Over 500,000 hospitalizations occur yearly in the VA system. Adverse events occur in a significant number of these. Many factors contribute to the development of adverse events; the care provided by physicians is one such factor. Past studies suggest that discontinuity of physician care can contribute to problems with patient safety, but this previous work is limited by the diffuse nature of discontinuity and the lack of an agreed-upon definition. For this proposal, physician discontinuity for hospitalized patients has been defined as the degree to which key aspects of a patient's hospitalization are performed by someone other than the physician primarily assigned to them.
The broad goal of this project was to evaluate the impact of inpatient physician discontinuity on hospitalized patients. The specific aims were 1) to describe the amount of discontinuity experienced by a group of general medical inpatients from diverse settings; 2) to determine the impact of selected aspects of discontinuity on the patient care outcomes of adverse events, test delays and readmission; and 3) to evaluate the relationship between behaviors associated with the sign-out process and the occurrence of adverse events.
A prospective cohort study of medical inpatients at three hospitals with different physician coverage structures and patient populations was conducted. Data collection on discontinuity included information about physicians' schedules and patients' admissions, hospital stays, and discharges. Three discontinuity variables were constructed: 1) percentage of hospital time covered by the primary inpatient physician; 2) time between admission and the first hand-off of care; and 3) admission-discharge discontinuity (being admitted and discharged by different physicians). Patient outcomes included adverse events, test delays and readmission. The patient outcomes were measured through medical record review. Comorbidity and demographic information were also collected. Data analysis to date includes univariate analyses to evaluate the hypothesized relationships between the discontinuity and the outcome variables.
Data collection for the clinicians ran between March 16, 2009 and March 15, 2010. The overall participation rate was 92% with 248 clinicians participating, 18 declining and 5 dropping out over the course of the year. The clinician demographics follow: 31 (12.7%) were hospitalists, 204 (83.3%) were residents/interns, and the remaining 10 (4.1%) were NPs or PAs. 49% were female and 51% male; 59% were Caucasian, 6% African-American, 25% were Asian.
The patient sample included 1180 randomly chosen patients distributed over the course of one year. This included 390 VA and 790 non-VA patients. The mean age was 61 years (SD 18). 41% of the sample was female. Racial breakdown included 51% Caucasian, 43% African-American, and 6% other. Mean Charlson score was 2.3 (SD 2.1). Mean length of stay was 5.2 (SD 4.1) days.
We looked at discontinuity in several ways. Mean time between admission and the first hand-off of care was 12 (SD 7) hours. Admission-discharge discontinuity was defined as being admitted and discharged by different clinicians, and this occurred in 64% of the sample. 30.5% of patients were in the hospital over at least one team switch day, and only 33% of patients had the same clinician admit, follow and discharge them. We are still working on calculating the percentage of hospital time covered by the primary inpatient clinician.
With respect to patient outcomes, 265 (22%) were readmitted within 30 days after discharge. An additional 147 (12%) had an emergency room visit that did not result in a readmission within 30 days. 543 (46%) of patients experienced at least one adverse event while hospitalized. The most common adverse events were adverse drug events experienced by 350 (30%) patients, serious electrolyte abnormalities experienced by 141 (12%), and mental status changes experienced by 97 (8%). There were 13 (1%) deaths, 24 (2%) rapid responses or codes and 27 unexpected transfers to the ICU (2%). Frequency of test delays at admission was also explored. When defined as a delay of greater than 24 hours between the first mention of the test and the performance of the test, between 12%-21% of patients experienced a delay (range across hospitals). This number dropped to between 1%-3% when the delay was defined as greater than 24 hours between ordering the test and performing the test.
We have only begun the analysis of the relationship between the discontinuity variables and patient outcomes. Univariate analysis of the relationship between admission-discharge discontinuity and readmission showed that discontinuity was associated with fewer readmissions (p=0.029), but this has not been tested in multivariable models yet.
The results thus far suggest that a significant number of hospitalized patients experience discontinuity while in the hospital. However, being admitted and discharged by different clinicians does not appear to have a harmful effect on readmission. There is a broad range in the amount of time that elapses between when a patient is admitted and when the first clinician hand-off of care occurs, with a mean of 12 hours. The new duty hour rules by the Accreditation Council for Graduate Medical Education do not allow interns to stay beyond 16 hours, so it seems likely that this time will shrink. As data analysis is completed, we will interpret the results accordingly, looking for any scheduling or other implications that may arise.
- Fletcher KE, Singh S, Schapira MM, Ratkalkar V, Visotcky AM, Laud P, Kallio C, Framberg S, Li J, Kordus A, Whittle J. Inpatient Housestaff Discontinuity of Care and Patient Adverse Events. The American journal of medicine. 2016 Mar 1; 129(3):341-7.e21.
- Fletcher KE, Singh S, Whittle J, Ratkalkar V, Visotcky AM, Laud P, Kordus A, Schapira MM. Multisite Study to Examine the Amount of Inpatient Physician Continuity Experienced by Hospitalized Patients. Journal of graduate medical education. 2015 Dec 1; 7(4):624-9.
- Miller DM, Schapira MM, Visotcky AM, Laud P, Arora VM, Kordus A, Whittle J, Singh S, Fletcher KE. Changes in written sign-out composition across hospitalization. Journal of hospital medicine. 2015 Aug 1; 10(8):534-6.