title: Consultant experience as a determinant of outcomes in emergency medical admissions.
abstract: BACKGROUND
  There are little data on the experiential learning of certified consultant specialists and outcomes in acute medicine. We have examined the 30-day in-hospital mortality and hospital length of stay (LOS) in relation to practice duration, using a database of emergency admissions.
  
  
  METHODS
  All emergency admissions (60,864 episodes in 35,168 patients) over eleven years (January 2002 to December 2012) were evaluated. Consultant staff were categorised by duration of clinical practice as <15 years, 15-20 years, >20≤25 years and >25 years. We used a stepwise logistic regression model to predict 30-day in-hospital death, adjusting risk estimates for major predictor variables. Marginal analysis used adjusted predictions to test for interactions of key predictors, while controlling for other variables.
  
  
  RESULTS
  Thirty-day in-hospital mortality correlated with time in clinical practice; decreasing from 8.9% and 9.1% with <15 and 15-20 years to 7.7% for each of the categories of >20≤25 years and >25 years. There was a progressive shortening of LOS with extent of clinical practice - from a median 5.0 days (IQR 1.8, 10.3) for consultants within 15 years of registration to 4.6 (IQR 1.7-8.9; p<0.05) at >20≤25 years and 4.4 (IQR 1.7-9.0; p<0.01) with >25 years. Duration of clinical practice predicted mortality in the univariable analysis - odds ratio (OR) 0.85 (95% CI: 0.78, 0.91; p<0.001); when adjusted in a multivariable model, it remained independently predictive--OR 0.87 (95% CI: 0.79, 0.96; p<0.001) for 30-day in-hospital mortality.
  
  
  CONCLUSIONS
  Certified specialists appear to continue with experiential learning with evidence of improved outcome after 20 years in clinical practice.
authors.affiliation: Department of Internal Medicine, St. James's Hospital, Dublin 8, Ireland.
authors.forename: Richard
authors.initials: R
authors.lastname: Conway
authors.affiliation: Department of Internal Medicine, St. James's Hospital, Dublin 8, Ireland.
authors.forename: Deirdre
authors.initials: D
authors.lastname: O'Riordan
authors.affiliation: Department of Internal Medicine, St. James's Hospital, Dublin 8, Ireland. Electronic address: bernardsilke@physicians.ie.
authors.forename: Bernard
authors.initials: B
authors.lastname: Silke
mesh_terms: D000208:Acute Disease / Q000401:mortality*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004630:Emergencies; D005260:Female; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D008505:Medical Staff, Hospital / Q000706:statistics & numerical data*; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D063728:Secondary Care Centers; D013997:Time Factors
keywords: AMAU; Consultant experience; Emergency admissions; Outcomes