Importance Hospitalist physicians face increasing pressure to maximize productivity, which may undermine the efficiency and quality of care. Objective To determine the association between hospitalist workload and the efficiency and quality of inpatient care. Design, Setting, and Participants We conducted a retrospective cohort study of 20 241 admissions of inpatients cared for by a private hospitalist group at a large academic community hospital system between February 1, 2008, and January 31, 2011. Exposures Daily hospitalist workload as measured by relative value units and patient encounters from the hospitalist billing records. Main Outcomes and Measures The main outcomes were length of stay (LOS), cost, rapid response team activation, in-hospital mortality, patient satisfaction, and 30-day readmission rates. Key covariates included hospital occupancy and patient-level characteristics. Results The LOS increased as workload increased, particularly at lower hospital occupancy. For hospital occupancies less than 75%, LOS increased from 5.5 to 7.5 days as workload increased. For occupancies of 75% to 85%, LOS increased exponentially above a daily relative value unit of approximately 25 and a census value of approximately 15. At high occupancy (>85%), LOS was J-shaped, with significant increases at higher ranges of workload. After controlling for LOS, cost increased by $111 for each 1-unit increase in relative value unit and $205 for each 1-unit increase in census across the range of values. Changes in workload were not associated with the remaining outcomes. Conclusions and Relevance Increasing hospitalist workload is associated with clinically meaningful increases in LOS and cost. Although our findings should be validated in different clinical settings, our results suggest the need for methods to mitigate the potential negative effects of increased hospitalist workload on the efficiency and cost of care.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/1847571/ioi140009.pdf

Effect of hospitalist workload on the quality and efficiency of care.

Modern hospital care should ostensibly be multi-professional and person-centred, yet it still seems to be driven primarily by a hegemonic, positivistic, biomedical agenda. This study aimed to describe the everyday practices of professionals and patients in a coronary care unit, and analyse how the routines, structures and physical design of the care environment influenced their actions and relationships. Ethnographic fieldwork was conducted over a 16-month period (between 2009 and 2011) by two researchers working in parallel in a Swedish coronary care unit. Observations, informal talks and formal interviews took place with registered nurses, assistant nurses, physicians and patients in the coronary care unit. The formal interviews were conducted with six registered nurses (five female, one male) including the chief nurse manager, three assistant nurses (all female), two cardiologists and three patients (one female, two male). We identified the structures that either promoted or counteracted the various actions and relationships of patients and healthcare professionals. The care environment, with its minimalistic design, strong focus on routines and modest capacity for dialogue, restricted the choices available to both patients and healthcare professionals. This resulted in feelings of guilt, predominantly on the part of the registered nurses. The care environment restricted the choices available to both patients and healthcare professionals. This may result in increased moral stress among those in multi-professional teams who work in the grey area between biomedical and person-centred care.

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Everyday practices at the medical ward: a 16-month ethnographic field study.

Care transitions from the hospital to home remain a vulnerable time for many patients, especially for those with heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Despite regular use in chronic disease management, it remains unclear how technology can best support patients during their transition from the hospital. We sought to evaluate the impact of a technology-supported care transition support program on hospitalizations, days out of the community and mortality. Using a pragmatic randomized trial, we enrolled patients (511 enrolled, 478 analyzed) hospitalized with CHF/COPD to “E-Coach,” an intervention with condition-specific customization and in-hospital and post-discharge support by a care transition nurse (CTN), interactive voice response post-discharge calls, and CTN follow-up versus usual post-discharge care (UC). The primary outcome was 30-day rehospitalization. Secondary outcomes included (1) rehospitalization and death and (2) days in the hospital and out of the community. E-Coach and UC groups were similar at baseline except for gender imbalance (p = 0.02). After adjustment for gender, our primary outcome, 30-day rehospitalization rates did not differ between the E-Coach and UC groups (15.0 vs. 16.3 %, adjusted hazard ratio [95 % confidence interval]: 0.94 [0.60, 1.49]). However, in the COPD subgroup, E-Coach was associated with significantly fewer days in the hospital (0.5 vs. 1.6, p = 0.03). E-Coach, an IVR-augmented care transition intervention did not reduce rehospitalization. The positive impact on our secondary outcome (days in hospital) among COPD patients, but not in CHF, may suggest that E-Coach may be more beneficial among patients with COPD.

/pdf/the-e-coach-technology-assisted-care-transition-system-a-12g3kyv1u6.pdf

The E-Coach technology-assisted care transition system: a pragmatic randomized trial

Fifty ways to reduce length of stay: An inventory of how hospital staff would reduce the length of stay in their hospital

Increased Mortality Rates During Resident Handoff Periods and the Effect of ACGME Duty Hour Regulations.

BACKGROUND:

Different hospitalist staffing models provide different levels of inpatient continuity of care, which may impact length of stay (LOS).



OBJECTIVE:

To determine if fragmentation of care (FOC) by hospitalist physicians is associated with LOS.



DESIGN:

Concurrent control study.



SETTING:

Hospitalist practices managed by IPC The Hospitalist Company.



PATIENTS:

A total of 10,977 patients admitted for diagnosis-related group (DRG) of 89 pneumonia with complications or comorbidities (PNA) or a DRG of 127 heart failure and shock (HF) between December 2006 and November 2007.



MEASUREMENTS:

FOC was defined as the percentage of care given by hospitalists other than the hospitalist who saw the patient the majority of the stay. Negative binomial regression was performed on DRG 89 and DRG 127 patients with LOS as the dependent variable. We adjusted for gender, age, severity of illness (SOI) scores, risk of mortality (ROM) scores, and number of secondary diagnoses, and admission day of the week.



RESULTS:

A 10% increase in fragmentation was associated with an increase of 0.39 days (P < 0.0001) in the LOS for pneumonia, and an increase of 0.30 days (P < 0.0001) in LOS for heart failure.



CONCLUSIONS:

As FOC increased for pneumonia and heart failure, the LOS increased significantly. Methods to reduce fragmentation should be explored, while more research is needed to identify the source of the relationship between FOC and LOS. Journal of Hospital Medicine 2010;5:335–338. © 2010 Society of Hospital Medicine.

/pdf/the-impact-of-fragmentation-of-hospitalist-care-on-length-of-37mmcfnu76.pdf

The impact of fragmentation of hospitalist care on length of stay

BACKGROUND

When patients are discharged from the hospital, they are assumed to be stable until follow-up as outpatients.



OBJECTIVE

To study the frequency of new or worsening symptoms within 2-5 days of hospital discharge.



DESIGN

Retrospective analysis of data from telephone calls to patients by centralized call center.



SETTING

Patients discharged by hospitalists employed by IPC—The Hospitalist Company.



PATIENTS

15,767 patients surveyed between May 1, 2003, and October 31, 2003.



INTERVENTION

Patients discharged home were contacted by a central call center in the first several days after discharge.



MEASUREMENTS

Patient demographics, self-rated health status, prevalence of new or worsening symptoms, medication issues, home health services issues, and status of scheduled follow-up appointments.



RESULTS

Of the patients surveyed, 11.9% reported new or worsening symptoms since leaving the hospital. There were no differences by age. Women were more likely than men to be symptomatic. Patients with worse health status were more likely to have new or worse symptoms (P < .0001). Symptomatic patients were minimally more likely to have made a follow-up appointment (61.0% vs. 58.4%, P < .05) and were more likely to have medication issues (22.2% vs. 6.8%, P < .0001) and problems with receiving home health care services (5.8% vs. 3.6%, P < .05).



CONCLUSIONS

A significant percentage of patients had new or worsening symptoms in the first several days after discharge. These patients were only minimally more likely to have made follow-up appointments. A system to manage the postdischarge transition period is essential to improving posthospitalization outcomes. Journal of Hospital Medicine 2007;2:58–68. © 2007 Society of Hospital Medicine.

/pdf/frequency-of-new-or-worsening-symptoms-in-the-53d9lujeoy.pdf

Esther Juarez

Papers

The impact of fragmentation of hospitalist care on length of stay

Frequency of New or Worsening Symptoms in the Posthospitalization Period