Comfort Zone

Previous patient-doctor relationship improves long-term outcomes in hospitalized adults

Comfort Zone
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The patient-doctor relationship may have a measurable positive impact on hospitalized patients’ care, according to a study published today in JAMA Internal Medicine.

The study, led by clinician researchers from Harvard Medical School and Beth Israel Deaconess Medical Center, reveals meaningful differences in care patterns and patient outcomes when hospitalized patients are treated by their own primary care physicians versus doctors with whom they do not have a prior relationship.

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“We aimed to estimate differences in care and outcomes of hospitalized patients cared for by three different types of generalists,” said first author Jennifer P. Stevens, associate director of the medical intensive care unit at Beth Israel Deaconess.

“Our results suggest a physician’s prior experience caring for a patient may be linked with improved patient outcomes during and after hospitalization,” she said.

Hospitalists, general physicians with expertise in hospital-level care, care for the vast majority of patients in U.S. hospitals.

Previous research gave the hospitalist model of care a slight edge in cost efficiency and improved patient outcomes compared to care by nonhospitalists. However, until now, no prior research distinguished between outcomes for nonhospitalist physicians who were familiar with the patient versus those who were not.

“We hypothesized familiarity with patients might make a difference in patient care and outcomes,” said Stevens, who is also an assistant professor of medicine at HMS.

“By distinguishing between patients cared for by their own primary care physicians versus other covering physicians who may have little prior knowledge of the patient, we attempted to unmask the potential benefits of familiarity that have not been seen in prior studies of the hospitalist model of care,” Stevens said.

Using Medicare claims data, Stevens and colleagues analyzed more than 560,000 records of admissions to acute care hospitals nationwide from 2013.

Tallying the numbers of in-hospital specialist consults, length of hospital stay, whether patients were discharged to home or to a secondary care facility, seven- and 30-day readmission rates and 30-day mortality rates, the researchers revealed patterns in the use of health care resources and outcomes among patients cared for by hospitalists, patients’ own primary care doctors, or nonhospitalist generalists with little previous knowledge of the patient.

Across the board, nonhospitalists with no prior knowledge of the patient had the worst patient outcomes. Primary care physicians accounted for only 14 percent of the hospitalized patients’ physicians of record.

Overall, hospitalized patients cared for by their primary care physicians saw similar outcomes as those cared for by hospitalists, with negligible differences in specialist consultations, seven- and 30-day readmission rates.

However, there were some noteworthy difference. While primary care doctors’ patients had slightly longer hospital stays (statistically about a half a day longer) than those cared for by hospitalists, they were also much more likely to be discharged to their homes rather than to a secondary or rehabilitation facility.

More striking, patients cared for by their primary care doctors had a lower 30-day mortality rate than hospitalists’ patients, with an absolute difference of 2 percentage points.

“Though the mortality results need to be confirmed in additional studies, these results are the first that we are aware of that suggest a benefit to continuity of care with a primary care physician,” said senior author Bruce E. Landon, professor of medicine at Beth Israel Deaconess and a professor in the Department of Health Care Policy at HMS.

“Our findings also highlight the importance of examining the entire episode of care because the effects of care for hospitalized patients extend into the post-hospital period as well,” Landon said.

“While not immediately actionable, these findings deserve further investigation,” said Stevens. “Reintegrating primary care doctors into their patients’ hospital care may yield substantial benefits that are meaningful to patients,” said Stevens.

In addition to Stevens and Landon, study authors include David Nyweide and Sha Maresh, of the Center for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services, Baltimore; Michael Howell of the Center for Healthcare Delivery Science and Innovation at the University of Chicago; and Laura Hatfield of the Department of Health Care Policy at HMS.

This work was supported by grant K08HS024288 from the Agency for Healthcare Research and Quality and the Charles A. King Trust Postdoctoral Fellowship Program.

This story is adapted from a Beth Israel Deaconess Medical Center news release.