Publications by Year: 2026

BACKGROUND: Patients can report respiratory discomfort (dyspnoea) on a 0-10 scale. Patients reporting dyspnoea at admission have a four-fold risk of in-hospital death. We asked whether assessing dyspnoea throughout hospitalisation identifies additional patients at risk of death or other poor outcomes.

METHODS: We conducted a retrospective cohort study of non-intensive care unit patients at a tertiary care hospital. On each shift, bedside nurses documented patients' pain and dyspnoea ratings. We tested associations with inpatient mortality, 2-year mortality and other outcomes.

RESULTS: We evaluated 9785 admissions; 18% of patients reported dyspnoea at admission and 10% developed post-admission dyspnoea. Patients with post-admission-onset dyspnoea had six-fold greater odds of death during hospitalisation (OR 6.0, 95% CI 4.2-8.5, p<0.0001) versus patients without dyspnoea. Compared with those without dyspnoea, patients with dyspnoea had 50% greater mortality during the following 2 years, and those with dyspnoea on the day of discharge had even greater mortality (HR 2.6, 95% CI 2.1-3.2, p<0.0001). Higher patient dyspnoea ratings predicted higher in-hospital and 2-year mortality. Pain (reported by 72% of patients) was not significantly associated with mortality. Dyspnoea was also related to greater length of stay, rapid response team activation, transfer to the intensive care unit and discharge to extended care.

CONCLUSIONS: In contrast to pain, both admission dyspnoea and post-admission-onset dyspnoea were associated with substantially increased odds of poor patient outcomes during hospitalisation and following discharge. Documenting dyspnoea throughout hospitalisation provides a powerful alarm of clinical compromise that may warrant additional attention and outpatient follow-up.

OBJECTIVES: Provider organizations are increasingly entering risk-based payment contracts with incentives to minimize medical expenditures. Little is known about physicians' role in controlling costs. This systematic review aims to identify and characterize physician-mediated cost-management interventions in risk-bearing organizations, assess their effectiveness, and evaluate the quality of the literature.

STUDY DESIGN: Systematic literature review.

METHODS: We searched PubMed and EconLit for studies published between 2000 and 2021 reporting physician-mediated interventions intended to reduce medical expenditures in risk-bearing provider organizations. We included quantitative studies evaluating single interventions, quantitative survey-based studies, and qualitative case studies. The quality of the quantitative studies was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework.

RESULTS: Twenty-seven studies were identified, including 12 quantitative evaluations, across diverse provider settings and payment models. We found 5 types of interventions: decision support and performance review, individual financial incentives, physician-led care management, expanded access, and provider-facing price transparency. All but 1 evaluation study found a statistically significant reduction in spending or utilization, but no intervention achieved substantial savings relative to total medical expenditures. The quality of this literature is low, with only 3 studies using a randomized controlled design. Generalizability of results to different provider contexts and payment models remains unclear.

CONCLUSIONS: There is a striking scarcity of high-quality studies on physician-mediated interventions to manage total medical expenditures. The limited evidence to date suggests that no single intervention has a substantial impact on total medical expenditures. Risk-bearing providers have limited guidance in the literature on the most effective practices clinicians can adopt to improve cost-related performance in risk-based contracts.

INTRODUCTION: Patients admitted for hip fracture surgery may receive care from a team led either by the operating surgeon or a hospitalist.

OBJECTIVE: To describe the prevalence of the hospitalist care model for hip fracture admissions and its association with patient outcomes.

DESIGN: We conducted a retrospective cohort study of patients admitted in 2018-2019 for fracture of the head and neck of the femur (ICD10 S72.0x-2x). We compared outcomes at hospitals with low versus high use of the hospitalist care model. Our exposure was the hospital-level adoption of hospitalist care, categorized into quartiles.

PARTICIPANTS: Fee-for-service Medicare patients 66 years old or greater.

MAIN MEASURES: Length of stay (LOS), professional services (Part B) inpatient spending, specialty consultation, discharge to home, all-cause 7- and 30-day readmissions, and 30-day mortality.

KEY RESULTS: A total of 294,150 patients with hip fracture were admitted to 2466 hospitals. Patients cared for in low-use (Q1) versus high-use (Q4) hospitals did not differ meaningfully in demographic characteristics or comorbidities. Hospitals ranged in use of the hospitalist care model from 12% in low-use (Q1) hospitals to 81% in high-use (Q4) hospitals. Low-use hospitals had significantly higher inpatient consult use (unadjusted: Q1 vs Q4, 1.06 vs 0.63 consults, p < 0.0001; adjusted: -0.36, p < 0.001) and length of stay (unadjusted: Q1 vs Q4, 6.04 vs 5.94 days, p < 0.0001; adjusted: -0.09 days, p < 0.05), but no significant difference in adjusted analyses for spending, likelihood of discharge home, 7- and 30-day readmission, or 30-day mortality.

CONCLUSIONS: Hospitalist care for older adults admitted for hip fracture surgery is both common and associated with slightly shorter length of stay.