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Patient-PCP history may affect resource use, health outcomes

Patients cared for by their own primary care physician had longer lengths of hospital stay, had greater odds of being discharged home and were less likely to die within 30 days compared with patients who received care from hospitalists or other generalists, according to recently published findings.

“Prior research has demonstrated few differences between hospitals and other internists in inpatient mortality and readmission, although some studies have noted decreased lengths of stay among patients cared for by hospitalists,” Jennifer P. Stevens, MD, MS, from the Center for Healthcare Delivery Science at Beth Israel Deaconess Medical Center, and colleagues wrote in JAMA Internal Medicine. “Those studies, however, do not distinguish between patients cared for by their own PCPs and other covering physicians who may have little prior knowledge of the patient, thereby potentially masking the benefits of familiarity with the patient.”

Researchers performed a retrospective study to determine the differences in use of health care resources and outcomes among hospitalized elderly patients cared for by hospitalists, PCPs and other generalists. They analyzed admissions for the 20 most common medical diagnoses among Medicare beneficiaries to determine the number of in-hospital specialist consultations, length of stay, discharge site, all-cause 7- and 30-day readmission rates, and 30-day mortality. Patients were included if they had at least one previous encounter with an outpatient clinician within 1 year prior to admission.

Of 560,651 patient admissions, 59.7% were cared for by hospitalists; 14.2% by PCPs; and 26.1% by other generalists. PCPs and generalists used consultations more than hospitalists (relative risk, 1.03; 95% CI, 1.02-1.05 and relative risk, 1.06; 95% CI, 1.05-1.07, respectively). Patients who received care from PCPs and other generalists had 12% and 6% longer lengths of stay compared with patients cared for by hospitalists (adjusted incidence rate ratios, 1.12; 95% CI, 1.11-1.13 and 1.06; 95% CI, 1.05-1.07, respectively). However, PCPs were linked with greater odds of discharging patients home (adjusted OR, 1.14; 95% CI, 1.11-1.17) while other generalists were less likely to do so (adjusted OR, 0.94; 95% CI, 0.92-0.96) compared with hospitalists. Notably, patients treated by their PCPs had lower 30-day mortality than patients treated by hospitalists (adjusted OR, 0.94; 95% CI, 0.91-0.97).

Relative to hospitalists, patients cared for by PCPs and hospitalists had similar readmission rates at 7 days and 30 days, but other generalists’ readmission rates were higher than hospitalists’ rates at 7 and 30 days.

“Our results suggest that longitudinal contact with a patient may translate into meaningful differences in care patterns and patient outcomes,” Stevens and colleagues wrote. “Novel models of care that integrate PCPs who care for patients in the ambulatory setting with their patients’ hospital care may yield substantial benefits in outcomes that are meaningful to patients.”

In a related commentary, Lisa L. Willett, MD, and C. Seth Landefeld, MD, from the department of medicine at the University of Alabama at Birmingham, wrote that these findings have significant implications for primary care. Primary care is under-resourced and there is a lack of PCPs, so the model of the primary physician who provides care in both the office and the hospital is rare, according to Willett and Landefeld. They question whether this model of care by a PCP is realistic, but understand that more patients want access to their own doctor.

“We believe that the findings of Stevens et al 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,” Willett and Landefeld 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.” – by Savannah Demko

Disclosures: The authors report no relevant financial disclosures.