Hopitalization and the Continuity of Care

We are undergoing fundamental and profound changes in healthcare in the United States. In order to make the care within a hospital more efficient, and discharge patients in a shorter length of time, many hospitals have changed the physicians who are responsible for the care of the patient while in the hospital. A group of physicians trained to give inpatient care, but not outpatient care, has developed and they are called “hospitalists.”

As a result of hospitalist care, the length of stays of individuals has shortened dramatically. The tests performed and care given for patients with the usual complaints or problems have been standardized and streamlined so that any necessary tests are not forgotten, and care is given according to guidelines so that no necessary treatment is omitted. With shorter hospital stays, hospitals are able to avoid losing money and being threatened with bankruptcy or closure. Patients benefit by earlier discharge, with fewer complications and less chance that some mistake will be made in their care.

But in the past, your own family physician or your own specialist had been in charge of your care. One of the major advantages of having your own physician responsible for your care in the hospital, rather than a hospitalist physician whom you have never known, is that there is a continuity of care from home and office into the hospital, familiarity with past history and problems while you are in the hospital, and a knowledge of all the aspects of your inpatient care that continues into the outpatient setting.

Continuity of care is important whether it be from the hospital to a nursing home, the nursing home to a patient’s actual home, or from the hospital to the patient’s home. Increased continuity is associated with improved patient satisfaction, an increased use of appropriate preventive health services, a greater likelihood that the appropriate medication will be taken by the patient, less likelihood that the patient will be readmitted to the hospital, and a lower cost of care once the patient is discharged from the hospital.

A recent article has examined what is happening in America to hospitalized older adults. Dr. G. Sharma and his associates from the University of Texas Medical Center and the Medical College of Wisconsin (JAMA, Volume 301, page 1671-1680, 2009) examined the characteristics of hospital care in 1996 and in 2006. They reviewed over 3 million hospital admissions Medicare records, and all patients were older than 66 years of age. They then evaluated whether patients were seen by any physician whom they had visited in the year before hospitalization, including their primary care physician.

In 1996, 50 percent of hospitalized patients were seen by at least one physician that they had seen in an outpatient setting in the prior year. Over 44 percent were seen by the patient’s primary care physician from the community.

However, by 2006 the percentage of patients who were seen by their own physician had reduced to 39.8 percent; only 31.9 percent were seen by their own primary care physician. This was even more striking in patients admitted on weekends and those in large cities. Interestingly, patients in New England were much less likely, compared to patients in other parts of the country, to have been seen by their own doctors when in the hospital.

They then looked at the likelihood that patients would be seen by any of their familiar physicians in different types of hospitals. In larger hospitals, patients were 15 percent less likely to be seen by their own physician compared to smaller hospitals. In public hospitals, there was a 22 percent reduced likelihood of being seen by their own physician. Surprisingly, hospitals with a major medical school affiliation showed a 42 percent reduced likelihood of a patient being seen by their own physician during the course of the hospitalization.

The conclusions are important for all individuals may ever need hospitalization. Since the satisfaction with care and efficiency of care when a patient is discharged from the hospital depends upon having a patient’s own physician see the patient while they are in the hospital, patients considering elective hospitalization (for a surgery or an evaluation) should ask their physicians whether they will see them while they are in the hospital. If the physician says that they will not see the patient, the patient should ask how continuity of care will be provided, since you want the best quality of care. If the answers are unsatisfactory, consider seeing another doctor who will be able to provide some continuity of care from the in-patient setting to the out-patient setting so that medication is more appropriately used, tests and treatments are given to prevent illness, and so that there is less overall expense to the patient in receiving care.

But also remember that hospital care is more efficient with a hospitalist. If you are admitted to a hospital in an emergency and receive hospitalist care, ask to have your own primary care physician or specialist called in to consult on your other medical conditions while the hospitalist cares for the emergency problem. In this way, your care will be fast and effective and continuity of care when you return to the office will be optimal.