CMO Brief: Continuity and Length of Stay (LOS)

As we continue our ongoing series on continuity of care, it’s time to start looking at the data on the impact of continuity of care on metrics that matter to us.  One of the biggest drivers of costs in the hospital, and thus a prime concern for hospitalist programs is length of stay.  And as it turns out, one of the drivers of length of stay is continuity of care.

In a recently published study van Walraven found that continuity of care (defined as the consecutive number of days a hospitalist treated a particular team of patients) correlated with discharge probability.  After adjusting for covariables, discharge probability increased with increasing continuity – increasing from 18.1% (with a new physician) vs 25.7% with a physician who had been on service for a month.  Now, this data is based on being on service without a day off, so there aren’t many environments where hospitalists are working for 28 days straight, but we can see the influence that continuity has on length of stay.

Epstein, et al looked at what they call fragmentation of care (FOC).  FOC was defined as “the percentage of care given by hospitalists other than the hospitalist who saw the patient the majority of the stay”.  They looked at two diagnoses (pneumonia and heart failure) and found that a 10% increase in FOC led to a 0.39 (pneumonia) and 0.30 (heart failure) increase in length of stay.  Now there is some question about the what is cause and what is effect (does the FOC lead to longer LOS, or does having a longer LOS increase the FOC since hospitalists eventually get days off), but it appears the interrupting continuity of care can lead to significant increases in LOS.

Another approach taken to evaluate the relationship between continuity of care and LOS was to look at weekend coverage.  Blecker, et al, looked at the usual provider of care (UPC) during the first weekend of the hospitalization.  They then looked at the relationship between low, moderate, and high UPC and LOS.  Patient with moderate or high UPC on that weekend had lower LOS compared to those with low UPC, and much higher rates of weekend discharge.  There was no demonstrable change in mortality of readmission rates.

So, we see that continuity of care during a hospital stay appears to have a significant impact on length of stay.  Next time, we’ll look at outcomes (costs, adverse events, mortality, etc…).