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Physician Continuity from Outpatient to Inpatient Care Is Declining

The surge in hospitalist care is among several factors responsible.

Continuity of physician care from outpatient to inpatient settings appears to be declining because of organizational changes in medical practice, including the growth of hospital medicine. In this study, researchers used a Medicare claims database for 3 million hospitalized adults to explore the perceived decline in continuity.

Continuity of inpatient care with any prior outpatient physician (i.e., one who submitted at least one outpatient bill in the prior year) declined from about 50% of cases in 1996 to 40% in 2006. Continuity of inpatient care with a primary care physician (i.e., a general practitioner, family physician, internist, or geriatrician who submitted at least 3 outpatient bills in the prior year) declined from 44% of hospitalizations in 1996 to 32% in 2006. Greater declines in continuity were associated with weekend admissions, larger metropolitan areas, hospitalist care, and major teaching hospitals.

The Journal Watch General Medicine Perspective

These data confirm what most physicians and patients already suspected: Continuity of care between the outpatient and inpatient settings is low and declining. Whether outpatient-to-inpatient continuity has identifiable benefits that might outweigh the presumed benefits of hospitalist care is unclear. However, financial and logistical pressures might have settled this question already by pushing outpatient and primary care physicians out of hospitals.

— Thomas L. Schwenk, MD

The Journal Watch Hospital Medicine Perspective

Continuity of care — as defined by these researchers (the same physician submitting an inpatient bill who also had submitted an outpatient bill) — is indeed low and declining. This study, by design, found an inevitable answer: When site-based clinicians (e.g., emergency medicine physicians, intensivists, or hospitalists) are introduced to a care continuum, one will find less "continuity" from the outpatient to the inpatient setting.

Whether lack of outpatient-to-inpatient continuity, when it is defined this way, is at odds with the clearly identifiable benefits of hospitalist care — 24/7 in-hospital coverage, improved hospital lengths of stay, and patient satisfaction — is unclear. Perhaps a more relevant question, in the era of hospital medicine, is "How do patients, families, and clinicians define continuity?" Rather than one individual assuming care throughout the treatment spectrum, continuity also can be defined as detailed, expedient, and interactive communication between inpatient and outpatient providers, such that care is functionally seamless. I don’t suggest that such ideal communication is occurring during every patient transition, but it should be. As physician professionals, if we create systems to assure accurate and efficient communication, we will ensure high-quality and seamless care continuity. In response to a medical system that has promoted the growth of hospitalists and is not turning back, optimizing care continuity is our greatest opportunity and should be our highest priority.

— Daniel D. Dressler, MD, FHM

Sharma G et al. Continuity of outpatient and inpatient care by primary care physicians for hospitalized older adults. JAMA 2009 Apr 22/29 ; 301:1671.

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— Thomas L. Schwenk, MD, and Daniel D. Dressler, MD, FHM

Published in Journal Watch Hospital Medicine June 15, 2009

Reader Remarks:

Review and add to remarks on this article

• Continuity of Care
  Carol K Smith, retired, 2 Jul 2009 12:48 PM EST
  This is so very sad. How did this decline start? Who gave birth to the hospitalists - really terrible idea... [more]
• Continuity of care
  Thos. D. Johnson, retired, 6 Jul 2009 1:59 PM EST
  There is a paucity of choice when dependence on hospitalists occurs. The problems are economic: a)more time is required by... [more]
• continuity of care
  julius eisenberg, retired, 20 Jul 2009 1:57 PM EST
  hospitalists provide an increase in quality of care,beyond that measured by length of hospital stay,etc.
  
  i base this this on... [more]

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