as the locum tenens docs are not as familiar with the hospital, local practices and policies, and how to get things done locally,” said Dr. Karl Bilimoria, director of the Surgical Outcomes and Quality Improvement Center at Northwestern University’s Feinberg School of Medicine, in Chicago.

“Thus, this study provides findings that may be counterintuitive to many people,” Bilimoria said by email.

Because Medicare requires locum tenens physicians to provide at least 60 days of coverage, however, these doctors may be reasonably familiar with the practices and culture of the hospitals where they fill in, Bilimoria said. Results from this study don’t offer insight into outcomes for doctors who substitute only for a day or week at a time, he noted.

It’s also possible that there are subtle differences in outcomes that the study didn’t detect.

“But just because the patients did not die more frequently under the care of locum tenens docs, does not mean that their disease-specific outcomes are equal,” Bilimoria added. “There may be more nuanced outcomes that could show a difference.”

SOURCE: JAMA, online December 5, 2017.

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