Variation Among Hospitals in the Continuity of Care for Older Hospitalized Patients: a Cross-sectional Cohort Study

Abstract

Background: Little is known about how continuity of care for hospitalized patients varies among hospitals. We describe the number of different general internal medicine physicians seeing hospitalized patients during a medical admission and how that varies by hospital.

Methods: We conducted a retrospective study of a national 20% sample of Medicare inpatients from 01/01/16 to 12/31/18. In patients with routine medical admissions (length of stay of 3-6 days, no Intensive Care Unit stay, and seen by only one generalist per day), we assessed odds of receiving all generalist care from one generalist. We calculated rates for each hospital, adjusting for patient and hospital characteristics in a multi-level logistic regression model.  

Results: Among routine medical admissions with 3- to 6-day stays, only 43.1% received all their generalist care from the same physician. In those with a 3-day stay, 50.1% had one generalist providing care vs. 30.8% in those with a 6-day stay. In a two-level (admission and hospital) logistic regression model controlling for patient characteristics and length of stay, the odds of seeing just one generalist did not vary greatly by patient characteristics such as age, race/ethnicity, comorbidity or reason for admission. There were large variations in continuity of care among different hospitals and geographic areas. In the highest decile of hospitals, the adjusted mean percentage of patients receiving all generalist care from one physician was >84.1%, vs. <24.1% in the lowest decile. This large degree of variation persisted when hospitals were stratified by size, ownership, location or teaching status.  

Conclusions: Continuity of care provided by generalist physicians to medical inpatients varies widely among hospitals. The impact of this variation on quality of care is unknown. 

Introduction

Provider continuity is an important aspect of medical care, associated with better health, fewer hospitalizations, higher quality of life and other important health outcomes [1–10]. Continuity of care can be important both in outpatient care and across community to hospital transitions. By 2006, most hospitalized Medicare patients did not receive any care from a physician who had previously provided care for them [7], and such discontinuity is associated with worse outcomes [8, 9].

Continuity of the care provided to hospitalized patients has been less well studied [10]. Recent studies have suggested that patients admitted for medical illness are likely to be cared for by more than one general internist during their stay [11]. Such discontinuity seems driven by the growth of care by hospitalists, and the fact that many hospitalists have work schedules that do not allow for continuity of care [11]. Just as with outpatient medicine, hospitalized patients who experience discontinuities in their care also have worse outcomes [12].

In this report, we analyze continuity of care in older patients hospitalized for a medical diagnosis, using a 20% sample of national Medicare data from 2016 to 2018. We calculate the number of different generalist physicians providing care for a patient, and how that varies by length of stay and patient characteristics. We also present the variation among hospitals and among hospital referral regions (HRRs) in the average number of different generalist physicians providing care, adjusted for length of stay, admitting diagnosis and other patient characteristics. We hypothesized that inpatient continuity would decline over time, that it would be only weakly related to patient characteristics such as age, sex, and race/ethnicity, but vary widely among hospitals and by type of hospital.

Methods

Results

Table 1 presents the number of medical admissions among Medicare enrollees age 66 or older with a 3-, 4-, 5- or 6-day length of stay stratified by how many different generalists submitted charges for their inpatient care. This was limited to admissions with no ICU stay and where there was a maximum of one generalist charge per day. Overall, 43.1% of admissions received care from only one generalist, with 15.7% receiving care from three or more generalists during their stay. The percentage of admissions seeing only one generalist declined substantially with increasing length of stay, from 50.1% for a 3-day stay to 30.8% for a 6-day stay.

Table 2 presents the unadjusted rates of seeing just one generalist during a routine medical admission, by admission characteristics. Also shown are the odds of seeing just one generalist, adjusted for other admission characteristics and also for clustering of admissions in hospitals, in a multilevel multiple logistic regression model (Model 1 in Table 2). In both unadjusted and adjusted analyses, there was a strong relationship with length of stay, with 6-day admissions only 38% as likely as 3-day admissions to receive care from just one generalist (Odds Ratio [OR = 0.38, 95% Confidence Interval [CI] = 0.38, 0.39). Admissions from nursing facilities were less likely to see just one generalist (OR = 0.94 CI, 95% CI = 0.92, 0.96), as were admissions from the emergency room (OR = 0.77; 0.75, 0.78) or those on weekends (OR = 0.73; 0.73, 0.74). There was very little influence of other patient characteristics, with the odds of seeing only one generalist varying only minimally by age, gender, race/ethnicity, education, Medicaid eligibility or number of prior hospitalizations. We also included the DRG-Major Diagnostic Category and individual patient comorbidities in this model, and they are shown in Supplementary eTable 2. The differences in odds of receiving care from one generalist by any pre-existing comorbidity were not large. There was some variation by DRG-Major Diagnostic Category, with admissions for mental disorders and burns more likely to be cared for by just one generalist. Odds of seeing just one generalist declined from 2016 to 2018.

Model 2 in Table 2 includes specific hospital characteristics in addition to admission characteristics. Hospital characteristics associated with increased odds of continuity of care include smaller size, rural location, for-profit status and major teaching hospital. Including hospital characteristics had minimal effect on the relative lack of association of admission characteristics with the odds of receiving care from just one generalist.

We estimated the variation among hospitals in continuity of care with ICCs. The ICC for the two-level null model was 0.29, indicating that 29% of the variation in whether a hospitalized patient experiences continuity of care is explained by which hospital they are in. It was unchanged when the admission characteristics listed in Table 2 and Supplementary eTable 1 were added (that is, Model 1 of Table 2). When the hospital characteristics listed in Table 2 were added, the ICC decreased to 0.26, suggesting that about 10% of the variation among hospitals in continuity of care is explained by those hospital characteristics.

Figure 1 shows the distribution among 4,523 US hospitals of the mean rate of a patient receiving care from just one generalist, adjusted for all the admission characteristics shown in Table 2 and Supplementary eTable 1. There was substantial variation, with 26.4% of hospitals having significantly greater continuity (79.2% of admissions seeing only one generalist) and 35.2% of hospitals having significantly lower continuity (29.6% of admissions seeing only one generalist). There were also large geographic variations in continuity of care (Fig. 2). The mean adjusted rate of seeing only one hospitalist was ≤ 32% in the lowest 20% of HRRs and was ≥ 52% in the highest 20%. Rates appeared generally lower in New England, the mid-Atlantic states and the Northwest.

Table 3 presents the distributions of adjusted percent of admissions seeing only one generalist among 4,523 US hospitals in the US, stratified by hospital characteristics. In the bottom 10% of all hospitals, the adjusted percent of routine medical admissions seeing only one generalist was ≤ 24.1%, vs. > 84.1% for the top 10% of hospitals. When the hospitals were stratified by size, location, profit status or medical school affiliation, the breadth of the distributions was not largely affected (i.e., the distance between the 10th and 90th percentiles). However, larger hospitals and those with medical school affiliation had somewhat less variation than the comparison categories (Table 3). Supplementary eTable 2 presents the same analyses but limited to the 442 major teaching hospitals. There was still a large degree of variation in inpatient continuity of care when the analysis was limited to large major teaching hospitals.

Discussion

Continuity of care has been threatened by an array of forces for at least two decades. These include the decrease in primary care physicians, changes in health insurance, the growth of specialization and the need to ensure easy and timely access to care [15–18]. Considerable attention has been paid to the discontinuities of care across the community to hospital and back to the community [1, 2, 7, 9].

Few studies have examined inpatient continuity of care in the hospital. Epstein et al. [19] studied a large national hospitalist group and reported that approximately 60% of admissions for pneumonia and heart failure saw at least two hospitalists. In a study of Medicare admissions for chronic obstruction pulmonary disease, congestive heart failure and pneumonia, we found that inpatient continuity of care provided by generalist physicians, including hospitalists, non-hospitalist generalists and primary care physicians, declined substantially between 1996 and 2006 [8].

Continuity of care for hospitalized patients is important for several reasons. It is unlikely that all relevant information communicated by patients and their families to a physician is included in the electronic medical record or is transmitted orally during hand-offs. In addition, information relevant to patient values and preferences and degree of family involvement can be key in medical and discharge decision making. Patients and their families may be less comfortable soliciting and following the advice of a physician they are seeing for the first time, particularly if the issue is value-laden such as end of life issues or discharge destination [4, 6, 20].

Few studies have explored associations of inpatient continuity of care with outcomes. A Joint Commission report blamed miscommunication between physicians during hospital hand-offs for the majority of serious adverse effects [21, 22]. Epstein et al. [19] reported that hospitalist discontinuity was associated with increased length of stay. In a single hospital study, hospitalist discontinuity was associated with a small increase in costs [23]. Another study of 474 admissions to a single hospital found no relationship of discontinuity with adverse events [24]. It is difficult to interpret the results of such studies because of potential biases. For example, hospital complications might lead to discontinuity because of care from an on-call physician and might also lead to increased length of stay and worse outcomes. In a recent study [12], we attempted to control for that bias by assessing the association of the working schedules of hospital physicians with the outcomes of patients under their care. We found that admissions cared for by hospitalists who usually worked several days in a row experienced lower post-discharge mortality, readmissions and costs than did admissions cared for by hospitalists with more intermittent schedules [12].

In the current study, we included medical admissions receiving care from any generalist physician (general internal medicine, family medicine, geriatrics), whether or not they were hospitalists. The diagnoses were predominately respiratory, cardiovascular, renal and gastroenterology (Supplementary eTable 1). We limited the sample to what we termed routine medical admissions, eliminating those with an ICU stay or who had received care from two generalist physicians on the same day, in order to better describe the usual care patterns of patients hospitalized for medical conditions. The variation among hospitals in continuity of care was substantial; in a two-level model, 29% of the variation in whether admissions were cared for by just one generalist was attributed to which hospital they were in. Conversely, the characteristics of the admission contributed very little to the variation in continuity. Adding admission characteristics did not measurably change the ICC. The 4,523 hospitals in the analyses were highly heterogeneous in size, location, ownership and academic affiliation. However, these characteristics explained only about 10% of the variation among hospitals, and this variation was substantial even after stratifying by hospital type (Table 3).

Limitations of the analyses include their reliance on Medicare fee-for-service data, which excludes older individuals enrolled in Medicare health maintenance organizations. In addition, it is possible that differences in patients among hospitals contributed to the variation in continuity. However, adjusting for age, diagnoses, comorbidity and other factors had very little effect on estimates of continuity.

Conclusions

In conclusion, there is great variability in the US in the likelihood that hospitalized Medicare patients will receive all their hospital care from one physician, and much of the variation is driven by the hospital to which the patient is admitted. The large degree of variation even among similar types of hospitals, such as major teaching hospitals, suggests that much of the variation in continuity of care is discretionary. Additional studies should examine the impact of these differences in continuity, if any, on quality of care and outcomes.

Abbreviations

HRR: Hospital Referral Region

DRG: Diagnosis Related Group

ICU: Intensive Care Unit

CI: Confidence Interval

OR: odds ratio

ICC: intraclass correlation coefficient

VRDC: Virtual Research Data Center

CMS: Center for Medicare and Medicaid Services

Declarations

Ethics approval and consent to participate:

All protocols were carried out in accordance with relevant guidelines and regulations. The University of Texas Medical Branch Institutional Review Board approved the study and waived the requirement for informed consent.

Consent for publication:

Not applicable.

Availability of data and materials:

The Medicare datasets used in this study are in the Virtual Research Data Center (VRDC) of the Center for Medicare and Medicaid Services (CMS). The authors analyzed all data within the CMS site and, as part of the Data Use Agreement (DUA), are not allowed to download VRDC data. The datasets used and/or analyzed during the current study are available from CMS after approval of a DUA and payment of a user fee to CMS.

Competing interests:

The authors state that they have no competing interests.

Funding:

This work was supported by the National Institutes of Health (R01 AG33134, P30 AG024832, and UL1 TR001439 to JSG). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Author Contributions:

Study concept and design: JSG and AN. Acquisition of data: JSG, SL. Analysis and interpretation of data: All authors. Preparation of the manuscript: All authors.

Acknowledgements:

The authors thank Sarah Smith, PhD for editorial assistance with this manuscript.

Impact Statement:

We certify that this work is novel. This is the first report that continuity of care provided to older individuals hospitalized with a medical illness varies widely among hospitals, even among hospitals of the same size and type.

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