Assessment of Care Handoffs Among Hospitalist Physicians and 30-Day Mortality in Hospitalized Medicare Beneficiaries

Key Points

Question

What is the association between inpatient physician handoff and mortality among hospitalized Medicare patients?

Findings

In a national cross-sectional study of Medicare beneficiaries hospitalized with a general medical condition and treated by a hospitalist physician, physician handoff was not associated with increased mortality overall. In an exploratory analysis, among patients in the top quartile of estimated mortality, 30-day mortality was higher for patients with high vs low likelihood of handoff.

Meaning

These findings suggest that among Medicare patients hospitalized with a general medical condition and treated by a hospitalist physician, inpatient physician handoffs appear safe overall but may be associated with slightly higher mortality among high-risk patients.

Abstract

Importance

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.

Objective

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.

Exposure

High vs low probability of physician handoff.

Main Outcomes and Measures

The main outcome was patient 30-day mortality rate.

Results

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%).

Conclusions and Relevance

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.

Abstract

This cross-sectional study examines the association between inpatient handoffs among hospitalist physicians and patient mortality among hospitalized Medicare beneficiaries.