title: Improved outcomes of high-risk emergency medical admissions cared for by experienced physicians.
abstract: BACKGROUND
  Physician experience has been shown to improve clinical outcomes. Limited numbers of experienced clinicians make it unfeasible that they would care for all patients. We hypothesized that physician experience would impact outcomes for patients with high, but not low, risk of mortality.
  
  
  METHODS
  All emergency admissions from 2002 to 2013 were studied. Two groups at low and high risk for mortality (1.3% (95% CI: 1.13, 1.62) vs. 19.4% (95% CI: 18.5, 20.3)) were defined by a risk prediction method comprising acute Illness Severity Score, Charlson Comorbidity Index and sepsis status. Length of stay (LOS) and 30-day in-hospital mortality were the primary end points. Consultant experience was studied univariately and also entered into a multiple logistic regression model to predict 30-day in-hospital survival. A zero-truncated Poisson regression model assessed LOS and incidence rate ratios (IRR) were calculated.
  
  
  RESULTS
  Over the 12-year study period 66 933 admissions were recorded in 36 271 patients. High-risk patients cared for by more experienced (≥20 years qualified) physicians had a lower 30-day in-hospital mortality (19.4 vs. 17.1% P < 0.001), relative risk reduction 11.9%. The multivariable odds ratio of a 30-day in-hospital death for an experienced physician was 0.89 (95% CI: 0.82, 0.97; P = 0.009). LOS was shorter for high-risk patients allocated to experienced physicians with a multivariable IRR of 0.77 (95% CI: 0.94, 0.99; P = 0.02). No difference in outcomes was found for low-risk patients.
  
  
  CONCLUSIONS
  High-risk but not low-risk patients have improved outcomes when cared for by physicians with greater experience.
authors.affiliation: From the Department of Internal Medicine, St. James Hospital, Dublin 8, Ireland drrichardconway@gmail.com.
authors.forename: R
authors.initials: R
authors.lastname: Conway
authors.affiliation: From the Department of Internal Medicine, St. James Hospital, Dublin 8, Ireland.
authors.forename: D G
authors.initials: DG
authors.lastname: Byrne
authors.affiliation: From the Department of Internal Medicine, St. James Hospital, Dublin 8, Ireland.
authors.forename: D
authors.initials: D
authors.lastname: O'Riordan
authors.affiliation: From the Department of Internal Medicine, St. James Hospital, Dublin 8, Ireland.
authors.forename: B
authors.initials: B
authors.lastname: Silke
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003253:Consultants; D004635:Emergency Medicine / Q000592:standards*; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007494:Ireland; D007902:Length of Stay / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010820:Physicians / Q000592:standards*; D012189:Retrospective Studies; D012720:Severity of Illness Index