The value of a hospitalist service: efficient care for the aging population?

Effects of a Dedicated Inpatient Diabetes Management Service on Glycemic Control in a Community Hospital Setting

BACKGROUND

Community hospitals account for over 84% of all hospitals and over 94% of hospital admissions in the United States. In academic settings, implementation of an Inpatient Diabetes Management Service (IDMS) model of care has been shown to reduce rates of hyper- and hypoglycemia, hospital length of stay (LOS), and associated hospital costs. However, few studies to date have evaluated the implementation of a dedicated IDMS in a community hospital setting.

METHODS

This retrospective study examined the effects of changing the model of inpatient diabetes consultations from a local, private endocrine practice to a full-time endocrine hospitalist on glycemic control, LOS, and 30-day readmission rates in a 267-bed community hospital.

RESULTS

Overall diabetes patient days for the hospital were similar pre- and post-intervention (20,191 vs 20,262); however, the volume of patients seen by IDMS increased significantly after changing models. Rates of hyperglycemia decreased both among patients seen by IDMS (53.8% to 42.5%, P < .0001) and those not consulted on by IDMS (33.2% to 29.9%; P < .0001). When examined over time, rates of hypoglycemia steadily decreased in the 24 months after dedicated IDMS initiation (P = .02); no such time effect was seen prior to IDMS (P = .34). LOS and 30DRR were not significantly different between IDMS models.

CONCLUSIONS

Implementation of an endocrine hospitalist-based IDMS at a community hospital was associated with significantly decreased hyperglycemia, while avoiding concurrent increases in hypoglycemia. Further studies are needed to investigate whether these effects are associated with improvements in clinical outcomes, patient or staff satisfaction scores, or total cost of care.

Assessing the Effects of Important Factors and Province Heterogeneity on Different Quantiles of Hospitalization Cost

Objectives: The aim of the study was to investigate the effects of some covariates on different quantiles of the cost of hospitalization. The effect of the province that the individual belongs to on these quantiles will be also examined.Methods: We employed a linear quantile-mixed model (LQMM) for analyzing the cost of hospitalization in Iranians Utilization of Health Services (IUHS) survey considering the province effect, the effects of some important covariates, and also the effect of the choice of the random-effects distribution. For this, both classical and Bayesian approaches are used for parameter estimation.Results: The results of data analysis show that ward, type of hospital, and duration of hospitalization are significant factors on quantiles of the cost of hospitalization, of course with different impacts on different quantiles. Our findings reveal significant discrepancies in the cost of hospitalization in different provinces and significant heterogeneity among provinces.Conclusion: More works must be done related to hospitalization cost and its consequences since it is a matter of social life. To be exact, one should notice that provinces with hospitals involving high hospitalization costs may have households dealing with poverty.

The Effect of Hospitalists on Average Length of Stay

EXECUTIVE SUMMARY

Hospitals experiencing financial pressures are seeking to gain efficiencies through innovation. One solution is to engage hospitalists to help reduce the average length of stay (ALOS). This study considers whether and to what extent hospitalists affect ALOS and whether an association exists between the number of hospitalists per occupied bed (density) and ALOS. We examined 2,858 hospitals nationwide, including 20,180 hospital-years of data from 2007 through 2015 derived from the American Hospital Association Annual Survey database. Key findings showed that hospitals using hospitalists reported a statistically significant shorter ALOS than hospitals without hospitalists. The results also indicated a statistically significant decrease in ALOS for an increase in hospitalist full-time equivalent per occupied bed. This study is important because of the generalizability of its results and suggests that hospitals may form partnerships with hospitalists to improve hospital efficiency.

Impact of hospitalists on the efficiency of inpatient care and patient satisfaction: a systematic review and meta-analysis

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.

Impact of Inpatient Consults by a Family Medicine Teaching Service

OBJECTIVES

Inpatient consult rates by family physicians significantly affect many aspects of medical care. Limited research has investigated the consultant rate by family medicine residents and their impact on length of stay (LOS) and direct cost. This study examines the inpatient consultant rate of family medicine residents.

METHODS

We conducted a retrospective electronic chart review of consults associated with hospitalizations on a family medicine teaching service at a large academic medical center during a 12-month period. The primary outcome was the consultant rate. Multivariate regressions were used to predict outcomes of LOS and direct costs while controlling for patient severity with the Charlson Comorbidity Index.

RESULTS

For hospitalized adults on a family medicine teaching service, almost 1 in 2 receives some type of consult (47%), with more than half of those (52%) to physician specialists as opposed to ancillary services. The top physician consults were to cardiology, infectious disease, and gastroenterology. LOS as well as cost significantly increased with any type of consult. After controlling for severity, consults to physician specialists (as opposed to ancillary services) had the greatest impact on LOS and cost.

CONCLUSIONS

Each consult placed for hospitalized adults on a family medicine teaching service resulted in an increase in LOS and direct cost, even after controlling for patient severity. Further analysis to ensure that appropriate referrals are being placed and that residents are receiving full-scope training is needed to ensure primary care graduates are prepared to care for a diverse and complex patient population.

PARTICIPATORY BULLSEYE TOOLKIT INTERVIEW: IDENTIFYING PHYSICIANS' RELATIVE PRIORITIZATION OF DECISION FACTORS WHEN ORDERING RADIOLOGIC IMAGING IN A HOSPITAL SETTING

Critical Decision Method (CDM), a popular cognitive task analysis (CTA) method, is an in-depth retrospective interview that uses a historical non-routine incident to identify experts' decision-making factors in complex socio-technical settings with high consequences for failure. However, it is challenging to use CDM to make comparisons, including those between experts and trainees. We describe an alternative CTA method used to study physicians' decision making for ordering diagnostic imaging. After being primed with 11 simulated patient scenarios, nine attending and 11 resident physicians were asked to map out and present their decision-making process with a bullseye participatory design toolkit. Interviews were analyzed qualitatively, revealing four common decision factors: diagnostic efficacy, patient safety, organizational constraints, and patient comfort. The bullseye maps were used to quantitatively measure priority differences between these decision factors. Attending and resident physicians both prioritized diagnostic efficacy over the other factors (2.38 vs. 3.71, p <.01, and 2.59 vs. 3.52, p<.01, respectively), but attending physicians' decisions had a higher proportion of non-diagnostic items (65% vs. 50%, p = .008). Our results demonstrate the usefulness of this method in eliciting decision factors for a complex, face-valid task and for identifying differences due to levels of expertise and training.

nhancing the quality and safety of care through training generalist doctors: a longitudinal, mixed-methods study of a UK broad-based training programme

OBJECTIVE

Changing patient demographics make it ever more challenging to maintain the quality and safety of care. One approach to addressing this is the development of training for generalist doctors who can take a more holistic approach to care. The purpose of the work we report here is to consider whether a broad-based training programme prepares doctors for a changing health service.

SETTING AND PARTICIPANTS

We adopted a longitudinal, mixed-methods approach, collecting questionnaire data from trainees on the broad-based training (BBT) programme in England (baseline n=62) and comparator trainees in the same regions (baseline n=90). We held 15 focus groups with BBT trainees and one-to-one telephone interviews with trainees post-BBT (n=21) and their Educational Supervisors (n=9).

RESULTS

From questionnaire data, compared with comparator groups, BBT trainees were significantly more confident that their training would result in: wider perspectives, understanding specialty complementarity, ability to apply learning across specialties, manage complex patients and provide patient-focused care. Data from interviews and focus groups provided evidence of positive consequences for patient care from BBT trainees' ability to apply knowledge from other specialties. Specifically, insights from BBT enabled trainees to tailor referrals and consider patients' psychological as well as physical needs, thus adopting a more holistic approach to care. Unintended consequences were revealed in focus groups where BBT trainees expressed feelings of isolation. However, when we explored this sentiment on questionnaire surveys, we found that at least as many in the comparator groups sometimes felt isolated.

CONCLUSIONS

Practitioners with an understanding of care across specialty boundaries can enhance patient care and reduce risks from poor inter-specialty communication. Internationally, there is growing recognition of the place of generalism in medical practice and the need to take a more person-centred approach. Broad-based approaches to training support the development of generalist doctors, which is well-suited to a changing health service.

The Effects of a Hospitalist Comanagement Model for Joint Arthroplasty Patients in a Teaching Facility

BACKGROUND

The goal of this study was to compare postoperative medical comanagement of total hip arthroplasty and total knee arthroplasty patients using a hospitalist (H) and nonhospitalist (NH) model at a single teaching institution to determine the clinical and economic impact of the hospitalist comanagement.

METHODS

We retrospectively reviewed the records of 1656 patients who received hospitalist comanagement with 1319 patients who did not. The NH and H cohorts were compared at baseline via chi-square test for the American Society of Anesthesiologists classification, the t test for age, and the Wilcoxon test for the unadjusted Charlson Comorbidity Index score and the age-adjusted Charlson Comorbidity Index score. Chi-square test was used to compare the postoperative length of stay, readmission rate at 30 days after surgery, diagnoses present on admission, new diagnoses during admission, tests ordered postoperatively, total direct cost, and discharge location.

RESULTS

The H cohort gained more new diagnoses (P < .001), had more studies ordered (P < .001), had a higher cost of hospitalization (P = .002), and were more likely to be discharged to a skilled nursing facility (P < .001). The H cohort also had a lower length of stay (P < .001), but we believe evolving techniques in both pain control and blood management likely influenced this. There was no significant difference in readmissions.

CONCLUSION

Any potential benefit of a hospitalist comanagement model for this patient population may be outweighed by increased cost.

Impact of an Overnight Internal Medicine Academic Hospitalist Program on Patient Outcomes

BACKGROUND

Many academic hospitals have implemented overnight hospitalists to supervise house staff and improve outcomes, but few studies have described the impact of this role.

OBJECTIVE

To investigate the effect of an overnight academic hospitalist program on patient-level outcomes. Secondary objectives were to describe the program's revenue generation and work tasks.

DESIGN

Retrospective interrupted time-series analysis of patients admitted to the medicine service before and after implementation of the program.

PARTICIPANTS

All patients aged 18 and older admitted to the acute or intermediate care units between 7:00 p.m. and 6:59 a.m. during the period before (April 2011-August 2012) and after (September 2012-April 2014) program implementation.

INTERVENTION

An on-site attending-level physician directly supervising medicine house staff overnight, providing clinical care during high-volume periods, and ensuring safe handoffs to daytime providers.

MAIN MEASURES

Primary outcomes included in-hospital mortality, 30-day hospital readmissions, length of stay, and upgrades in care on the night of admission and during hospitalization. Multivariable models estimated the effect on outcomes after adjusting for secular trends. Revenue generation and work tasks are reported descriptively.

KEY RESULTS

During the study period, 6484 patients were admitted to the medicine service: 2722 (42 %) before and 3762 (58 %) after implementation. No differences were found in mortality (1.1 % vs. 0.9 %, p=0.38), 30-day readmissions (14.8 % vs. 15.6 %, p=0.39), mean length of stay (3.09 vs. 3.08 days, p=0.86), or upgrades to intensive care on the night of admission (0.4 % vs. 0.7 %, p=0.11) or during hospitalization (3.5 % vs. 4.2 %, p=0.20). During the first year, hospitalists billed 1209 patient encounters (3.3/shift) and 63 procedures (0.2/shift), and supervised 1939 patient admissions (6.12/shift) while supervising house staff 3-h/shifts.

CONCLUSIONS

Implementation of an overnight academic hospitalist program showed no impact on several important clinical outcomes, and revenue generation was modest. As overnight hospitalist programs develop, investigations are needed to delineate the return on investment and focus on other outcomes that may be more sensitive to change, such as errors and provider/patient satisfaction.

Association of hospitalist presence and hospital-level outcome measures among Medicare patients

BACKGROUND

Hospitalists have been shown to lower patient costs through better resource utilization and decreased length of stay, but it is unclear whether hospitalists are associated with quality of care. We examined the association between the presence of hospitalists and 30-day predicted excess all-cause hospital mortality and readmissions among Medicare patients admitted to a hospital with any of 3 conditions: heart failure, acute myocardial infarction, and pneumonia.

METHODS

Using national hospital-level, case mix-adjusted, risk-standardized, 30-day all-cause excess mortality and readmission data from the Centers for Medicare and Medicaid Services, we used descriptive and bivariate statistics to illustrate trends across hospitals. Using multivariable ordinary least squares regression to control for hospital-level characteristics, we then estimated the association between the presence of hospitalists and predicted hospital mortality and readmission.

RESULTS

After multivariable adjustment, the presence of hospitalists was associated with lower probability of readmission for all 3 target conditions. No significant associations for any of the target conditions were found in all-cause mortality models.

CONCLUSIONS

Hospitalists are already integral to the delivery of inpatient care at most institutions. This study, however, showed an association at the national level of the presence of hospitalists with an important and timely quality measure: reduction of readmission rates. Future research is indicated to explore specific causation pathways for the impact of hospitalists on quality of care.

A controlled investigation of optimal internal medicine ward team structure at a teaching hospital

Background

The optimal structure of an internal medicine ward team at a teaching hospital is unknown. We hypothesized that increasing the ratio of attendings to housestaff would result in an enhanced perceived educational experience for residents.

Methods

Harbor-UCLA Medical Center (HUMC) is a tertiary care, public hospital in Los Angeles County. Standard ward teams at HUMC, with a housestaff∶attending ratio of 5∶1, were split by adding one attending and then dividing the teams into two experimental teams containing ratios of 3∶1 and 2∶1. Web-based Likert satisfaction surveys were completed by housestaff and attending physicians on the experimental and control teams at the end of their rotations, and objective healthcare outcomes (e.g., length of stay, hospital readmission, mortality) were compared.

Results

Nine hundred and ninety patients were admitted to the standard control teams and 184 were admitted to the experimental teams (81 to the one-intern team and 103 to the two-intern team). Patients admitted to the experimental and control teams had similar age and disease severity. Residents and attending physicians consistently indicated that the quality of the educational experience, time spent teaching, time devoted to patient care, and quality of life were superior on the experimental teams. Objective healthcare outcomes did not differ between experimental and control teams.

Conclusions

Altering internal medicine ward team structure to reduce the ratio of housestaff to attending physicians improved the perceived educational experience without altering objective healthcare outcomes.

Patient satisfaction with hospital care provided by hospitalists and primary care physicians

BACKGROUND

Compared to hospital care provided by primary care physicians (PCPs), the hospitalist model provides equal-to-superior efficiency and outcomes; however, little is known about how the model affects patient satisfaction.

METHODS

Random patient satisfaction telephone interviews were conducted on discharged adult medicine inpatients at 3 Massachusetts hospitals between 2003 and 2009. Questionnaires included variables assessing patient satisfaction with various physician care domains. Patient age, gender, admission year, education level, language, illness severity, emergency room admission status, institution, and attending physician type were extracted from billing records. We used adjusted multivariable models to compare patient satisfaction with hospitalists and PCPs for domains of: physician care quality, physician behavior, pain management, communication.

RESULTS

Inpatients completed discharge surveys for 8295 encounters (3597 hospitalist, 4698 PCP). Multivariate-adjusted satisfaction scores for physician care quality were slightly higher for PCPs than hospitalists (4.24 vs 4.20, P = 0.04); there was no statistical difference at any individual hospital, and no difference among different hospitalist groups. Patient ratings of hospitalists and PCPs for behavior, pain control, and communication were equivalent (all P values >0.23). In multivariable models, hospitalists and PCPs had similar adjusted proportions in the highest satisfaction category (79.2% vs 80.5%, respectively, P = 0.17) and lowest category (5.1% vs 4.5%, respectively, P = 0.19). Quality ratings of both groups improved equivalently (P slope interaction = 0.47) but significantly over time (PCP 4.21 (2003) to 4.36 (2009), hospitalist 4.11 to 4.33, P Δ <0.001).

CONCLUSIONS

Patients appear similarly satisfied with inpatient care provided by several hospitalist models and by primary care physicians.

Hospitalists at an academic medical center, part 1: impact of a voluntary pilot hospitalist program

The use of hospitalists-physicians who limit their practice largely or exclusively to hospital inpatient care-has been a growing trend in the United States. The authors examine some pressures affecting an academic medical center and present the results of a hospitalist pilot project there. Based on the criteria of reduced patient length of hospital stay, hospital financial savings, physician satisfaction, and payer interest, the pilot hospitalist program was successful within 6 months.

Operational and quality outcomes of a mobile acute care for the elderly service

BACKGROUND

The traditional acute care for the elderly (ACE) unit has demonstrated improved functional outcomes without increased costs or changes in length of stay (LOS). It is, however, limited in scope to patients cared for on a fixed geographical unit.

OBJECTIVE

To compare operational and quality outcomes for patients cared for on a mobile ACE (MACE) service to those cared for on a unit-based ACE service and matched controls on other general medical services.

DESIGN

Retrospective cohort study with propensity-score matching.

SETTING

An urban academic medical center.

PATIENTS

A total of 8094 hospitalized adults >64 years old admitted to an ACE, MACE, and general medical services from July 2006 to June 2009.

INTERVENTION

An interdisciplinary MACE service com- posed of a geriatrician-hospitalist, fellow, nurse coordinator, and social worker.

MEASUREMENTS

LOS, total cost, 7- and 30-day readmission rates, and in-hospital mortality.

RESULTS

Mean LOS and total cost were significantly lower for patients in the MACE service compared with the ACE unit service (5.8 vs 7.9 days, P < 0.001, and $10,315 vs $13,187, P = 0.002) and compared with propensity-score matched controls during the second year of operation (5.6 vs 7.2 days, P < 0.001, and $10,693 vs $15,636, P < 0.001). In-hospital mortality and 7- and 30-day readmission rates were similar in all groups.

CONCLUSIONS

A mobile ACE service may result in reduced LOS and lower costs with no change in in-hospital mortality or 7- or 30-day readmission rates when compared with standard medical service and a traditional unit-based ACE service.

Do hospitalist physicians improve the quality of inpatient care delivery? A systematic review of process, efficiency and outcome measures

BACKGROUND

Despite more than a decade of research on hospitalists and their performance, disagreement still exists regarding whether and how hospital-based physicians improve the quality of inpatient care delivery. This systematic review summarizes the findings from 65 comparative evaluations to determine whether hospitalists provide a higher quality of inpatient care relative to traditional inpatient physicians who maintain hospital privileges with concurrent outpatient practices.

METHODS

Articles on hospitalist performance published between January 1996 and December 2010 were identified through MEDLINE, Embase, Science Citation Index, CINAHL, NHS Economic Evaluation Database and a hand-search of reference lists, key journals and editorials. Comparative evaluations presenting original, quantitative data on processes, efficiency or clinical outcome measures of care between hospitalists, community-based physicians and traditional academic attending physicians were included (n = 65). After proposing a conceptual framework for evaluating inpatient physician performance, major findings on quality are summarized according to their percentage change, direction and statistical significance.

RESULTS

The majority of reviewed articles demonstrated that hospitalists are efficient providers of inpatient care on the basis of reductions in their patients' average length of stay (69%) and total hospital costs (70%); however, the clinical quality of hospitalist care appears to be comparable to that provided by their colleagues. The methodological quality of hospitalist evaluations remains a concern and has not improved over time. Persistent issues include insufficient reporting of source or sample populations (n = 30), patients lost to follow-up (n = 42) and estimates of effect or random variability (n = 35); inappropriate use of statistical tests (n = 55); and failure to adjust for established confounders (n = 37).

CONCLUSIONS

Future research should include an expanded focus on the specific structures of care that differentiate hospitalists from other inpatient physician groups as well as the development of better conceptual and statistical models that identify and measure underlying mechanisms driving provider-outcome associations in quality.

Who cares for the caregivers? Why medical social workers belong on end-of-life care teams

Changes within the health care industry have resulted in a shift that, to a large extent, places patients in the position of managing their own health care. While self-determination is desirable, it can also lead to new challenges, as when patients who are critically ill and/or dying must rely on family members to function as primary caregivers and managers of their treatment plans. Typically, patients and their families lack the guidance and oversight of a medical professional to coordinate a multifaceted health care regimen instituted by the variety of specialists involved in patients' diagnoses and treatments. As the patients' health declines and treatment plans become more complex, so too does the level of involvement of family caregivers, who often must manage treatment plans in addition to providing bedside care. This article cites the example of a woman who was exhausted by her role as sole caregiver for her dying husband and describes her feelings of powerlessness within the hospital setting as she struggled to coordinate assistance from her husband's medical specialists during end-of-life decision making. This case illustrates the importance of the following: (a) in cases involving hospitalized patients who require complex care from multiple specialists, it should become standard practice to enlist medical social workers to provide an overall assessment of the patients' status, prognoses, and home care plans, (b) in cases involving prolonged home care culminating in end-of-life decisions, the needs of nonprofessional caregivers must be recognized, evaluated, and addressed.

A systematic review of outcomes and quality measures in adult patients cared for by hospitalists vs nonhospitalists

A systematic review of English-language literature was undertaken to answer the question, "Are there differences in cost or quality of inpatient medical care provided to adults by hospitalists vs nonhospitalists?" A computerized search was performed, using hospitalist and either quality, outcome, or cost as search terms. References from relevant articles were searched by hand. A standard data-extraction tool was used, and articles were included on the basis of quality and relevance. The reports that were included (N=33) show general agreement that hospitalist care leads to shorter length of stay and lower cost per stay. Three reports show improvement in outcomes for orthopedic surgery patients who had hospitalist consultation or comanagement, 3 reports show improvement in markers of quality of care for patients with pneumonia, and 2 reports show improvement in aspects of heart failure management. Further research should seek to determine why differences in care exist, whether these improvements might be generalized to other physicians, and whether hospitalists provide demonstrable benefit in other areas of care.

A systematic review of outcomes and quality measures in adult patients cared for by hospitalists vs nonhospitalists

A systematic review of English-language literature was undertaken to answer the question, "Are there differences in cost or quality of inpatient medical care provided to adults by hospitalists vs nonhospitalists?" A computerized search was performed, using hospitalist and either quality, outcome, or cost as search terms. References from relevant articles were searched by hand. A standard data-extraction tool was used, and articles were included on the basis of quality and relevance. The reports that were included (N=33) show general agreement that hospitalist care leads to shorter length of stay and lower cost per stay. Three reports show improvement in outcomes for orthopedic surgery patients who had hospitalist consultation or comanagement, 3 reports show improvement in markers of quality of care for patients with pneumonia, and 2 reports show improvement in aspects of heart failure management. Further research should seek to determine why differences in care exist, whether these improvements might be generalized to other physicians, and whether hospitalists provide demonstrable benefit in other areas of care.

Economic and healthcare forces of hospitalist movement

The field of hospital medicine has become a widely accepted model for inpatient care and has grown rapidly in the past ten years. The impetus for growth has largely been pressure to contain costs for inpatient care and improve efficiency in the hospital. Studies have shown that care by hospitalists is generally more cost-effective than care by faculty or private practice physicians without affecting quality. The field faces challenges in continuity of patient care and retention of physicians in the workforce.

Consultation patterns and clinical correlates of consultation in a tertiary care setting

Background

Consultation in hospital is an essential tool for acquiring subspecialty support when managing patients. There is limited knowledge on the utilization of subspecialty consultation from hospital based general internists. Consultation patterns to medical subspecialists and the patient factors that may influence consultation are reported for general medical services.

Methods and findings

Hospital discharge data were obtained for patients from medical services over a 2-year period. Consultations requested to medicine subspecialties were identified, and then reported by type and frequency. Information on demographic factors, clinical diagnoses, length of stay (LOS), time in critical care units, and disposition were compared for patients with and without consultation.

3979 patients were hospitalized during the study and 2885 consultations occurred. Almost half of the patients received at least one consultation (48.3%). Gastroenterology (26.3%), infectious diseases (14.6%) and respirology (13.6%) were the most frequently consulted services. Patients with consultation had a greater number of total diagnoses (7.3 vs. 5.5, P < 0.001), a greater mean LOS (15.9 vs. 6.8 days), were more likely to spend time in the ICU (11.5% vs. 3.5%) and CCU (4.3% vs. 1.2%), and to expire in hospital (10.7% vs. 4.9%).

Conclusion

Consultation occurs frequently and its presence is an indicator of patient complexity and high use of health system resources. Analysis of consultation patterns for specific patient populations could assist in optimizing efficiency in health care delivery. Targeting quality improvement strategies toward optimizing consultation processes, engaging heavily utilized subspecialties in educational roles and assisting with resource planning are areas for future consideration.

Hospitalist care and length of stay in patients requiring complex discharge planning and close clinical monitoring

BACKGROUND

Academic medical centers are increasingly employing hospitalists to staff teaching wards. Although studies have demonstrated reduced lengths of stay (LOSs) associated with hospitalist care, it is unclear which patients are most likely to benefit. We sought to determine whether patients with specific diagnoses or discharge needs account for the association between hospitalist care and reduced LOS.

METHODS

Hospital admissions were divided into the following 2 groups based on type of attending physician: teaching hospitalist (full-time faculty hospitalist with no outpatient responsibilities) vs nonhospitalist (full-time or voluntary faculty contributing 1 or 2 months of teaching service per year). We included all patients discharged from an academic teaching service for a 2-year period. Data were extracted from the Montefiore Medical Center's clinical information system and the Social Security Death Registry.

RESULTS

Mean LOS was lower for teaching hospitalists than for nonhospitalists (5.01 vs 5.87 days [P < .02]). The reduction in LOS was greatest for patients requiring close clinical monitoring (patients with congestive heart failure, stroke, asthma, or pneumonia) and for those requiring complex discharge planning. There were no significant differences between the groups in readmission, in-hospital mortality, or 30-day mortality.

CONCLUSION

Teaching hospitalist care was associated with shorter LOS in patients requiring close clinical monitoring and complex discharge planning, without adversely affecting readmission or mortality rates.

Impact of a hospitalist system on length of stay and cost for children with common conditions

OBJECTIVE

This study examined mechanisms of efficiency in a managed care hospitalist system on length of stay and total costs for common pediatric conditions.

PATIENTS AND METHODS

We conducted a retrospective cohort study (October 1993 to July 1998) of patients in a not-for-profit staff model (HMO 1) and a non-staff-model (HMO 2) managed care organization at a freestanding children's hospital. HMO 1 introduced a hospitalist system for patients in October 1996. Patients were included if they had 1 of 3 common diagnoses: asthma, dehydration, or viral illness. Linear regression models examining length-of-stay-specific costs for prehospitalist and posthospitalist systems were built. Distribution of length of stay for each diagnosis before and after the system change in both study groups was calculated. Interrupted time series analysis tested whether changes in the trends of length of stay and total costs occurred after implementation of the hospitalist system by HMO1 (HMO 2 as comparison group) for all 3 diagnoses combined.

RESULTS

A total of 1970 patients with 1 of the 3 study conditions were cared for in HMO 1, and 1001 in HMO 2. After the hospitalist system was introduced in HMO 1, length of stay was reduced by 0.23 days (13%) for asthma and 0.19 days (11%) for dehydration; there was no difference for patients with viral illness. The largest relative reduction in length of stay occurred in patients with a shorter length of stay whose hospitalizations were reduced from 2 days to 1 day. This shift resulted in an average cost-per-case reduction of $105.51 (9.3%) for patients with asthma and $86.22 (7.8%) for patients with dehydration. During the same period, length of stay and total cost rose in HMO 2.

CONCLUSIONS

Introduction of a hospitalist system in one health maintenance organization resulted in earlier discharges and reduced costs for children with asthma and dehydration compared with another one, with the largest reductions occurring in reducing some 2-day hospitalizations to 1 day. These findings suggest that hospitalists can increase efficiency and reduce costs for children with common pediatric conditions.

Comparison of hospital costs and length of stay for community internists, hospitalists, and academicians

BACKGROUND

The model of inpatient medical management has evolved toward Hospitalists because of greater cost efficiency compared to traditional practice. The optimal model of inpatient care is not known.

OBJECTIVE

To compare three models of inpatient Internal Medicine (traditional private practice Internists, private Hospitalist Internists, and Academic Internists with resident teams) for cost efficiency and quality at a community teaching hospital.

DESIGN

Single-institution retrospective cohort study.

MEASUREMENTS AND MAIN RESULTS

Measurements were hospital cost, length of stay (LOS), mortality, and 30-day readmission rate adjusted for severity, demographics, and case mix. Academic Internist teams had 30% lower cost and 40% lower LOS compared to traditional private Internists and 24% lower cost and 30% lower LOS compared to private Hospitalists. Hospital mortality was equivalent for all groups. Academic teams had 2.3-2.6% more 30-day readmissions than the other groups.

CONCLUSIONS

Academic teams compare favorably to private Hospitalists and traditional Internists for hospital cost efficiency and quality.

Developing a gastroenterology hospitalist service

The concept of a gastroenterologist functioning primarily as a hospitalist is a new development in the way that gastrointestinal (GI) care is provided. The main advantages are rapid availability of endoscopic and consultative services, a close working relationship with other hospital-based providers, and enhanced familiarity with complex acute care and GI treatment algorithms. The GI hospitalist concept offers significant advantages for the outpatient providers and their ambulatory endoscopy centers, even for smaller and mid-sized groups; however, it hinges on finding the right individual for the job. The buy-in of all group members before launching the concept is crucial and a better quality of life for each team member can be the result.

Pediatric hospitalists: report of a leadership conference

OBJECTIVES

To summarize a meeting of academic pediatric hospitalists and to describe the current state of the field.

METHODS

The Ambulatory Pediatric Association sponsored a meeting for academic pediatric hospitalists in November 2003. The purpose of the meeting was to discuss and to define roles of academic pediatric hospitalists, including their roles as clinicians, educators, and researchers, and to discuss organizational issues and unique hospitalist issues within general academic pediatrics. Workshops were held in the areas of organization and administration, academic life, research, and education. A literature review was also conducted in the areas discussed.

RESULTS

More than 130 physicians attended. Thirteen workshops were held, and all information was summarized in large-group sessions for all attendees.

CONCLUSIONS

Pediatric hospital medicine is a rapidly growing field, with an estimated 800 to 1000 pediatric hospitalists currently practicing. Initial work has defined the clinical environment and has begun to stake out a unique knowledge and skill set. The Pediatric Hospitalists in Academic Settings conference demonstrated the audience for additional development and the resources to move forward.

The effect of a multidisciplinary hospitalist/physician and advanced practice nurse collaboration on hospital costs

OBJECTIVE

To compare nurse practitioner/physician management of hospital care, multidisciplinary team-based planning, expedited discharge, and assessment after discharge to usual management.

BACKGROUND

In the context of managed care, the goal of academic medical centers is to provide quality care at the lowest cost and minimize length of stay (LOS) while not compromising quality.

METHODS

Comparative, 2-group, quasiexperimental design was used; 1,207 general medicine patients (n=581 in the experimental group and n=626 in the control group) were enrolled. The control unit provided usual care. The care management in the experimental unit had 3 different components: an advanced practice nurse who followed the patients during hospitalization and 30 days after discharge, a hospitalist medical director and another hospitalist, and daily multidisciplinary rounds. LOS, hospital costs, mortality, and readmission 4 months after discharge were measured.

RESULTS

Average LOS was significantly lower for patients in the experimental group than the control group (5 vs. 6 days, P<.0001). The "backfill profit" to the hospital was US$1591 per patient in the experimental group (SE, US$639). There were no significant group differences in mortality or readmissions.

CONCLUSIONS

Collaborative physician/nurse practitioner multidisciplinary care management of hospitalized medical patients reduced LOS and improved hospital profit without altering readmissions or mortality.

Associations between the hospitalist model of care and quality-of-care-related outcomes in patients undergoing hip fracture surgery

OBJECTIVE

To investigate the relationship between the hospitalist consultant model of care and both length of hospital stay (LOS) and hospital cost for patients undergoing hip fracture surgery.

PATIENTS AND METHODS

We retrospectively studied 118 consecutive patients admitted with hip fracture (diagnosis related groups 79.35 and 81.52) between January 1, 2002, and December 31, 2002, at a community-based academic medical center. For each patient, consultations for preoperative medical evaluation and management of postoperative complications were performed by a hospitalist or a traditional medical consultant (nonhospitalist). We defined "hospitalist" as dedicated hospital-based physicians who provide their maximum professional time in inpatient health care delivery and who are completely free of outpatient responsibilities. Time to consultation (TTC), time to surgery (TTS), LOS, and total hospital costs were determined for each patient by review of the medical records and were compared between hospitalist and nonhospitalist consultants.

RESULTS

Both TTC and TTS were significantly lower for hospitalist patients (P < .001 and P = .004, respectively). Although not statistically significant, cost and LOS also were lower for patients receiving hospitalist care. In the hospitalist group, median cost was an estimated dollar 1777 less, and median LOS was 1 day less than in the nonhospitalist group.

CONCLUSION

Hospitalist Involvement in the medical management of patients undergoing hip fracture surgery may be associated with decreases in TTC, TTS, LOS, and total hospital cost. The results of this study have implications for consultative medical care of patients undergoing urgent surgery and their health outcomes.

Is there a geriatrician in the house? Geriatric care approaches in hospitalist programs

BACKGROUND

The rapid growth of the hospitalist movement presents an opportunity to reconsider paradigms of care for hospitalized older patients.

METHODS

To determine the impact of the hospitalist movement on acute care geriatrics, we conducted a cross-sectional survey of the hospitalist community in 2003 and 2004.

RESULTS

We identified innovations in geriatric hospital care in only 11 hospitalist programs. These innovations varied widely in complexity, goals, structure, and staffing. The majority targeted patients using age as a criterion and incorporated geriatrics training for nurses or physicians. Several innovations had one or more of the following features: geriatrician-hospitalists or gerontology nurse-practitioners, perioperative management for complex older patients, specialized geriatric services such as skilled nursing units or acute care for elders units, and quality improvement initiatives targeted to the older patient. A case study of the Hospital Internal Medicine group at the Mayo Clinic is presented as an example of a complex innovation highlighting several of these features.

CONCLUSIONS

The scarcity of geriatric care approaches among hospitalist groups highlights the need for collaboration between hospitalists and geriatricians, with the goals of rethinking staffing models and organization of care and focusing on quality-improvement activities. In particular, perioperative care and postdischarge care are two clinical areas where innovation in hospital care may particularly benefit older patients. Significant opportunities remain for collaboration, coordination, and research to improve the care of acutely ill older patients at the intersection of geriatric and hospital medicine.

An alternative approach to reducing the costs of patient care? A controlled trial of the multi-disciplinary doctor-nurse practitioner (MDNP) model

OBJECTIVE

Hospitals adapt to changing market conditions by exploring new care models that allow them to maintain high quality while containing costs. The authors examined the net cost savings associated with care management by teams of physicians and nurse practitioners, along with daily multidisciplinary rounds and postdischarge patient follow-up.

METHODS

One thousand two hundred and seven general medicine inpatients in an academic medical center were randomized to the intervention versus usual care. Intervention costs were compared to the difference in nonintervention costs, estimated by comparing changes between preadmission and postadmission in regression-adjusted costs for intervention versus usual care patients. Intervention costs were calculated by assigning hourly costs to the time spent by different providers on the intervention. Patient costs during the index hospital stay were estimated from administrative records and during the 4-month follow-up by weighting self-reported utilization by unit costs.

RESULTS

Intervention costs were $1187 per patient and associated with a significant $3331 reduction in nonintervention costs. About $1947 of the savings were realized during the initial hospital stay, with the remainder attributable to reductions in postdischarge service use. After adjustment for possible attrition bias, a reasonable estimate of the cost offset was $2165, for a net cost savings of $978 per patient. Because health outcomes were comparable for the 2 groups, the intervention was cost-effective.

CONCLUSIONS

Wider adoption of multidisciplinary interventions in similar settings might be considered. The savings previously reported with hospitalist models may also be achievable with other models that focus on efficient inpatient care and appropriate postdischarge care.

The impact of hospitalists on the cost and quality of inpatient care in the United States: a research synthesis

There is substantial disagreement regarding the impact of hospitalists on costs, quality, and satisfaction with inpatient care. The authors reviewed 21 evaluations of the use of hospitalists in U.S. hospitals. Most evaluations found that patients managed by hospitalists had lower total costs or charges than patients in comparison groups and that these savings were achieved primarily by reducing length of stay. Most evaluations found no statistically significant differences in quality of care or satisfaction. However, lack of random assignment limits the ability to draw causal inferences from many of the evaluations. All randomized studies were conducted in teaching hospitals, raising questions as to the generalizability of findings to nonteaching hospitals. Further research is needed to better identify the mechanisms by which hospitalists reduce length of stay and to ascertain which types of hospitalist programs are most effective and which patients are most likely to benefit.

Hospitalists and Improved Cost Savings in Patients With Bacterial Pneumonia at a State Level

OBJECTIVES

In the hospitalist literature, most studies have focused on outcomes related to cost savings for individual hospital systems. This study sought to determine if hospitalists could improve cost savings at a state level.

METHODS

This is a retrospective analysis of a statewide database for inpatients in 2002 with bacterial pneumonia. The primary outcomes measured were mean length of stay (LOS) and mean charges per patient between hospitalists and nonhospitalists. The secondary outcome measured was percentage of patients by severity of illness between the groups.

RESULTS

The difference of LOS in the moderate illness category was 4.9 days for hospitalists and 5.2 for nonhospitalists (P = 0.04). The major illness category was 7.4 and 8 (P = 0.03), and the extreme illness category was 10.6 and 12.9 (P = 0.02). The difference of mean charges per patient in the major category were dollars 20,950 and dollars 23,259 (P = 0.03) and dollars 42,045 and dollars 56,867, respectively (P = 0.002), in the extreme category. Patients in the major/extreme categories of illness accounted for 41% of hospitalist patients versus 32% of nonhospitalist patients (P < 0.001).

CONCLUSIONS

Hospitalists have shorter LOS, lower charges per patient, and admit a larger proportion of high acuity patients at a state level.

Hospitalists: Evolution, evidence, and eventualities

Hospitalists are physicians who spend at least 25% of their professional time serving as the physicians-of-record for inpatients, during which time they accept "hand-offs" of hospitalized patients from primary care providers, returning the patients to their primary care providers at the time of hospital discharge. The hospitalist movement is only about 5 years old, yet at least 7000 hospitalists practice today and an estimated 19,000 will ultimately practice, approximately the current number of emergency medicine physicians. The emerging positivist literature on hospitalists' impact is the subject of this review. It traces the nature and evolution of the hospitalist movement; summarizes empirical evidence about costs, clinical outcomes, patient satisfaction, and education; and appraises whether the hospitalist model is indeed novel. The review concludes by outlining research questions about the hospitalist model's viability over time, the mechanisms by which it produces benefits, and especially hospitalists' longitudinal effect on continuity of patient care. A literature "scorecard" might rank evidence to date on costs as positive, evidence on clinical outcomes and education as nonnegative, and evidence on patient satisfaction and continuity of care as inconclusive. Above all, longitudinal research must illuminate whether hospitalists' advantages comeat the cost of the doctor-patient relationship.

Efecto de la adscripción de internistas a un servicio quirúrgico

BACKGROUND AND OBJECTIVE

Although surgical units commonly request the collaboration of internists via medical consultation, the efficiency of this system is low and expensive. We studied the effect of the integration of full-time internists in a surgical department.

PATIENTS AND METHOD

The study group consisted of the patients admitted during intervention in the Orthopedic Surgery and Traumatology Department. Those patients admitted during the same period of the previous year made up the control group. We analyzed pre-surgical stay, post-surgical stay and total stay. We also studied in-hospital mortality, re-admissions and those patients who were not submitted to surgery (NSS). Control variables were age, sex, type of admission (programmed/emergency) and main diagnosis.

RESULTS

1,216 patients were included, 599 in the control group and 617 in the study group, 48.0% were emergency admissions and 11.7% NSS patients. Study of programmed patients did not suggest any differences between both groups in any of the analyzed variables. In emergency patients, the total stay was decreased in 18.2%, and it was reduced in 40.2% of the NSS. The distribution of the re-admissions was similar in both study and control groups. We observed a decrease in the NSS and a 50% decrease in the deaths of the study group. The obtained saving was 329,170 Euros.

CONCLUSIONS

The adscription of full-time internists to a surgical service clearly improves the quality of the service it provides, with important hospital savings.

Comparison of hospitalists and nonhospitalists in inpatient length of stay adjusting for patient and physician characteristics

OBJECTIVE

To determine the independent effect of hospitalist status upon inpatient length of stay after controlling for case mix, as well as patient-level and provider-level variables such as age, years since physician medical school graduation, and volume status of provider.

DESIGN

Observational retrospective cohort study employing a hierarchical random intercept logistic regression model.

SETTING

Tertiary-care teaching hospital.

PATIENTS

All admissions during 2001 to the department of medicine not sent initially to the medical intensive care unit or coronary care unit.

MEASUREMENTS

Observed length of stay (LOS) compared to principle diagnosis related group (DRG)-specific mean LOS for hospitalist and nonhospitalist patients adjusting for patient age, gender, years since physician graduation from medical school, and physician volume status.

MAIN RESULTS

The 9 hospitalists discharged 2,027 patients while the nonhospitalists discharged 9,361 patients. On average, hospitalist patients were younger, 63.3 versus 73.3 years (P < .0001). Hospitalists were more recently graduated from medical school, 13.8 versus 22.5 years (P= .02). Each year of patient age was found to increase the likelihood of an above average LOS (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.01 to 1.02; P < .001). In unadjusted analysis, hospitalists were less likely to have an above average LOS (OR, 0.51; 95% CI, 0.28 to 0.93; P= .03). Adjustment for effects of patient age and gender, physician gender, years since medical school graduation, and quintile of physician admission volume did not appreciably change the point estimate that hospitalist patients remained less likely to have above average LOS (OR, 0.60; 95% CI, 0.32 to 1.11; P= .11).

CONCLUSIONS

For a given principle DRG, hospitalist patients were less likely to exceed the average LOS than were nonhospitalist patients. This effect was rather large, in that hospitalist status reduced the likelihood of above average LOS by about 49%. Adjustment for patient age, years since physician graduation, and admission volume did not significantly alter this finding. Further research should focus on identifying specific practices that account for hospitalism's effects.

The positive impact of initiation of hospitalist clinician educators

OBJECTIVE

Although hospitalists have been shown to improve both financial and educational outcomes, their ability to manage dual roles as clinicians and educators has been infrequently demonstrated, particularly in the community setting where large numbers of residents train. We evaluated the impact of hospitalists on financial and educational outcomes at a mid-sized community teaching hospital 1 year after implementation.

DESIGN

Two hospitalist clinician educators (HCEs) were hired to provide inpatient medical care while participating in resident education. Length of stay and cost per case data were calculated for all patients admitted to the hospitalist service during their first year and compared with patients admitted to private physicians. The hospitalists' top 11 discharge diagnoses were individually assessed. For the same time period, categorical medicine residents (N = 36) were given an anonymous written survey to assess the HCEs' impact on resident education and service.

RESULTS

Resource consumption: length of stay was reduced by 20.8% and total cost per case was reduced by 18.4% comparing the HCEs with community-based physicians. Reductions in both length of stay and cost per case were noted for 8 of the 11 most common discharge diagnoses. Resident survey: over 75% of residents responded, with all noting improvement in the quality of attending rounds, bedside teaching, and the overall inpatient experience. Residents' roles as teachers and team leaders were largely unchanged.

CONCLUSION

Hospitalist clinician educators as inpatient teaching attendings effectively reduce length of stay and resource utilization while improving resident education at community-based teaching hospitals.

CEO's perceptions of hospitalists: diffusion of the strategy

Many hospitals have initiated a strategy to reduce costs and improve quality of care by using physicians as "hospitalists." A hospitalist specializes in inpatient care. This article reports the findings of survey research examining CEO perceptions of the hospitalist model, with particular interest in diffusion of the strategy in rural and low managed care hospital markets. Findings indicate there is less diffusion of the hospitalist model to rural areas because of lack of information about the cost effectiveness of the program and medical staff resistance. Recommendations to increase adoption of the hospitalist strategy include educating about the benefits of the strategy and paying attention to areas of concern by the medical staff.

Medical errors related to discontinuity of care from an inpatient to an outpatient setting

OBJECTIVE

To determine the prevalence of medical errors related to the discontinuity of care from an inpatient to an outpatient setting, and to determine if there is an association between these medical errors and adverse outcomes.

PATIENTS

Eighty-six patients who had been hospitalized on the medicine service at a large academic medical center and who were subsequently seen by their primary care physicians at the affiliated outpatient practice within 2 months after discharge.

DESIGN

Each patient's inpatient and outpatient medical record was reviewed for the presence of 3 types of errors related to the discontinuity of care from the inpatient to the outpatient setting: medication continuity errors, test follow-up errors, and work-up errors.

MEASUREMENTS

Rehospitalizations within 3 months after the initial postdischarge outpatient primary care visit.

MAIN RESULTS

Forty-nine percent of patients experienced at least 1 medical error. Patients with a work-up error were 6.2 times (95%confidence interval [95% CI], 1.3 to 30.3) more likely to be rehospitalized within 3 months after the first outpatient visit. We did not find a statistically significant association between medication continuity errors (odds ratio [OR], 2.5; 95%CI, 0.7 to 8.8) and test follow-up errors (OR, 2.4; 95%CI, 0.3 to 17.1) with rehospitalizations.

CONCLUSION

We conclude that the prevalence of medical errors related to the discontinuity of care from the inpatient to the outpatient setting is high and may be associated with an increased risk of rehospitalization.

The evolution of the hospitalist model in the United States

Emerging data support the hypothesis that the use of hospital-based physicians can lead to improved efficiency without compromising patient [table: see text] outcomes or satisfaction. Nevertheless, for the foreseeable future, hospital care in the United States will likely remain a highly pluralistic system in which the organization of care is determined by efforts to improve the value of care in the context of local culture, patient populations, and patient and provider preferences. The method of hospital care chosen by each institution and group of physicians should be the one that promotes the best clinical outcomes and highest patient satisfaction at the lowest costs. With these goals in mind, it is likely that hospitalists will play an increasingly important and visible role in many institutions across the country.