Patients Benefit When Hospitalists Work Several Days in a Row

Marcia Frellick

November 26, 2019

When hospitalists work several consecutive days, as opposed to working intermittent shifts, patient outcomes improve and costs decrease, new research suggests.

Among 114,777 patient admissions studied, major outcomes, including 30-day mortality risk after discharge, readmission risk, and discharge to home improved with hospitalist continuity of care, report James S. Goodwin, MD, of the Department of Preventive Medicine and Community Health at the University of Texas Medical Branch at Galveston, and colleagues.

Findings were published online November 25 in JAMA Internal Medicine. The work was funded by the National Institute on Aging.

Table. Highest- vs Lowest-Continuity Cohort

Outcome Adjusted Odds Ratio 95% CI
30-day mortality after discharge 0.88 0.81 - 0.95
Readmission 0.94 0.90 - 0.99
Discharge to home 1.08 1.03 - 1.13

 

Researchers also found that 30-day postdischarge costs were $223 lower per patient (95% CI, −$441 to −$7) for the highest-continuity cohort.

The results were consistent across a range of methods for defining continuity of hospitalist schedules and different ways of selecting the cohort, and after controlling for length of stay and diagnosis, among other factors.

The authors suggest the improvement in outcomes with continuity may be partly attributed to fewer handoffs with rotating providers and less chance that information could be lost between conversations and entries in the electronic health record. Trust in a provider is also key to patient care, they note.

"Patients and their families may be less comfortable soliciting and following the advice of a physician they are seeing for the first time, particularly if the issue is value-laden, such as end-of-life issues or discharge destination," the authors write.

In an audio interview with JAMA Internal Medicine, Goodwin said they worked to avoid selection bias by doing a conditional analysis of schedules across hospitals and within each hospital because they found such a wide range of scheduling models.

"None of the analyses suggested that hospitalists with discontinuous schedules took care of sicker patients, patients more likely to die, or patients more likely to be readmitted," he said.

The researchers assessed Medicare claims data for patients with a 3-day to 6-day length of stay from January 1, 2014, through November 30, 2016. The patients received all general medical care from hospitalists in 229 hospitals.

Goodwin explained in the JAMA interview that his team found schedules varied from 1 day a week to 10 days in a row.

"We found, for example, that 665 of 2334 (28%) Texas hospitalists had 0 working days in a year that were part of a 7-day or longer block of consecutive working days, whereas 591 of 2334 (25%) hospitalists had more than 54% of their working days as part of a 7-day or longer block," the authors explain.

Balancing Burnout With Better Outcomes

Goodwin said sometimes intermittent scheduling is designed to help physicians reduce burnout and the results from this study suggest that scheduling should take into consideration the balance between potential burnout and the potential for better outcomes with continuous care.

"What I hope this study does is start the discussion about the balance," Goodwin said.

The average age of people in the cohort was 79.9 (SD 8.3) years, and 61% were women. The lowest quartile for continuity of care included hospitalists who worked 0% to 30% of their total working days as part of a block of 7 days or more. The highest quartile of continuity included those who worked 67% to 100% of their total working days as part of a block of 7 consecutive days or more.

JAMA Intern Med. Published online November 25, 2019. Abstract

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