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Research

Patient characteristics, resource use and outcomes associated with general internal medicine hospital care: the General Medicine Inpatient Initiative (GEMINI) retrospective cohort study

Amol A. Verma, Yishan Guo, Janice L. Kwan, Lauren Lapointe-Shaw, Shail Rawal, Terence Tang, Adina Weinerman, Peter Cram, Irfan A. Dhalla, Stephen W. Hwang, Andreas Laupacis, Muhammad M. Mamdani, Steven Shadowitz, Ross Upshur, Robert J. Reid and Fahad Razak
December 13, 2017 5 (4) E842-E849; DOI: https://doi.org/10.9778/cmajo.20170097
Amol A. Verma
Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass.
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Yishan Guo
Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass.
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Janice L. Kwan
Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass.
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Lauren Lapointe-Shaw
Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass.
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Shail Rawal
Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass.
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Terence Tang
Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass.
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Adina Weinerman
Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass.
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Peter Cram
Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass.
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Irfan A. Dhalla
Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass.
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Stephen W. Hwang
Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass.
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Andreas Laupacis
Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass.
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Muhammad M. Mamdani
Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass.
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Steven Shadowitz
Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass.
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Ross Upshur
Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass.
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Robert J. Reid
Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass.
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Fahad Razak
Li Ka Shing Centre for Healthcare Analytics Research and Training (Verma, Mamdani), St. Michael's Hospital; Eliot Phillipson Clinician-Scientist Training Program (Verma), Department of Medicine, University of Toronto; Li Ka Shing Knowledge Institute (Guo, Dhalla, Hwang, Laupacis, Mamdani, Razak), St. Michael's Hospital; Department of Medicine (Kwan), Sinai Health System; Department of Medicine (Kwan, Lapointe-Shaw, Rawal, Razak, Tang, Weinerman), University of Toronto; Division of General Internal Medicine (Rawal), University Health Network; Institute for Better Health (Tang, Reid), Trillium Health Partners; Sunnybrook Health Sciences Centre (Weinerman); University Health Network, Sinai Health System (Cram), University of Toronto; Health Quality Ontario (Dhalla); Sunnybrook Health Sciences Centre (Shadowitz), University of Toronto; Bridgepoint Health (Upshur), University of Toronto, Toronto, Ont.; Harvard Center for Population and Development Studies (Razak), Cambridge, Mass.
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    Figure 1

    Trends in resource use in general internal medicine between Apr. 1, 2010, and Mar. 31, 2015. *Readmission to general internal medicine at 1 of the participating hospitals within 30 days of discharge. †Proportion of patients who received at least 1 ultrasound examination, computed tomography scan or magnetic resonance imaging scan, as an indicator of the intensity of investigations patients received.

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    Table 1: Characteristics of hospital admissions in the General Medicine Inpatient Initiative study cohort
    CharacteristicNo. (%) of admissions*
    n = 136 208
    Age, median (IQR), yr73 (57-84)
    Age group, yr
        < 6039 004 (28.6)
        60-8046 039 (33.8)
        > 8051 165 (37.6)
    Female sex68 971 (50.6)
    No. of comorbidities, median (IQR)6 (3-9)
    Charlson Comorbidity Index score
        058 257 (42.8)
        120 620 (15.1)
        ≥ 257 331 (42.1)
    Most common comorbid conditions
        Hypertension51 204 (37.6)
        Type 2 diabetes mellitus45 376 (33.3)
        Atrial fibrillation and flutter19 947 (14.6)
        Dyslipidemia19 518 (14.3)
        Electrolyte abnormality19 113 (14.0)
        Heart failure18 736 (13.8)
    Discharge disposition
        Home96 414 (70.8)
        Nursing home or rehabilitation facility25 804 (18.9)
        Death8916 (6.5)
        Discharge against medical advice2543 (1.9)
        Other acute care hospital1841 (1.4)
        Other690 (0.5)

    Note: IQR = interquartile range.

    *Except where noted otherwise.

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      Table 2: Characteristics of hospital admissions and outcomes among most prevalent conditions in general internal medicine*
      CharacteristicCondition; no. (%) of admissions†
      Total cohort
      n = 136 208
      Pneumonia
      n = 6804
      Heart failure
      n = 6341
      Chronic obstructive pulmonary disease
      n = 5574
      Urinary tract infection
      n = 5466
      Stroke
      n = 4912
      Age, median (IQR), yr73 (57-84)80 (64-87)83 (75-88)77 (66-84)80 (69-87)76 (64-84)
      Comorbidities, median (IQR)6 (3-9)5 (3-8)7 (5-10)6 (3-8)6 (4-9)5 (3-7)
      Intensive care unit use‡10 031 (9.9)460 (8.6)409 (8.0)589 (12.6)185 (5.3)337 (14.5)
      Death in hospital8916 (6.5)534 (7.8)491 (7.7)293 (5.3)150 (2.7)410 (8.3)
      30-day readmission§14 387 (10.9)620 (9.4)990 (16.1)893 (16.5)663 (12.4)268 (5.7)

      Note: IQR = interquartile range.

      *Identified with the use of Canadian Institute for Health Information case-mix groups.

      †Except where noted otherwise.

      ‡Intensive care or step-up unit. Does not include data for 34 453 patients at Trillium Health Partners (data not available at the time of submission).

      §Readmission to general internal medicine service at 1 of the participating hospitals within 30 days of discharge. Patients with no health insurance number could not be linked across admissions and were excluded from this calculation, as were patients discharged within the last 30 days of the study.

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        Table 3: Resource use among most prevalent conditions in general internal medicine
        ResourceTotal cohortPneumoniaHeart failureChronic obstructive pulmonary diseaseUrinary tract infectionStroke
        Cost, median (IQR), $*5850
         (3915-10 061)
        5935
         (4343-8068)
        6706
         (4956-9403)
        6148
         (4459-8741)
        5391
         (3981-7140)
        6915
         (5584-11 455)
        Length of stay, median (IQR), d4.6 (2.5-8.6)4.5 (2.5-7.7)5.6 (3.1-9.7)4.4 (2.5-7.5)4.4 (2.7-6.9)6.4 (3.9-10.4)
        Bed-days, no. (% of total for cohort)1 310 717 (100.0)50 059 (3.8)56 799 (4.3)39 159 (3.0)39 552 (3.0)64 550 (4.9)
        Alternate level of care designation, no. (%) of admissions16 868 (12.4)567 (8.3)614 (9.7)434 (7.8)609 (11.1)1197 (24.4)
        Alternate level of care days, no. (% of total alternate level of care days)288 250 (100.0)6713 (2.3)7585 (2.6)4949 (1.7)7531 (2.6)19 075 (6.6)

        Note: IQR = interquartile range.

        *Forty-eight admissions with missing cost data were excluded.

          • View popup
          Table 4: Use of diagnostic and therapeutic services among most prevalent conditions in general internal medicine
          ServiceCondition; no. (%) of admissions*
          Total cohortPneumoniaHeart failureChronic obstructive pulmonary diseaseUrinary tract infectionStroke
          Radiography†84 481 (83.0)5242 (98.5)5040 (99.0)4592 (98.5)3069 (87.7)1562 (67.1)
          Computed tomography†53 125 (52.2)2327 (43.7)1459 (28.6)1571 (33.7)1631 (46.6)2265 (97.3)
          Ultrasonography†28 893 (28.4)985 (18.5)1606 (31.5)777 (16.7)1261 (36.0)841 (36.1)
          Magnetic resonance imaging†11 649 (11.4)118 (2.2)72 (1.4)55 (1.2)131 (3.7)1512 (64.9)
          Interventional radiology†10 778 (10.6)259 (4.9)201 (3.9)141 (3.0)322 (9.2)150 (6.4)
          Erythrocyte transfusion†9325 (9.2)213 (4.0)243 (4.8)105 (2.3)114 (3.3)55 (2.4)
          Endoscopy/bronchoscopy13 832 (10.2)360 (5.3)169 (2.7)182 (3.3)101 (1.8)139 (2.8)
          Dialysis2448 (1.8)130 (1.9)91 (1.4)44 (0.8)41 (0.8)36 (0.7)

          *Number of admissions with at least 1 of this test or treatment.

          †Data not available for 34 453 patients at Trillium Health Partners.

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          CMAJ Open: 5 (4)
          Vol. 5, Issue 4
          21 Dec 2017
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          Patient characteristics, resource use and outcomes associated with general internal medicine hospital care: the General Medicine Inpatient Initiative (GEMINI) retrospective cohort study
          Amol A. Verma, Yishan Guo, Janice L. Kwan, Lauren Lapointe-Shaw, Shail Rawal, Terence Tang, Adina Weinerman, Peter Cram, Irfan A. Dhalla, Stephen W. Hwang, Andreas Laupacis, Muhammad M. Mamdani, Steven Shadowitz, Ross Upshur, Robert J. Reid, Fahad Razak
          Dec 2017, 5 (4) E842-E849; DOI: 10.9778/cmajo.20170097

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          Patient characteristics, resource use and outcomes associated with general internal medicine hospital care: the General Medicine Inpatient Initiative (GEMINI) retrospective cohort study
          Amol A. Verma, Yishan Guo, Janice L. Kwan, Lauren Lapointe-Shaw, Shail Rawal, Terence Tang, Adina Weinerman, Peter Cram, Irfan A. Dhalla, Stephen W. Hwang, Andreas Laupacis, Muhammad M. Mamdani, Steven Shadowitz, Ross Upshur, Robert J. Reid, Fahad Razak
          Dec 2017, 5 (4) E842-E849; DOI: 10.9778/cmajo.20170097
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