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Original Investigation
November 25, 2019

Association of the Work Schedules of Hospitalists With Patient Outcomes of Hospitalization

Author Affiliations
  • 1Department of Preventive Medicine and Community Health, The University of Texas Medical Branch at Galveston
  • 2Sealy Center on Aging, The University of Texas Medical Branch at Galveston
  • 3Department of Internal Medicine, The University of Texas Medical Branch at Galveston
JAMA Intern Med. 2020;180(2):215-222. doi:10.1001/jamainternmed.2019.5193
Key Points

Question  Are hospitalist schedules associated with care outcomes for patients?

Findings  In this cohort study of 3 years of Medicare data from 229 hospitals in Texas, covering 114 777 medical admissions of patients with a 3-day to 6-day length of stay, patients receiving care from hospitalists whose schedules permitted continuity of care had significantly better outcomes, including lower 30-day mortality after discharge, lower readmissions, higher rates of discharge to the home, and $223 lower 30-day postdischarge costs.

Meaning  Hospitalist schedules promoting inpatient continuity of care may be associated with better outcomes of hospitalization.

Abstract

Importance  The working schedules of hospitalists vary widely. Discontinuous schedules, such as 24 hours on and 48 hours off, result in several hospitalists providing care during a patient’s hospital stay. Poor continuity of care during hospitalization may be associated with poor patient outcomes.

Objective  To determine whether admitted patients receiving care from hospitalists with more discontinuous schedules experience worse outcomes.

Design, Setting, and Participants  This retrospective cohort study used conditional models to assess Medicare claims data for 114 777 medical admissions of patients with a 3-day to 6-day length of stay from January 1, 2014, through November 30, 2016, who received all general medical care from hospitalists in 229 hospitals in Texas. Data were analyzed from November 2018 to June 2019.

Exposures  For each admission, the weighted mean of schedule continuity for the treating hospitalists, assessed as the percentage of all their working days in that year that were part of a block of 7 or more consecutive working days, was calculated.

Main Outcomes and Measures  The primary outcome was patient mortality in the 30 days after discharge. Secondary outcomes were readmission rates and Medicare costs in the 30 days after discharge, and discharge destination.

Results  Of the 114 777 patient admissions, the mean (SD) age was 79.9 (8.3) years, and 70 047 (61.0%) were women. For admissions in the lowest quartile for continuity of hospitalist schedules, the hospitalists providing care worked 0% to 30% of their total working days as part of a block of 7 or more consecutive days vs 67% to 100% for hospitalists providing care for patients in the highest quartile for continuity. Patient characteristics were not associated with the continuity of working schedules for the hospitalist(s) providing care. In conditional logistic regression models, admitted patients cared for by hospitalists in the highest quartile of schedule continuity (vs the lowest quartile) had lower 30-day mortality after discharge (adjusted odds ratio [aOR], 0.88; 95% CI, 0.81-0.95), lower readmission rates (aOR, 0.94; 95% CI, 0.90-0.99), higher rates of discharge to the home (aOR, 1.08; 95% CI, 1.03-1.13), and lower 30-day postdischarge costs (−$223; 95% CI, −$441 to −$7). The results were similar across a range of different methods for defining continuity of hospitalist schedules and selecting the cohort.

Conclusions and Relevance  Hospitalist schedules vary widely. Admitted patients receiving care from hospitalists with schedules that promote inpatient continuity of care may experience better outcomes of hospitalization.

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    3 Comments for this article
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    Imagine
    John Clark, MD | Alaska Native Medical Center
    If being cared for by the same hospitalist for 7 or more days improved outcomes, imagine the benefit of being cared for by someone who had taken care of a patient for a year, or a decade, or several decades. Our current system was designed for the convenience, comfort and profit of hospitals, providers and insurance companies and not for the benefit of patients. The "new" field of palliative care is necessary because hospitalists and specialists in the hospital setting do not know their patients and thus, in the patient's time of greatest need, their providers have neither the personal knowledge, time, or skill to care for them. Our current health care system is delivering exactly the results it is designed to deliver. If we wanted a system where a patient could count on being taken care of by a provider who knew their story, knew their strengths, resources, vulnerabilities, hopes, goals and end of life wishes we would need to begin a major redesign of our delivery system and its incentives. For primary care providers we would need to increase reimbursement so that it was commensurate with hospital based physicians who have no overhead, and with specialists, who enhance their income by often performing well executed but unnecessary procedures. We would need to reduce the administrative burden of running small medical offices. We would need to replace the hospitals goal of "efficiency" (a euphemism for profit) with the primary goal of taking care of individual patients in a way that best meets their needs. We would need to redesign the electronic medical record from being a bloated "billing document" to being an accurate, lucid, concise record of the patients illness. I am all for continuity of care. To achieve it to the fullest extent possible is a worthy goal, but a goal that can only be achieved if we make fundamental changes to the organization and incentives of our current health-care, or more accurately, our current illness-care delivery system.
    CONFLICT OF INTEREST: None Reported
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    On An Incessant Time Schedule
    Priscilla Shaheen, RN,MS,MA | retired
    My graduate degree in nursing administration (many years ago) focused on staffing and scheduling nursing personnel. Subsequently, an article with schematic representations describing the schedule appeared in, "Nursing Management" Vol. 16, No. 10, October, 1985. The title was, "Staffing and Scheduling:Reconcile Practical Means with the Real Goal." It maintained a four day work and four day leisure format. The seven day week was determined inadequate for hospitalized patient care scheduling.

    Since that time, many changes have taken place which I consider detrimental to hospitalized patients and nursing personnel. For example, twelve hour shifts are brutal for nurses and dangerous
    to patients. The same may apply to "hospitalists."

    Unless both physicians and nursing personnel adjust their schedules to meet patient needs, all other manipulations will not accommodate goals. At the present time, physicians ultimately control the process of patient care delivery according to the schedules and needs of physicians. Particularly as it applies to the preferences of surgeons and their selection of patient admission and discharge dates.

    Predictions for both patient and personnel on duty on any given day remain essential for administering adequate care.
    CONFLICT OF INTEREST: None Reported
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    Outpatients also?
    Jose M LOPEZ VEGA, MD PhD | Cantabria University
    What is verified in admitted patients may not be entirely true in outpatients. Years of follow-up by the same doctor can be harmful: from time to time it is convenient for other colleagues to bring new approaches.
    CONFLICT OF INTEREST: None Reported
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