Background:
Hospital medical groups use various staffing models which systematically affect care continuity during the admission process. Our service changed models of care from a “general model”, where hospitalists who perform hospital rounds and discharges also perform admissions on the same service day, to an “admitter-rounder model”, where service work is divided each day between hospitalists who perform only admissions and hospitalists who perform only rounding and discharge activity. We compared the association of our service models with rates of transfer to critical care within the first 24 hours of hospitalization, hospital or emergency department length of stay, and hospital readmission rates ≤ 30 days post-discharge.
Methods:
A retrospective observational cohort study was conducted on 19,270 admissions at our hospital. Four 18-month long cohorts of activity were analyzed: the hospital medicine non-teaching general and admitter-rounder models of service, and teaching services time-matched to the hospital medicine services of interest. Odds ratios for transfer to critical care and readmission, and median of change in emergency department and hospital length of stay were calculated, after logistic regression adjustment for age, sex, race, Elixhauser score, payer status, case mix, accepting service patient census on the day after admission, and hospital occupancy on the day of admission. Difference-of-difference analysis was then conducted to compare changes in adjusted outcomes before and after the hospital medicine service change to teaching services during the same time period.
Results:
Compared to the hospitalist general model of admissions, the hospitalist admitter-rounder model was associated with an increased rate of transfer to the intensive care unit within the first 24 hours of hospitalization (OR 1.292, 95% CI 1.026-1.629, p=0.03) as well as an increased hospital length of stay (LOS) (+12.96 hours, p<0.001), with no significant change in these measures compared to the teaching service during the study period (difference-of-difference values of p=0.32 and p=0.87, respectively). The hospitalist admitter-rounder model was associated with no change in hospital readmission ≤ 30 days post-discharge compared to the hospitalist general model (OR 1.048, 95% CI 0.966-1.136, p=0.26), but with decreased readmissions compared to the teaching service over time (OR 1.298, 95% CI 1.127-1.495, p<0.001; difference-of-difference value p=0.01). The hospitalist admitter-rounder model was associated with a significantly increased ED length of stay compared to the hospitalist general model (median increase of 0.40 hours, p<0.001), and compared to the teaching service over time (median decrease of 0.09 hours, p=0.29; difference-of-difference value p<0.001).
Conclusions:
Rates of transfer to intensive care and overall hospital length of stay between the hospitalist admission models did not differ significantly. The hospitalist admitter-rounder admission service structure was associated with extended emergency department length of stay. While readmission rates on the hospitalist service did not change between models, the time-matched teaching service experienced a rise in readmission rates, suggesting a potentially protective effect against readmission risks from an admitter-rounder structure. Further analysis of hospitalist workflow is indicated to determine causative factors related to our observations.