Previous patient-doctor relationship influences long-term outcomes in hospitalized adults

BOSTON – The patient-doctor relationship may have a measurable and positive impact on hospitalized patients’ care, according to a study by clinician-researchers at Beth Israel Deaconess Medical Center (BIDMC). A paper published today in the journal JAMA Internal Medicine reveals meaningful differences in care patterns and patient outcomes when hospitalized patients are treated by their own primary care physicians (PCPs) versus doctors with whom they do not have a prior relationship.

“We aimed to estimate differences in care and outcomes of hospitalized patients cared for by three different types of generalists,” said first author Jennifer P. Stevens, MD, associate director of the medical intensive care unit at BIDMC. “Our results suggest a physician’s prior experience caring for a patient may be linked with improved patient outcomes during and after hospitalization.”

General physicians with expertise in hospital-level care, hospitalists care for the vast majority of patients in U.S. hospitals. Previous research gave the hospitalist model of care a slight edge in cost-efficiency and improved patient outcomes compared to care by non-hospitalists. However, until now, no prior research distinguished between outcomes for non-hospitalist physicians who were familiar with the patient versus those who were not.

“We hypothesized familiarity with patients might make a difference in patient care and outcomes,” said Stevens, who is also an assistant professor of medicine at Harvard Medical School (HMS). “By distinguishing between patients cared for by their own PCPs versus other covering physicians who may have little prior knowledge of the patient, we attempted to unmask the potential benefits of familiarity that have not been seen in prior studies of the hospitalist model of care.”

Using Medicare claims data, Stevens and colleagues analyzed more than 560,000 records of admissions to acute care hospitals nationwide from 2013. Tallying the numbers of in-hospital specialist consults, length of hospital stay, whether patients were discharged to home or to a secondary-care facility, seven- and 30-day readmission rates and 30-day mortality rates, the researchers revealed patterns in the use of health care resources and outcomes among patients cared for by hospitalists, patients’ own PCPs, or non-hospitalist generalists with little previous knowledge of the patient.

Across the board, non-hospitalists with no prior knowledge of the patient had the worst patient outcomes. Though PCPs accounted for only 14 percent of the hospitalized patients’ physicians of record, their patients saw similar outcomes overall as those cared for by hospitalists, with negligible differences in specialist consultations, 7- and 30-day readmission rates. However, while PCPs’ patients had slightly longer hospital stays (statistically about a half a day longer) than those cared for by hospitalists, they were also much more likely to be discharged to their homes, rather than a secondary or rehabilitation facility. More striking, patients cared for by their PCPs had a lower 30-day mortality rate than hospitalists’ patients, with an absolute difference of 2 percentage points.

“Though the mortality results need to be confirmed in additional studies, these results are the first that we are aware of that suggest a benefit to continuity of care with a PCP,” said senior author Bruce E. Landon, MD, MBA, MSc, a professor of medicine at BIDMC and a professor in the Department of Health Care Policy at HMS. “Our findings also highlight the importance of examining the entire episode of care because the effects of care for hospitalized patients extend into the post-hospital period, as well.”

“While not immediately actionable, these findings deserve further investigation,” said Stevens. “Re-integrating PCPs into their patients’ hospital care may yield substantial benefits that are meaningful to patients,” said Stevens.”

In addition to Stevens and Landon, study authors include, David J. Nyeweide, PhD and Sha Maresh, DrPH, of the Center for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services, Baltimore, MD; Michael D. Howell, MD, MPH, of the Center for Healthcare Delivery Science and Innovation at the University of Chicago; and Laura A. Hatfield, PhD, of the Department of Health Care Policy at Harvard Medical School.

This work was supported by grant K08HS024288 from the Agency for Healthcare Research and Quality and the Charles A. King Trust Postdoctoral Fellowship Program.