Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.
Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, California.
JAMA Netw Open. 2021 Mar 1;4(3):e213040. doi: 10.1001/jamanetworkopen.2021.3040.
Inpatients treated by hospitalist physicians, who often work contiguous days, experience handoffs at the end of a scheduled shift block. Evidence suggests that transitions of patient care, or handoffs, among physician trainees are associated with adverse patient outcomes. However, little is known about the association between handoffs and patient outcomes among attending physicians, even though similar concerns apply.
To examine the association between inpatient handoffs of hospitalist physicians and patient mortality among hospitalized Medicare beneficiaries.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study analyzed a random sample of Medicare beneficiaries who were hospitalized with a general medical condition between January 1, 2011, and December 31, 2016, and treated by a hospitalist. The study compared outcomes of patients with low vs high probability of physician handoff based on date of patient admission relative to the admitting hospitalist's last working day in a scheduled block, hypothesizing that otherwise similar patients admitted toward the end of a physician's shift block would be more likely to be handed off to another physician compared with patients admitted earlier in the shift block. Data analysis was performed from July 1, 2018, to January 12, 2021.
High vs low probability of physician handoff.
The main outcome was patient 30-day mortality rate.
A total of 1 074 000 patients (mean [SD] age, 75.9 [13.7] years; 57.4% female; 82.1% White) were studied. Multivariable regression models adjusted for beneficiary clinical and demographic characteristics and hospital fixed effects (a within-hospital analysis, effectively comparing patients treated at the same hospital). Among 597 288 hospitalizations, no overall difference in 30-day mortality was observed between patients admitted in the 2 days prior (days -1 and -2) to the treating hospitalist's last working day (a high handoff probability) compared with days -6 and -7 (a low handoff probability) (adjusted rate, 10.6%; 95% CI, 10.5%-10.7% vs 10.6%; 95% CI, 10.5%-10.7%; adjusted difference, 0.0%; 95% CI, -0.2% to 0.1%). However, in an exploratory analysis, among patients with high illness severity, defined as those in the top quartile of estimated mortality, 30-day mortality was higher for those with high vs low likelihood of physician handoff (adjusted mortality, 27.8%; 95% CI, 27.6%-27.9% vs 26.8%; 95% CI, 26.6%-27.1%; absolute adjusted difference, 1.0%; 95% CI, 0.5%-1.4%).
In this national analysis of Medicare beneficiaries hospitalized with a general medical condition and treated by a hospitalist physician, physician handoff was not associated with increased mortality overall.
由医院医师治疗的住院患者通常连续工作数天，会在预定班次结束时进行交接。有证据表明，医师培训生之间的患者护理交接（即交接班）与患者不良结局有关。然而，尽管存在类似的问题，但人们对主治医生的交接与患者结局之间的关系知之甚少。
研究医院医师的住院患者交接与医疗保险受益人的住院患者死亡率之间的关系。
设计、地点和参与者：本横断面研究分析了 2011 年 1 月 1 日至 2016 年 12 月 31 日期间因一般医疗条件住院并由医院医师治疗的医疗保险受益人的随机样本。该研究比较了低概率与高概率交接的患者的结局，根据患者入院日期相对于主治医生在预定班次中的最后一个工作日的关系来确定，假设与在班次开始时入院的患者相比，在班次接近尾声时入院的患者更有可能被交接给另一位医师。数据分析于 2018 年 7 月 1 日至 2021 年 1 月 12 日进行。
低概率与高概率交接。
主要结局为患者 30 天死亡率。
共有 1074000 名患者（平均[标准差]年龄，75.9[13.7]岁；57.4%为女性；82.1%为白人）接受了研究。多变量回归模型调整了受益人的临床和人口统计学特征以及医院固定效应（院内分析，实际上比较了在同一家医院接受治疗的患者）。在 597288 次住院治疗中，与主治医生最后一个工作日的前两天（第-1 天和-2 天）入院的患者相比，在主治医生最后一个工作日前两天（第-6 天和-7 天）入院的患者在 30 天死亡率方面没有总体差异（调整后的死亡率为 10.6%；95%CI，10.5%-10.7% vs 10.6%；95%CI，10.5%-10.7%；调整后的差异，0.0%；95%CI，-0.2%至 0.1%）。然而，在一项探索性分析中，在病情严重程度较高的患者中（定义为估计死亡率处于前四分之一的患者），高概率与低概率交接的患者 30 天死亡率更高（调整后的死亡率，27.8%；95%CI，27.6%-27.9% vs 26.8%；95%CI，26.6%-27.1%；绝对调整差异，1.0%；95%CI，0.5%-1.4%）。
在这项针对医疗保险受益人的全国性分析中，这些患者因一般医疗条件住院并接受医院医师治疗，医师交接并未导致整体死亡率增加。
