Much attention has been paid to the effect of hospital staffing problems on clinicians with respect to issues such as work–life balance, said lead author Kenneth R. Epstein, MD, from IPC The Hospitalist Company Inc, North Hollywood, California. "But much less focus has been given to the impact of discontinuity of care on patient length of stay and other utilization and quality metrics," Dr. Epstein explained here at Hospital Medicine 2008, the annual meeting of the Society of Hospital Medicine. Drawing on IPC's billing and clinical database, Dr. Epstein and his colleagues analyzed the records of 1724 patients admitted with pneumonia and its complications and comorbidities and 8509 patients admitted with heart failure and shock between December 2006 and November 2007. These patients stayed at 223 hospitals across 16 states.
The percentage of care administered by a different hospitalist than the hospitalist who saw the patient most of the time was defined as fragmentation of care (FOC). "For example, if a patient who was hospitalized for 5 days saw 1 doctor for 3 days and other doctors the other 2 days, FOC would be 2 of 5, or 40%," Dr. Epstein said.
Overall, patients with pneumonia had a mean length of stay (LOS) of 5.81 days, and those with heart failure had a mean LOS of 4.69 days, but for every 10% increase in FOC, LOS increased by 0.45 days for people with pneumonia and 0.38 days for people with heart failure (P < .0001 for both groups).
In an analysis of a subset of 2445 patients with either illness for whom postdischarge call data were available, FOC appeared to have no significant effect on postdischarge complications. However, every 10% increase in FOC was associated with a 25% increase in the likelihood of problems with follow-up appointments, which approached statistical significance, Dr. Epstein noted.
In all, for people with pneumonia or heart failure, it appears that greater fragmentation of care results in longer length of stay, he concluded.
The exact reason for these findings is "anyone's guess, but there's no way to convey 100% of the information each time you hand off a patient to someone else," said Bryan Huang, MD, assistant clinical professor of medicine at the University of California, San Diego.
Dr. Huang, who was not involved in the study, suggested that some physicians might feel more comfortable watching patients who are new to them for an extra day or so. He himself is always reluctant to discharge a patient on the day of a handoff, "because you don't know what the previous day was like."
Dr. Epstein has disclosed no relevant financial relationships.
Hospital Medicine 2008: Abstract 20. Presented April 5, 2008.
J Hosp Med. 2008;3(suppl 1):11.
Reviewed By Dr. Ramaz MItaishvili