Higher hospitalist workload tied to increased length of stay, higher costs

Increased workload among hospitalists, particularly beyond 15 patients per provider, is linked to clinically significant increases in patient length of stay and cost, according to recent findings.

In the retrospective cohort study by Daniel J. Elliot, MD, MSCE, of Christiana Care Health System in Newark, Del., and colleagues, inpatient admission data were evaluated for 20,241 patients seen at a private hospitalist service between Feb. 1, 2008, and Jan. 31, 2011. The patients were admitted to either a general medicine or step-down unit at Christiana Care Health System, an academic community health system in northern Delaware consisting of Christiana Hospital and Wilmington Hospital. The study analyzed the experience of one of the three hospitalist groups that provided 24-hour care to patients at both hospitals.

Physician workload was determined based on billing records of the hospitalist group. There were two definitions for workload: the total number of generated relative value units (RVUs) and the number of patients for whom the doctor submitted a billable appointment. The researchers allocated the workload value for each hospitalist to every patient the doctor had seen for a billable interaction that day. This was repeated for each day of the study.

Hospital length of stay (LOS) and cost were the primary efficiency outcomes of the study; LOS was gleaned from the Christiana Health System data warehouse, and cost was established using the Truven Health Analytics CareDiscovery. Primary quality outcomes included rapid response team activation, in-hospital death, patient satisfaction and rates of 30-day readmission. Hospital occupancy and patient demographic information were key covariates.

The researchers found that the LOS increased in proportion to the workload, especially in cases of lower hospital occupancy. In cases where hospital occupancy was less than 75%, LOS increased from 5.5 to 7.5 days as workload increased. For occupancies of 75% to 85%, LOS increased exponentially above a daily RVU of roughly 25, and a census value of roughly 15 patients per hospitalist. At hospital occupancies of greater than 85%, LOS was J-shaped, with significant increases at higher workload ranges.

After adjusting for LOS, the researchers found that cost increased by $111 for each 1-unit increase in RVU and by $205 for each 1-unit increase in census across the range of values. There was no correlation between the remaining outcomes and variations in workload.

“Although our findings should be validated in different clinical settings, our results suggest the need for methods to mitigate the potential negative effects of increased hospitalist workload on the efficiency and cost of care,” Elliott and colleagues concluded.

“For now, this study illustrates that, although 15 patients per hospitalist might not be a magic number in every setting, programs that generally run censuses of more than 15 may want to find ways to lower this workload, perhaps by employing more physicians or by using nonphysician providers,” Robert M. Wachter, MD, of the University of California, San Francisco, wrote in an accompanying editorial. “They should also look at local data to see what their own workload vs. outcomes curves look like. The right census number will be the one in a given setting that maximizes patient outcomes, efficiency, and the satisfaction of both patients and clinicians.”

For more information:

Elliott DJ. JAMA Intern Med. 2014;doi:10.1001/jamainternmed.2014.300.

Wachter RM. JAMA Intern Med. 2014;doi:10.1001/jamainternmed.2014.18.

Disclosure: Please see the study and accompanying editorial for a full list of relevant disclosures.