https://immattersacp.org/weekly/archives/2017/11/21/4.htm

Resource use, outcomes of hospitalization may be associated with care continuity

Patients were more likely to be discharged home if they were cared for by their primary care physician versus by a hospitalist, while patients cared for by other generalists were less likely to be discharged home than patients cared for by hospitalists.


Hospitalized patients had longer length of stay but lower 30-day mortality rates if cared for by their primary care physicians during their stay, a new study suggests.

Researchers performed a retrospective study of hospital admissions for the 20 most common medical diagnoses among elderly fee-for-service Medicare patients from Jan. 1 through Dec. 31, 2013, to determine whether use of health care resources and outcomes differed according to which type of physician provided care. All patients had had at least one previous encounter with an outpatient clinician in the year before admission. Physicians were included in the study if most of their submitted Medicare claims from 2013 involved general practice, internal medicine, family medicine, or geriatrics.

Physicians were categorized as hospitalists, primary care physicians (defined as physicians who had provided a plurality of ambulatory visits in the year before admission), or generalists (defined as physicians who were not hospitalists or a patient's primary care physician). The study's main outcome measures were number of in-hospital specialist consultations, length of stay, discharge site, all-cause readmission rates at seven and 30 days, and 30-day mortality rates. The study results were published Nov. 13 by JAMA Internal Medicine.

Overall, 560,651 admissions were included in the study analysis, 41.9% in men and 59.1% in women. The mean patient age was 80 years. Patients were cared for by hospitalists in 59.7% of admissions, primary care physicians in 14.2% of admissions, and other generalists in 26.1% of admissions. Consultations were more likely among primary care physicians (relative risk, 1.03; P<0.001) and other generalists (relative risk, 1.06; P<0.001) than among hospitalists. Patients of primary care physicians and other generalists had a longer length of stay than hospitalists' patients (adjusted incidence rate ratio for an additional day of hospital stay, 1.12 and 1.06, respectively; P<0.001 for both comparisons).

Patients were more likely to be discharged home if they were cared for by their primary care physician versus by a hospitalist (68.5% vs. 64.0%; adjusted odds ratio, 1.14; P<0.001), while patients cared for by other generalists were less likely to be discharged home than patients cared for by hospitalists (62.1% vs. 64.0%; adjusted odds ratio, 0.94; P<0.001). Primary care physicians' patients had similar readmission rates at seven days (adjusted odds ratio, 0.98; P=0.31) and 30 days (adjusted odds ratio, 1.02; P=0.17) compared to hospitalists' patients, but readmission rates among patients cared for by other generalists were higher (adjusted odds ratio, 1.05 and 1.04, respectively; P<0.001 for both comparisons) versus those cared for by hospitalists. Thirty-day mortality rate was higher in generalists' patients than in hospitalists' patients (11.0% vs. 10.8%; adjusted odds ratio, 1.09; P<0.001) but was lower in primary care physicians' patients (8.6% vs. 10.8%; adjusted odds ratio, 0.94; P<0.001).

The authors noted that their results may not be generalizable to populations other than older fee-for-service Medicare beneficiaries and may have been affected by unmeasured confounding, among other limitations. However, they concluded that contact with a patient over time may have a positive effect on both patterns of care and outcomes. “Novel models of care that integrate [primary care physicians] who care for patients in the ambulatory setting with their patients' hospital care may yield substantial benefits in outcomes that are meaningful to patients,” the authors wrote.

The authors of an accompanying invited commentary also acknowledged the study's limitations but said its results were probably valid, noting that the findings have implications for both health care as a whole and for primary care specifically. “We believe that [these findings] of benefits of outpatient-to-inpatient continuity of care by primary physicians is the signal of a much larger effect of comprehensive relationship-based care that is also evidence based,” the commentary authors wrote. “Recognizing the unique needs of each patient, including the patient's preferences, need for information, social support, and the emotional and physical impact of illness, is the core of patient-centered care for which we strive.”