Background:
Continuity of care—one provider caring for an individual patient throughout an episode of care—is a highly valued ideal in healthcare. However with the complexity of inpatient care involving hospitalists, consultants, and trainees, it is difficult to achieve. There is little known about the effect of an increasing number of physicians and patient movement between various nursing units on the patient’s care experience. We sought to explore the impact of provider discontinuity on patient ratings of their care on the post-discharge Healthcare Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey or the patient experience.
Methods:
The sample in this study was all patients discharged from internal medicine inpatient services during a four-month period who returned the HCAHPS survey. The setting was an urban, academic health system with two hospitals with equal numbers of resident and non-resident care teams. Study personnel reviewed the medical record of each patient. A “discontinuity index” was developed for each patient which was the sum of the following: number of nursing unit changes, number of consulting services, and total number of resident and/or attending physicians that were on the primary service during the hospital stay. The dependent variables were the overall hospital rating on a scale of 0-10 (with 0 being the worst and 10 being the best hospital possible) and the ratings of physician courtesy, listening, and effective explanations (4 point frequency scale of never to always). Patients were asked how well staff worked together using a 5-point response scale ranging from very poor to very good. A linear mixed model was used to determine whether the discontinuity index was a significant predictor of the overall hospital rating or physician communication and controlled for length of stay as a dichotomized variable of < 14 days or > 14 days.
Results:
During the four-month study period, 191patients completed HCAHPS surveys and these medical records underwent retrospective review. Approximately 53% respondents were male and the average age was 60 +16 years. Eighty-seven percent of respondents were white and 10% African American. The average length of stay was 7.79 days (SD 21.46) with a median of 4 days. The mean number of primary service physicians seen by each patient was 4.3+ 2.6. The median number of consultants was 1 (IQR 0 to 2). In this sample, 119 (62.3%) rated the hospital as a 9 or 10. In a linear mixed model when controlling for nurse and doctor communication, resident involvement, and length of stay, the discontinuity index did not independently impact overall rating of the hospital. Staff working together was a significant predictor of overall rating with each one level increase in the patient’s response to this question corresponding to an increase of 1.0 in the overall rating of the hospital on the 0-10 scale.
Conclusions:
Complexity of the care model and number of care providers did not negatively impact patient ratings of the hospital or physician communication. The patients’ rating of how well the staff worked together was the strongest predictor of the patient’s experience. These data imply that the complex schedules of internal medicine inpatient physicians and trainees may not negatively affect patient ratings of care. Our findings support that it is not the absolute number of care providers but rather how well they collaboratively work together that determines the patient experience.