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Concept: Residency

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Objectives To investigate whether outcomes of patients who were admitted to hospital differ between those treated by younger and older physicians.Design Observational study.Setting US acute care hospitals.Participants 20% random sample of Medicare fee-for-service beneficiaries aged ≥65 admitted to hospital with a medical condition in 2011-14 and treated by hospitalist physicians to whom they were assigned based on scheduled work shifts. To assess the generalizability of findings, analyses also included patients treated by general internists including both hospitalists and non-hospitalists.Main outcome measures 30 day mortality and readmissions and costs of care. Results 736 537 admissions managed by 18 854 hospitalist physicians (median age 41) were included. Patients' characteristics were similar across physician ages. After adjustment for characteristics of patients and physicians and hospital fixed effects (effectively comparing physicians within the same hospital), patients' adjusted 30 day mortality rates were 10.8% for physicians aged <40 (95% confidence interval 10.7% to 10.9%), 11.1% for physicians aged 40-49 (11.0% to 11.3%), 11.3% for physicians aged 50-59 (11.1% to 11.5%), and 12.1% for physicians aged ≥60 (11.6% to 12.5%). Among physicians with a high volume of patients, however, there was no association between physician age and patient mortality. Readmissions did not vary with physician age, while costs of care were slightly higher among older physicians. Similar patterns were observed among general internists and in several sensitivity analyses.Conclusions Within the same hospital, patients treated by older physicians had higher mortality than patients cared for by younger physicians, except those physicians treating high volumes of patients.

Concepts: Medicine, Death, Patient, Hospital, Physician, Doctor-patient relationship, Internal medicine, Residency

139

Background Concern persists that inflexible duty-hour rules in medical residency programs may adversely affect the training of physicians. Methods We randomly assigned 63 internal medicine residency programs in the United States to be governed by standard duty-hour policies of the 2011 Accreditation Council for Graduate Medical Education (ACGME) or by more flexible policies that did not specify limits on shift length or mandatory time off between shifts. Measures of educational experience included observations of the activities of interns (first-year residents), surveys of trainees (both interns and residents) and faculty, and intern examination scores. Results There were no significant between-group differences in the mean percentages of time that interns spent in direct patient care and education nor in trainees' perceptions of an appropriate balance between clinical demands and education (primary outcome for trainee satisfaction with education; response rate, 91%) or in the assessments by program directors and faculty of whether trainees' workload exceeded their capacity (primary outcome for faculty satisfaction with education; response rate, 90%). Another survey of interns (response rate, 49%) revealed that those in flexible programs were more likely to report dissatisfaction with multiple aspects of training, including educational quality (odds ratio, 1.67; 95% confidence interval [CI], 1.02 to 2.73) and overall well-being (odds ratio, 2.47; 95% CI, 1.67 to 3.65). In contrast, directors of flexible programs were less likely to report dissatisfaction with multiple educational processes, including time for bedside teaching (response rate, 98%; odds ratio, 0.13; 95% CI, 0.03 to 0.49). Average scores (percent correct answers) on in-training examinations were 68.9% in flexible programs and 69.4% in standard programs; the difference did not meet the noninferiority margin of 2 percentage points (difference, -0.43; 95% CI, -2.38 to 1.52; P=0.06 for noninferiority). Conclusions There was no significant difference in the proportion of time that medical interns spent on direct patient care and education between programs with standard duty-hour policies and programs with more flexible policies. Interns in flexible programs were less satisfied with their educational experience than were their peers in standard programs, but program directors were more satisfied. (Funded by the National Heart, Lung, and Blood Institute and the ACGME; iCOMPARE ClinicalTrials.gov number, NCT02274818 .).

Concepts: Physician, Medical school, Percentage point, Residency, Medical education, Medical education in the United States, Intern, Internship

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The association between industry payments to physicians and prescribing rates of the brand-name medications that are being promoted is controversial. In the United States, industry payment data and Medicare prescribing records recently became publicly available.

Concepts: Medicine, United States, Poverty in the United States, U.S. state, Residency, Lyndon B. Johnson

112

Perhaps the only health policy issue on which Republicans and Democrats agree is the need to move from volume-based to value-based payment for health care providers. Rather than paying for activity, the aspirational goal is to pay for outcomes that take into account quality and costs. In keeping with this notion of paying for value rather than volume, the Affordable Care Act (ACA) created the “value-based payment modifier,” or “value modifier,” a pay-for-performance approach for physicians who actively participate in Medicare. By 2017, physicians will be rewarded or penalized on the basis of the relative calculated value of the care . . .

Concepts: Health care, Health care provider, Health economics, Medicine, Healthcare, Health insurance, Barack Obama, Residency

64

To examine whether peppy comments from attending physicians increased the workload of residents working in the emergency department (ED).

Concepts: Hospital, Randomized controlled trial, Residency, Physicians, Dublin

42

Financial relationships between pharmaceutical manufacturers and health care professionals remain controversial. Some interactions, such as those involving research and exchange of expertise, promote the development and study of new drugs; by contrast, payments in the form of meals and continuing medical education (CME) programs have been criticized for being promotional and have been linked to non-evidence-based prescribing practices. The prevalence of these relationships has been estimated from national physician surveys, which found that, across seven specialties, about 83% of physicians received gifts from industry (excluding samples) in 2004. The prevalence has decreased slightly in recent years: a 2009 survey showed . . .

Concepts: Health care, Pharmacology, Medicine, Physician, Medical school, Residency, Medical education, Doctor of Medicine

36

“Moving from volume to value” is health care reform’s latest mantra. Policymakers hope to replace fee-for-service systems with value-based approaches that reward improved outcomes achieved at lower cost. Ground zero in these efforts is the Medicare Physician Fee Schedule (MPFS). What payment reformers often fail to recognize is that the specific MPFS payment rates have important implications for Medicare and its beneficiaries. The relative payment levels for the thousands of service codes and the absence of payment for other activities powerfully influence how physicians spend their time - and their tendency to perform unneeded tests and procedures. The mix of . . .

Concepts: Health care, Health economics, Medicine, Healthcare reform, Health insurance, Density, Physician, Residency

31

Under the Physician Payments Sunshine Act, drug and device manufacturers and group purchasing organizations will report to the Centers for Medicare and Medicaid Services payments made to physicians and teaching hospitals, and the data will be posted on a public website.

Concepts: Medicare, Health insurance, Hospital, Physician, Surgeon, Centers for Medicare and Medicaid Services, Medicaid, Residency

27

To compare the delivery of end of life care given to US Medicare beneficiaries in hospital by internal medicine physicians with Republican versus Democrat political affiliations.

Concepts: Observational study, United States, Physician, Residency, Lyndon B. Johnson, Democratic Party, Ronald Reagan, George W. Bush

26

To explore medical students' experiences working with frequently rotating pediatric inpatient attending physicians.

Concepts: Medicine, Physician, Pediatrics, Medical school, Specialty, Residency, Physicians