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As Hospitalist Patient Loads Rise, So Do Hospital Costs

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   April 11, 2014

A study stops short of identifying the optimal hospitalist-to-patient ratio, but "workload does have implications for efficiency of care," says the study's lead author.

The maximum number of patients a hospitalist can efficiently manage is approximately15, research suggests.

In an efficiency and safety study conducted at a Delaware healthcare system, patients assigned to hospitalists who were responsible for more than 15 inpatients per day were linked to longer patient stays and higher costs than patients of hospitals with lighter patient loads.

The study findings are published in a recent JAMA Internal Medicine report examining the potential impact of increasing patient loads on hospitalists. Patient load is measured by relative value units or RVUs, a unit of measure Medicare uses to determine how doctors should be paid for patient care.

"We did this study because the question about how many patient contacts is the right number has been hotly debated in hospital medicine for years," says Daniel Elliott, MD, principal author of the report and co-director of ambulatory medicine research at the two-hospital, 1,100-bed Christiana Care Health System in Wilmington, DE.

Though regional recommendations range between having 10 and 15 patients per hospitalist, depending on typical patient mix and acuity, 40% of hospitalists in a recent survey said their workloads spiked beyond safe levels at least monthly.

Higher patient loads lead to delays in care, poor communication, delivery of unnecessary care, medication errors, and complications due to a faster, more hurried pace, hospitalists say.

But in the Delaware study, quality outcomes such as 7-day and 30-day readmissions rates, in-hospital mortality, and patient experience scores did not change, according to the JAMA report.

In an effort to identify a maximum patient load using real data, Elliott's project looked at outcomes and costs for 20,241 patients admitted between Feb. 1, 2008 and Jan. 31, 2011 at the Christiana hospitals.

It found that for every RVU unit increase in workload, the cost of caring for a patient rose by $111, and rose $205 for each one unit increase in census. In hospitals with census of 75%, length of stay increased from 5.5 to 7.5 days as workload increased. For hospitals with occupancy levels between 75% and 85%, length of stay increased exponentially.

And while this study stopped short of identifying the optimal hospitalist-to-patient ratio "it does help people understand that at some point, workload does have implications for efficiency of care," Elliott says.

The study was limited to care by only one hospitalist group, prompting Elliott to caution that one study in one healthcare system is not enough to dictate policy. It should, however, "spur people to look at this in other settings."

Data to Push Back
Elliott's finding "changes the nature of negotiations between hospitals and hospitalists," says Robert Wachter, MD, associate chairman of the department of medicine at the University of California, San Francisco. He is an internal medicine specialist who is regarded as a leader of the hospitalist movement.

"If market dynamics create a census of 20 (patients per hospitalist) that may affect the hospital's cost, and now hospitalists have the ability to argue there's a return on investment calculation that needs to be made," he says.

"Yes, it may cost the hospital a few more dollars to allow us to keep a census at 15 or 16 (patients per hospitalist, rather than 20 or 25,) but those dollars may pay off in terms of throughput and lower hospital cost. We need to change the nature of this conversation, and that conversation happens in every hospital in the country that has hospitalists."

In the past, Wachter says, hospitalists may have believed they were overworked, "but they didn't have the data to push back, to tell [hospital administrators], 'You're shooting yourself in the foot when you make us run this fast on the treadmill.' "

Wachter, who wrote a commentary in the same issue of the journal, says that while the study's conclusions didn't surprise him, the magnitude of the difference did. "It's a strikingly large effect. There's a sweet spot, and above that sweet spot, things start to deteriorate from the standpoint of efficiency."

Wachter says that ordinarily a higher hospitalist-to-patient ratio would "make you worry about" seeing more clinical judgment errors, which could result in higher mortality or readmissions.

"But my guess is what [hospitalists are] doing is triage. They're putting out fires first and doing a pretty good job. What falls off the back of the cart when you're too busy is that the patient who could get discharged today, they just can't get to it, and that instead ends up happening a day later."

Hospitalists are among the fastest growing medical specialties in the U.S.
According to the Society of Hospital Medicine, an advocacy group for the profession, there are 44,000 physicians working as hospitalists nationally, up from 11,159 in 2003.

Additionally, hospitalists were employed by or contracted in 72% of the nation's hospitals, up from 29% in 2003. Ninety percent of hospitalists receive some or all of their reimbursement from hospitals.

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