Increased hospitalist workload associated with decreased efficiency

Image: PD 

1. In an academic community hospital system, increasing hospitalist workload was associated with an increased length of stay (LOS) and cost. 

2. In this setting, there was no relationship between hospitalist workload and rapid response team (RRT) activation, 30-day readmission, patient satisfaction, or mortality. 

Evidence Rating Level: 2 (Good) 

Study Rundown: Hospitalist medicine is a growing medical specialty in the United States. This study was conducted to determine the association between the workload of hospitalists and the resulting efficiency and quality of care. The study participants were chosen from the Christiana Care Health System, and the physicians were from one of the three hospitalist groups that provide care for the system. The results suggested there was an association between increased workload of hospitalists and increased LOS and cost. However, there was no association with RRT activation, 30-day readmission, patient satisfaction, or mortality.

The strength of the study was the large number of patients and hospitalizations examined over a long period of time, although they were all from one health care system. Even though the investigators did a thorough evaluation of time and cost associated with the hospitalists compared to larger system inefficiencies, the study only looked at one health care system so it is difficult to generalize to a differently organized health care system. Additionally, the investigators used modeling to determine what a “normal” LOS should be for certain medical problems and compared them to actual LOS, but this could add uncertainty to the association they found.

Click to read the study, published today in JAMA Internal Medicine

Click to read an accompanying editorial in JAMA Internal Medicine

Relevant Reading: Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists

In-Depth [retrospective cohort]: This study examined 20,241 hospitalizations for 13,916 patients from the Christiana Care Health Care System, an academic community system from northern Delaware. The providers from one of three hospitalist groups were examined for the study. The efficiency outcomes included cost and LOS. The quality outcomes included RRT activation, in-hospital mortality, 30-day readmission, and patient satisfaction. The study authors also measured total hospital occupancy as a covariate. Physician workload was determined based on the standardized relative value unit (RVU) and/or the number of patients seen based on billing.

The results showed that the LOS increased with workload. For hospital occupancies less than 75%, the LOS increased from 5.5 to 7.5 days with increasing workload. For occupancies ranging from 75-85%, the LOS increased exponentially above RVU of 25 or census of 15. For occupancies >85%, LOS graph was a J-curve and more difficult to interpret in the larger context. Cost was also associated with increasing workload (P<0.001). After controlling for LOS, cost increased by $111 for a one unit increase in RVU, and it increased by $205 for a one unit increase in the census. Workload was not associated with the aforementioned quality outcome measures.

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