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Authors

Lee YK, et al. Show all

Journal

Emerg Med J. 2013 Apr 25. [Epub ahead of print]

Affiliation

Emergency Department, Buddhist Tzu Chi Dalin General Hospital, Chiayi, Taiwan.

Abstract

BACKGROUND: The intensive physical and psychological stress of emergency medicine has evoked concerns about whether emergency physicians could work in the emergency department for their entire careers. Results of previous studies of the attrition rates of emergency physicians are conflicting, but the study samples and designs were limited.

OBJECTIVE: To use National Health Insurance claims data to track the work status and work places of emergency physicians compared with other specialists. To examine the hypothesis that emergency physicians leave their specialty more frequently than other hospital-based specialists.

METHODS: Three types of specialists who work in hospitals were enrolled: emergency physicians, surgeons and radiologists/pathologists. Every physician was followed up until they left the hospital, did not work anymore or were censored. A Kaplan-Meier curve was plotted to show the trend. A multivariate Cox regression model was then applied to evaluate the adjusted HRs of emergency physicians compared with other specialists.

RESULTS: A total of 16 666 physicians (1584 emergency physicians, 12 103 surgeons and 2979 radiologists/pathologists) were identified between 1997 and 2010. For emergency physicians, the Kaplan-Meier curve showed a significantly decreased survival after 10 years. The log-rank test was statistically significant (p value <0.001). In the Cox regression model, after adjusting for age and sex, the HRs of emergency physicians compared with surgeons and radiologists/pathologists were 5.84 (95% CI 2.98 to 11.47) and 21.34 (95% CI 8.00 to 56.89), respectively.

CONCLUSION: Emergency physicians have a higher probability of leaving their specialties than surgeons and radiologists/pathologists, possibly owing to the high stress of emergency medicine. Further strategies should be planned to retain experienced emergency physicians in their specialties

Volume 50, Issue 1, July 2009, Pages 54–60

Introduction

Advances in endovascular interventions have expanded the options available for the invasive treatment of lower extremity peripheral arterial disease (PAD). Whether endovascular interventions substitute for conventional bypass surgery or are simply additive has not been investigated, and their effect on amputation rates is unknown.

Methods

We sought to analyze trends in lower extremity endovascular interventions (angioplasty and atherectomy), lower extremity bypass surgery, and major amputation (above and below-knee) in Medicare beneficiaries between 1996 and 2006. We used 100% samples of Medicare Part B claims to calculate annual procedure rates of lower extremity bypass surgery, endovascular interventions (angioplasty and atherectomy), and major amputation between 1996 and 2006. Using physician specialty identifiers, we also examined trends in the specialty performing the primary procedure.

Results

Between 1996 and 2006, the rate of major lower extremity amputation declined significantly (263 to 188 per 100,000; risk ratio [RR] 0.71, 95% confidence interval [CI] 0.6-0.8). Endovascular interventions increased more than threefold (from 138 to 455 per 100,000; RR = 3.30; 95% CI: 2.9-3.7) while bypass surgery decreased by 42% (219 to 126 per 100,000; RR = 0.58; 95% CI: 0.5-0.7). The increase in endovascular interventions consisted both of a growth in peripheral angioplasty (from 135 to 337 procedures per 100,000; RR = 2.49; 95% CI: 2.2-2.8) and the advent of percutaneous atherectomy (from 3 to 118 per 100,000; RR = 43.12; 95% CI: 34.8-52.0). While radiologists performed the majority of endovascular interventions in 1996, more than 80% were performed by cardiologists and vascular surgeons by 2006. Overall, the total number of all lower extremity vascular procedures almost doubled over the decade (from 357 to 581 per 100,000; RR = 1.63; 95% CI: 1.5-1.8).

Conclusion

Endovascular interventions are now performed much more commonly than bypass surgery in the treatment of lower extremity PAD. These changes far exceed simple substitution, as more than three additional endovascular interventions were performed for every one procedure declined in lower extremity bypass surgery. During this same time period, major lower extremity amputation rates have fallen by more than 25%. However, further study is needed before any causal link can be established between lower extremity vascular procedures and improved rates of limb salvage in patients with PAD.