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Original Investigation |

Effect of Hospitalist Workload on the Quality and Efficiency of Care

Daniel J. Elliott, MD, MSCE1,2; Robert S. Young, MD, MS3; Joanne Brice, MD4; Ruth Aguiar, BA2; Paul Kolm, PhD2
[+] Author Affiliations
1Department of Medicine, Christiana Care Health System, Newark, Delaware
2Christiana Care Value Institute, Newark, Delaware
3Feinberg School of Medicine, Northwestern University College of Medicine, Chicago, Illinois
4Christiana Medical Group, Newark, Delaware
JAMA Intern Med. 2014;174(5):786-793. doi:10.1001/jamainternmed.2014.300.
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Published online

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 Participants  We 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 Measures  The 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.

Results  The 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 in workload were not associated with the remaining outcomes.

Conclusions and Relevance  Increasing hospitalist workload is associated with clinically meaningful increases in LOS and cost. Although our findings should be validated in different clinical settings, our results suggest the need for methods to mitigate the potential negative effects of increased hospitalist workload on the efficiency and cost of care.

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Figure 1.
Population Flow Diagram

Reasons for exclusions are indicated. ED indicates emergency department; ICU, intensive care unit; and LOS, length of stay.

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Figure 2.
Plots of Predicted Length of Stay by Relative Value Units (RVU) and Census

Three levels of occupancy overlaid with fractional polynomial regression fit and 95% CIs are shown.

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Figure 3.
Plots of Predicted Cost by Relative Value Units (RVU) and Census
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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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