Are Difficult Inpatients Also Difficult Primary Care Patients?

Patients in both inpatient and clinic settings are sometimes experienced as difficult by their providers. Among inpatients, characteristics that increase difficulty include personality disorders, length of stay, and chronic pain. Among ambulatory patients, difficulty is increased by having medically unexplained symptoms, mental disorders such as depression and anxiety, and personality disorders or chronic pain.

Our study's purpose was to explore whether patients experienced by inpatient providers as difficult are also considered difficult by their primary care providers (PCPs) and whether patients perceived as difficult have similar characteristics in the two settings.

In this prospective cohort of Veterans Affairs (VA) patients, we compared patient difficulty ratings by providers in both inpatient and primary care clinic settings. We randomly sampled hospitalized veterans and asked their inpatient and primary care providers to complete surveys assessing patient difficulty using dichotomous (yes/no) and continuous (0-10, sliding scale) questions. Inpatient providers were surveyed from April to Nov 2023 and PCPs from Jan to Sept 2024. We abstracted patient characteristics from the electronic health record.

Among 192 inpatients,161 (84%) had PCPs. PCPs completed surveys on 132 (82%) of the eligible inpatients. Sixty-seven percent of difficult inpatients were also rated as difficult by their primary care providers. Independent predictors of clinic difficulty included inpatient difficulty (OR 5.1, 95% CI 2.1-12.4), having a personality disorder (OR 4.9, 95% CI 1.1-8.5), or depression (OR 3.5, 95% CI 1.6-7.9).

Most difficult inpatients were also considered difficult by their PCPs. Personality disorders and depression increased difficulty for PCPs.