Physician Continuity from Outpatient to Inpatient Care Is Declining

Continuity of physician care from outpatient to inpatient settings appears to be declining because of organizational changes in medical practice, including the growth of hospital medicine. In this study, researchers used a Medicare claims database for 3 million hospitalized adults to explore the perceived decline in continuity.

Continuity of inpatient care with any prior outpatient physician (i.e., one who submitted at least one outpatient bill in the prior year) declined from about 50% of cases in 1996 to 40% in 2006. Continuity of inpatient care with a primary care physician (i.e., a general practitioner, family physician, internist, or geriatrician who submitted at least 3 outpatient bills in the prior year) declined from 44% of hospitalizations in 1996 to 32% in 2006. Greater declines in continuity were associated with weekend admissions, larger metropolitan areas, hospitalist care, and major teaching hospitals.

These data confirm what most physicians and patients already suspected: Continuity of care between the outpatient and inpatient settings is low and declining. Whether outpatient-to-inpatient continuity has identifiable benefits that might outweigh the presumed benefits of hospitalist care is unclear. However, financial and logistical pressures might have settled this question already by pushing outpatient and primary care physicians out of hospitals.

— Thomas L. Schwenk, MD

The Journal Watch Hospital Medicine Perspective

Continuity of care — as defined by these researchers (the same physician submitting an inpatient bill who also had submitted an outpatient bill) — is indeed low and declining. This study, by design, found an inevitable answer: When site-based clinicians (e.g., emergency medicine physicians, intensivists, or hospitalists) are introduced to a care continuum, one will find less “continuity” from the outpatient to the inpatient setting.

Whether lack of outpatient-to-inpatient continuity, when it is defined this way, is at odds with the clearly identifiable benefits of hospitalist care — 24/7 in-hospital coverage, improved hospital lengths of stay, and patient satisfaction — is unclear. Perhaps a more relevant question, in the era of hospital medicine, is “How do patients, families, and clinicians define continuity?” Rather than one individual assuming care throughout the treatment spectrum, continuity also can be defined as detailed, expedient, and interactive communication between inpatient and outpatient providers, such that care is functionally seamless. I don’t suggest that such ideal communication is occurring during every patient transition, but it should be. As physician professionals, if we create systems to assure accurate and efficient communication, we will ensure high-quality and seamless care continuity. In response to a medical system that has promoted the growth of hospitalists and is not turning back, optimizing care continuity is our greatest opportunity and should be our highest priority.

— Daniel D. Dressler, MD, FHM