November 13, 2023
With the variability of patient complexity, time of presentation, resource availability, and a whole slew of other external factors, patient’s presenting to the ED can have high morbidity and mortality. But should they be worrying about the age of the provider caring for them? In this recent Annals of Emergency Medicine article, the answer, at least on the surface, appears to be yes- there was a link between physician age and patient mortality. But there is so much more to the story. In this podcast we appraise and discuss this articles findings, as well as discuss practical ways to take its take-home points to your clinical practice.
Distinguished or Deadly?- Physician Age and Its Association with Patient Mortality – The SimKit Podcast
Hello everybody and welcome back to the SimKit podcast. I am here as your host doctor Jason. Now I definitely have a little bit of the sniffles, the snouts, a little bit of a change in voice here. I apologize for that and I appreciate you all taking on a little bit of change in my voice quality. You know, I’ve got three kids, three kids under 5, so if I only record when I’m not sick, it basically excludes, you know, October to April. I’m sure a lot of people out there can understand that. So we’re going to record anyway on an interesting and important paper that was. Published in Annals of Emergency Medicine, this is the association between emergency physicians age and mortality of Medicare patients aged 65 to 89 years after emergency department visit. So little bit of background here. There were 143,000,000 Ed visits in 2018 as they start in the paper. Interestingly, that’s. 23 million more compared to 2006. The urgent and unscheduled nature of this care that we’re providing in the emergency room leads to high morbidity and mortality rates as well as kind of, you know, variability in care. The evidence has been pretty mixed as to whether younger or older clinicians offer higher or lower or equal quality care in the emergency department. So again this is the paper in Annals association between emergency physicians age and mortality. For Medicare patients aged 65 to 89 years after emergency department visit. It was published in September 2023. Now the clinical question they are posing is emergency physician age associated with short term mortality in emergency department patients who are Medicare beneficiaries. The design is a retrospective observational study of Medicare claims data from 2016 to 2017, as well as Medicare data on physician practice and specialty just for association of the claims data with the specific provider that’s caring for the patient. Obviously, we need to link the visit to the doctor if we’re looking at the doctor’s demographics so that. They define emergency medicine physician as a physician who reported emergency medicine as their primary specialty, the. Makes sense and they had to build 90% or more of their claims in an Ed setting. What were the inclusion and exclusion criteria for the study? The inclusion were fee for service beneficiaries aged 65 to 89, with an easy visit in those years sick 20/16/2017 who received care by an emergency medicine physician. Pretty straightforward there. They excluded beneficiaries who used Hospice in the year. Prior and those who left AMA because they don’t want that AMA status to affect their mortality. And that’s really it. That’s pretty clean inclusion exclusion, right? They looked at elderly, I guess you’d say 65 to 89 year old Medicare beneficiaries in the years 20/16/2017 and they only excluded patients that were Hospice and who left AMA. Now there’s a lot of secondary analysis we’ll get into. So they broke it down a little bit more, but that’s the simple design. Association between physician age and mortality in this patient population. So what were their outcomes? Their primary outcome was seven day mortality from the Ed visit. Super straightforward again. Now there were several analyses of this primary outcome that were completed to assess for confounders. Obviously is population-based study. We’re going to look at a lot of different interpretations and computations of the data. So the confounders they evaluated their patient and their physician characteristics, patient characteristics, they looked at age, sex, race, ethnicity, indicators of 27 different chronic conditions. The number of these chronic conditions they. Add if they were duly eligible for Medicare or Medicaid as well as median income level of the residents. At the zip. Code level. Really. They’re looking at, you know, income and ability or assets to pay for medical care or effects of income on mortality itself. The primary diagnosis at. The Ed visit and the day of the week of the Edu visit, the physician characteristics were outside of age. Obviously, sex, credentials and the rank of the medical school they attended, which I think is super interesting. They did not have the same system obviously for residency. So the secondary analysis they performed on the primary outcome, there were ten of them in total plus or minus the things that they looked at were the years of practice for the Ed physician instead of the physicians age, they looked at 3, 14 and 30-day mortality versus 7 day. They looked at the data when they excluded patients discharged to Hospice or with a cancer diagnosis. They adjusted for. The physician patient volumes, they adjusted for indicators of end stage renal disease on the patient level. They restricted visits to the 1st Ed presentation for the beneficiary during that study period of 20/16/2017. They excluded physicians who were classified to different age categories during the study period. So if you jumped from one to the other, you know there was less than 40, 40 to 49, 50 to 59 et cetera. So if you jumped categories, they did a computation excluding those providers. They did a comparison of a physician’s probability of admitting patient between physician. Age groups. They looked at large certification and or formal training effect on mortality rates and some other computations they did on the data related again to volumes to whether or not the physician was academic and to whether or not the billing was under the physician’s name but performed by the AP. So these are just computations, secondary analysis. They did. There were 10 plus of them coming back to the idea collectively outcomes primary Outcomes, 7 day mortality from the E visit de Visit and its relationship to the age of. The clinician, pretty straightforward there.
So what were the results? They had a total sample of 2.6 + 1,000,000 Ed visits treated by 32,570 emergency physicians when they did a audit of 50 of the physician profiles, they found that 88% of the physicians had completed an emergency medicine. Presidency and 12 did not. Of those twelve, 6% had done an internal medicine and 6% had done family. And interestingly, when they did epidemiological stuff on the physicians, it was found that the older physicians disproportionately provided care in small for profit, non teaching hospitals located in rural environments. So primary outcome again, seven day mortality from the Ed visit, the overall mortality rate was 1.36% plane, that’s our number overall in aggregate. Unadjusted mortality rates, again breaking down by less than 4040 to 4950 to 59 and older than 60. The rate was 1.33% for docs less than 40 and the same for Docs 40 to 49. It jumped to 1.42 for Docs 50 to 59 and 1.49 for docs older than 60 when adjusting for some of the confounders we talked about above, the rates were 1.33 for docs less than 40. 1.36 for dogs 40 to 49. 1.4 for docs 50 to 59 and 4.3 for docs greater than 60. The difference in mortality between docs less than 40 and those 50 to 59 and 60 or older were statistically significant. So just to go over those numbers a little bit more, it’s basically a change of .03% give or take as you move up a decade in life. 1.33% for doxygen 40. 1.36% for Docs 40 to 49. Then 1.4. So oh .04% increase for docs 50 to 59 and 1.43 for docs greater than 60. So .03% ish increase in mortality for each decade of the clinician. Now, when age was modified as a continuous. Variable. They actually find that every decade of practice was associated with 1.04, so slightly higher than our rough numbers there 1.04% higher seven day mortality from the group below you. And interestingly, when they look at the patients at different severity of illness scores, right, low, medium and high when assessing patients at different severity of illness. They actually found that the magnitude of association between older physician age and higher seven day mortality was greatest for patients with the highest severity of illness. This is to say that for sicker patients, older doctors in this paper did worse. They had a higher rate of mortality and a greater degree of change compared to younger doctors. This was followed by the medium severity of illness and there was no difference. Interestingly, for patients with a low severity of illness. So there is no difference in the mortality rate between younger, middle-aged and older docs for low severity of illness there was a difference for medium severity and the difference between groups was highest for severely sick. And then secondary analysis, importantly, this is an annals article. They looked at many computations and they have a huge data set, so they can do different computations without really diluting significantly down their data, right? They have 2.6 + 1,000,000 Ed visits, 32,000 plus Ed. These stratifications and computations are not watered down too, too badly when they do. But they did many of them and there was no change in the seven day mortality rates and the difference by age of the provider, those persisted. It was noticed that there were modest but statistically significant declines in emission rates with the increasing age of the practitioner, and that certainly could come into play. But all of the other demographic and other stratification. Information that we talked about, no changes when they did these computations. Was there a different, you know, 30 day, 14 day, 30 day mortality when they excluded patients that went to Hospice or had cancer diagnosis when they adjusted by patient? Volume all of these computations really had no effect on the trend of increasing mortality rate with increasing provider age. And interestingly, just to add on to the statistically significant decline in emission rate for you know increasing practitioner age, they did analysis of admitted versus discharged patients, the trend of increasing mortality persisted in looking at discharge patients only by age stratification of the provider. Increasing mortality with age for admitted patients only increasing mortality with age. So while this is worth recognizing and may potentially play into. The trends toward higher mortality rates, even for admitted patients, the mortality rate was higher for older clinicians, unfortunately.
OK, So what are the authors conclusions they say and I quote Medicare patients aged 65 to 89 years treated by an emergency physician aged under 40 years had lower seven day mortality rates than those treated by physicians 50 to 59 years. And sixty years or older within the same hospita,l End Quote.
What is our opinion? What do we at SimKit think about this paper? First, it is well done right? It is in Annals of emergency medicine. It is a huge data set and they did many many computations and permutations of the data we want to recognize that in retrospective observational large data set samples we are talking about correlation. Of course not. Causation, and I applaud the authors. They seemed in earnest to attempt to address and look for confound. There are many secondary analysis. Unfortunately, if you’re looking at the primary article, they are not contained in that. They are supplemental. If they were contained in the initial text, it wouldn’t be 12 pages, it would be 55. So you do want to find that supplemental text to look at some of these secondary analyses. But kudos to the authors for doing an effort and trying and assessing where these trends lie when they do different computations. All of this said, what are our conclusions for the paper? So we say mortality rates for elderly patients do appear to increase slightly, but statistically significantly with increasing age of the physician providing care for them. This is true for both admitted and discharged patients. Older docs were found to have lower admission rates. And were more likely to practice in rural small for profit, non teaching hospitals. These differences along with the potential declines in working memory capacity, stamina and cognitive sales could explain these differences. Regardless, these differences do appear to be real and require obviously more work to determine and address the root cause. So in discussing those conclusions, I think there are a few really interesting points for me obviously as we mentioned, you can’t get away from the fact that older physicians seem to be in rural small non teaching for profit hospitals is the quality of care in these hospitals lower than the quality of care in the ivory tower? Probably not universally, but there’s likely a trend toward yes. I think that that in some part can explain these differences. The other reality is if we do an assessment of someone whose freshly graduated from residency versus someone that’s 25 years out, looking at simple things like guideline adherence facility with the MRI. The ability to use an order set to order antibiotics early for a patient who. Is in septic shock- We’re probably going to see differences there. So is the quality of provision of care different between the two, or is the younger physician just more sort of updated in adherence to medicine and practicing medicine that’s contemporary to their time of training? I think both of these probably are at play here, and I’m excited to see further research on the topic.
Finally, and I think probably most importantly, especially especially for these docs who are 50 plus and you know may see this article as a personal attack on the quality of care or a challenge to what they are doing and how beneficial they are for their patients, you may be asking yourselves. How do I combat this? How do I prove this article wrong in its own right? Well, some of those answers are from what we talked about in our dissection of you know why this relationship might exist. Being up-to-date, being evidence based, making sure as a clinician that you are finding ways to be alerted to changes and updates in guidelines and national society recommendations and following those guidelines and recommendations as accurately and as closely as you can. Secondly, being up to date. Evidence based medicine, blogs and podcasts have been fantastic in decreasing that knowledge. Question Time, but make sure that you are a sponge in that capacity. Finding blogs, podcasts that you trust that you know are high quality and just soaking them up every month to gain what knowledge you can through them and some of them you want to stop and you go through the primary literature and you read it when. It’s landmark right, but being a sponge and being. Involved in foam and evidence-based medicine is going to help decrease some of this gap in my. Opinion. I would love to hear other people’s perspectives and opinion on this, especially again if you are in that 50 plus age demographic and have opinions about the endpoints, the conclusions of this article, both from the authors and from ourselves, you can reach us at SimKitCo on Twitter to to have a discussion. But everyone thank you so much for listening. And until next time.
All right. We talked a lot today about declining skills, particularly with age, but want to let you know that we at SimKit are very focused on your procedural skills, your skill set decay in these rare procedures like Cricothyrotomy, lateral canthotomy, etcetera. We have taken away all the barriers to keeping your skills up with monthly boxes that deliver right to your door. Check out the link at the bottom for more.
There were 143 million ED visits in 2018, and 1 in 5 Americans will visit an ED annually. The urgent and unscheduled nature of care leads room for high morbidity and mortality rates as well as variability in care. The evidence has been mixed as to whether younger or olde clinicians higher, lower, or equal quality of care in the ED.
Miyawaki A, Jena AB, Burke LG, Figueroa JF, Tsugawa Y. Association Between Emergency Physician’s Age and Mortality of Medicare Patients Aged 65 to 89 Years After Emergency Department Visit. Ann Emerg Med. 2023 Sep;82(3):301-312. doi: 10.1016/j.annemergmed.2023.02.010. Epub 2023 Mar 23. PMID: 36964007.
Is emergency physician age associated with short-term mortality in emergency department patients who are Medicare beneficiaries?
Retrospective, observational study of Medicare claims data in 2016-2017 as well as Medicare Data on Physical Practice and Specialty.
Defined emergency medicine physician as physicians who reported emergency medicine as their primary specialty and who billed 90% or more of their claims in an ED setting.
Fee-for-service beneficiaries aged 65-89 with an ED visit in the 2016-2017 years who received care by an emergency medicine physician.
Beneficiaries who used hospice in the year prior or those who left AMA.
Primary Outcome: 7-day mortality from the ED visit
Several analyses of the primary outcome were completed to assess for confounders:
- Several analyses of the primary outcome were completed to assess for confounders:
- Patient characteristics – age, sex, race/ethnicity, indicators of 27 chronic conditions, the number of chronic conditions, dual eligibility for Medicare and Medicaid, median income level of residence at the ZIP code level, the primary diagnosis at ED visit, day of the week of the ED visit.
- Physician characteristics – sex, credentials, rank of the medical school attended.
Several secondary analyses of the primary outcome were done including:
1. Years of practice instead of physician age.
2. 3, 14, and 30 day mortality.
3. Exclusion of patient’s discharged on hospice and with a cancer diagnosis.
4. Adjusted for physician patient volumes.
5. Adjustment for indicator of end-stage renal disease.
6. Restricted to the first ED visit per beneficiary for the study period.
7. Excluding physicians who were classified into different age categories during the study period.
8. Comparison of physician’s probability of admitting patients between physician age groups.
9. Board certification and/or formal training effect on mortality rates.
10. Three other stratified analyses were related to the number of patients the physician saw, where the physician was academic or not, and if there was billing under their name by an APP.
In their random audit of 50 physicians, all were confirmed EM practitioners, 88% completed an Emergency Medicine residency and 12% did not- of those 6% had studies in internal medicine and 6% in family medicine).
The final sample was of 2.6+ million ED visits treated by 32,570 emergency physicians. It was found older physicians disproportionately provided care in small, for-profit nonteaching hospitals located in rural areas.
Primary Outcome: Overall mortality was 1.36%. Unadjusted morality rates were 1.33% for docs <40% and the same for docs 40-49, 1.42% for docs 50-59 and 1.49% for docs older than 60%.
- When adjusted for confounders, the rates were 1.33% for docs <40, 1.36% for docs 40-49, 1.40% for docs 50-59, and 1.43% for docs >60. The difference in mortality between docs <40 and 50-59 and >60 was statistically significant.
- When age was modified as a continuous linear variable, every decade of practice was associated with a 0.04% higher 7-day mortality.
- When assessing patients of different severity of illness, the magnitude of association between older physician age and higher 7-day mortality was greatest for patients with the highest severity of illness, followed by medium-severity of illness. There was no different for patients with a low severity of illness.
After completing analyses related to the many above mentioned stratifications, there was no change in the 7-day mortality rates and the difference by age of the provider persisted. It was noted there were modest but statistically significant declines in admission rates with increasing practitioner age.
Medicare patients aged 65-89 years treated by emergency physicians aged under 40 years had lower 7-day mortality rates than those treated by physicians 50-59 years and 60 years or older within the same hospital.
Mortality rates for elderly patients appear to increase slightly but significantly with the increasing age of the physician providing care for them. This is true for both admitted and discharged patients. Older docs were found to have lower admission rates, and were more likely to practice in rural, small, for-profit, non-teaching hospitals. These differences, along with potential declines in working memory capacity, stamina, and cognitive skills, could explain these differences. Regardless, these differences appear to be real and will require more work to determine and address root cause.
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- Miyawaki A, Jena AB, Burke LG, Figueroa JF, Tsugawa Y. Association Between Emergency Physician’s Age and Mortality of Medicare Patients Aged 65 to 89 Years After Emergency Department Visit. Ann Emerg Med. 2023 Sep;82(3):301-312. [pubmed]