Does experience matter?
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
OBJECTIVE: To compare the utilization of health care resources and patterns of chronic disease care by patients of medical residents and patients of their attending physicians.
MATERIALS AND METHODS: This study involved a longitudinal cohort of 14,554 patients seen over a 1-year period by 149 residents and 36 attendings located in an urban academic medical center. Data were acquired prospectively through a practice management system used to order tests, write prescriptions, and code ambulatory visits. We assessed resource utilization by measuring the total direct costs of care over a 1-year period, including ambulatory and inpatient costs, and the numbers and types of resources used.
RESULTS: Residents’ patients were similar to attendings’ patients in age and gender, but residents’ patients were more likely to have Medicaid or Medicare and to have a higher burden of comorbidity. Total annual ambulatory care costs were almost 60% higher for residents’ patients than for attendings’ patients in unadjusted analyses, and 30% higher in analyses adjusted for differences in case mix (adjusted mean $888 vs $750; P=.0001). The primary cost drivers on the outpatient side were consultations and radiological procedures. Total inpatient costs were almost twice as high for residents’ patients compared to attendings’ patients in unadjusted analyses, but virtually identical in analyses adjusted for case mix differences (adjusted mean of $849 vs $860). Admission rates were almost double for residents’ patients. Total adjusted costs for residents’ patients were slightly, but not significantly, higher than for attendings’ patients (adjusted mean $1,651 vs $1,540; P>.05). Residents’ and attendings’ patients generally did not differ in the patterns of care for diabetes, asthma/chronic obstructive pulmonary disease (COPD), congestive heart failure, ischemic heart disease, and depression, except that residents’ patients with asthma/COPD, ischemic heart disease, and diabetes were admitted more frequently than attendings’ patients.
CONCLUSIONS: Our results indicate that residents’ patients had higher costs than attendings’ patients, but the differences would have been seriously overestimated without adjustment. We conclude that it costs about 7% more for residents to manage patients than for attendings. On the ambulatory side, the larger number of procedures and consults ordered for residents’ patients appears to drive the higher costs.
- Mechanic R, Coleman K, Dobson A. Teaching hospital costs: implications for academic missions in a competitive market. JAMA. 1998;280:1015–9. CrossRef
- Sloan FA, Feldman RD, Steinwald AB. Effects of teaching on hospital costs. J Health Econ. 1983;2:1–28. CrossRef
- Cameron JM. The indirect costs of graduate medical education. J Engl J Med. 1985;312:1233–8. CrossRef
- Jones KR. Predicting hospital charge and stay variation. The role of patient teaching status, controlling for diagnosis-related group, demographic characteristics, and severity of illness. Med Care. 1985;23:220–35. CrossRef
- Epstein AM, Begg CB, McNeil BJ. The effects of physicians’ training and personality on test ordering for ambulatory patients. Am J Public Health. 1984;74:1271–3. CrossRef
- Pineault R. The effect of medical training factors on physician utilization behavior. Med Care. 1977;15:51–67. CrossRef
- Kroenke K, Hanley JF, Copley JB, et al. Improving house staff ordering of three common laboratory tests. Reductions in test ordering need not result in underutilization. Med Care. 1987;25:928–35. CrossRef
- Detsky AS, McLaughlin JR, Abrams HB, L’Abbe K, Markel FM. Do interns and residents order more tests than attending staff? Results of a house staff strike. Med Care. 1986;24:526–34. CrossRef
- Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83. CrossRef
- Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45:613–9. CrossRef
- Wong MD, Hollenberg JP, Charlson ME. A comparison of clinical performance of primary care and traditional internal medicine residents. Med Care. 1999;37:773–84. CrossRef
- Health Plan Employee Data and Information Set 2.0. Washington, DC: National Committee for Quality Assurance; 1993.
- Inglehart J. The National Committee for Quality Assurance. N Engl J Med. 1996;335:99–9. CrossRef
- SAS Institute Inc. SAS Procedures Guide, Version 7-1. Cary, NC: SAS Institute Inc.; 1999.
- Newhouse JP, Wilensky GR. Paying for graduate medical education: the debate goes on. Health Aff (Millwood). 2001;20:136–47. CrossRef
- Shine D, Beg S, Jaeger J, Pencak D, Panush R. Association of resident coverage with cost, length of stay, and profitability at a community hospital. J Gen Intern Med. 2001;16:1–8. CrossRef
- Dunn PM, Parker DF, Levinson W, Mullooly JP. The effect of resident involvement on community hospital charges. J Gen Intern Med. 1989;4:115–20. CrossRef
- Udvarhelyi IS, Rosborough T, Lofgren RP, Lurie N, Epstein AM. Teaching status and resource use for patients with acute myocardial infarction: a new look at the indirect costs of graduate medical education. Am J Public Health. 1990;80:1095–100.
- Franks P, Dickinson JC. Comparisons of family physicians and internists. Process and outcome in adult patients at a community hospital. Med Care. 1986;24:941–8. CrossRef
- Bernard AM, Shapiro LR, McMahon LF Jr. The influence of attending physician subspecialization on hospital length of stay. Med Care. 1990;28:170–4. CrossRef
- Kosecoff J, Brook RH, Fink A, et al. Providing primary general medical care in university hospitals: efficiency and cost. Ann Intern Med. 1987;107:399–405.
- Garber AM, Fuchs VR, Silverman JF. Case mix, costs, and outcomes. Differences between faculty and community services in a university hospital. N Engl J Med. 1984;310:1231–7. CrossRef
- Cherkin DC, Rosenblatt RA, Hart LG, Schneeweiss R, LoGerfo J. The use of medical resources by residency-trained family physicians and general internists. Is there a difference? Med Care. 1987;25:455–69. CrossRef
- Sexton JD, Heller MB, Patterson JD, Pronchik D, Melanson SW. Impact of emergency medicine residents on ancillary test utilization. Am J Emerg Med. 1998;16:245–8. CrossRef
- McNamara RM, Kelly JJ. Cost of care in the emergency department: impact of an emergency medicine residency program. Ann Emerg Med. 1992;21:956–62. CrossRef
- Hueston WJ. The influence of a family practice residency on the costs of inpatient diagnostic testing. J Fam Pract. 1986;23:559–63.
- Wells RD, Dahl B, Nilson B. Comparison of the levels of quality of inpatient care delivered by pediatrics residents and by private, community pediatricians at one hospital. Acad Med. 1998;73:192–7. CrossRef
- Bertakis KD, Helms LJ, Azari R, Callahan EJ, Robbins JA, Miller J. Differences between family physicians’ and general internsis’ medical charges. Med Care. 1999;37:78–82. CrossRef
- Bertakis KD, Robbins JA. Utilization of hospital services. A comparison of internal medicine and family practice. J Fam Pract. 1989;28:91–6.
- Bertakis KD, Azari R, Callahan EJ, Helms LJ, Robbins JA. The impact of physician practice style on medical charges. J Fam Pract. 1999;48:31–6.
- Feinglass J, Martin GJ, Sen A. The financial effect of physician practice style on hospital resource use. Health Serv Res. 1991;26:183–205.
- Roos NP, Flowerdew G, Wajda A, Tate RB. Variations in physicians’ hospitalization practices: a population-based study in Manitoba, Canada. Am J Public Health. 1986;76:45–51.
- Hofer TP, Hayward RA, Greenfield S, Wagner EH, Kaplan SH, Manning WG. The unreliability of individual physician “report cards” for assessing the costs and quality of care of a chronic disease. JAMA. 1999;281:2098–105. CrossRef
- Hayward RA, Manning WG Jr, McMahon LF, Jr, Bernard AM. Do attending or resident physician practice styles account for variations in hospital resource use? Med Care. 1994;32:788–94. CrossRef
- Tingle LE, Lambert CT. Comparison of a family practice teaching service and a hospitalist model: costs, charges, length of stay, and mortality. Fam Med. 2001;33:511–5.
- Hobus PP, Schmidt HG, Boshuizen HP, Patel VL. Contextual factors in the activation of first diagnostic hypotheses: expert-novice differences. Med Educ. 1987;21:471–6.
- Hartley RM, Charlton JR, Harris CM, Jarman B. Patterns of physicians’ use of medical resources in ambulatory settings. Am J Public Health. 1987;77:565–7.
- Gottlieb RH, Hollenberg GM, Fultz PJ, Rubens DJ. Radiologic consultation: effect on inpatient diagnostic imaging evaluation in a teaching hospital. Acad Radiol. 1997;4:217–21. CrossRef
- Bree RL, Kazerooni EA, Katz SJ. Effect of mandatory radiology consultation on inpatient imaging use. A randomized controlled trial. JAMA. 1996;276:1595–8. CrossRef
- Braham RL, Ron A, Ruchlin HS, Hollenberg JP, Pompei P, Charlson ME. Diagnostic test restraint and the specialty consultation. J Gen Intern Med. 1990;5:95–103. CrossRef
- Does experience matter?
Journal of General Internal Medicine
Volume 20, Issue 6 , pp 497-503
- Cover Date
- Print ISSN
- Online ISSN
- Additional Links
- resource utilization
- Industry Sectors
- Author Affiliations
- 1. Department of Medicine, Weill Medical College of Cornell University, New York, NY, USA
- 2. Division of General Internal Medicine, University of California, Los Angeles, CA, USA