Abstract
Inpatients treated by hospitalist physicians, who often work contiguous days, experience handoffs at the end of a scheduled shift block. Evidence suggests that transitions of patient care, or handoffs, among physician trainees are associated with adverse patient outcomes. However, little is known about the association between handoffs and patient outcomes among attending physicians, even though similar concerns apply. To examine the association between inpatient handoffs of hospitalist physicians and patient mortality among hospitalized Medicare beneficiaries. This cross-sectional study analyzed a random sample of Medicare beneficiaries who were hospitalized with a general medical condition between January 1, 2011, and December 31, 2016, and treated by a hospitalist. The study compared outcomes of patients with low vs high probability of physician handoff based on date of patient admission relative to the admitting hospitalist's last working day in a scheduled block, hypothesizing that otherwise similar patients admitted toward the end of a physician's shift block would be more likely to be handed off to another physician compared with patients admitted earlier in the shift block. Data analysis was performed from July 1, 2018, to January 12, 2021. High vs low probability of physician handoff. The main outcome was patient 30-day mortality rate. A total of 1 074 000 patients (mean [SD] age, 75.9 [13.7] years; 57.4% female; 82.1% White) were studied. Multivariable regression models adjusted for beneficiary clinical and demographic characteristics and hospital fixed effects (a within-hospital analysis, effectively comparing patients treated at the same hospital). Among 597 288 hospitalizations, no overall difference in 30-day mortality was observed between patients admitted in the 2 days prior (days -1 and -2) to the treating hospitalist's last working day (a high handoff probability) compared with days -6 and -7 (a low handoff probability) (adjusted rate, 10.6%; 95% CI, 10.5%-10.7% vs 10.6%; 95% CI, 10.5%-10.7%; adjusted difference, 0.0%; 95% CI, -0.2% to 0.1%). However, in an exploratory analysis, among patients with high illness severity, defined as those in the top quartile of estimated mortality, 30-day mortality was higher for those with high vs low likelihood of physician handoff (adjusted mortality, 27.8%; 95% CI, 27.6%-27.9% vs 26.8%; 95% CI, 26.6%-27.1%; absolute adjusted difference, 1.0%; 95% CI, 0.5%-1.4%). In this national analysis of Medicare beneficiaries hospitalized with a general medical condition and treated by a hospitalist physician, physician handoff was not associated with increased mortality overall.
Highlights
In an exploratory analysis, among patients with high illness severity, defined as those in the top quartile of estimated mortality, 30-day mortality was higher for those with high vs low likelihood of physician handoff. In this national analysis of Medicare beneficiaries hospitalized with a general medical condition and treated by a hospitalist physician, physician handoff was not associated with increased mortality overall
In a national cross-sectional study of Medicare beneficiaries hospitalized with a general medical condition and treated by a hospitalist physician, physician handoff was not associated with increased mortality overall
Using data on Medicare beneficiaries hospitalized with a general medical condition and treated by a hospitalist physician during 2011 to 2016, we analyzed the association between physician handoffs and patient mortality by comparing outcomes of patients admitted at the beginning vs the end of a scheduled work block, at which point a handoff to another physician would usually occur
Summary
Transitions of patient care, or handoffs, have been associated with greater adverse events, preventable medical errors, and costs.[1,2,3,4,5,6,7] handoffs occur in a number of medical settings, their impact has primarily been studied and associated with adverse events and errors in the trainee setting.[5,7] Interventions to improve the safety and efficacy of handoffs,[8,9,10,11] including a patient safety training and a structured handoff tool implemented at multiple centers,[12] have focused on trainees.Handoffs are ubiquitous in the clinical practice that occurs once physicians complete their residency training, yet limited large-scale data exist on the association between physician handoffs and patient outcomes outside the trainee setting.[13]. An important setting where handoffs commonly occur is inpatient care provided by hospitalist physicians.[14] Hospitalists, usually general internists who specialize in hospital-based care, provide most inpatient general medical care in the US and typically work contiguous days in which handoff of patients to another physician occurs at the end of a scheduled block. Using data on Medicare beneficiaries hospitalized with a general medical condition and treated by a hospitalist physician during 2011 to 2016, we analyzed the association between physician handoffs and patient mortality by comparing outcomes of patients admitted at the beginning vs the end of a scheduled work block, at which point a handoff to another physician would usually occur. On the basis of prior studies[15,16,17,18] and the way in which patients are typically assigned to hospitalist physicians, we hypothesized that patients treated by a given hospitalist at the beginning vs the end of a scheduled work block would otherwise be similar on both observable and unobservable characteristics that are associated with mortality, a quasi-experimental analysis
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