Consultant experience as a determinant of outcomes in emergency medical admissions

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.

CONCLUSION: Certified specialists appear to continue with experiential learning with evidence of improved outcome after 20 years in clinical practice.