The "continuity visit" and the hospitalist model of care

Comparison of Hospital Resource Use and Outcomes Among Hospitalists, Primary Care Physicians, and Other Generalists

IMPORTANCE

A physician's prior experience caring for a patient may be associated with patient outcomes and care patterns during and after hospitalization.

OBJECTIVE

To examine differences in the use of health care resources and outcomes among hospitalized patients cared for by hospitalists, their own primary care physicians (PCPs), or other generalists.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective study analyzed admissions for the 20 most common medical diagnoses among elderly fee-for-service Medicare patients from January 1 through December 31, 2013. Patients had at least 1 previous encounter with an outpatient clinician within the 365 days before admission, and diagnoses were restricted to the 20 most common diagnosis related groups. Data were collected from Medicare Parts A and B claims data, and outcomes were analyzed from January 1, 2013, through January 31, 2014.

EXPOSURES

Physician types included hospitalists, PCPs (ie, the physicians who provided a plurality of ambulatory visits in the year preceding admission), or generalists (not the patients' PCPs).

MAIN OUTCOMES AND MEASURES

Number of in-hospital specialist consultations, length of stay, discharge site, all-cause 7- and 30-day readmission rates, and 30-day mortality.

RESULTS

A total of 560 651 admissions were analyzed (41.9% men and 59.1% women; mean [SD] age, 80 [8] years). Patients' physicians were hospitalists in 59.7% of admissions; PCPs, in 14.2%; and other generalists, in 26.1%. Primary care physicians used consultations 3% more (relative risk, 1.03; 95% CI, 1.02-1.05) and other generalists used consultations 6% more (relative risk, 1.06; 95% CI, 1.05-1.07) than hospitalists. Lengths of stay were 12% longer among patients cared for by PCPs (adjusted incidence rate ratio, 1.12; 95% CI, 1.11-1.13) and 6% longer among those cared for by other generalists (adjusted incidence rate ratio, 1.06; 95% CI, 1.05-1.07) compared with patients cared for by hospitalists. However, PCPs were more likely to discharge patients home (adjusted odds ratio [AOR], 1.14; 95% CI, 1.11-1.17), whereas other generalists were less likely to do so (AOR, 0.94; 95% CI, 0.92-0.96). Relative to hospitalists, patients cared for by PCPs had similar readmission rates at 7 days (AOR, 0.98; 95% CI, 0.96-1.01) and 30 days (AOR, 1.02; 95% CI, 0.99-1.04), whereas other generalists' readmission rates were greater than hospitalists' rates at 7 (AOR, 1.05; 95% CI, 1.02-1.07) and 30 (AOR, 1.04; 95% CI, 1.03-1.06) days. Patients cared for by PCPs had lower 30-day mortality than patients of hospitalists (AOR, 0.94; 95% CI, 0.91-0.97), whereas the mortality rate of patients of other generalists was higher (AOR, 1.09; 95% CI, 1.07-1.12).

CONCLUSIONS AND RELEVANCE

A PCP's prior experience with a patient may be associated with inpatient use of resources and patient outcomes. Patients cared for by their own PCP had slightly longer lengths of stay and were more likely to be discharged home but also were less likely to die within 30 days compared with those cared for by hospitalists or other generalists.

Use of hospitalists and office-based primary care physicians' productivity

BACKGROUND

Growth in the care of hospitalized patients by hospitalists has the potential to increase the productivity of office-based primary care physicians (PCPs) by allowing them to focus on outpatient practice.

OBJECTIVE

Our aim was to examine the association between utilization of hospitalists and the productivity of office-based PCPs.

DESIGN/PARTICIPANTS

The cross-sectional study was conducted using the 2008 Health Tracking Physician Survey Restricted Use File linked to the Area Resource File. We analyzed a total of 1,158 office-based PCPs representing a weighted total of 97,355 physicians.

MAIN MEASURES

Utilization of hospitalists was defined as the percentage of a PCP's hospitalized patients treated by a hospitalist. The measures of PCPs' productivity were: (1) number of hospital visits per week, (2) number of office and outpatient clinic visits per week, and (3) direct patient care time per visit.

KEY RESULTS

We found that the use of hospitalists was significantly associated with a decreased number of hospital visits. The use of hospitalists was also associated with an increased number of office visits, but this was only significant for high users. Physicians who used hospitalists for more than three-quarters of their hospitalized patients had an extra 8.8 office visits per week on average (p = 0.05), which was equivalent to a 10 % increase in productivity over the predicted mean of 87 visits for physicians who did not use hospitalists. We did not find any significant differences in direct patient care time per visit.

CONCLUSIONS

Our study demonstrates that the increase in productivity for the one-third of PCPs who use hospitalists extensively may not be sufficient to offset the current loss of PCP workforce. However, our findings provide cautious optimism that if more PCPs effectively and efficiently used hospitalists, this could help mitigate a PCP shortage and improve access to primary care services.

Communicating with clinicians: the experiences of surrogate decision-makers for hospitalized older adults

OBJECTIVES

To describe communication experiences of surrogates who had recently made a major medical decision for a hospitalized older adult.

DESIGN

Semistructured interviews about a recent hospitalization.

SETTING

Two hospitals affiliated with one large medical school: an urban public hospital and a university-affiliated tertiary referral hospital.

PARTICIPANTS

Surrogates were eligible if they had recently made a major medical decision for a hospitalized individual aged 65 and older and were available for an interview within 1 month (2-5 months if the patient died).

MEASUREMENTS

Interviews were audio-recorded, transcribed, and analyzed using methods of grounded theory.

RESULTS

Thirty-five surrogates were interviewed (80% female, 44% white, 56% African American). Three primary themes emerged. First, it was found that the nature of surrogate-clinician relationships was best characterized as a relationship with a "team" of clinicians rather than individual clinicians because of frequent staff changes and multiple clinicians. Second, surrogates reported their communication needs, including frequent communication, information, and emotional support. Surrogates valued communication from any member of the clinical team, including nurses, social workers, and physicians. Third, surrogates described trust and mistrust, which were formed largely through surrogates' communication experiences.

CONCLUSION

In the hospital, surrogates form relationships with a "team" of clinicians rather than with individuals, yet effective communication and expressions of emotional support frequently occur, which surrogates value highly. Future interventions should focus on meeting surrogates' needs for frequent communication and high levels of information and emotional support.

A conceptual model of the role of communication in surrogate decision making for hospitalized adults

OBJECTIVE

To build a conceptual model of the role of communication in decision making, based on literature from medicine, communication studies and medical ethics.

METHODS

We proposed a model and described each construct in detail. We review what is known about interpersonal and patient-physician communication, described literature about surrogate-clinician communication, and discussed implications for our developing model.

RESULTS

The communication literature proposes two major elements of interpersonal communication: information processing and relationship building. These elements are composed of constructs such as information disclosure and emotional support that are likely to be relevant to decision making. We propose these elements of communication impact decision making, which in turn affects outcomes for both patients and surrogates. Decision making quality may also mediate the relationship between communication and outcomes.

CONCLUSION

Although many elements of the model have been studied in relation to patient-clinician communication, there is limited data about surrogate decision making. There is evidence of high surrogate distress associated with decision making that may be alleviated by communication-focused interventions. More research is needed to test the relationships proposed in the model.

PRACTICE IMPLICATIONS

Good communication with surrogates may improve both the quality of medical decisions and outcomes for the patient and surrogate.

The ethics of the hospitalist model

The hospitalist model was founded on the premise that it could improve the quality and reduce the cost of hospital care. Many randomized studies have all but definitively proven this original assertion. Nevertheless, the hospitalist specialty raises lingering classical ethical issues: protecting the patient-physician relationship in an environment of increasing specialization and discontinuity of care, preserving patient autonomy and choice when structural changes are made in the provision of care, and ensuring that a model founded on efficiency and cost-effectiveness does not erode the public trust in hospitalists to always serve their patients' best interests. This work aims to serve as an update of these initial criticisms, showing how some questions have been answered, while some have not.

Physicians' experience with surrogate decision making for hospitalized adults

BACKGROUND

Hospitalized patients frequently lack decision-making ability, yet little is known about physicians' approaches to surrogate decision making.

OBJECTIVE

To describe physicians' experiences with surrogate communication and decision making for hospitalized adults.

DESIGN

Cross-sectional written survey.

PARTICIPANTS

Two hundred eighty-one physicians who recently cared for adult inpatients in one academic and two community hospitals.

MEASUREMENTS

Key features of physicians' most recent surrogate decision-making experience, including the nature of the decision, the physician's reaction, physician-surrogate communication and physician-surrogate agreement about the best course of action.

RESULTS

Nearly three fourths of physicians (73%, n = 206) had made a major decision with a surrogate during the past month. Although nearly all patients (90%) had a surrogate, physicians reported trouble contacting the surrogate in 21% of cases. Conflict was rare (5%), and a majority of physicians agreed with surrogates about the medical facts (77%), prognosis (72%) and best course of action (65%). After adjustment for patient, physician and decision characteristics, agreement about the best course of action was more common among surrogates for older patients [prevalence ratio (PR) = 1.17 for each decade; 95% confidence interval (CI) 1.02-1.31], ICU patients (PR = 1.40; CI 1.14-1.51) and patients who had previously discussed their wishes (PR = 1.60; CI 1.30-1.76), and less common when surrogates were difficult to contact (PR = 0.59; CI 0.29-0.92) or when the physician self-identified as Asian (PR = 0.60; CI 0.30-0.94).

CONCLUSION

Surrogate decision making is common among hospitalized adults. Physician-surrogate decision making may be enhanced if patients discuss their preferences in advance and if physician contact with surrogate decision makers is facilitated.

Pediatric hospitalists and primary care providers: a communication needs assessment

BACKGROUND/OBJECTIVE

Existing research on hospitalist-primary care provider (PCP) communication focuses mainly on adult hospitalist models with little known about the quality of current pediatric hospitalist-PCP communication. Our objective was to perform a needs assessment by exploring important issues around communication between pediatric hospitalists and PCPs.

METHODS

Six previously identified issues around hospitalist-PCP communication from the adult hospitalist literature were abstracted and incorporated into an open-ended and closed-ended questionnaire. The questionnaire was pretested, revised, and administered by phone to 10 pediatric hospitalists and 12 pediatric PCPs residing in our 5-state catchment area. Interviews were transcribed and openly coded, and themes compared using qualitative methods.

RESULTS

The 6 identified issues were: quality of communication, barriers to communication, methods of information sharing, key data element requirements, critical timing, and perceived benefits. Hospitalists and PCPs rated overall quality of communication from "poor" to "very good." Both groups acknowledge that significant barriers to optimal communication currently exist, yet the barriers differ for each group. Hospitalists and PCPs agree on what information is important to transmit (diagnoses, medications, follow-up needs, and pending laboratory test results) and critical times for communication during the hospitalization (at discharge, admission, and during major clinical changes). Both groups also agree that optimal communication could improve many aspects of patient care.

CONCLUSIONS

Identifying and addressing barriers to these 6 issues may help both hospitalists and PCPs implement targeted interventions aimed at improving communication. Future studies will need to demonstrate the link between improved hospitalist-PCP communication and improved patient care and outcomes.

Do hospitalists or physicians with greater inpatient HIV experience improve HIV care in the era of highly active antiretroviral therapy? Results from a multicenter trial of academic hospitalists

BACKGROUND

Little is known about the effect of provider type and experience on outcomes, resource use, and processes of care of hospitalized patients with human immunodeficiency virus (HIV) infection. Hospitalists are caring for this population with increasing frequency.

METHODS

Data from a natural experiment in which patients were assigned to physicians on the basis of call cycle was used to study the effects of provider type-that is, hospitalist versus nonhospitalist-and HIV-specific inpatient experience on resource use, outcomes, and selected measures of processes of care at 6 academic institutions. Administrative data, inpatient interviews, 30-day follow-up interviews, and the National Death Index were used to measure outcomes.

RESULTS

A total of 1207 patients were included in the analysis. There were few differences in resource use, outcomes, and processes of care by provider type and experience with HIV-infected inpatients. Patients who received hospitalist care demonstrated a trend toward increased length of hospital stay compared with patients who did not receive hospitalist care (6.0 days vs. 5.2 days; P = .13). Inpatient providers with moderate experience with HIV-infected patients were more likely to coordinate care with outpatient providers (odds ratio, 2.40; P = .05) than were those with the least experience with HIV-infected patients, but this pattern did not extend to providers with the highest level of experience.

CONCLUSION

Provider type and attending physician experience with HIV-infected inpatients had minimal effect on the quality of care of HIV-infected inpatients. Approaches other than provider experience, such as the use of multidisciplinary inpatient teams, may be better targets for future studies of the outcomes, processes of care, and resource use of HIV-infected inpatients.