November 27, 2017

Patients fare better post-discharge if treated by their PCP, not a hospitalist, study finds

Daily Briefing

    Medicare beneficiaries hospitalized for certain common conditions fare slightly better post-discharge if treated by their primary care physician (PCP) rather than a hospitalist, according to a study published this month in JAMA Internal Medicine.

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    Study details

    For the study, researchers assessed Medicare claims data on 560,651 acute care hospitalizations for beneficiaries ages 66 and older. Beneficiaries included in the study had to have been hospitalized for at least one of the 20 most common diagnosis-related groups (DRG)—such as pneumonia, heart failure, or a urinary infection—and must have had at least one outpatient visit with a clinician within the year prior to hospitalization.

    The researchers then divided the beneficiaries into three groups: those who had seen their PCP, those who had seen a hospitalist, and those who had seen a generalist physician who had not previously met them.

    Key findings

    Overall, the researchers found that hospitalists treated 59.7% of assessed hospitalizations and generalist physicians treated 26.1% of cases, while patients' PCPs treated 14.2% of cases.

    When the researchers compared outcomes among patients, they found that:

    • 68.5% of patients treated by their PCP were discharged home versus a long-term care facility, compared with 64% of those treated by hospitalists and 62.1% of those treated by generalists;
    • 11.1% of patients treated by their PCP were readmitted within seven days, compared with 11.6% of those treated by hospitalists and 12% of those treated by generalists; and
    • 8.6% of patients treated by their PCP died within 30 days of discharge, compared with 10.8% of those treated by hospitalists and 11% of those treated by other generalists.

    The researchers also found patients who saw hospitalists had a lower median length of stay than those who saw their PCP. However according to the study's lead author, Jennifer Stevens of the Center for Healthcare Delivery Science at Beth Israel Deaconess Medical Center, the difference was "to the tune of hours."

    Discussion

    According to the researchers, the findings suggest that a PCP's "prior experience with a patient may be associated with inpatient use of resources and patient outcomes." And while the researchers did not suggest that the hospitalist role should be replaced, Stevens said the study "challenges us to take another look at the hospitalist model and re-evaluate the full-scale adoption of hospitalist coverage in 75% of hospitals."

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    Ultimately, according to Stevens, the main takeaway from this study is that "a prior relationship with a physician has a meaningful impact for patient outcomes, particularly those outside the walls of the hospital. The idea that many funders are interested in care models that extend both in the inpatient and outpatient setting means that simply efficiency-related outcomes may not be the be-all and end-all."

    In an accompanying editorial, Seth Landefeld and Lisa Willett—both from the Department of Medicine at the University of Alabama in Birmingham—said the study shows the importance of care continuity, which itself could be "a proxy for what might improve care, a combination of deep knowledge of a patient and his or her situation with a therapeutic trusting relationship, and easy access to care"  (AP/STAT News, 11/13; Gooch, Becker's Hospital Review, 11/13; MacReady, Medscape, 11/13).

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