Restrict subspecialists to their own field or risk quality problems

New study raises serious concerns about patient safety

How many subspecialists do you have working outside their field, treating patients either just to stay busy or because you don’t have enough physicians to handle the load?

Subspecialists caring for patients outside their specialties pose a significant risk to patients, according to worrisome new research, and experts are urging hospital quality professionals to take immediate steps to restrict the most dangerous types of care. Quality assurance leaders may have to take some difficult steps that physicians will resist, they say.

Scott R. Weingarten, MD, MPH, a researcher at Cedars-Sinai Medical Center in Los Angeles, was the lead author on a recent study that confirmed what many quality assurance leaders have suspected for years. Subspecialists may be an asset when they work in their own fields, but they are a risk to patients when they work outside their specialties.1

Previous studies have shown that subspecialists can provide better quality care than primary care physicians when working within their subspecialty for patients with some medical conditions, Weingarten says. However, many subspecialists care for patients outside of their chosen subspecialty.

These latest study results show that their patients are at risk, Weingarten tells Hospital Peer Review. "The results show that quality of care may vary between types of physicians in a meaningful and clinically important way," he says. "These results call attention to the importance of hospitals monitoring quality of care for different types of physicians."

That conclusion is endorsed by Martin Merry, MD, a health care quality consultant and associate professor of health management and policy at the University of New Hampshire in Exeter. He says quality professionals have long suspected there was a problem with subspecialists working outside their field, but this study shows the problem is worse than he had imagined. "I’ve seen other research suggesting this, but now we have to say it’s true," Merry says. "More and more materials are revealing the dirty little secret in health care, that to allow an MD or a DO to do anything he wants to do just because he has the credentials after his name is not good for the patient."

In their recent study, Weingarten and his colleagues used severity-adjusted mortality rate and severity-adjusted length of stay as indexes of quality of care. They collected data from 5,112 hospital admissions (301 different physicians) for community-acquired pneumonia, acute myocardial infarction, congestive heart failure, or upper gastrointestinal hemorrhage at six hospitals in the greater Cleveland area.

The data indicated that subspecialists working outside of their subspecialty cared for 25% of hospitalized patients. When the researchers compared patients cared for by subspecialists practicing outside of their subspecialty, the problems were readily apparent. Severity-adjusted lengths of stay were 23% longer for patients with congestive heart failure, 22% longer for upper gastrointestinal hemorrhage, and 14% longer for community-acquired pneumonia than for patients cared for by subspecialists practicing within their subspecialty.

The analysis also revealed that patients had a slightly higher hospital mortality rate when cared for by subspecialists practicing outside of their specialty than by those practicing within their subspecialty.

Even when compared to general internists, the subspecialists fared poorly outside of their specialty. Patients cared for by subspecialists practicing outside of their subspecialty had longer lengths of stay, and prolongation of stay was observed for patients with congestive heart failure (16% longer), upper gastrointestinal hemorrhage (15% longer), and community-acquired pneumonia (18% longer) than patients cared for by general internists.

Weingarten, et al, conclude, "subspecialists commonly care for patients outside of their subspecialty, despite the fact that their patients may have longer lengths of stay than those cared for by subspecialists practicing within their specialty or by general internists. In addition, such patients may have slightly higher mortality rates than those cared for by subspecialists practicing within their subspecialty."

Merry says he was surprised to see that subspecialists cared for 25% of the patients in the hospitals studied; he didn’t know the practice was that common. He says quality professionals should take notice of the study results and the implications for credentialing and privileging in hospitals, even though he doesn’t find the researchers’ other conclusions surprising.

"This is not rocket science. When we look at patient care outcomes, we find that physicians do best at what they’re trained to do," Merry says. "Anybody with common sense has known that a lot of physicians haven’t been busy enough in their own specialties, and they get outside of it for economic reasons. And they don’t serve their patients well there."

Restrict physicians to protect patients

Weingarten and Merry agree that hospitals should take steps to protect patients from subspecialists practicing outside of their fields.

The first step, Weingarten says, is to conduct in your own facility a quality of care study similar to the one he did. The results probably will confirm the study results and will provide specific information about subspecialists and treatment areas that need your attention, he says. "I think that hospitals should consider monitoring the quality of care of subspecialists who are practicing outside of their subspecialty," Weingarten says. "In cases when objective and clinically meaningful evidence of substandard care is demonstrated, hospital credentialing committees must decide upon the best course of action."

Hospitals must act on this information to protect patients, Merry adds. The necessary action is likely to upset some physicians, he says, but the "credential committee has to get serious about the notion of developing specialty-specific profiles and incorporate them more rigorously."

Merry advises HPR readers to check into the policies and procedures currently in place to determine what, if any, restrictions there are to keep subspecialists from practicing outside their fields. Don’t be surprised if you find that there are few restrictions, he says.

Next, you should investigate how your overall scope of care compares to the number and type of physicians who are credentialed at your hospital, Merry says. How much gastroenterology are you doing, for instance, and how much cardiology? What does your specialist cadre look like?

"Ask yourself, What is our supply of cardiologists, and how does that compare to how many cardiology patients we get? Do we have a shortage so that other specialists are forced to practice outside their specialties? Or if we have plenty of cardiologists around and we still have a gastroenterologist practicing cardiology, then we have a real credentialing and quality issue here,’" Merry says.

Once you have assessed your own situation, possibly by analyzing outcomes data, credentials committees must enact strict rules that ensure subspecialists only practice outside their fields irregularly, when necessary because of physician shortages, Merry says. And even then, some restrictions should be carved in stone.

"It should be just like it is in surgery, with everyone knowing that just because you’re a surgeon you can’t do anything you want in the OR," he says. "You’re not going to let a general surgeon schedule a craniotomy. The OR scheduler just wouldn’t let it happen. You should have the same sort of procedures in medicine."

Preventing the problem may not be easy in the short run, Merry says. If you have subspecialists working outside their fields just because you don’t have enough physicians on hand, remedying that situation could take time.

But Merry says you would be well advised to take whatever steps are necessary, and you must brace yourself for an inevitable flurry of complaints by subspecialists.

"We’re learning more and more about how there is not a good match between the supply of physicians and the needs of patients," he says. "We might have to redesign systems, and that might include limiting the scope of what physicians are allowed to do. Maximum freedom for providers is not necessarily what is in the best interest of the patient."

Reference

1. Weingarten SR, Lloyd L, Chiou C, et al. Do subspecialists working outside of their specialty provide less efficient and lower-quality care to hospitalized patients than do primary care physicians? Arch Intern Med 2002; 162:527-532.