A comparison of generalist and pulmonologist care for patients hospitalized with severe chronic obstructive pulmonary disease: resource intensity, hospital costs, and survival

doi:10.1016/S0002-9343(98)00290-3

The American Journal of Medicine

Volume 105, Issue 5, November 1998, Pages 366-372

https://doi.org/10.1016/S0002-9343(98)00290-3 Get rights and content

Abstract

PURPOSE: Both generalist and pulmonologist physicians care for patients with severe chronic obstructive pulmonary disease (COPD). We studied patients hospitalized with severe COPD to explore whether supervision of care by pulmonologists is associated with greater costs or better survival.

SUBJECTS AND METHODS: We studied 866 adults with severe COPD enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), a prospective study at five academic medical centers. Patients were admitted to the hospital or transferred to an intensive care setting for treatment of severe COPD, defined by hypoxia (PaO2 <60 mm Hg) and hypercapnia (PaCO2 >50 mm Hg) or hypercapnia alone if on supplemental oxygen. Resource intensity was measured using a modified version of the Therapeutic Intervention Scoring System and estimated hospital costs. To account for differences in the patient case mix, propensity scores were developed to represent each patient’s probability of having a pulmonologist as attending physician and each patient’s probability of being in an intensive care unit (ICU) at study admission.

RESULTS: Of the 866 patients studied, 512 had generalists and 354 pulmonologists as their attending physicians. The median patient age was 70 years; 52% were male; 14% died within 30 days. After adjusting for baseline differences in patient characteristics, there were no differences in resource intensity and hospital costs in those treated by pulmonologists or generalists. Adjusted average resource intensity scores for the entire hospitalization were 16.5 for pulmonologists and 17.0 for generalists (P = 0.34). Estimated hospital costs were the same ($6,400) for patients treated by pulmonologists and generalists (P = 0.99).

Patients with pulmonologists as attending physicians did not experience better survival. Comparing patients of pulmonologists to patients of generalists, the adjusted hazard ratio for 30-day mortality was 1.6 (95% confidence interval: 0.98, 2.5); the hazard ratio for 180-day mortality was 1.2 (0.9, 1.7).

CONCLUSIONS: Our findings suggest that for patients hospitalized with exacerbation of severe COPD, those with pulmonologist attending physicians do not have higher hospital resource use or better survival than those with generalist attending physicians.

Section snippets

Study design

We analyzed data from patients enrolled from 1989 to 1994 in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), a prospective study of patient preferences, decision making, and outcomes in seriously ill hospitalized adults 18, 19. The study had two parts: an observational period (Phase I) and a subsequent interventional period (Phase II). During Phase II, patients assigned to the intervention had a dedicated clinical nurse specialist to facilitate

Physician and patient characteristics

Pulmonologists (n = 65) were slightly older than generalists (n = 235; median age 43 years for pulmonologists versus 42 years for generalists, P <0.001) and were more likely to be male (96% versus 80%, P <0.001). Patients of pulmonologists were younger, less likely to be female, and had more severe acute disease as evidenced by worse mean acute physiology score upon enrollment, worse arterial oxygenation, and worse estimated survival than did patients cared for by generalists (Table 1). There

Discussion

In our study of hospitalized, seriously ill patients with COPD, we found that patients who had pulmonologists as their attending physicians received more resource intensive care and experienced higher mortality than those cared for by generalists. However, these patients were younger and more acutely ill upon admission as evidenced by worse APACHE III scores, measures of oxygenation, and prognostic models. After adjustment for differences in case mix, there were no significant differences in

References (37)

C.S Levetan et al.
Impact of endocrine and diabetes team consultation on hospital length of stay for patients with diabetes
Am J Med
(1995)
P.M Layde et al.
Generalizability of clinical studies conducted at tertiary care medical centersa population based analysis
J Clin Epidemiol
(1996)
J.M Eisenberg
Doctors Decisions and the Cost of Medical Care
(1986)
S Greenfield et al.
Outcomes of patients with hypertension and non-insulin dependent diabetes mellitus treated by different systems and specialties
JAMA
(1995)
J.G Jollis et al.
Outcome of acute myocardial infarction according to the specialty of the admitting physician
NEJM
(1996)
S.O Rhee et al.
Domain of practice and the quality of physician performance
Med Care
(1981)
A Auerbach et al.
Effect of physician specialty on resource use and survival among seriously ill patients with congestive heart failure
J Gen Intern Med
(1997)
Higgins MW, Thom T. Incidence, prevalence, and mortality: intra- and inter country differences. In: Hensley MJ,...
Ingram RH Jr. Chronic bronchitis, emphysema and airways obstruction. In: Wilson JD, Braunwald E, Isselbacher KJ, et al,...
Wise RA, Liu MC. Obstructive airways disease: asthma and chronic obstructive pulmonary disease. In: Barker LR, Burton...

R.S Mitchell et al.

Chronic obstructive bronchopulmonary diseasefactors influencing prognosis

Am Rev Respir Dis

(1963)

A.D Renzetti et al.

The Veterans Administration cooperative study of pulmonary function. 3. Mortality in relation to respiratory function in chronic obstructive pulmonary disease

Aspen Emphysema Conf

(1968)

B Burrows et al.

Course and prognosis of chronic obstructive lung disease. A prospective study of 200 patients

NEJM

(1969)

S.F Boushy et al.

Prognosis in chronic obstructive pulmonary disease

Am Rev Respir Dis

(1973)

G.A Traver et al.

Predictors of mortality in chronic obstructive pulmonary diseasea 15-year follow-up study

Am Rev Respir Dis

(1979)

N.R Anthonisen et al.

Prognosis in chronic obstructive pulmonary disease

Am Rev Respir Dis

(1986)

D Postma et al.

Prognosis of chronic obstructive pulmonary diseasethe Dutch experience

Am Rev Respir Dis

(1989)

B Burrows et al.

The course and prognosis of different forms of chronic airways obstruction in a sample from the general population

NEJM

(1987)

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Pothirat et al. [35] compared the management of patients with COPD by pulmonologists vs internists and also found higher guideline adherence by pulmonologists as well as significantly lower rates and frequencies of severe adverse events in patients managed by them. Other studies, however, did not observe differences in resource utilization intensity or patient survival [36,37]. Nevertheless, the overall results suggest that in order to maximize treatment efficiency it might be beneficial to integrate specialists early into the treatment process [38].
Guidelines for chronic obstructive pulmonary disease (COPD) recommend supplementing pharmacotherapy with non-pharmacological interventions. Little is known about the use of such interventions by patients. We analyzed the utilization of a number of non-pharmacological interventions and identified potential determinants of use.
Based on self-reports, use of interventions (smoking cessation, influenza vaccination, physiotherapy, sports program, patient education, pulmonary rehabilitation) and recommendation to use were assessed in 1410 patients with COPD. The utilization was analyzed according to sex and severity of disease. Potential determinants of utilization included demographic variables and disease characteristics and were analyzed using logistic regression models.
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Geographic Accessibility of Pulmonologists for Adults With COPD: United States, 2013
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It is also unclear whether current outcomes of patients with COPD in the United States differ between those treated by pulmonologists and those treated by primary care physicians. In one US study of patients with COPD hospitalized with severe COPD from 1989 to 1994, patients seen by pulmonologists compared with those seen by generalists were younger, had more severe acute disease, and had worse estimated survival on admission, but survival at 30 days did not differ significantly after adjustment for differences in case mix.24 Whether patients with COPD seen by a pulmonologist in the United States are more likely to receive recommended therapies and show greater adherence than those seen by primary care physicians in actual practice also is not established; however, it could be assumed that pulmonologists would be more likely to have greater awareness of new treatment modalities.
Geographic clusters in prevalence and hospitalizations for COPD have been identified at national, state, and county levels. The study objective is to identify county-level geographic accessibility to pulmonologists for adults with COPD.
Service locations of 12,392 practicing pulmonologists and 248,160 primary care physicians were identified from the 2013 National Provider Identifier Registry and weighted by census block-level populations within a series of circular distance buffer zones. Model-based county-level population counts of US adults ≥ 18 years of age with COPD were estimated from the 2013 Behavioral Risk Factor Surveillance System. The percentages of all estimated adults with potential access to at least one provider type and the county-level ratio of adults with COPD per pulmonologist were estimated for selected distances.
Most US adults (100% in urbanized areas, 99.5% in urban clusters, and 91.7% in rural areas) had geographic access to a primary care physician within a 10-mile buffer distance; almost all (≥ 99.9%) had access to a primary care physician within 50 miles. At least one pulmonologist within 10 miles was available for 97.5% of US adults living in urbanized areas, but only for 38.3% in urban clusters and 34.5% in rural areas. When distance increased to 50 miles, at least one pulmonologist was available for 100% in urbanized areas, 93.2% in urban clusters, and 95.2% in rural areas. County-level ratios of adults with COPD per pulmonologist varied greatly across the United States, with residents in many counties in the Midwest having no pulmonologist within 50 miles.
County-level geographic variations in pulmonologist access for adults with COPD suggest that those adults with limited access will have to depend on care from primary care physicians.
Impact of exacerbations and admissions in chronic obstructive pulmonary disease
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En la historia natural de los pacientes con enfermedad pulmonar obstructiva crónica (EPOC) hay períodos de incremento de los síntomas, que conocemos como agudizaciones de la EPOC (AEPOC), que en ocasiones precisan de ingreso hospitalario. Aunque todavía hay debate en cuanto a su definición, y ello ha generado una falta de homogenidad en los múltiples estudios realizados, estas agudizaciones repercuten de manera muy negativa en los pacientes, y producen un deterioro clínico y de la función pulmonar a largo plazo. También conllevan una disminución de la calidad de vida, que se ve afectada a medio y largo plazo, y un coste sociosanitario elevado, especialmente durante los ingresos hospitalarios. Finalmente, las AEPOC incrementan la mortalidad de los pacientes tanto a corto plazo, durante el ingreso hospitalario, como después de la hospitalización. Por todo lo anterior, prevenir las AEPOC se ha convertido en uno de los objetivos fundamentales en estos pacientes.
During the natural history of patients with chronic obstructive pulmonary disease (COPD), an increase in symptom severity can occur, called exacerbated COPD (ECOPD), sometimes requiring hospital admission. Although there is ongoing debate on the definition of ECOPD –leading to a lack of homogeneity in the numerous studies performed– exacerbations negatively affect patients, producing clinical and pulmonary function deterioration in the long term. Exacerbations also decrease quality of life in the medium- and long-term and have a high social and health cost, especially during hospital admission. Finally, ECOPD increases mortality in patients in the short-term, during hospital admission, and after discharge. In view of all of the above, prevention of ECOPD has become one of the main objectives in these patients.
A review of the application of propensity score methods yielded increasing use, advantages in specific settings, but not substantially different estimates compared with conventional multivariable methods
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We excluded 48 articles that did not include analysis of data (28), randomized clinical trials (9), case-control studies (2), and articles primarily analyzing cost-effectiveness (6) or practice patterns (3). Our search revealed 58 substantive medical research studies that used PS in 2003 [18–75], 38 in 2002 [76–113], 28 in 2001 [114–141], 6 in 2000 [142–147], 5 in 1999 [148–152], 5 in 1998 [153–157], and a total of 5 before 1998 [158–162]. Additional articles found through a citation search of the significant methods articles written about PS, using Science Citation Index, yielded 13 medical research studies that used PS in 2003 [163–175], 13 in 2002 [176–188], 11 in 2001 [189–199], 3 in 2000 [200–202], 1 in 1999 [203], 3 in 1998 [204–206], and a total of 3 before 1998 [207–209].
Propensity score (PS) analyses attempt to control for confounding in nonexperimental studies by adjusting for the likelihood that a given patient is exposed. Such analyses have been proposed to address confounding by indication, but there is little empirical evidence that they achieve better control than conventional multivariate outcome modeling.
Using PubMed and Science Citation Index, we assessed the use of propensity scores over time and critically evaluated studies published through 2003.
Use of propensity scores increased from a total of 8 reports before 1998 to 71 in 2003. Most of the 177 published studies abstracted assessed medications (N = 60) or surgical interventions (N = 51), mainly in cardiology and cardiac surgery (N = 90). Whether PS methods or conventional outcome models were used to control for confounding had little effect on results in those studies in which such comparison was possible. Only 9 of 69 studies (13%) had an effect estimate that differed by more than 20% from that obtained with a conventional outcome model in all PS analyses presented.
Publication of results based on propensity score methods has increased dramatically, but there is little evidence that these methods yield substantially different estimates compared with conventional multivariable methods.
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^☆: This study was supported by the Robert Wood Johnson Foundation. The opinions and findings contained in this article are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation or its board of trustees. Dr. Regueiro was supported in part by National Research Service Award: 5 T32 PE11001-09. Dr. Hamel was supported in part by a Career Development Award from the National Institute on Aging (KO8 A60075-02).

^∗: Access the “Journal Club” discussion of this paper at http://www.elsevier.com/locate/ajmselect/

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Clinical StudiesA comparison of generalist and pulmonologist care for patients hospitalized with severe chronic obstructive pulmonary disease: resource intensity, hospital costs, and survival∗☆,

Abstract

Section snippets

Study design

Physician and patient characteristics

Discussion

Am J Med

J Clin Epidemiol

Doctors Decisions and the Cost of Medical Care

Outcomes of patients with hypertension and non-insulin dependent diabetes mellitus treated by different systems and specialties

JAMA

Outcome of acute myocardial infarction according to the specialty of the admitting physician

NEJM

Domain of practice and the quality of physician performance

Med Care

Effect of physician specialty on resource use and survival among seriously ill patients with congestive heart failure

J Gen Intern Med

Chronic obstructive bronchopulmonary diseasefactors influencing prognosis

Am Rev Respir Dis

The Veterans Administration cooperative study of pulmonary function. 3. Mortality in relation to respiratory function in chronic obstructive pulmonary disease

Aspen Emphysema Conf

Course and prognosis of chronic obstructive lung disease. A prospective study of 200 patients

NEJM

Prognosis in chronic obstructive pulmonary disease

Am Rev Respir Dis

Predictors of mortality in chronic obstructive pulmonary diseasea 15-year follow-up study

Am Rev Respir Dis

Prognosis in chronic obstructive pulmonary disease

Am Rev Respir Dis

Prognosis of chronic obstructive pulmonary diseasethe Dutch experience

Am Rev Respir Dis

The course and prognosis of different forms of chronic airways obstruction in a sample from the general population

NEJM

Clinical Studies
A comparison of generalist and pulmonologist care for patients hospitalized with severe chronic obstructive pulmonary disease: resource intensity, hospital costs, and survival∗☆,