While there is a wealth of literature dealing with the association between workload and patient outcomes and costs for nurses and housestaff, there has been relatively little literature on the impact of attending physician workload.
A new study has looked at the impact of hospitalist workload on quality and efficiency of care (Elliott 2014). They found clinically meaningful increases in length of stay and costs associated with increased hospitalist workloads. They found that LOS and cost increased exponentially above a hospitalist census value of about 15 patients per day. Length of stay accounted for most of the excess cost but even after adjustment for length of stay cost increased by $205 per unit increase in hospitalist census.
Hospital occupancy was also a factor. For occupancies less than 75%, LOS increased linearly from 5.5 to 7.5 days from low to high workloads. At occupancies between 75-85% LOS was stable across lower workloads but increased to 8.0 days at higher workloads.
Importantly, they did not find associations between hospitalist workload and in-hospital mortality, rapid response team activation, 30-day readmissions, or patient satisfaction.
While the Elliott study found no adverse effects on patient safety issues related to higher hospitalist workloads, in a previous survey of hospitalists (Michtalik 2013) respondents strongly felt that excessive workloads did impact patient safety and outcomes. In that survey 40% of hospitalists responding felt that their typical inpatient workload exceeded “safe” levels at least monthly. The hospitalists felt that excess workload frequently interfered with full discussion of treatment options, led to delays in discharges (or admissions), more testing and consults, worsened patient satisfaction, and probably also contributed to patient transfers, morbidity and mortality. Keep in mind, however, that this study had no objective measurements of quality and patient safety and was based on the perceptions of the responding hospitalists.
In an editorial accompanying the Elliott study, Bob Wachter (Wachter 2014) notes that there are considerations other than simply patient census that need be taken into account. For example, hospitalists in most institutions play key roles in some of the quality improvement and patient safety initiatives. They may also have other administrative and/or teaching responsibilities. He, therefore, notes that the number 15 patients per hospitalist may not apply at all settings and in all circumstances.
The key is probably consideration of models to better intervene when physician workloads approach such thresholds.
Elliott DJ, Young RS, Brice J, et al. Effect of HospitalistWorkload on the Quality and Efficiency of Care. JAMA Intern Med 2014; Published online March 31, 2014
Wachter RM. HospitalistWorkload: The Search for the Magic Number. JAMA Intern Med 2014; Published online March 31, 2014
Michtalik HJ, Yeh H-C, Pronovost PJ, Brotman DJ. Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists. JAMA Intern Med 2013; 173(5): 375-377
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