Care by locum tenens hospitalists, often thought to be an expensive solution to staffing shortages, may have advantages in patient outcomes and hospital costs, a new observational study suggests.
The results — which surprised the researchers — may help debunk common perceptions that care either by teaching services or by locum tenens is inferior, lead author Moaath K. Mustafa Ali, MD, MPH, told Medscape Medical News. Mustafa Ali, from the department of medicine at the University of Toledo College of Medicine/ProMedica in Ohio, and colleagues published the results January 25 in the Journal of General Internal Medicine.
An expert not involved with the research said that while this study has strengths prior ones have not, it is still observational data, and a randomized trial would be needed to truly find the best staffing model.
Dr Moaath K. Mustafa Ali
For the prospective cohort study, Mustafa Ali and colleagues compared length of stay (LOS), hospital costs, inpatient mortality, 30-day all-cause readmission, and 30-day mortality for hospitalized patients treated by teaching internal medicine hospitalists services vs nonteaching hospitalist services. Researchers also compared those outcomes between patients treated by locum hospitalists vs employed hospitalists.
Patients seen only by teaching internal medicine physicians had a shorter adjusted hospital stay by 0.6 days (95% confidence interval [CI], −1.07 to −0.22; P = .003) compared with patients seen by nonteaching hospitalists. There were no differences in hospital cost, inpatient mortality, 30-day all-cause readmission, or mortality compared with nonteaching services.
Patients seen only by locum tenens were associated with an adjusted LOS of 1 day shorter compared with patients seen exclusively by employed physicians (95% CI, −1.6 to −0.43; P < .001), with an adjusted average hospital cost saving of $1339 dollars per hospitalization (95% CI, −2037 to −642; P < .001). There was no statistically significant difference in other outcomes.
“On weighted-multivariable regression for log-transformed [hospital costs], locum physician care resulted in a 23% lower cost compared to employed hospitalists (95% CI −40% to −7%, p = .005),” the authors write.
Unexpected Findings
“I was really surprised by the results. I did not expect that,” Mustafa Ali said. “I thought when I designed the study I would find the opposite.”
Patients seen only by locum tenens had the same readmission, and mortality compared with those seen by employed hospitalists, the researchers found.
As to why locum tenens might compare so favorably in outcomes while reducing care costs, Mustafa Ali could only offer a theory that, “Locums have a lot of competition.” They want to do well so they get called for additional shifts and that could play a role, he said.
Among the 1273 patients in the study, average age was 61 years. Teaching internal medicine physicians admitted 526 patients and nonteaching hospitalists admitted 747 patients.
Limitations of the study include that it is based on patients seen in a single 800-bed medical center, which may limit generalizability. Mustafa Ali noted that the type of locum tenens may vary at each hospital.
On the other hand, the authors write, single-institution studies allow for a homogenous distribution of variables such as having the same nursing floors, the same nursing staff, and the same study period.
Large-Scale Studies Needed
The sophisticated propensity scoring in the study with matching patients is something previous studies have not been able to do, Marisha Burden, MD, associate professor of medicine in the Division of Hospital Medicine at the University of Colorado School of Medicine in Aurora, told Medscape Medical News. The subcomparisons between locums and employed hospitalists also set this study apart from previous work.
Dr Marisha Burden
However, she added, “I don’t think the results would make me change my staffing model, but what it does is lend itself to giving great ideas for larger-scale studies.”
The authors acknowledge potential confounding given the observational nature of the study.
“A great next step would be to see how some of the other operational factors play into the results found,” Burden said. “In our own research we have found that hospital visits and workload can impact your length of stay, as an example.”
She pointed out that the teaching teams in this study had safety mechanisms, such as caps on the number of patients in their services, whereas others did not.
“The great thing about observational studies is they are a great idea builder for the next step, which could be a randomized control trial.”The question is vital, she said, as hospitals wrestle with capacity: “How do we build hospital teams so that we can all thrive?”
Mustafa Ali said the findings are important as hospitals look for ways to bridge shortages exacerbated by the COVID-19 pandemic.
The researchers note that in the 2020 Survey of Temporary Physician Staffing Trends, about 85% of healthcare facilities used locum physicians in the previous year, and one-quarter used locum hospitalists in the previous year.
Studying these groups was particularly important because “there are no prospective studies comparing hospitalization and post-hospitalization outcomes between teaching internal medicine services and non-teaching hospitalists, and no prospective studies comparing these outcomes between locum and employed hospitalists,” the authors write.
Study authors and Burden have declared no relevant financial relationships.
JGIM. Published online January 25, 2021. Full text
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