Hospitalist Caseload Does Not Affect Patient Outcomes

Jennifer P. Stevens, MD

Contrary to popular perception, the workload of hospital caregivers on any given day is not affecting the care received by individual patients.

A national cohort analysis from Beth Israel Deaconess Medical Center in Boston found no substantive differences in hospital-admitted patient outcomes during the busiest days being experienced by hospitalists. The findings, which account for results of care including discharge, readmission and 30-day mortality, divert from previous studies showing an increased risk of harm to patients admitted to busier intensive care units (ICUs) or obstetric floors.

Led by Jennifer P. Stevens, MD, of the Center for Healthcare Delivery Science at Beth Israel Deaconess, investigators sought to understand whether hospitalists who admit patients on relatively busy days—and the practices they use to compensate for their limited availability—are at all associated with patient health outcomes.

Such compensation methods, they noted, include increased use of inpatient resources including specialist care and delay on urgent tasks. Though at least the latter is associated with extended length of hospital stay for patients, they hypothesized these resolves would not be found to negatively affect patients’ health.

The significance of their research was simple: hospitalized patients in the US are increasingly cared for by hospitalists, who use particular strategies to manage patients. “When caseloads are higher or patients require more acute care than usual, hospitalists may respond to their cognitive and time constraints by shifting diagnostic or procedural work to specialist colleagues, thereby delaying discharges or missing preventable safety events,” they wrote.

Stevens and colleagues used Medicare claims data to identify hospitalizations from 2018. Patient demographic data, including ethnicity, were obtained via the Chronic Conditions Data Warehouse. Assessed admissions were restricted to non-federal hospitals with ≥250 beds. Eligible hospitalists had ≥8 admissions at a particular hospital during the year to measure their busyness.

Admissions among the 25 most prevalent medical diagnosis-related groups were analyzed. The team compared admissions to hospitalists on their busiest admissions days—defined as each hospitalist’s busiest 25% of observed days, averaging ≥6 additional patients—with admissions on less busy days, defined as the other 75% of days. Outcomes included inpatient resource use-specialist consultations, total Part B physician spending, length of patient stay, discharge, all-cause readmission at 7 and 30 days, and all-cause mortality at 30 days post-admission.

The final analysis included 754,160 admissions carried out by 19,428 hospitalists from 959 hospitals. Mean patient age was 80 years old; 55.3% were women, and another 83.2% of patients were non-Hispanic White.

Investigators observed no significant difference for outcomes among patients admitted during hospitalists’ busiest days versus normal days: rates of discharge (41.1% vs 41.6%) 7-day readmission (6.0% vs 5.9%), 30-day readmission (17.6% vs 17.5%), and 30-day mortality (10.5% vs 10.7%) were similar among the 2 groups, respectively.

That said, Medicare beneficiaries with eligible data were shown to be provided slightly fewer resource use and consultations during the full stay when admitted on hospitalists’ busiest days. As Stevens and colleagues noted, this resulted in a slightly longer length of hospital stay for such patients (mean 5.72 days vs 5.63 days; P <.001) and ultimately, no discernable difference in treatment outcomes.

Though the findings are limited as they reflect clinician-level data versus care delivery team data, the investigators called them nonetheless “reassuring” that hospitalists provide similar care with consistent outcomes regardless of their caseload.

The study, “Comparison of Health Outcomes Among Patients Admitted on Busy vs Less Busy Days for Hospitalists,” was published online in JAMA Network Open.