Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists

Michtalik, Henry J.; Yeh, Hsin Chieh; Pronovost, Peter J.; Brotman, Daniel J.

doi:10.1001/jamainternmed.2013.1864

Cited by 124 publications

(113 citation statements)

References 6 publications

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“…We did not find associations between workload and in-hospital mortality, RRT activation, 30-day readmissions, or patient satisfaction. Our findings are consistent with those of previous research, 10 suggesting that increasing workload may reduce hospitalist efficiency. Hospitalists spend most of their time in indirect patient care activities, including documentation, clinical decision making, and coordination of care with the patient, family, and other providers, all of which are critical to delivering efficient, high-quality care.…”

Section: Discussionsupporting

confidence: 93%

“…Hospitalists have related 10 workload excesses with prescribing errors, delays in response to abnormal test results, and even morbidity and mortality. We did not find an association between increased hospitalist workload and adverse events, including in-hospital mortality or RRT activations, although these events occurred rarely in our population, and our findings may reflect inadequate power.…”

Section: Discussionmentioning

confidence: 99%

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Effect of Hospitalist Workload on the Quality and Efficiency of Care

Elliott

Young

Brice³

et al. 2014

JAMA Intern Med

137

136

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ospital medicine is the fastest growing medical specialty in the United States. 1,2 A major driver of this growth has been empirical evidence suggesting that hospitalists provide inpatient care that is more efficient, less costly, and of equal or higher quality than traditional models of care. 3,4 Currently, hospitalist programs face growing pressure to increase productivity to compensate for declining revenue or to meet operational demands resulting from policy and practice changes, such as limitations on resident work hours, specialty comanagement, and decreased presence of primary care physicians in the hospital. [5][6][7] Increased workloads for nurses and resident physicians have been associated 6,8 with adverse events, leading to mandated workload reductions, but there is little empirical evidence illuminating the association of hospitalist workload and clinical outcomes.Historically, benchmark recommendations for US hospitalist workload range from 10 to 15 patient encounters per day, but these figures lack empirical support. 9 In a recent national survey of hospitalists, 10 40% of respondents reported exceeding what they perceived as a safe workload at least monthly and that increased workload led to delays in care, poor communication between physicians and patients, delivery of unnecessary care, medication errors, and complications of care, including death. Although the correlations between these physician perceptions and patient outcomes are not known, increasing productivity requirements for hospitalists could un-IMPORTANCE Hospitalist physicians face increasing pressure to maximize productivity, which may undermine the efficiency and quality of care.OBJECTIVE To determine the association between hospitalist workload and the efficiency and quality of inpatient care. DESIGN, SETTING, AND PARTICIPANTSWe conducted a retrospective cohort study of 20 241 admissions of inpatients cared for by a private hospitalist group at a large academic community hospital system between February 1, 2008, and January 31, 2011.EXPOSURES Daily hospitalist workload as measured by relative value units and patient encounters from the hospitalist billing records. MAIN OUTCOMES AND MEASURESThe main outcomes were length of stay (LOS), cost, rapid response team activation, in-hospital mortality, patient satisfaction, and 30-day readmission rates. Key covariates included hospital occupancy and patient-level characteristics. RESULTSThe LOS increased as workload increased, particularly at lower hospital occupancy. For hospital occupancies 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 relative value unit of approximately 25 and a census value of approximately 15. At high occupancy (>85%), LOS was J-shaped, with significant increases at higher ranges of workload. After controlling for LOS, cost increased by $111 for each 1-unit increase in relative value unit and $205 for each 1-unit increase in census across the range of values. Changes i...

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Section: Discussionsupporting

confidence: 93%

Section: Discussionmentioning

confidence: 99%

Effect of Hospitalist Workload on the Quality and Efficiency of Care

Elliott

Young

Brice³

et al. 2014

JAMA Intern Med

137

136

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“…Balancing these priorities becomes more difficult while dividing time among a large number of patients. 38 While many patients clearly medically require admission, or are safe for discharge, a number of cases are equivocal; patients have some risk of deterioration and require further testing which may be reasonably accomplished via either admission or further ED workup and well-coordinated follow-up. While admission in general increases the overall amount of healthcare resources used for an individual patient, from the standpoint of the emergency physician, admission saves the time and resources necessary to arrange for safe discharge and follow-up; these duties are handed off to the inpatient team.…”

Section: Discussionmentioning

confidence: 99%

The Impact of Emergency Department Census on the Decision to Admit

Gorski

Batt

Ötleş

et al. 2017

Academic Emergency Medicine

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Objective: We evaluated the effect of emergency department (ED) census on disposition decisions made by ED physicians.Methods: We performed a retrospective analysis using 18 months of all adult patient encounters seen in the main ED at an academic tertiary care center. Patient census information was calculated at the time of physician assignment for each individual patient and included the number of patients in the waiting room (waiting room census) and number of patients being managed by the patient's attending (physician load census). A multiple logistic regression model was created to assess the association between these census variables and the disposition decision, controlling for potential confounders including Emergency Severity Index acuity, patient demographics, arrival hour, arrival mode, and chief complaint.Results: A total of 49,487 patient visits were included in this analysis, of whom 37% were admitted to the hospital. Both census measures were significantly associated with increased chance of admission; the odds ratio (OR) per patient increase for waiting room census was 1.011 (95% confidence interval [CI] = 1.001 to 1.020), and the OR for physician load census was 1.010 (95% CI = 1.002 to 1.019). To put this in practical terms, this translated to a modeled rise from 35.3% to 40.1% when shifting from an empty waiting room and zero patient load to a 12-patient wait and 16-patient load for a given physician. Conclusion:Waiting room census and physician load census at time of physician assignment were positively associated with the likelihood that a patient would be admitted, controlling for potential confounders. Our data suggest that disposition decisions in the ED are influenced not only by objective measures of a patient's disease state, but also by workflow-related concerns. E mergency care is receiving increasing scrutiny as a potential area for cost reductions.1-3 Management of emergency department (ED) costs begins with examining how ED operational characteristics contribute to both patient-level and system-level outcomes. One such characteristic under scrutiny is ED crowding, a phenomenon that can be partially attributed to rising practice intensity 4,5 and inpatient boarding. 6-8 As ED utilization rises, research on the effects of crowding has primarily focused on its influence on patient outcomes, including treatment delays 9-11 and patient mortality.12-15 Less well characterized are organizational responses to increasing operational pressure, such as changes to rates of admission.Highly relevant to the discussion of the cost of emergency care is the growing role of the ED as a "gatekeeper" for inpatient services. 1,16,17 In a 2013 RAND report, hospital admissions rose 4% from 34.7 The authors have no relevant financial information or potential conflicts to disclose. Author contributions: JKG, RJB, and BWP conceived the study; JKG conducted the primary data analysis, with advice and input from RJB and BWP; EO helped with data analysis and offered further methodologic input; JKG pri...

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“…We used the average number of daily patient encounters to estimate providers workload according to the previous studies. [20,21] We excluded visits for prescription refill only. The rank of the medical school the physician graduated from and the residency training hospitals attended were classified into two categories: (i) in US top 5 and (ii) not in US top 5 or non-US (with reference to the list of best medical schools in research rank in 2012 released by US News and World Report [22]).…”

Section: Page 7 Of 31mentioning

confidence: 99%

The effect of provider characteristics on the responses to medication-related decision support alerts

Cho

Slight

Nanji

et al. 2015

International Journal of Medical Informatics

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. (2015) 'The eect of provider characteristics on the responses to medication-related decision support alerts.', International journal of medical informatics., 84 (9). pp. 630-639. Further information on publisher's website: Use policyThe full-text may be used and/or reproduced, and given to third parties in any format or medium, without prior permission or charge, for personal research or study, educational, or not-for-prot purposes provided that:• a full bibliographic reference is made to the original source • a link is made to the metadata record in DRO • the full-text is not changed in any way The full-text must not be sold in any format or medium without the formal permission of the copyright holders.Please consult the full DRO policy for further details. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Page 1 of 31A c c e p t e d M a n u s c r i p t

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Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists

Cited by 124 publications

References 6 publications

Effect of Hospitalist Workload on the Quality and Efficiency of Care

Effect of Hospitalist Workload on the Quality and Efficiency of Care

The Impact of Emergency Department Census on the Decision to Admit

The effect of provider characteristics on the responses to medication-related decision support alerts

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