|
Morbidity, mortality, and charges for hospital care of the elderly: a comparison of internists' and family physicians' admissions |
McGann K P, Bowman M A, Davis S W |
|
|
Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Hospital care of elderly patients for common medical problems. Technologies include magnetic resonance imaging, haemodialysis, transplant service, radiation therapy, therapeutic radioisotope, open heart surgery, and cardiac catheterisation.
Economic study type Cost-effectiveness analysis.
Study population Elderly patients aged 65 and over hospitalised for common medical problems in Pennsylvania, USA. The average age of patients was around 77.4 years. Approximately 60% were female.
Setting The settings for the clinical and economic studies were hospitals in Pennsylvania, USA.
Dates to which data relate Resource use and effectiveness analysis related to data taken from the 1989 MedisGroups Comparative Database.
Source of effectiveness data Evidence for final outcomes was derived from a single study.
Link between effectiveness and cost data Costing was undertaken on the same patient sample as that used in the effectiveness study. It appears that the costing was undertaken at the same time as the effectiveness study.
Study sample The study consisted of 31,321 hospital admissions, encompassing the top 10 admission diagnostic-related groups in patients aged 65 years and older. Only the hospitals that reviewed admissions from all departments are included. 19,154 admissions were made by internists, and 12,167 by family physicians. The sample size was adequate to detect a 1.6% difference between groups at a power of 0.80, and a 1.8% difference at a power of 0.90.
Study design A retrospective cohort study which used patients from 40 hospitals. Length of follow-up is restricted to time spent as an inpatient.
Analysis of effectiveness The analysis of the clinical study was based on intention to treat. The primary health outcomes were morbidity and mortality. At analysis, there was control of patient variables such as age, sex, Medicaid insurance payment, admission from nursing home, admission severity scores, and hospital variables such as number of beds, teaching status, and available technologies and procedures.
Effectiveness results Before adjusting for patient and hospital variables, there were no significant differences between the groups in terms of mortality (11.8% for internists' admissions vs 11.9% for family physicians' admissions). However, the patients of internists experienced slightly higher morbidity (37.8% vs 35.7% for patients of family physicians, p<0.01). After adjusting for patient and hospital characteristics, there remained no significant difference in mortality rates between the two groups. After adjustment for patient characteristics, patients of internists experienced slightly lower mortality rates (odds ratio=0.9677, 95% CI: 0.899 - 1.041), as they did after adjustment for hospital characteristics (odds ratio=0.98, 95% CI: 0.911 - 1.054). After adjustments, patients of internists still suffered slightly greater morbidity. After adjusting for patient characteristics, the odds ratio was 1.085 (95% CI: 1.031 - 1.142; p<0.05), while the odds ratio after adjustment for hospital characteristics was 1.069 (95% CI: 1.017 - 1.123; p<0.05).
Clinical conclusions It made little difference in medical outcomes whether family physicians or internists managed the hospital care of elderly patients for common medical problems. Due to the large number of patients in the sample, any small statistically significant difference will not necessarily imply a clinically significant difference.
Measure of benefits used in the economic analysis The effectiveness analysis showed little clinical difference between the two groups and so the economic analysis was based on the difference between hospital charges, with length of stay used as a further proxy of cost.
Direct costs Costs referred to total hospital charges on an inpatient basis, with total charges made up of per diem hospital charges and ancillary service charges.
Statistical analysis of costs Average total charges and average length of stay were compared between the two groups using a t test for independent means. The same variables were also compared between groups after controlling for patient and hospital characteristics. This was done by analyses of covariance. Because these variables were not normally distributed, square root and natural logarithm transformations were performed on these data.
Estimated benefits used in the economic analysis Cost results Average total hospital charges, without adjustment for patient or hospital characteristics, were not significantly different between the two groups ($17,577 for internists' admissions vs $17,021 for family physicians' admissions). After controlling for patient characteristics, the difference between the groups remained statistically insignificant ($17,508 for internists' admissions vs $17,130 for family physicians' admissions), as it did after controlling for hospital characteristics ($17,558 for internists' admissions vs $17,081 for family physicians' admissions).
Synthesis of costs and benefits Authors' conclusions It makes little difference in medical outcomes or hospital charges whether family physicians or internists manage the hospital care of elderly patients for common medical problems. Previously documented lower costs of care by family physicians may be due to outpatient rather than inpatient care, and so savings to the health care system attributable to physician speciality may occur predominantly outside the hospital.
CRD Commentary The study was useful in showing the similarities that exist between admissions made by internists and family physicians. The sample size was certainly large enough to detect relatively small differences. However, the size of the sample may also present its own problems because, as the authors pointed out, any small difference was likely to be statistically significant. However, its clinical significance needs to be carefully evaluated. The economic analysis is very limited, being restricted to a comparison of average hospital charges, with length of stay as a proxy of costs. However, given the design of the study and the information available to the authors, it is unlikely that the economic analysis could have been more comprehensive. Also, the analysis referred only to inpatient data within a subset of hospitals which are predominantly situated within one US state. For these reasons, generalisability to other settings and other countries is likely to be limited. The authors could have elaborated on this point (they did mention it) i.e. by explaining more fully how resources/charges used in these hospitals may differ from those used in other settings.
Implications of the study The medical and resource implications of these findings are important given the number of hospital admissions of the elderly. However, it is difficult to generalise the results beyond the hospitals used in this study, particularly with any reference to the UK health care system.
Bibliographic details McGann K P, Bowman M A, Davis S W. Morbidity, mortality, and charges for hospital care of the elderly: a comparison of internists' and family physicians' admissions. Journal of Family Practice 1995; 40(5): 443-448 Indexing Status Subject indexing assigned by NLM MeSH Aged; Family Practice; Female; Health Services for the Aged /economics /standards; Hospitalization /economics; Humans; Information Systems; Insurance, Health; Internal Medicine; Length of Stay; Male; Patient Admission AccessionNumber 21995000637 Date bibliographic record published 30/09/1997 Date abstract record published 30/09/1997 |
|
|
|