Trends in Inpatient Continuity of Care 1996-2006
Trends in Inpatient Continuity of Care 1996-2006
BACKGROUND: Little is known about how changes in health care delivery, such as the use of hospitalists, have impacted inpatient continuity.
OBJECTIVE: To examine the extent of inpatient discontinuity (ie, being seen by more than one generalist physician) during hospitalization for selected patients.
DESIGN: Retrospective cohort.
SETTING: 4,859 US hospitals.
PATIENTS: Medicare fee-for-service beneficiaries hospitalized for chronic obstructive pulmonary disease (COPD), pneumonia, and congestive heart failure (CHF) from 1996 through 2006.
MEASUREMENTS: We analyzed the proportion of Medicare beneficiaries who received care from 1, 2, or 3 or more generalist physicians during hospitalization. We also examined the factors associated with continuity during the hospitalization.
RESULTS: Between 1996 and 2006, 64.3% of patients received care from 1, 26.9% from 2 and 8.8% from 3 or more generalist physicians during hospitalization. The percentage of patients who received care from one generalist physician declined from 70.7% in 1996 to 59.4% in 2006 (P < 0.001). In a multivariable analysis, continuity with one generalist physician decreased by 5.5% (95% CI, 5.3%–5.6%) per year between 1996 and 2006. Patients receiving all care from hospitalists saw fewer generalist physicians compared to those who received all care from a non-hospitalist or both. Older patients, females, non-Hispanic whites, those with higher socioeconomic status, and those with more comorbidities were more likely to receive care from multiple generalist physicians.
LIMITATIONS: The results may not be generalizable to non-Medicare populations.
CONCLUSIONS: Hospitalized patients are experiencing less continuity than 10 years ago. The hospitalist model of care does not appear to play a role in this discontinuity. Journal of Hospital Medicine 2011;6:441–447. © 2011 Society of Hospital Medicine.
Continuity of care is considered by many physicians to be of critical importance in providing high-quality patient care. Most of the research to date has focused on continuity in outpatient primary care. Research on outpatient continuity of care has been facilitated by the fact that a number of measurement tools for outpatient continuity exist. Outpatient continuity of care has been linked to better quality of life scores, lower costs, and less emergency room use. As hospital medicine has taken on more and more of the responsibility of inpatient care, primary care doctors have voiced concerns about the impact of hospitalists on overall continuity of care and the quality of the doctor–patient relationship.
Recently, continuity of care in the hospital setting has also received attention. When the Accreditation Council for Graduate Medical Education (ACGME) first proposed restrictions to resident duty hours, the importance of continuity of inpatient care began to be debated in earnest in large part because of the increase in hand-offs which accompanies discontinuity. A recent study of hospitalist communication documented that as many as 13% of hand-offs at the time of service changes are judged as incomplete by the receiving physician. These incomplete hand-offs were more likely to be associated with uncertainty regarding the plan of care, as well as perceived near misses or adverse events. In addition, several case reports and studies suggest that systems with less continuity may have poorer outcomes.
Continuity in the hospital setting is likely to be important for several reasons. First, the acuity of a patient's problem during a hospitalization is likely greater than during an outpatient visit. Thus the complexity of information to be transferred between physicians during a hospital stay is correspondingly greater. Second, the diagnostic uncertainty surrounding many admissions leads to complex thought processes that may be difficult to recreate when handing off patient care to another physician. Finally, knowledge of a patient's hospital course and the likely trajectory of care is facilitated by firsthand knowledge of where the patient has been. All this information can be difficult to distill into a brief sign-out to another physician who assumes care of the patient.
In the current study, we sought to examine the trends over time in continuity of inpatient care. We chose patients likely to be cared for by general internists: those hospitalized for chronic obstructive pulmonary disease (COPD), pneumonia, and congestive heart failure (CHF). The general internists caring for patients in the hospital could be the patient's primary care physician (PCP), a physician covering for the patient's PCP, a physician assigned at admission by the hospital, or a hospitalist. Our goals were to describe the current level of continuity of care in the hospital setting, to examine whether continuity has changed over time, and to determine factors affecting continuity of care.
Abstract and Introduction
Abstract
BACKGROUND: Little is known about how changes in health care delivery, such as the use of hospitalists, have impacted inpatient continuity.
OBJECTIVE: To examine the extent of inpatient discontinuity (ie, being seen by more than one generalist physician) during hospitalization for selected patients.
DESIGN: Retrospective cohort.
SETTING: 4,859 US hospitals.
PATIENTS: Medicare fee-for-service beneficiaries hospitalized for chronic obstructive pulmonary disease (COPD), pneumonia, and congestive heart failure (CHF) from 1996 through 2006.
MEASUREMENTS: We analyzed the proportion of Medicare beneficiaries who received care from 1, 2, or 3 or more generalist physicians during hospitalization. We also examined the factors associated with continuity during the hospitalization.
RESULTS: Between 1996 and 2006, 64.3% of patients received care from 1, 26.9% from 2 and 8.8% from 3 or more generalist physicians during hospitalization. The percentage of patients who received care from one generalist physician declined from 70.7% in 1996 to 59.4% in 2006 (P < 0.001). In a multivariable analysis, continuity with one generalist physician decreased by 5.5% (95% CI, 5.3%–5.6%) per year between 1996 and 2006. Patients receiving all care from hospitalists saw fewer generalist physicians compared to those who received all care from a non-hospitalist or both. Older patients, females, non-Hispanic whites, those with higher socioeconomic status, and those with more comorbidities were more likely to receive care from multiple generalist physicians.
LIMITATIONS: The results may not be generalizable to non-Medicare populations.
CONCLUSIONS: Hospitalized patients are experiencing less continuity than 10 years ago. The hospitalist model of care does not appear to play a role in this discontinuity. Journal of Hospital Medicine 2011;6:441–447. © 2011 Society of Hospital Medicine.
Introduction
Continuity of care is considered by many physicians to be of critical importance in providing high-quality patient care. Most of the research to date has focused on continuity in outpatient primary care. Research on outpatient continuity of care has been facilitated by the fact that a number of measurement tools for outpatient continuity exist. Outpatient continuity of care has been linked to better quality of life scores, lower costs, and less emergency room use. As hospital medicine has taken on more and more of the responsibility of inpatient care, primary care doctors have voiced concerns about the impact of hospitalists on overall continuity of care and the quality of the doctor–patient relationship.
Recently, continuity of care in the hospital setting has also received attention. When the Accreditation Council for Graduate Medical Education (ACGME) first proposed restrictions to resident duty hours, the importance of continuity of inpatient care began to be debated in earnest in large part because of the increase in hand-offs which accompanies discontinuity. A recent study of hospitalist communication documented that as many as 13% of hand-offs at the time of service changes are judged as incomplete by the receiving physician. These incomplete hand-offs were more likely to be associated with uncertainty regarding the plan of care, as well as perceived near misses or adverse events. In addition, several case reports and studies suggest that systems with less continuity may have poorer outcomes.
Continuity in the hospital setting is likely to be important for several reasons. First, the acuity of a patient's problem during a hospitalization is likely greater than during an outpatient visit. Thus the complexity of information to be transferred between physicians during a hospital stay is correspondingly greater. Second, the diagnostic uncertainty surrounding many admissions leads to complex thought processes that may be difficult to recreate when handing off patient care to another physician. Finally, knowledge of a patient's hospital course and the likely trajectory of care is facilitated by firsthand knowledge of where the patient has been. All this information can be difficult to distill into a brief sign-out to another physician who assumes care of the patient.
In the current study, we sought to examine the trends over time in continuity of inpatient care. We chose patients likely to be cared for by general internists: those hospitalized for chronic obstructive pulmonary disease (COPD), pneumonia, and congestive heart failure (CHF). The general internists caring for patients in the hospital could be the patient's primary care physician (PCP), a physician covering for the patient's PCP, a physician assigned at admission by the hospital, or a hospitalist. Our goals were to describe the current level of continuity of care in the hospital setting, to examine whether continuity has changed over time, and to determine factors affecting continuity of care.