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Van Groningen N, Mosenifar Z, Sax HC, Friedman R, Kim S, Nuckols TK. "Physician Advocates": a novel strategy for improving the value of hospital care by employing hospitalists part time to support non-hospitalist physicians. Hosp Pract (1995) 2022; 50:17-26. [PMID: 35179433 DOI: 10.1080/21548331.2022.2044702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND OBJECTIVE At many hospitals, private-practice physicians still admit their own patients and are accustomed to autonomy in clinical practice. This creates challenges for hospital's efforts to improve the efficiency, quality, and value of care. Experienced inpatient-focused physicians-"Physician Advocates"-could act as liaisons between private practitioners and the fast-paced inpatient microsystem. METHODS We conducted a controlled pre-post ("differences-in-differences") analysis at an academic medical center where private-practice physicians care for about 40% of medical inpatients and hospitalist groups care for 60%. In the intervention, "Physician Advocates" participated in daily multidisciplinary "Progression of Care Rounds," offering suggestions to increase care quality for private-practice physicians' patients. Controls were cared for by a large, well-established hospitalist group, which convened separate, unchanged multidisciplinary rounds. Outcomes were length of stay (LOS; primary outcome), 30-day readmissions, and inpatient mortality. RESULTS In a risk-adjusted analysis of 31,632 medical inpatients, LOS declined by 4 hours more from the baseline period to the post-intervention period in the intervention group relative to the control group (ratio: 0.96, 95% CI: 0.93-0.99, p=0.004). Readmissions declined 22% more in the intervention group (OR: 0.78, 95% CI: 0.63-0.97, p=0.023). Mortality was unchanged (OR: 1.23, 95% CI: 0.78-1.93 p-value=0.378). CONCLUSION Among inpatients cared for by private practitioners, adding Physician Advocates to multidisciplinary rounds was associated with improved LOS and reduced readmissions-measures of efficiency and value. The Physician Advocates approach should be tested in diverse health systems because it allows hospitals to leverage the expertise of on-site clinicians while respecting the traditional private-practice care model, in which primary care physicians manage their hospitalized patients.
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Affiliation(s)
| | | | - Harry C Sax
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Sungjin Kim
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Salim SA, Elmaraezy A, Pamarthy A, Thongprayoon C, Cheungpasitporn W, Palabindala V. Impact of hospitalists on the efficiency of inpatient care and patient satisfaction: a systematic review and meta-analysis. J Community Hosp Intern Med Perspect 2019; 9:121-134. [PMID: 31044043 PMCID: PMC6484472 DOI: 10.1080/20009666.2019.1591901] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 03/01/2019] [Indexed: 12/29/2022] Open
Abstract
Background: Over the past 20 years, hospitalists have assumed a greater portion of healthcare service for hospitalized patients. This was mainly due to reducing the length of stay (LOS) and hospital costs shown by many studies. In contrast, other studies suggested increased cost and resources utilization associated with hospitalist-run care models. Aim: We aimed to provide class 1 evidence regarding the effect of hospitalist-run care models on the efficiency of care and patient satisfaction. Design: Meta-analysis. Methods: Four electronic medical databases were searched to retrieve all relevant studies. Two authors screened titles and abstracts of search results for eligibility according to predefined criteria. Initially eligible studies were screened for full text inclusion. Included studies were reviewed for data on LOS, hospital cost, readmission, mortality, and patient satisfaction. Available data were abstracted and analyzed using Comprehensive Meta-Analysis. Results: Sixty-one studies were included for analysis. The overall effect size favored hospitalist-run care models in terms of LOS (MD = -0.67 day, 95% CI [-0.78, -0.56], p < 0.001). There was no significant difference in terms of hospital cost (MD = $92.1, 95% CI [-910.4, 1094.6], p = 0.86) whereas patient satisfaction was similar or even better in hospitalist compared to non-hospitalist (NH) service. Conclusion: Our analysis showed that hospitalist care is associated with decreased LOS and increased patient satisfaction compared to NH. This indicates an increase in the efficiency of care that does not come at the expense of care quality.
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Affiliation(s)
- Sohail Abdul Salim
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Ahmed Elmaraezy
- Global Clinical Scholars Research Training (GCSRT) Program, Harvard Medical School, Boston, MA, USA.,Faculty of Medicine, Al-Azhar University, Cairo, Egypt.,Al-Razi Medical Research Academy, Cairo, Egypt
| | - Amaleswari Pamarthy
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS, USA
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Padula WV, Millis MA, Worku AD, Pronovost PJ, Bridges JFP, Meltzer DO. Individualized cost-effectiveness analysis of patient-centered care: a case series of hospitalized patient preferences departing from practice-based guidelines. J Med Econ 2017; 20:288-296. [PMID: 27786569 DOI: 10.1080/13696998.2016.1254091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To develop cases of preference-sensitive care and analyze the individualized cost-effectiveness of respecting patient preference compared to guidelines. METHODS Four cases were analyzed comparing patient preference to guidelines: (a) high-risk cancer patient preferring to forgo colonoscopy; (b) decubitus patient preferring to forgo air-fluidized bed use; (c) anemic patient preferring to forgo transfusion; (d) end-of-life patient requesting all resuscitative measures. Decision trees were modeled to analyze cost-effectiveness of alternative treatments that respect preference compared to guidelines in USD per quality-adjusted life year (QALY) at a $100,000/QALY willingness-to-pay threshold from patient, provider and societal perspectives. RESULTS Forgoing colonoscopy dominates colonoscopy from patient, provider, and societal perspectives. Forgoing transfusion and air-fluidized bed are cost-effective from all three perspectives. Palliative care is cost-effective from provider and societal perspectives, but not from the patient perspective. CONCLUSION Prioritizing incorporation of patient preferences within guidelines holds good value and should be prioritized when developing new guidelines.
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Affiliation(s)
- William V Padula
- a Department of Health Policy & Management , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - M Andrew Millis
- b Pritzker School of Medicine , University of Chicago , Chicago , IL , USA
| | - Aelaf D Worku
- c Section of Hospital Medicine, University of Chicago , Chicago , IL , USA
- d CareMore Health Plan , Las Vegas , NV , USA
| | - Peter J Pronovost
- e Departments of Anesthesiology , Critical Care and Surgery, Johns Hopkins School of Medicine , Baltimore , MD , USA
| | - John F P Bridges
- a Department of Health Policy & Management , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - David O Meltzer
- c Section of Hospital Medicine, University of Chicago , Chicago , IL , USA
- f Center for Health and the Social Sciences (CHeSS), University of Chicago , Chicago , IL , USA
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Meltzer DO, Ruhnke GW. Redesigning care for patients at increased hospitalization risk: the Comprehensive Care Physician model. Health Aff (Millwood) 2015; 33:770-7. [PMID: 24799573 DOI: 10.1377/hlthaff.2014.0072] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Patients who have been hospitalized often experience care coordination problems that worsen outcomes and increase costs. One reason is that hospital care and ambulatory care are often provided by different physicians. However, interventions to improve care coordination for hospitalized patients have not consistently improved outcomes and generally have not reduced costs. We describe the rationale for the Comprehensive Care Physician model, in which physicians focus their practice on patients at increased risk of hospitalization so that they can provide both inpatient and outpatient care to their patients. We also describe the design and implementation of a study supported by the Center for Medicare and Medicaid Innovation to assess the model's effects on costs and outcomes. Evidence concerning the effectiveness of the program is expected by 2016. If the program is found to be effective, the next steps will be to assess the durability of its benefits and the model's potential for dissemination; evidence to the contrary will provide insights into how to alter the program to address sources of failure.
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Teno J, Meltzer DO, Mitchell SL, Fulton AT, Gozalo P, Mor V. Type of attending physician influenced feeding tube insertions for hospitalized elderly people with severe dementia. Health Aff (Millwood) 2015; 33:675-82. [PMID: 24711330 DOI: 10.1377/hlthaff.2013.1248] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Striking variation has been documented in the rates of feeding tube insertion for hospitalized patients with advanced dementia. This occurs despite the harms of the procedure, which may outweigh its benefits, and the procedure's inconsistency with care focused on the patient's comfort. Among nursing home residents with advanced dementia who were hospitalized in 2001-10 with an infection or dehydration, we found that rates of insertion of a percutaneous endoscopic gastrostomy feeding tube varied by type of attending physician. Insertion rates were markedly lower when all of a patient's attending physicians were hospitalists (1.6 percent) or nonhospitalist generalists (2.2 percent), compared to all subspecialists (11.0 percent) or a mixture of physicians by type, which typically included a subspecialist (15.6 percent). The portion of patients seen by a mixture of attending physicians increased from 28.9 percent in 2001 to 38.3 percent in 2010. Efforts to improve decision making in the care of patients with advanced dementia should include interventions to improve communication among physicians and the education of subspecialists about the merits of using feeding tubes with this population.
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Affiliation(s)
- David O Meltzer
- Department of Medicine Section of Hospital Medicine, Harris School of Public Policy Studies, and the Department of Economics, The University of Chicago, 5841 S Maryland MC 5000, Chicago, IL, 60637, USA,
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Schaffer AC, Puopolo AL, Raman S, Kachalia A. Liability impact of the hospitalist model of care. J Hosp Med 2014; 9:750-5. [PMID: 25331989 DOI: 10.1002/jhm.2244] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 07/15/2014] [Accepted: 07/19/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND An increasingly large proportion of inpatient care is provided by hospitalists. The care discontinuities inherent to hospital medicine raise concerns about malpractice risk. However, little published data exist on the medical liability risks associated with care by hospitalists. OBJECTIVE We sought to determine the risks and outcomes of malpractice claims against hospitalists in internal medicine. DESIGN Retrospective observational analysis. MEASUREMENTS Using claims data from a liability insurer-maintained database of over 52,000 malpractice claims, we measured the rates of malpractice claims against hospitalists compared to other physician specialties, types of allegations against hospitalists, contributing factors, and the severity of injury in and outcomes of these claims. RESULTS Hospitalists had a malpractice claims rate of 0.52 claims per 100 physician coverage years (PCYs), which was significantly lower than that of nonhospitalist internal medicine physicians (1.91 claims per 100 PCYs), emergency medicine physicians (3.50 claims per 100 PCYs), general surgeons (4.70 claims per 100 PCYs), and obstetricians-gynecologists (5.56 claims per 100 PCYs) (P < 0.001 for all comparisons). The most common allegation types made against hospitalists were for errors in medical treatment (41.5%) and diagnosis (36.0%). The most common contributing factors underlying claims were deficiencies in clinical judgment (54.4%) and communication (36.4%). Of the claims made against hospitalists, 50.4% involved the death of the patient. CONCLUSIONS Despite fears of increased liability from the hospitalist model of care, hospitalists in internal medicine are subject to medical malpractice claims less frequently when compared to other internal medicine physicians and specialties.
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Affiliation(s)
- Adam C Schaffer
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Probasco JC, George BP, Dorsey ER, Venkatesan A. Neurohospitalists: perceived need and training requirements in academic neurology. Neurohospitalist 2014; 4:9-17. [PMID: 24381705 PMCID: PMC3869308 DOI: 10.1177/1941874413495880] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND PURPOSE We sought to determine the current practices and plans for departmental hiring of neurohospitalists at academic medical centers and to identify the core features of a neurohospitalist training program. METHODS We surveyed department chairs or residency program directors at 123 Accreditation Council for Graduate Medical Education (ACGME)-accredited US adult neurology training programs. RESULTS Sixty-three(51% response rate) responded, 76% of whom were program directors. In all, 24 (38%) academic neurology departments reported employing neurohospitalists, and an additional 10 departments have plans to hire neurohospitalists in the next year. In all, 4 academic neurology departments have created a neurohospitalist training program, and 10 have plans to create a training program within the next 2 years. Hospitals were the most frequent source of funding for established and planned programs (93% of those reporting). Most (n = 39; 65%) respondents felt that neurohospitalist neurology should be an ACGME-accredited fellowship. The highest priority neurohospitalist training elements among respondents included stroke, epilepsy, and consult neurology as well as patient safety and cost-effective inpatient care. The most important procedural skills for a neurohospitalist, as identified by respondents, include performance of brain death evaluations, lumbar punctures, and electroencephalogram interpretation. CONCLUSIONS Neurohospitalists have emerged as subspecialists within neurology, growing both in number and in scope of responsibilities in practice. Neurohospitalists are in demand among academic departments, with many departments developing their existing presence or establishing a new presence in the field. A neurohospitalist training program may encompass training in stroke, epilepsy, and consult neurology with additional focus on patient safety and cost-effective care.
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Affiliation(s)
- John C. Probasco
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Benjamin P. George
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - E. Ray Dorsey
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Arun Venkatesan
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Goodwin JS, Lin YL, Singh S, Kuo YF. Variation in length of stay and outcomes among hospitalized patients attributable to hospitals and hospitalists. J Gen Intern Med 2013; 28:370-6. [PMID: 23129162 PMCID: PMC3579964 DOI: 10.1007/s11606-012-2255-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 09/26/2012] [Accepted: 10/03/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND There have been no prior population-based studies of variation in performance of hospitalists. OBJECTIVE To measure the variation in performance of hospitalists. DESIGN Retrospective research design of 100 % Texas Medicare data using multilevel, multivariable models. SUBJECTS 131,710 hospitalized patients cared for by 1,099 hospitalists in 268 hospitals from 2006-2009. MAIN MEASURES We calculated, for each hospitalist, adjusted for patient and disease factors (case mix), their patients' average length of stay, rate of discharge home or to skilled nursing facility (SNF) and rate of 30-day mortality, readmissions and emergency room (ER) visits. KEY RESULTS In two-level models (admission and hospitalist), there was significant variation in average length of stay and discharge location among hospitalists, but very little variation in 30-day mortality, readmission or emergency room visit rates. There was stability over time (2008-2009 vs. 2006-2007) in hospitalist performance. In three-level models including admissions, hospitalists and hospitals, the variation among hospitalists was substantially reduced. For example, hospitals, hospitalists and case mix contributed 1.02 %, 0.75 % and 42.15 % of the total variance in 30-day mortality rates, respectively. CONCLUSIONS There is significant variation among hospitalists in length of stay and discharge destination of their patients, but much of the variation is attributable to the hospitals where they practice. The very low variation among hospitalists in 30-day readmission rates suggests that hospitalists are not important contributors to variations in those rates among hospitals.
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Affiliation(s)
- James S Goodwin
- Department of Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA.
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Wild DMG, Kwon N, Dutta S, Tessier-Sherman B, Woddor N, Sipsma HL, Rizzo T, Bradley EH. Who's behind an HCAHPS score? Jt Comm J Qual Patient Saf 2011; 37:461-8. [PMID: 22013820 DOI: 10.1016/s1553-7250(11)37059-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) survey asks patients how frequently their physicians treated them with courtesy and respect, listened carefully, and explained things in a way they could understand. Such summary reports may obscure differences among the types of physicians involved. A study was conducted to examine the association between ratings for different physician types and the overall HCAHPS rating of physicians. METHODS A mixed-methods study included closed-ended surveys and in-depth interviews of patients on a hospitalist teaching service. The three HCAHPS physician communication items were used to interview patients about their communication experiences with emergency medicine (EM) physicians, hospitalists, and specialists. The association between the overall score and the scores of each physician type was examined using Spearman correlation coefficients and linear regression. Qualitative data from additional in-depth interviews were analyzed using the constant comparative method to identify recurrent themes. RESULTS Ninety-six patients were recruited for the survey, and additional in-depth interviews were conducted with the first 30 patients. Hospitalist and specialist scores were significantly associated (p values < .05) with overall scores. Recurrent themes regarding determinants of patients' ratings were categorized in three broad domains: individual physician behavior, team communication, and system issues. The influence of each domain differed across physician types. DISCUSSION Physician communication scores may be most strongly influenced by patient experiences with hospitalists and specialists rather than with EM physicians. Several team communication and system issues represent opportunities for improving physician communication.
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Hinami K, Whelan CT, Konetzka RT, Edelson DP, Casalino LP, Meltzer DO. Effects of provider characteristics on care coordination under comanagement. J Hosp Med 2010; 5:508-13. [PMID: 20635410 DOI: 10.1002/jhm.797] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Care coordination is critical in settings characterized by high levels of uncertainty, time constraints, and interdependent work processes. The effects of provider characteristics on coordination in comanaged teams has never been examined. OBJECTIVE To characterize individual providers based on their contribution to team coordination. PARTICIPANTS Hospitalists, nonphysician providers, hepatologists, and fellows on a comanaged liver service of an academic hospital. DESIGN Between April 2008 and October 2008, participants were surveyed at baseline and repeatedly at the completion of physician rotations to assess their preferred and actual comanagement structures. In addition, they repeatedly rated their comanagers' contributions to overall coordination using an instrument that assessed relational coordination (RC). Providers were categorized into tertiles of RC. Their management preferences and the frequency of a "composite bad outcome" (intensive care unit [ICU] transfer or inpatient death) in each tertile were evaluated. RESULTS All (100%) Baseline Surveys and 177/224 (79%) Repeated Surveys were completed by 32 providers. RC was shown to be a stable attribute of providers and not of adverse patient outcomes. Higher coordinators were characterized by their "ownership of patients" (higher 86% vs. lowest 20%, P < 0.01). High compared to low coordinator hepatologists demonstrated leadership through a broader delegation of tasks as well as self-assignment of responsibilities. A trend toward more frequent "composite bad outcomes" was seen for low tertile physicians: hospitalists (low 8.6% vs. high 1.1%, P < 0.01), hepatologists (low 5.2% vs. high 2.0%, P = 0.22), fellows (low 5.8% vs. high 1.8%, P = 0.08). CONCLUSION Individual provider's teamwork-related disposition affects perceived coordination on comanaged team and may influence patient outcomes.
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Affiliation(s)
- Keiki Hinami
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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Meltzer DO, Chung JW. U.S. trends in hospitalization and generalist physician workforce and the emergence of hospitalists. J Gen Intern Med 2010; 25:453-9. [PMID: 20352367 PMCID: PMC2855010 DOI: 10.1007/s11606-010-1276-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Revised: 12/17/2009] [Accepted: 01/21/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND General internists and other generalist physicians have traditionally cared for their patients during both ambulatory visits and hospitalizations. It has been suggested that the expansion of hospitalists since the mid-1990s has "crowded out" generalists from inpatient care. However, it is also possible that declining hospital utilization relative to the size of the generalist workforce reduced the incentives for generalists to continue providing hospital care. OBJECTIVE To examine trends in hospital utilization and the generalist workforce before and after the emergence of hospitalists in the U.S. and to investigate factors contributing to these trends. DESIGN Using data from 1980-2005 on inpatient visits from the National Hospital Discharge Survey, and physician manpower data from the American Medical Association, we identified national trends before and after the emergence of hospitalists in the annual number of inpatient encounters relative to the number of generalists. RESULTS Inpatient encounters relative to the number of generalists declined steadily before the emergence of hospitalists. Declines in inpatient encounters relative to the number of generalists were driven primarily by reduced hospital length of stay and increased numbers of generalists. CONCLUSIONS Hospital utilization relative to generalist workforce declined before the emergence of hospitalists, largely due to declining length of stay and rising generalist workforce. This likely weakened generalist incentives to provide hospital care. Models of care that seek to preserve dual-setting generalist care spanning ambulatory and inpatient settings are most likely to be viable if they focus on patients at high risk of hospitalization.
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Affiliation(s)
- David O Meltzer
- Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, IL 60637, USA.
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Dynan L, Stein R, David G, Kenny LC, Eckman M, Short AD. Determinants of Hospitalist Efficiency. Med Care Res Rev 2009; 66:682-702. [DOI: 10.1177/1077558709338484] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Using qualitative and quantitative methods, the authors develop and test hypotheses about the impact of hospitalists on efficiency and quality of care relative to teaching teams. Departure of actual from self-perceived benefits for hospitalists, both individually and collectively, is studied. It was found that hospitalists are, on average, more efficient diagnosticians and/or enhance throughput, as evidenced by having relatively lower charges, through reductions in testing and length-of-stay, than teaching teams. Much of that benefit is concentrated among patients admitted by intensivists. The authors find little evidence of quality focus or of greater use of community resources among hospitalists. Indeed, hospitalists were found to have no effect on the choice of postdischarge outlets. The authors document variation in care delivery among hospitalists. In particular, it was found that among hospitalists there is more variation in achieving shorter length of stay but less variation in use of diagnostic testing.
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Affiliation(s)
- Linda Dynan
- Northern Kentucky University, Highland Heights
| | | | - Guy David
- University of Pennsylvania, Philadelphia
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Burns LR, Muller RW. Hospital-physician collaboration: landscape of economic integration and impact on clinical integration. Milbank Q 2008; 86:375-434. [PMID: 18798884 PMCID: PMC2690342 DOI: 10.1111/j.1468-0009.2008.00527.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
CONTEXT Hospital-physician relationships (HPRs) are an important area of academic research, given their impact on hospitals' financial success. HPRs also are at the center of several federal policy proposals such as gain sharing, bundled payments, and pay-for-performance (P4P). METHODS This article analyzes the HPRs that focus on the economic integration of hospitals and physicians and the goals that HPRs are designed to achieve. It then reviews the literature on the impact of HPRs on cost, quality, and clinical integration. FINDINGS The goals of the two parties in HPRs overlap only partly, and their primary aim is not reducing cost or improving quality. The evidence base for the impact of many models of economic integration is either weak or nonexistent, with only a few models of economic integration having robust effects. The relationship between economic and clinical integration also is weak and inconsistent. There are several possible reasons for this weak linkage and many barriers to further integration between hospitals and physicians. CONCLUSIONS Successful HPRs may require better financial conditions for physicians, internal changes to clinical operations, application of behavioral skills to the management of HPRs, changes in how providers are paid, and systemic changes encompassing several types of integration simultaneously.
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Affiliation(s)
- Lawton Robert Burns
- Wharton Center for Health Management and Economics, Wharton School, University of Pennsylvania, Philadelphia, PA 19104-6218, USA.
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Cebul RD, Rebitzer JB, Taylor LJ, Votruba ME. Organizational fragmentation and care quality in the U.S healthcare system. THE JOURNAL OF ECONOMIC PERSPECTIVES : A JOURNAL OF THE AMERICAN ECONOMIC ASSOCIATION 2008; 22:93-113. [PMID: 19791306 DOI: 10.1257/jep.22.4.93] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Many goods and services can be readily provided through a series of unconnected transactions, but in health care, close coordination over time and within care episodes improves both health outcomes and efficiency. Close coordination is problematic in the U.S. healthcare system because the financing and delivery of care is distributed across a variety of distinct and often competing entities, each with its own objectives, obligations, and capabilities. These fragmented organizational structures lead to disrupted relationships, poor information flows, and misaligned incentives that combine to degrade care quality and increase costs. We illustrate our argument with examples taken from the insurance and hospital industries, and discuss possible responses to the problems resulting from organizational fragmentation.
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Affiliation(s)
- Randall D Cebul
- Center for Health Care Research & Policy, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
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Abstract
The traditional pattern of medical practice is a combination of outpatient and inpatient care. There has been a recent trend for many specialties to separate this care, concentrating on only one of these spheres. A clinician caring only for inpatients is a Hospitalist. The care pattern for airway and swallowing disease adopted at the University of Maryland Hospital is in the form of the laryngology hospitalist. This new surgical specialty is a hybrid of an airway surgery subspecialist and a pure hospitalist. It offers an array of advantages to patients and colleague clinicians. One advantage is that of ubiquitous availability, which offers obvious safety benefits to patients with airway patency problems. Other advantages include the potential for consistent in-depth collaboration with other clinicians such as emergency room physicians, intensivists, neurologists/neurosurgeons, pulmonologists, gastroenterologists, speech and language pathologists, and radiologists. Financial benefits to the clinician include a more favorable ratio of operative disease versus total patient contacts. Benefits to third-party payers include the more efficient and timely delivery of care in the context of an inpatient stay.
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Affiliation(s)
- Paul Castellanos
- Center for Voice, Swallowing, and Esophageal Disorders, North Hospital, University of Maryland Hospital System, Baltimore, 21201, USA.
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