Increasing hospitalist workload linked to longer length of stay, higher costs

An increasing workload for hospitalists (physicians who care exclusively for hospitalized patients) was associated with increased length of stay and costs at a large academic community hospital system in Delaware, which may undermine the efficiency and cost of care.

Hospital medicine is a fast growing medical specialty in the United States because evidence has suggested that hospitalists provide inpatient care to more efficiently and less costly than traditional models of care. Benchmark recommendations are that range from 10 to 15 patient encounters per day, but hospitalists are under growing pressure to increase productivity.

The authors evaluated the association between hospitalist workload and the efficiency and quality of care by examining 20,241 inpatient admissions for 13,916 patients cared for by hospitalists at the Christiana Care Health System between February 2008 and January 2011. The hospitalists had an average of 15.5 patient encounters per day.

Length of stay (LOS) increased as workload increased, particularly at lower hospital occupancy. For hospital occupancies less than 75 percent, LOS increased from 5.5 to 7.5 days as workload increased and for hospital occupancies between 75 percent and 85 percent, LOS generally remained stable with lower workloads but increased to about eight days at high workloads. Costs rose with increasing workload and occupancy, with each additional patient a physician saw increasing costs by $262. Increasing workload did not affect other outcomes including mortality, 30-day readmission or patient satisfaction.

"Although our findings require validation in different clinical settings given the likely variability of these associations across systems, our results suggest that incentives aimed at increasing workload may lead to inefficient and costly care. In systems that incentivize physicians based on productivity, consideration should be given to including measures of efficiency and quality," Daniel J. Elliott, M.D., M.S.C.E, of the Christiana Care Health System, Newark, Del., and colleagues wrote in thier JAMA Internal Medicine paper.

In a related commentary, Robert M. Wachter, M.D., of the University of California, San Francisco, writes: "Reassuringly, the study did not find that larger workloads were associated with harm or patient dissatisfaction."

"For now, this study illustrates that, although 15 patients per hospitalist might not be a magic number in every setting, programs that generally run censuses of more than 15 may want to find ways to lower this workload, perhaps by employing more physicians or by using nonphysician providers (nurse practitioners, physician assistants or even scribes)," Wachter continues.

"The right census number will be the one in a given setting that maximizes patient (and, in a teaching , educational) outcomes, efficiency and the satisfaction of both patients and clinicians, and does so in an economically sustainable way," Wachter concludes.

More information: JAMA Intern Med. Published online March 31, 2014. DOI: 10.1001/jamainternmed.2014.300
JAMA Intern Med. Published online March 31, 2014. DOI: 10.1001/jamainternmed.2014.18

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