Abstract & Commentary
Discontinuity of Care Is Associated with Increased Hospital Cost
By Deborah J. DeWaay, MD, FACP
Assistant Professor, Medical University of South Carolina, Charleston, SC
Dr. DeWaay reports no financial relationships in this field of study
SYNOPSIS: This study demonstrated an association between increased discontinuity of physician care in the inpatient setting and increased hospital costs at a tertiary care center.
Source: Turner J; Hansen L; Hinami K; Christensen N; Peng J; Lee J; Williams M; O’Leary K. The impact of hospitalist discontinuity on hospital cost, readmissions, and patient satisfaction. JGIM 29(7):1004-8
Continuity of care in the outpatient setting is associated with improvements in blood pressure control, patient satisfaction, and physician satisfaction. It is also associated with fewer emergency room visits and lower risk of hospitalization. There are less data on the effects of continuity within the inpatient setting. One study demonstrated that less continuity in the hospital setting was associated with a longer length of stay. However, it is difficult to interpret this finding since the longer a patient stays, the more likely it is that there will be discontinuity of care. It is hypothesized that discontinuity of physician care in the hospital may be associated with unnecessary testing, loss of clinical information and increased difficulty in building rapport with patients. The authors of this study looked at the relationship between hospitalist continuity of care and three outcomes: cost of hospitalization, 30-day readmission rates, and patient satisfaction.
This retrospective observational study was done in a tertiary care center in which the hospitalists caring for the patients were on a seven days on, seven days off schedule, with a hospitalist on from 7 a.m. to 7 p.m. followed by a nocturnist on from 7 p.m. to 7 a.m. This hospitalist service did not have house staff assistance. The data were extracted from the Northwestern Medicine Enterprise Data Warehouse (EDW) and included the health record, the billing system and the admission/discharge/transfer system. Patients admitted to the nonteaching service, who met inpatient status, and who were direct admits to the service (as opposed to transfers from another service) were included in the study. The chart was reviewed for each patient, and the authors counted the number of physicians involved to determine the continuity of that patient’s care using two indices: the Number of Physicians Index (NPI) and the Usual Provider of Continuity (UPC) index. For these measures, higher NPI and lower UPC numbers represent more fragmented care. Administrative data on hospital costs, as opposed to charges, was used to determine the cost of hospitalization. Patient satisfaction data regarding physician communication were assessed using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which asked about how well physicians showed respect, listened, and explained the plan of care. The authors used regression modeling to see if continuity of care metrics predicted outcomes in the areas of cost of hospitalization, 30-day readmission rates, and patient satisfaction with physician communication and hospitalist continuity of care.
More than 18,000 hospitalizations were analyzed. The patients were an average age of 58 years old, and the average length of stay was 2.9 days. The median cost of hospitalization was $6306, and there was a 22.2% readmission rate. Based on the calculated NPI, the patients were cared for by an average of 1.90 physicians during their hospitalization. The UPC, the number of encounters by the hospitalist who saw the patient the most often divided by the total number of hospitalist physician encounters, was 0.75 ± 0.21. The authors analyzed the adjusted effect of decreased continuity on cost, 30-day readmission, and patient satisfaction scores by treating them as continuous variables and categorizing them into quartile values. With every increase by +1 of the NPI, the average number of hospitalist physicians to see the patient increased by +1, the cost increased by 8.0% (p<0.001). For every decrease in UPC of 0.1, the cost increased by 12.6% (p<0.001). Although there was a trend toward an association between increased readmissions and decreased patient satisfaction scores, there was no statistical significance.
The authors suggest that when a new physician takes over the patient, there is an increased likelihood of additional testing, either because the physician thinks of new diagnoses to rule out or because they are not as familiar with the patient’s history. There are several limitations to this study. First, this study was performed at a single institution, so the findings are not necessarily generalizable. Second, this study did not analyze the effect of the discontinuity of the nighttime coverage of the patients. Third, this study did not look to see if when the handoffs occurred during the hospitalization affected the outcomes analyzed.
COMMENTARY
This study is important for several reasons. First, it asks a very important question. There have been a lot of studies on the effects of discontinuity within graduate medical education. However, there has been little discussion on the effects of handoffs at the attending level. I am not sure that much can be done to improve continuity of care for hospitalists. Nonetheless, if handoffs do adversely affect length of stay, cost and readmission, we need to know so that perhaps we can implement strategies to mitigate these effects. This study is just a start, but hopefully it will be the beginning of more global discussion and research. Second, residency programs are now training residents on how to appropriately hand off patients. There are many hospitalists who graduated prior to receiving this training. Perhaps this is an area that should be covered more frequently in continuing medical education. Although there remains a sparse amount of data, it is logical to believe that the struggles of residents to do adequate handoffs do not cease with graduation.
