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Increasing hospitalist workloads to more than 15 patients a day is associated with clinically meaningful increases in both length of stay and cost of care, according to a study of a single hospitalist practice in Delaware.
The study, published in JAMA Internal Medicine, could serve as a warning to hospital administrators who have linked hospitalist incentives to productivity.
"Most hospitalist programs are subsidized by hospital systems, and incentives based on productivity are common," Dr. Daniel J. Elliott of the Christiana Care Health System, Newark, and his colleagues wrote. "Programs that employ or support hospitalist practices should be aware that policies and incentives that increase workload to minimize short-term costs may undermine larger system efforts targeting efficiency and costs of care. At a minimum, incentive programs should balance productivity, efficiency, and quality measures."
In a retrospective cohort study, researchers analyzed 20,241 inpatient admissions to a 780-bed tertiary care hospital and a 291-bed urban community hospital. The researchers looked at the experience of one of the private hospital medicine groups serving the Delaware health system (JAMA Intern Med. 2014 Mar. 31 [doi:10.1001/jamainternmed.2014.300]).
They found that, as workload increased above the mean of 15.5 patient encounters per day, so did the length of stay. The association was linear at lower hospital occupancies. For instance, with hospital occupancies less than 75%, the length of stay increased from 5.5 to 7.5 days as the daily census climbed from 11 to 22 patients.
For middle occupancies of 75% to 85%, the length of stay was stable across lower workloads but increased to about 8 days when the census hit 22 patients. For high occupancies of more than 85%, there was a J-shaped pattern, with length of stay dipping slightly when the census was 16-17 patients and rising to more than 7 days when the census rose to 21 patients, Dr. Elliott and his associates said.
Costs also increased with workload. After controlling for the length of stay, the researchers found that cost increased by $111 for every 1-unit increase in the relative value unit; it increased $205 for every 1-unit increase in patient census, they reported.
The study, however, showed no statistically significant associations between hospitalist workload and certain quality metrics, including the activation of a rapid response team, mortality, readmissions at 7 and 30 days, and patient satisfaction.
Dr. Elliott and his colleagues recommended that hospital medicine practices provide extra support to physicians for care coordination and discharge services as their census climbs.
The study was supported by the Chairs Leadership Council at Christiana Care Health System. One of the authors, Dr. Joanne Brice, served as division chief of hospital medicine at Christiana during the study and evaluation period.
On Twitter @maryellenny
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In an accompanying editorial, Dr. Robert M. Wachter, who coined the term "hospitalist" in 1996, said the Christiana Care Health System study was an "important and well-executed" study that helps shed light on whether a census of 15 is the "magic number" for hospitalist workload.
"For now, this study illustrates that, although 15 patients per hospitalists 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). They should also look at local data to see what their own workload vs. outcomes curves look like. The right census number will be the one in a given setting that maximizes patient (and, in a teaching hospital, educational) outcomes, efficiency, and the satisfaction of both patients and clinicians, and does so in an economically sustainable way," he wrote (JAMA Intern Med. 2014 Mar. 31 [doi:10.1001/jamainternmed.2014.18]).
Dr. Wachter is professor and associate chairman of the department of medicine at the University of California, San Francisco. He is also the chief of the division of hospital medicine and chief of the medical service at UCSF Medical Center.
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In an accompanying editorial, Dr. Robert M. Wachter, who coined the term "hospitalist" in 1996, said the Christiana Care Health System study was an "important and well-executed" study that helps shed light on whether a census of 15 is the "magic number" for hospitalist workload.
"For now, this study illustrates that, although 15 patients per hospitalists 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). They should also look at local data to see what their own workload vs. outcomes curves look like. The right census number will be the one in a given setting that maximizes patient (and, in a teaching hospital, educational) outcomes, efficiency, and the satisfaction of both patients and clinicians, and does so in an economically sustainable way," he wrote (JAMA Intern Med. 2014 Mar. 31 [doi:10.1001/jamainternmed.2014.18]).
Dr. Wachter is professor and associate chairman of the department of medicine at the University of California, San Francisco. He is also the chief of the division of hospital medicine and chief of the medical service at UCSF Medical Center.
|
|
In an accompanying editorial, Dr. Robert M. Wachter, who coined the term "hospitalist" in 1996, said the Christiana Care Health System study was an "important and well-executed" study that helps shed light on whether a census of 15 is the "magic number" for hospitalist workload.
"For now, this study illustrates that, although 15 patients per hospitalists 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). They should also look at local data to see what their own workload vs. outcomes curves look like. The right census number will be the one in a given setting that maximizes patient (and, in a teaching hospital, educational) outcomes, efficiency, and the satisfaction of both patients and clinicians, and does so in an economically sustainable way," he wrote (JAMA Intern Med. 2014 Mar. 31 [doi:10.1001/jamainternmed.2014.18]).
Dr. Wachter is professor and associate chairman of the department of medicine at the University of California, San Francisco. He is also the chief of the division of hospital medicine and chief of the medical service at UCSF Medical Center.
Increasing hospitalist workloads to more than 15 patients a day is associated with clinically meaningful increases in both length of stay and cost of care, according to a study of a single hospitalist practice in Delaware.
The study, published in JAMA Internal Medicine, could serve as a warning to hospital administrators who have linked hospitalist incentives to productivity.
"Most hospitalist programs are subsidized by hospital systems, and incentives based on productivity are common," Dr. Daniel J. Elliott of the Christiana Care Health System, Newark, and his colleagues wrote. "Programs that employ or support hospitalist practices should be aware that policies and incentives that increase workload to minimize short-term costs may undermine larger system efforts targeting efficiency and costs of care. At a minimum, incentive programs should balance productivity, efficiency, and quality measures."
In a retrospective cohort study, researchers analyzed 20,241 inpatient admissions to a 780-bed tertiary care hospital and a 291-bed urban community hospital. The researchers looked at the experience of one of the private hospital medicine groups serving the Delaware health system (JAMA Intern Med. 2014 Mar. 31 [doi:10.1001/jamainternmed.2014.300]).
They found that, as workload increased above the mean of 15.5 patient encounters per day, so did the length of stay. The association was linear at lower hospital occupancies. For instance, with hospital occupancies less than 75%, the length of stay increased from 5.5 to 7.5 days as the daily census climbed from 11 to 22 patients.
For middle occupancies of 75% to 85%, the length of stay was stable across lower workloads but increased to about 8 days when the census hit 22 patients. For high occupancies of more than 85%, there was a J-shaped pattern, with length of stay dipping slightly when the census was 16-17 patients and rising to more than 7 days when the census rose to 21 patients, Dr. Elliott and his associates said.
Costs also increased with workload. After controlling for the length of stay, the researchers found that cost increased by $111 for every 1-unit increase in the relative value unit; it increased $205 for every 1-unit increase in patient census, they reported.
The study, however, showed no statistically significant associations between hospitalist workload and certain quality metrics, including the activation of a rapid response team, mortality, readmissions at 7 and 30 days, and patient satisfaction.
Dr. Elliott and his colleagues recommended that hospital medicine practices provide extra support to physicians for care coordination and discharge services as their census climbs.
The study was supported by the Chairs Leadership Council at Christiana Care Health System. One of the authors, Dr. Joanne Brice, served as division chief of hospital medicine at Christiana during the study and evaluation period.
On Twitter @maryellenny
Increasing hospitalist workloads to more than 15 patients a day is associated with clinically meaningful increases in both length of stay and cost of care, according to a study of a single hospitalist practice in Delaware.
The study, published in JAMA Internal Medicine, could serve as a warning to hospital administrators who have linked hospitalist incentives to productivity.
"Most hospitalist programs are subsidized by hospital systems, and incentives based on productivity are common," Dr. Daniel J. Elliott of the Christiana Care Health System, Newark, and his colleagues wrote. "Programs that employ or support hospitalist practices should be aware that policies and incentives that increase workload to minimize short-term costs may undermine larger system efforts targeting efficiency and costs of care. At a minimum, incentive programs should balance productivity, efficiency, and quality measures."
In a retrospective cohort study, researchers analyzed 20,241 inpatient admissions to a 780-bed tertiary care hospital and a 291-bed urban community hospital. The researchers looked at the experience of one of the private hospital medicine groups serving the Delaware health system (JAMA Intern Med. 2014 Mar. 31 [doi:10.1001/jamainternmed.2014.300]).
They found that, as workload increased above the mean of 15.5 patient encounters per day, so did the length of stay. The association was linear at lower hospital occupancies. For instance, with hospital occupancies less than 75%, the length of stay increased from 5.5 to 7.5 days as the daily census climbed from 11 to 22 patients.
For middle occupancies of 75% to 85%, the length of stay was stable across lower workloads but increased to about 8 days when the census hit 22 patients. For high occupancies of more than 85%, there was a J-shaped pattern, with length of stay dipping slightly when the census was 16-17 patients and rising to more than 7 days when the census rose to 21 patients, Dr. Elliott and his associates said.
Costs also increased with workload. After controlling for the length of stay, the researchers found that cost increased by $111 for every 1-unit increase in the relative value unit; it increased $205 for every 1-unit increase in patient census, they reported.
The study, however, showed no statistically significant associations between hospitalist workload and certain quality metrics, including the activation of a rapid response team, mortality, readmissions at 7 and 30 days, and patient satisfaction.
Dr. Elliott and his colleagues recommended that hospital medicine practices provide extra support to physicians for care coordination and discharge services as their census climbs.
The study was supported by the Chairs Leadership Council at Christiana Care Health System. One of the authors, Dr. Joanne Brice, served as division chief of hospital medicine at Christiana during the study and evaluation period.
On Twitter @maryellenny
FROM JAMA INTERNAL MEDICINE
