Category Archives: Readmisson

Increase in hospitalist workload associated with higher LOS and cost

Does increased hospitalist workload affect efficiency and quality of care?

Bottom Line

Increased hospitalist workload is associated with increased cost and length of stay (LOS). Quality metrics such as 30-day readmission rate, in-hospital mortality, and patient satisfaction were not affected by changes in workload.(LOE = 2b)

Reference

Elliott DJ, Young RS, Brice J, Aguiar R, Kolm P. Effect of hospitalist workload on the quality and efficiency of care. JAMA Intern Med 2014;174(5):786-793. Deveraux PJ, Mrkobrada M, Sessler DI et al. Clonidine in patients undergoing noncardiac surgery. N Engl J Med 2014;370:1504-1513.

Study Design: Cohort (retrospective)
Funding: Other
Setting: Inpatient (any location)
Allocation: Uncertain

Synopsis

Using data abstracted from the central data warehouse of an academic community health system, these authors examined the association between hospitalist workload and the efficiency and quality of care provided. A private hospitalist group that provided 24-hour care to patients at 2 hospitals within the system was selected for the study. Patients included were those who either had an attending of record or had admission and discharge bills submitted by a physician in this hospitalist group. Physician daily workload was measured using the total number of relative value units (RVUs) generated and the physician’s census as determined by the number of billable encounters submitted. Efficiency was measured by LOS and cost. Quality was measured by in-hospital mortality, rapid response team activation, 30-day readmission rate, and patient satisfaction. Models were adjusted for patient characteristics, including demographics; severity of illness; visit characteristics, including admission day of the week; and hospital-level characteristics, including hospital occupancy. Approximately 20,000 hospitalizations were included in the study. Hospitalists had a mean of 15.5 patient encounters and 28.6 RVUs per day. Results for LOS were stratified by hospital occupancy. For less than 75% occupancy, LOS increased linearly from 5.5 days to 7.5 days as workload increased. For greater than 85% occupancy, the change in LOS was J-shaped with a significant increase around an RVU of 30 or a census of 17. Cost also increased with higher workloads. For every unit increase in RVU, cost increased by $111; for every unit increase in census, cost increased by $205 (after adjustment for LOS). There were no significant associations with change in workload and patient satisfaction, in-hospital mortality, rapid response team activation, or 30-day readmission rate.

Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL

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Greater continuity of care associated with fewer preventable hospitalizations

Clinical Question

In the elderly Medicare population, does greater continuity of care lower the risk of preventable hospitalizations?

Bottom Line

Elderly patients who are treated by a smaller set of providers or by a single provider (ie, have greater continuity of care) may be less likely to have preventable hospitalizations. (LOE = 2b)

Reference

Nyweide DJ, Anthony DL, Bynum JP, et al. Continuity of care and the risk of preventable hospitalization in older adults. JAMA Intern Med 2013;173(20):1879-1885.

Study Design:  Cohort (retrospective)  Setting:  Outpatient

Funding: Government  Allocation: Concealed

Synopsis

Using Medicare data, these investigators identified preventable hospitalizations for Medicare fee-for-service beneficiaries older than 65 years using definitions previously provided by the Agency for Healthcare Research and Quality.Preventable hospitalizations were conditions that can potentially be treated with good outpatient care, such as asthma, chronic obstructive pulmonary disease, congestive heart failure, and bacterial pneumonia. Continuity of care was defined by 2 metrics: the continuity of care score and the usual provider continuity score. The continuity of care score measures physicians’ shares of a patient’s visits, with higher scores indicating a greater number of visits with fewer providers, whereas the usual provider continuity score measures the percentage of a patient’s total visits to a single provider. Both are scored on a scale from 0 to 1, with higher scores indicating greater continuity of care. Only data from patients with 4 or more visits during a course of a year were analyzed.Of approximately 3.2 million patients, 13% of this cohort had a preventable hospitalization over a 24-month observation period. These patients were more likely to have a higher illness burden at baseline and were more likely to have Medicaid dual eligibility. The top 2 reasons for preventable hospitalizations were congestive heart failure and bacterial pneumonia. As compared with those without preventable hospitalizations, patients with preventable hospitalizations had lower scores on both continuity metrics. After adjusting for patient characteristics, illness burden, and regional market-related and practice-related characteristics, a 0.1-unit increase in either continuity metric was associated with a 2% decrease in preventable hospitalizations.

Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL