Costs, LOS increase with hospitalist workloads

Heavier hospitalist workloads may lead to longer lengths of stay (LOS) and higher costs, according to a new study published in JAMA Internal Medicine.

Researchers, led by Daniel J. Elliott, M.D., of Wilmington, Del.-based Christiana Care Health System, analyzed inpatient admissions to a private hospitalist service at Christiana from February 2008 to January 2011, adjusting for visit-, hospital- and patient-related variables. The analysis comprised 20,241 admissions for 13,916 patients, with an average of 15.5 daily patient encounters per hospitalist.

Increased workload correlated with increased LOS, the researchers found. In hospitals with low occupancy, or under 75 percent, LOS rose from 5.5 days to 7.5 days across low to high workload levels. In hospitals classified as medium-occupancy (between 75 percent and 85 percent occupancy) and high-occupancy (more than 85 percent), LOS was relatively stable for lower workloads, but jumped to about eight days under higher workloads, according to the study. For high occupancies, LOS dipped slightly at midrange workload levels but spiked after that.

Cost also increased with workload and occupancy, according to the study. "For every unit increase in RVU [relative value units], cost increased by $133, and for every unit increase in census, cost increased by $262," the authors wrote. For each successive occupancy level, cost increased $1,634. LOS was the strongest cost predictor, according to the researchers, but workload remained significant even after adjusting for LOS.

Researchers found no association between workload and hospital mortality, patient satisfaction, readmissions or rapid response activation.

"[O]ur findings highlight the need for hospitals and hospitalist groups to have mechanisms to account for fluctuations in census," the researchers wrote. "Certainly practices need to have appropriate coverage schemes and support structures, but our results suggest that hospitals should be prepared to increase services to handle high clinical loads as well, perhaps through additional care coordination or discharge support for providers."

A recent survey found that increased workloads correlate with higher employee stress levels, which were higher in healthcare than any other industry, FierceHealthcare previously reported.

To learn more:
- here's the study