Capsule Commentary on van Walraven’s “The influence of inpatient physician continuity on hospital discharge”

As hospitals strive to reduce patients’ length of stay, it is necessary to identify factors that improve clinical efficiency and facilitate discharge. In this retrospective study, Carl van Walraven¹ used patient-level data from admissions to the medical service of a large teaching hospital to determine if continuity of inpatient attending physician is associated with the probability that a patient will be discharged from the hospital on a given day. After adjusting for various confounders, he found that the likelihood of discharge increased as patients were followed by the same attending physician for more consecutive days.

Although the study’s predictive modelling accounted for an extensive array of variables that may influence daily discharge probability, a couple of relevant physician factors were not included. The first is house-staff continuity. While attending physicians are ultimately responsible for patient care decisions, house-staff in teaching services provide direct care and perform most of the required physician tasks when discharging patients. The second factor is physician service workload.² How efficiently physicians manage individual patients may be affected by overall workload-related issues, such as the total service size and the complexity of other patients in the same service.

van Walraven’s primary finding is consistent with that of a prior study by Turner et al.,³ which showed modest increases in cost of hospitalization associated with lower physician continuity. Physicians assuming care from their colleagues may take more time to discharge patients and are more likely to order additional testing.⁴ However, providing perfect physician continuity for hospitalized patients is not always feasible and is often difficult to operationalize in academic settings. In addition, physician discontinuity may actually be beneficial as it may offer an opportunity for another physician to independently review a patient’s plan of care with a fresh set of eyes.⁵ Future studies evaluating physician continuity should include other important patient outcomes, such as patient satisfaction, transfer to intensive care unit, inpatient mortality, and hospital readmission.

For clinicians and hospital administrators, this study highlights how attending physician scheduling can potentially impact hospital throughput. But further research is needed to assess its effect on quality of care.