Care as a continuum: Will hospital outcomes be influenced by outpatient care?

© 2014 Society of Hospital Medicine

Patients who are hospitalized for an acute event often have a range of prior outpatient experiences within the healthcare system, both before and after a hospitalization. In particular, continuity with a primary care provider can influence health outcomes.[1] In this issue of the Journal of Hospital Medicine, Boonyasai et al. found several characteristics of primary care physicians that were associated with whether their hospitalized patients were cared for by hospitalists.[2] Using Medicare claims data from the state of Texas during years 2001 to 2009, the authors calculated the percent of primary care physicians' hospitalized patients who were cared for by hospitalists. Hospitalist use increased overall during the time period, but primary care physicians differed in the rate and extent of hospitalist use. A minority of physicians were early adopters, with the majority of their hospitalized patients cared for by hospitalists during the entire time period. A sizeable group of primary care physicians mostly avoided using hospitalists. Moreover, there was a significant cluster of primary care physicians who, at some point during the study period, rapidly began using hospitalists within a relatively short time.

Several physician characteristics were associated with a greater adoption of the hospitalist model, including being female, in a family practice specialty, or in a rural practice setting. What this study lacks is the ability to explain why some physicians used hospitalists and others did not. It is probable that adoption (or not) of hospitalists is less an individual physician decision and instead reflects a choice of their clinical practice group. If an outpatient practice group or provider can influence whether or not their patients are cared for by hospitalists, it is also conceivable that they can affect hospital‐based outcomes as well. This finding reinforces the importance of examining the care and outcomes of patient care across the continuum of care, rather than focusing on the inpatient or outpatient setting.

As a result of the Affordable Care Act and rising healthcare costs, provider groups are beginning to form accountable care organizations (ACOs). An ACO is partnership between payers and providers to care for a population of patients across the continuum of care. In these arrangements, the providers often take on financial risk for the total cost of care for a population as well as for providing high‐quality care as monitored by specific metrics.[3] The population of patients for which ACOs take risks often include predominantly patients who receive primary care from the group.[4] For overall cost management, given that acute hospitalizations are disproportionately high cost, a primary focus of a majority of ACOs is to reduce unnecessary hospital days. Overall, ACOs that have been successful in the short term in managing costs have done so primarily by reducing overall hospital days.[5] ACOs have started to do so by creating intensive outpatient care management programs for high‐risk patients, by focusing on transitions of care to help decrease readmissions, by working with primary care clinics to transform into patient‐centered medical homes, where same‐day access to care is a priority, and developing other disease‐management tools to keep patients healthy.

To manage hospital utilization, many ACOs have developed plans to transform primary care and shift hospital care to outpatient care through enhanced outpatient case management for complex cases. As the way primary care is delivered changes, it will be very important to understand how this will modify the utilization and impact of hospitalist care on patients. The hope is that these modifications will work synergistically with hospitalist programs.

As the lines between outpatient and inpatient care become increasingly blurred, it may not be fair to attribute hospitalization outcome measures to hospitalists alone, particularly as ACOs are likely to move only the sickest or most difficult to manage patients to the inpatient setting. This may affect hospital‐based quality metrics such as readmissions and mortality. Seamless communication and transfer of information between outpatient and inpatient care will be vital to the success of ACOs.[6] In addition to improved communication, however, some systems may look to hospitalists to staff postdischarge clinics or act as extensivists or ambulatory intensivists to help manage the sickest in the population.[7]

Boonyasi et al. show that primary care physician characteristics as associated with whether or not patients' receive care from hospitalists.[2] As such, it reinforces the concept that providers in part of the continuum of care are integrally tied to care received by patients in different treatment settings. As our healthcare system rapidly transforms over the next few years, it will become more important to understand how outpatient and inpatient providers influence one another's care patterns and how these relationships influence care and cost‐related outcomes for patients.


Disclosure: Nothing to report.


   Comments ()