By John Palmer
Anyone who has visited a doctor knows how frustrating the healthcare process can be: Multiple consultations with different doctors, referrals to specialists, and lengthy delays.
As it turns out, it can also be dangerous for the patient. A new report from Birmingham, Alabama–based point-of-care technology company IllumiCare says that having more providers involved in an individual’s treatment can significantly increase hospital length of stay.
“Patients may think that more providers involved in their treatment means more expertise that leads to better overall care,” the report concludes.
In fact, the report finds that for every additional doctor involved in a patient’s care, patients will stay nearly an extra day in the hospital.
“Once the patient’s stay passes three providers involved and three days in the hospital, each additional provider adds 0.58 days to the length of stay,” the report says. “With the national average for a hospital stay at 4.5 days, according to the Agency for Healthcare Research and Quality, fragmentation of specialties in the inpatient setting may be fostering inefficiencies.”
Basically, the report concludes that the saying “too many cooks in the kitchen” can also apply to healthcare.
A serious illness or complicated diagnosis should of course warrant a second opinion or more specialized doctor where necessary, but the report surmises that a multitude of providers on a case can complicate and bog down information exchange. In addition, the industry is suffering from what IllumiCare researchers call “note bloat,” a phenomenon that occurs where electronic notes become difficult to read, leading to inefficient communication.
“Given these effects, one would hypothesize that the fewer providers on a case, the better (with respect to efficiency)—even when risk adjusting by severity of illness,” the report concludes. “More or less, for every additional doc, patients will stay an extra day in the hospital. We also find that not all generalists are alike in the frequency of consulting other providers, giving us an opportunity to reduce this excess length of stay.”
The cost of an extra day or two in the hospital is quite expensive, according to the Kaiser Family Foundation, which estimates that the average cost per hospital day runs at around $2,424.
Nor can the extra cost be blamed solely on the involvement of more specialties. In fact, the report found that one hospitalist handing a patient off to another hospitalist is no different than handing the patient off to, say, a cardiologist or a neurologist.
“The number of different specialties did not seem to matter,” according to a written statement from IllumiCare. “The analysis shows that even patients who saw only one or a small number of different specialties saw an increased length of stay. Each provider brings their own background, practice habits, preferences, etc. to the case. Also, there is often an imperfect information exchange from one provider to the next.”
The study authors concluded that so-called “over-consulting” should be discouraged, given the correlation between the number of providers and length of stay.
Additionally, a wide variation was found in the hospitalist practice of consulting other specialists. In gathering results, the study looked at hospitalists who wrote a medication/laboratory/radiology order and asked questions about how many other non-hospitalist providers they encountered per case. Hospitalists consulted with an average of 4.29 providers per case, but the range varied across 45,000 admissions studied. In some cases, an average 1.3 other specialists were consulted, while some hospitalists consulted an average of 11.84 other specialists. In fact, the study authors noted that one hospitalist is known for consulting with specialists so frequently that he is referred to as the “consultologist” in his facility, leading to the conclusion that over-consultation is a behavior to discourage.
“This data is the perfect representation of the common saying, ‘Too many cooks in the kitchen,’ clearly demonstrating the challenges hospitals face in streamlining care,” said G.T. LaBorde, CEO of IllumiCare, in a written statement. “Executives are looking to get a better hold on provider behaviors that drive unnecessary cost and risk. Since medicine is not formulaic, it is difficult to manage each provider’s practice habits and tendencies, like the habit of consulting. Our goal is to shed more light on various provider habits that not only increase the cost of care, but also risks to the patient, and help executives and care teams be more judicious.”
The study results were adjusted for the argument that patients who are sicker (and stay longer) would naturally have more providers caring for them.
To determine whether the correlation remained after risk adjustment, study authors researched each diagnosis-related group (DRG) separately. DRGs classify a patient’s expected level of care into one of about 900 disease/severity classes.
“If it is just sicker patients needing more sub-specialists that drives length of stay and more ordering providers on the case, then one would expect the correlation between number of providers and length of stay would largely disappear when including patients who saw only one or a small number of different provider specialties,” the report concluded. But that was not the case. The correlation looked very similar whether a patient was seen by one specialty or up to seven specialties.
The report stopped short of giving strategies to eliminate unnecessary consultations, and instead focused on the data collected.
“Excess length of stay drives up both the cost of care and iatrogenic risks to patients,” the report concluded, adding that care coordination and timely discharge of a patient is more challenging as more providers must adjudicate the process. “This leaves the admitting physician, the ‘gatekeeper,’ with additional challenges that extend length of stay.”
In addition, the report said that unnecessary test ordering leads to delays in discharge and can potentially extend days in the hospital as doctors must wait for these tests to be completed.
“The more providers order tests, the more likely delays may occur,” the report authors wrote. “Providers need to judiciously consult their peers and do so only for the right reasons.”
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at firstname.lastname@example.org.