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PubMed1999

A new doctor in the house: ethical issues in hospitalist systems.

The traditional patient-primary care physician (PCP) relationship provides many ethical protections for patients, including confidentiality, shared medical decision making, and respect for patient autonomy. Hospitalist models, which introduce a purposeful discontinuity of care, threaten these protections and raise certain ethical concerns. We analyze 2 cases that explore ethical issues arising in hospitalist systems and suggest ways to ensure ethical protection for patients. The first case examines how hospitalization can disrupt the patient-PCP relationship and raise ethical issues regarding confidentiality. In the second case, we discuss decision making when the patient's goals and preferences for care change as a result of hospitalization. Effective hospitalist systems provide a model for a trusting patient-physician relationship. Although the hospitalist must take responsibility for inpatient management, the PCP has a key role in addressing important issues in the hospital and providing care after discharge. As hospitalists assume control of inpatient care, they must also provide ethical protections to patients to supplement those currently vested in the patient-PCP relationship. An approach that keeps the patient's best interests foremost, defines a clear role for the PCP, and takes advantage of the expertise and availability of hospitalists will best serve patients and physicians.

Advance Directive Adherence↗
PubMed2001

Palliative care and the hospitalist: an opportunity for cross-fertilization.

Most US citizens die in acute care hospitals, often in physical pain, without attention to emotional and spiritual suffering. This represents an ethical failure of our current health-care system. The field of palliative medicine aims to address the physical, emotional, and spiritual needs of patients with advanced disease. At the same time, a new specialty of hospitalists is emerging, providing care for acutely ill hospitalized patients, many of whom will die. Thus, the hospitalist may become the primary deliverer of palliative care. This presents many potential opportunities for dying patients and their families, including increased time and attention from a physician; enhanced knowledge and skills around the physical symptoms, and emotional and spiritual distress; perhaps more detached and therefore more accurate prognostication; and increased efficiency, leading to a more rapid discharge to home. Hospitalists could enhance the quality of care for the dying by emphasizing interdisciplinary communication and involvement of hospital-based health professionals to address emotional and spiritual distress and bereavement issues, as well as through specific quality-improvement efforts. Finally, hospitalists can provide strong role modeling of optimal care for dying patients and their families. When hospitalists are not selected and trained effectively around palliative care issues, the risks are great. Discontinuity of physicians can lead to miscommunication and misunderstanding (by professionals, patient, and family); disagreement about treatment focus (especially as it relates to a shift from curative to palliative); inappropriate deferring of advance care planning to the hospital setting; and, most worrisome, a lack of expertise in symptom control, communication skills, and attention to patient and family distress and the provision of emotional and spiritual support. This article evaluates the convergence of the 2 fields of palliative medicine and hospitalist medicine and reviews the opportunities for mutual education and improved patient care.

Continuity of Patient Care↗
PubMed2002

Palliative care and the hospitalist: an opportunity for cross-fertilization.

Most US citizens die in acute care hospitals, often in physical pain, without attention to emotional and spiritual suffering. This represents an ethical failure of our current health-care system. The field of palliative medicine aims to address the physical, emotional, and spiritual needs of patients with advanced disease. At the same time, a new specialty of hospitalists is emerging, providing care for acutely ill hospitalized patients, many of whom will die. Thus, the hospitalist may become the primary deliverer of palliative care. This presents many potential opportunities for dying patients and their families, including increased time and attention from a physician; enhanced knowledge and skills around the physical symptoms, and emotional and spiritual distress; perhaps more detached and therefore more accurate prognostication; and increased efficiency, leading to a more rapid discharge to home. Hospitalists could enhance the quality of care for the dying by emphasizing interdisciplinary communication and involvement of hospital-based health professionals to address emotional and spiritual distress and bereavement issues, as well as through specific quality-improvement efforts. Finally, hospitalists can provide strong role modeling of optimal care for dying patients and their families. When hospitalists are not selected and trained effectively around palliative care issues, the risks are great. Discontinuity of physicians can lead to miscommunication and misunderstanding (by professionals, patient, and family); disagreement about treatment focus (especially as it relates to a shift from curative to palliative); inappropriate deferring of advance care planning to the hospital setting; and, most worrisome, a lack of expertise in symptom control, communication skills, and attention to patient and family distress and the provision of emotional and spiritual support. This article evaluates the convergence of the 2 fields of palliative medicine and hospitalist medicine and reviews the opportunities for mutual education and improved patient care.

Communication↗
PubMed2005

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.

Adult↗
PubMed2004

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.

Adult↗
PubMedDate not supplied

Pediatric hospitalists: quality care for the underserved?

Despite the rapid growth in pediatric hospitalist services, there is little empiric information about the impact of pediatric hospitalists. This study compared process and outcome variables related to the inpatient care of 182 pediatric patients, half of whom were cared for by hospitalists and half by their primary care providers (PCP). Results indicated that, while hospitalists cared for patients of substantially lower socioeconomic status, they delivered care more economically for patients with asthma, with no significant differences in rates of return to the emergency room or rehospitalizations. Children in both services demonstrated equivalent levels of returning to their PCP for follow-up visits and were in equally good health 1 month after discharge. Additionally, no negative impact was evident on patient satisfaction at discharge; in fact, the hospitalists' patients were more satisfied with aspects of their care. Hospitalists may, therefore, provide a vital service by ensuring quality inpatient care for low-income children.

Analysis of Variance↗
PubMed2002

Impact of a health maintenance organization hospitalist system in academic pediatrics.

OBJECTIVE: Hospitalist systems decrease length of stay (LOS) and cost for hospitalized adults. Whether hospitalist systems decrease LOS and cost for hospitalized children has not been conclusively established. We wanted to determine whether a health maintenance organization's (HMO's) implementation of a pediatric hospitalist system affected LOS, costs, mortality, readmission rate, follow-up rate, and parents' ratings of care. DESIGN: Interrupted time-series study of general pediatric patients admitted to a freestanding pediatric teaching hospital from 1993 to 1998. The intervention group consisted of all patients admitted to a staff model not-for-profit HMO that began using hospitalists in October 1996. Patients in other HMOs and traditional insurance groups were studied for comparison. The main outcomes were mean LOS and inflation-adjusted costs. Other outcomes included parents' ratings of care and mortality, readmission, and follow-up rates. RESULTS: Immediately after the introduction of the hospitalist system, mean LOS for staff model not-for-profit HMO fell 12% (0.3 days), and mean cost of hospitalization decreased 16% ($217) compared with prehospitalist levels. Parental ratings of care, initially somewhat low, improved substantially. Seven-day follow-up rates, mortality, and readmission rates did not change. Comparison groups experienced no concurrent improvements in LOS, cost, parental ratings, mortality, or readmission rates. CONCLUSIONS: A pediatric hospitalist system within a staff-model HMO significantly improved LOS, cost, and parental ratings of care without affecting rates of posthospitalization follow-up. Additional studies are needed both to measure broader aspects of quality and to assess the impact of such a program on patients being cared for through other types of delivery and insurance systems.

Adolescent↗
PubMed2006

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.

Hospitalists↗
PubMed1999

Evaluating the impact of hospitalists.

The hospital-based generalist physician is a recent organizational innovation in health care in the United States. Does the hospitalist model provide improved health care? The answer to this question lies in a rigorous evaluation of the hospitalist system in the clinical setting. This paper describes key outcomes that need to be assessed and methodologic issues that need to be addressed when conducting and interpreting the results of evaluations of the hospitalist model. To provide evidence about the value of the hospitalist model, quality of care should be evaluated through the measurement of both processes and outcomes. The clinical processes assessed may include diagnostic tests and treatments that are causally linked with outcomes. A variety of outcomes can be measured, such as death, clinical or physiologic status, physical function, and psychological well-being. The analysis of resource use data can aid in an assessment of the relative costs and effectiveness of clinical services. An evaluation of the hospitalist model requires an adequate research design, which should include a precise definition of the model being studied, the selection of an appropriate comparison group, the collection of clinical and demographic information on patients, the specification of both process and outcome measures, and the use of statistical techniques that are appropriate to the questions being asked and the data being collected. The design must distinguish between outcomes attributable to the introduction of hospitalists and those attributable to other changes in medical treatments and the organization of care.

Forecasting↗
PubMedDate not supplied

The evolution of the hospitalist movement in the USA.

The hospitalist movement represents a novel paradigm of health care delivery in the USA, its evolution hastened by a variety of financial, clinical, and time pressures. Hospitalists are site-defined specialists who spend the majority of their professional time practising in the hospital, and in this respect are similar to emergency medicine or critical care specialists. Community hospitals were the sites of early growth in hospitalist systems, and academic medical centres quickly followed suit. The field has grown rapidly, and now has its own textbook, professional society, training programme, and research and educational agenda. Published research to date has upheld the promise of the hospitalist model: improving efficiency of care by reducing length of stay and hospital costs without compromising quality or patient satisfaction. Future hospitalist research will aim to elucidate the role of hospitalists in the care of critically ill and surgical patients, identify the competencies that will ultimately define this specialty, and expand our understanding of key inpatient issues, such as prevention of nosocomial infections, end-of-life care, and hospital quality measurement.

Continuity of Patient Care↗
PubMed1999

Financial implications of implementing a hospitalist program.

The use of hospitalists, who are physicians specializing in providing hospital inpatient care, has become increasingly popular. Preliminary data suggest that hospitalists can shorten inpatient lengths of stay and lower costs without compromising clinical outcomes or patient satisfaction. The role of hospitalists, their position in the organizational framework, and their contractual and financial relationships are influenced by the structure of the healthcare organization in which they work. Although hospitalist programs can benefit hospitals and medical groups financially, they rarely become self-supporting through professional fees alone. The long-term viability of hospitalist programs frequently will depend on the support the programs receive from whichever entity benefits from hospitalist-generated efficiencies.

California↗
PubMed2001

Effects of an HMO hospitalist program on inpatient utilization.

OBJECTIVE: To assess the impact of a health maintenance organization (HMO) hospitalist program on inpatient utilization. PATIENTS: The study sample consisted of patients admitted to the hospital for a routine, uncomplicated acute surgical or medical diagnosis included under Milliman and Robertson's Optimal Recovery Guidelines (ORGs). Evaluation involved comparison of 2 physician management groups: inpatients managed by staff primary care physicians (PCPs) (study group) and inpatients managed by network PCPs (comparison group). STUDY DESIGN: Data before and after introduction of the hospitalist program were available. From the same period, data were available from patients of network PCPs who managed their own inpatient stays (nonhospitalist comparison sample). Three outcomes were used to represent inpatient utilization: (1) number of inpatient stays meeting ORG goals; (2) number of inpatient stays not meeting ORG goals that had > or =1 medically necessary days; and (3) number of inpatient stays not meeting ORG goals that had > or =1 medically unnecessary days. RESULTS: Multiple logistic regression results indicated that inpatient stays were more likely to be within ORG utilization goals when managed by hospitalists vs nonhospitalists (P < .05). Introduction of the hospitalist program reduced the number of stays with unnecessary days among staff inpatients. There was an increase in stays with unnecessary days in the comparison group, ie, inpatients managed by network physicians. CONCLUSIONS: Full-time hospitalists are efficient managers of HMO inpatients. The ORGs for acute, uncomplicated diagnoses provided useful hospital utilization measures that captured inpatient management by hospitalists and PCPs.

Adolescent↗
PubMed2001

A pneumonia practice guideline and a hospitalist-based reorganization lead to equivalent efficiency gains.

OBJECTIVE: To compare the impact of a practice guideline for a common inpatient disorder with that of a hospitalist-based reorganization of an academic medical service. STUDY DESIGN: Retrospective cohort study. PATIENTS AND METHODS: In July 1995 we introduced a clinical practice guideline for the treatment of community-acquired pneumonia at University of California San Francisco Moffitt-Long Hospital. Simultaneously, we implemented a structural change for half of the inpatient medical service, requiring earlier and more intensive faculty intervention, primarily by hospitalists. For 1 year, we studied the effect of these interventions on hospital costs, length of stay, and resource use. RESULTS: As reported previously, the hospitalist-based intervention resulted in significant decreases in average adjusted cost ($7777 vs $7007, P = .05) and length of stay (4.9 days vs 4.3 days, P = .01) compared with both concurrent and historical controls. For patients with community-acquired pneumonia, a similar savings occurred when fiscal year 1996 was compared with fiscal year 1995 ($8164 vs $6282, P= .015; 5.0 vs 4.2 days, P= .04). However, the effect was identical for the hospitalist and nonhospitalist groups. The reduced length of stay was associated with a borderline significant reduction in readmission rates (from 4.8% to 0.7%, P = .055) and no change in mortality rates. CONCLUSIONS: In this study, a hospitalist-based reorganization improved efficiency, with its greatest impact on the care of patients with disorders not covered by a practice guideline. The introduction of a guideline for a common diagnosis improved efficiency on both hospitalist- and nonhospitalist-based services. For common diagnoses amenable to practice guidelines, successful implementation of and compliance with guidelines may be an alternative to major organizational change.

Adult↗
PubMed2004

Associations with reduced length of stay and costs on an academic hospitalist service.

BACKGROUND: Prior studies of hospitalist services have suggested improved efficiency and quality of care compared with traditional inpatient services. OBJECTIVES: To compare outcomes of patients on a new hospitalist service with those on traditional inpatient services and to determine the impact of hospitalists on particular patient subgroups. STUDY DESIGN: Prospective, quasiexperimental, observational. METHODS: The study was conducted on the general medicine service at an academic teaching hospital, staffed by hospitalist physicians (HP) and nonhospitalist physicians (NHP), and included 1706 consecutive, directly admitted patients over 1 year. RESULTS: The 447 HP patients and 1259 NHP patients had similar rates of in-hospital mortality (1.3% vs 2.1%, respectively; P = .29) and 30-day readmission (7.8% vs 8.7%, respectively; P= .55). Mean hospital length of stay (LOS) was 1 day shorter for HP patients in unadjusted analyses (5.5 vs 6.5 days, respectively; P = .009) and in multivariable analyses adjusting for clustering and patient factors. Physician experience was not correlated (P < .2) with LOS. In stratified analyses, differences in LOS between HP and NHP patients were greater for patients residing closer to the hospital. Mean total costs were $917 less for HP patients (P = .08) and 10% less (P= .04) in multivariable analyses. Decreases in costs were significant (P < .05) for nursing ($604; P = .002) and laboratory services ($126; P = .04). Nonetheless, mean costs per day were $122 higher (P= .003) for HP patients. CONCLUSIONS: Patients managed by hospitalists had shorter LOS and lower costs than patients managed by nonhospitalists, but had higher costs per day. These results suggest that hospitalists increase the intensity of care and may have their greatest impact on specific types of patients and classes of hospital costs.

Diagnosis-Related Groups↗
PubMed2006

Hospitalists in medical education: coming to an academic medical center near you.

Hospitalists are physicians whose medical practice focuses on general medical inpatient care. In the past decade, the number of practicing hospitalists has soared, and hospitalist programs have been established at both community hospitals and academic medical centers. As hospitalists increasingly assume a greater share of inpatient care responsibilities, they will contribute to the training of medical students and house staff. This paper reviews current data on the impact of hospitalists on medical education and the future of hospitalist training.

Academic Medical Centers↗
PubMed2006

Preparing for "diastole": advanced training opportunities for academic hospitalists.

Academic hospital medicine can be described as comprising periods of "systole," during which hospitalists provide clinical care, and periods of "diastole," the portion of a hospitalist's time spent in nonclinical activities. Far from being a period of relaxation, diastole is an active component of a hospitalist's work, the time devoted to the pursuit of career advancement. This period is a critical opportunity for career development in terms of medical research, education, quality improvement, or administration. An appropriate balance of systole and diastole may potentially prevent burnout and allow hospitalists opportunities to focus on academic advancement. Although an increasing number of residency graduates opt for a career in academic hospital medicine, few are prepared for the period of diastole. This article describes several career options in academic hospital medicine, specifically, opportunities in education, research, quality improvement, and administrative opportunities. By informing future hospitalists about the career opportunities within academic hospital medicine possible through managing their diastolic time, we hope that future generations of trainees will be better prepared to enter this field.

Education, Medical, Graduate↗
PubMed2001

Commentary of "Hospitalists and the doctor-patient relationship".

The use of the hospitalist is a means to increase the efficiency of hospitals by achieving equal or better outcomes of care while reducing the cost of care. I comment on David Meltzer's controlled study of the costs and outcomes of hospitalist care, which showed increased cost savings and no change in patients' satisfaction with their care. Relative to full-time community practice, Meltzer's findings probably exaggerate the effect of hospitalists on costs. The physicians in charge of the control group of patients were full-time academic faculty, who typically spend 1 or 2 months per year doing inpatient care, in contrast to hospitalists, who spent most of their time caring for hospitalized patients. His findings probably minimize differences in satisfaction with care. Resident physicians did most of the bedside care for the hospitalist patients and the control group patients, an arrangement that would reduce any intrinsic differences.

Cost-Benefit Analysis↗
PubMed2001

Response to David Meltzer's paper "Hospitalists and the doctor-patient relationship".

The hospitalist movement, in which a generalist physician assumes the physician-of-record role for hospitalized patients in place of the patients' own primary physician is transforming American hospital care. Studies, including those by David Meltzer, support the premise that hospitalist care is less expensive and possibly of higher quality than inpatient care provided by primary physicians. Meltzer's survey of randomly selected individuals indicates that, although many would prefer that their own physician orchestrate their inpatient care, relatively few would pay more than $100 for this privilege. This indicates that patient dissatisfaction with the hospitalist model is unlikely to impede its widespread implementation. Hospitalists are just the latest example of the ongoing tension between generalism and specialization in American medicine. The hospitalist--unlike most traditional medical specialists--is actually a generalist by nature whose specialty is defined by the the site of the care rather than by organ, disease, patient population, or procedure.

Attitude↗