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Reza JA, Steve Eubanks W, de la Fuente SG. Clinical and Financial Implications of Consulting Physicians in the Management of Surgical Patients. Am Surg 2020; 88:578-586. [PMID: 33291943 DOI: 10.1177/0003134820952439] [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: 11/16/2022]
Abstract
BACKGROUND The present study was designed to evaluate the immediate consequences that the number of consulting physicians has on length of stay (LOS), in-hospital mortality, 30-day readmission rates, direct health care costs, and contribution margins. METHODS A retrospective review of administrative databases for the years 2013 and 2014 was performed at the Florida Hospital Adventist Healthcare System. RESULTS 11 274 patients were included in the analysis. Total and variable costs increased by $1347 and $592, respectively, with each consulting physician service per patient. The contribution margin decreased by $354 per patient/consulting physician. Each consulting physician increased LOS by .72 days and increased odds ratio of mortality and 30-day readmission by 5% and 3%, respectively. CONCLUSIONS Our research suggests that each consulting physician added to the care of an individual surgical patient negatively affected LOS, readmission rates, in-hospital mortality, and costs.
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Affiliation(s)
- Joseph A Reza
- Department of Surgery, AdventHealth Orlando, FL, USA
| | - W Steve Eubanks
- Department of Surgery, AdventHealth Orlando, FL, USA.,University of Central Florida, Orlando, FL, USA
| | - Sebastian G de la Fuente
- Department of Surgery, AdventHealth Orlando, FL, USA.,University of Central Florida, Orlando, FL, USA
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Hudali T, Papireddy M, Bhattarai M, Deckard A, Hingle S. Evaluating YouTube as a Source of Patient Education on the Role of the Hospitalist: A Cross-Sectional Study. Interact J Med Res 2017; 6:e1. [PMID: 28073738 PMCID: PMC5263860 DOI: 10.2196/ijmr.6393] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Revised: 12/05/2016] [Accepted: 12/13/2016] [Indexed: 11/21/2022] Open
Abstract
Background Hospital medicine is a relatively new specialty field, dedicated to the delivery of comprehensive medical care to hospitalized patients. YouTube is one of the most frequently used websites, offering access to a gamut of videos from self-produced to professionally made. Objective The aim of our study was to determine the adequacy of YouTube as an effective means to define and depict the role of hospitalists. Methods YouTube was searched on November 17, 2014, using the following search words: “hospitalist,” “hospitalist definition,” “what is the role of a hospitalist,” “define hospitalist,” and “who is a hospitalist.” Videos found only in the first 10 pages of each search were included. Non-English, noneducational, and nonrelevant videos were excluded. A novel 7-point scoring tool was created by the authors based on the definition of a hospitalist adopted by the Society of Hospital Medicine. Three independent reviewers evaluated, scored, and classified the videos into high, intermediate, and low quality based on the average score. Results A total of 102 videos out of 855 were identified as relevant and included in the analysis. Videos uploaded by academic institutions had the highest mean score. Only 6 videos were classified as high quality, 53 as intermediate quality, and 42 as low quality, with 82.4% (84/102) of the videos scoring an average of 4 or less. Conclusions Most videos found in the search of a hospitalist definition are inadequate. Leading medical organizations and academic institutions should consider producing and uploading quality videos to YouTube to help patients and their families better understand the roles and definition of the hospitalist.
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Affiliation(s)
- Tamer Hudali
- Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, United States
| | - Muralidhar Papireddy
- Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, United States
| | - Mukul Bhattarai
- Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, United States
| | - Alan Deckard
- Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, United States
| | - Susan Hingle
- Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL, United States
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Gotlib Conn L, Reeves S, Dainty K, Kenaszchuk C, Zwarenstein M. Interprofessional communication with hospitalist and consultant physicians in general internal medicine: a qualitative study. BMC Health Serv Res 2012. [PMID: 23198855 PMCID: PMC3520700 DOI: 10.1186/1472-6963-12-437] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Studies in General Internal Medicine [GIM] settings have shown that optimizing interprofessional communication is important, yet complex and challenging. While the physician is integral to interprofessional work in GIM there are often communication barriers in place that impact perceptions and experiences with the quality and quantity of their communication with other team members. This study aims to understand how team members’ perceptions and experiences with the communication styles and strategies of either hospitalist or consultant physicians in their units influence the quality and effectiveness of interprofessional relations and work. Methods A multiple case study methodology was used. Thirty-one semi-structured interviews were conducted with physicians, nurses and other health care providers [e.g. physiotherapist, social worker, etc.] working across 5 interprofessional GIM programs. Questions explored participants’ experiences with communication with all other health care providers in their units, probing for barriers and enablers to effective interprofessional work, as well as the use of communication tools or strategies. Observations in GIM wards were also conducted. Results Three main themes emerged from the data: [1] availability for interprofessional communication, [2] relationship-building for effective communication, and [3] physician vs. team-based approaches. Findings suggest a significant contrast in participants’ experiences with the quantity and quality of interprofessional relationships and work when comparing the communication styles and strategies of hospitalist and consultant physicians. Hospitalist staffed GIM units were believed to have more frequent and higher caliber interprofessional communication and collaboration, resulting in more positive experiences among all health care providers in a given unit. Conclusions This study helps to improve our understanding of the collaborative environment in GIM, comparing the communication styles and strategies of hospitalist and consultant physicians, as well as the experiences of providers working with them. The implications of this research are globally important for understanding how to create opportunities for physicians and their colleagues to meaningfully and consistently participate in interprofessional communication which has been shown to improve patient, provider, and organizational outcomes.
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Affiliation(s)
- Lesley Gotlib Conn
- Department of Surgery, St, Michael's Hospital, 30 Bond St., Toronto, ON M5B 1W8, Canada.
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Spellberg B, Lewis RJ, Sue D, Chavoshan B, Vintch J, Munekata M, Kim C, Lanks C, Witt MD, Stringer W, Harrington D. A controlled investigation of optimal internal medicine ward team structure at a teaching hospital. PLoS One 2012; 7:e35576. [PMID: 22532860 PMCID: PMC3330818 DOI: 10.1371/journal.pone.0035576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 03/20/2012] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Brad Spellberg
- Division of General Internal Medicine, Los Angeles Biomedical Research Institute at Harbor-University of California Los Angeles Medical Center, Torrance, California, United States of America.
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Ali NA, Hammersley J, Hoffmann SP, O'Brien JM, Phillips GS, Rashkin M, Warren E, Garland A. Continuity of care in intensive care units: a cluster-randomized trial of intensivist staffing. Am J Respir Crit Care Med 2011; 184:803-8. [PMID: 21719756 DOI: 10.1164/rccm.201103-0555oc] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Little is known about the consequences of intensivists’ work schedules, or intensivist continuity of care. OBJECTIVES To assess the impact of weekend respite for intensivists, with consequent reduction in continuity of care, on them and their patients. METHODS In five medical intensive care units (ICUs) in four academic hospitals we performed a prospective, cluster-randomized, alternating trial of two intensivist staffing schedules. Daily coverage by a single intensivist in half-month rotations (continuous schedule) was compared with weekday coverage by a single intensivist, with weekend cross-coverage by colleagues (interrupted schedule). We studied consecutive patients admitted to study units, and the intensivists working in four of the participating units. MEASUREMENTS AND MAIN RESULTS The primary patient outcome was ICU length of stay (LOS);we also assessed hospital LOS and mortality rates. The primary intensivist outcome was physician burnout. Analysis was by multivariable regression. A total of 45 intensivists and 1,900 patients participated in the study. Continuity of care differed between schedules (patients with multiple intensivists = 28% under continuous schedule vs. 62% under interrupted scheduling; P < 0.0001). LOS and mortality were nonsignificantly higher under continuous scheduling (ΔICU LOS 0.36 d, P = 0.20; Δhospital LOS 0.34 d, P = 0.71; ICU mortality, odds ratio = 1.43, P = 0.12; hospital mortality, odds ratio = 1.17,P = 0.41). Intensivists experienced significantly higher burnout, work–home life imbalance, and job distress working under the continuous schedule. CONCLUSIONS Work schedules where intensivists received weekend breaks were better for the physicians and, despite lower continuity of intensivist care, did not worsen outcomes for medical ICU patients.
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Affiliation(s)
- Naeem A Ali
- Division of Pulmonary, Allergy, Critical CAre and Sleep Medicine, Indiana University, Indianapolis, Indiana, USA
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Frank E, Paul DP, Nersesian R. Hospitalists at an academic medical center, part 1: impact of a voluntary pilot hospitalist program. Hosp Top 2011; 89:75-81. [PMID: 22149937 DOI: 10.1080/00185868.2011.627313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
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.
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Frank E, Paul DP, Nersesian R. Hospitalists at an academic medical center, part 2: guidelines and suggestions for the successful expansion of a voluntary pilot hospitalist program. Hosp Top 2011; 89:82-91. [PMID: 22149938 DOI: 10.1080/00185868.2011.627314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Previously, the authors discussed the successful introduction of a pilot hospitalist program at an academic medical center. Here they examine best practices for the expansion of such a program. Many studies have shown hospitalists to be associated with improvements in hospital quality indicators such as decreased length of stay, but the conditions necessary for the expansion of a hospitalist program have received considerably less attention. The authors review guidelines and empirical evidence from the literature for the successful implementation of hospitalist programs generally and present specific recommendations for a previously described pilot hospitalist program at an academic medical center.
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Howrey BT, Kuo YF, Goodwin JS. Association of care by hospitalists on discharge destination and 30-day outcomes after acute ischemic stroke. Med Care 2011; 49:701-7. [PMID: 21765377 DOI: 10.1097/mlr.0b013e3182166cb6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The use of hospitalists is increasing. Hospitalists have been associated with reductions in length of stay and associated costs while not negatively impacting outcomes. We examine care for stroke patients because it requires complex care in the hospital and has high post discharge complications. We assessed the association of care provided by a hospitalist with length of stay, discharge destination, 30-day mortality, 30-day readmission, and 30-day emergency department visits. METHODS This study used the 5% Medicare sample from 2002 to 2006. Models included demographic variables, prior health status, type of admission and hospital, and region. Multinomial logit models, generalized estimating equations, Cox proportional hazard models, and propensity score analyses were explored in the analysis. RESULTS After adjusting models for covariates, hospitalists were associated with increased odds of discharge to inpatient rehabilitation or other facilities compared with discharge home (Odds Ratio, 1.24; 95% CI, 1.07-1.43 and Odds Ratio, 1.34; 95% CI 1.05-1.69, respectively). Mean length of stay was 0.37 days lower for patients in hospitalist care compared to nonhospitalist care. This reduction in length of stay was not appreciably changed after adjusting for discharge destination. Hospitalist care was not associated with differences in 30-day emergency department use or mortality. Readmission rates were higher for patients in hospitalist care (Hazard, 1.30; 95% CI, 1.11-1.52). CONCLUSIONS Hospitalists are associated with reduced length of stay and higher rates of discharge to inpatient rehabilitation. The higher readmission rates should be further explored.
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Affiliation(s)
- Bret T Howrey
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX, USA.
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Kuo YF, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med 2011; 155:152-9. [PMID: 21810708 PMCID: PMC3196599 DOI: 10.7326/0003-4819-155-3-201108020-00005] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Hospitalist care has grown rapidly, in part because it is associated with decreased length of stay and hospital costs. No national studies examining the effect of hospitalist care on hospital costs or on medical utilization and costs after discharge have been done. OBJECTIVE To assess the relationship of hospitalist care with hospital length of stay, hospital charges, and medical utilization and Medicare costs after discharge. DESIGN Population-based national cohort study. SETTING Hospital care of Medicare patients. PATIENTS A 5% national sample of enrollees in Medicare parts A and B with a primary care physician who were cared for by their primary care physician or a hospitalist during medical hospitalizations from 2001 to 2006. MEASUREMENTS Length of stay, hospital charges, discharge location and physician visits, emergency department visits, rehospitalization, and Medicare spending within 30 days after discharge. RESULTS In propensity score analysis, hospital length of stay was 0.64 day less among patients receiving hospitalist care. Hospital charges were $282 lower, whereas Medicare costs in the 30 days after discharge were $332 higher (P < 0.001 for both). Patients cared for by hospitalists were less likely to be discharged to home (odds ratio, 0.82 [95% CI, 0.78 to 0.86]) and were more likely to have emergency department visits (odds ratio, 1.18 [CI, 1.12 to 1.24]) and readmissions (odds ratio, 1.08 [CI, 1.02 to 1.14]) after discharge. They also had fewer visits with their primary care physician and more nursing facility visits after discharge. LIMITATION Observational studies are subject to selection bias. CONCLUSION Decreased length of stay and hospital costs associated with hospitalist care are offset by higher medical utilization and costs after discharge. PRIMARY FUNDING SOURCE National Institute on Aging and National Cancer Institute.
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Affiliation(s)
- Yong-Fang Kuo
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas 77555-0177, USA.
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Do hospitalist physicians improve the quality of inpatient care delivery? A systematic review of process, efficiency and outcome measures. BMC Med 2011; 9:58. [PMID: 21592322 PMCID: PMC3123228 DOI: 10.1186/1741-7015-9-58] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Accepted: 05/18/2011] [Indexed: 11/10/2022] Open
Abstract
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.
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Kuo YF, Goodwin JS. Effect of hospitalists on length of stay in the medicare population: variation according to hospital and patient characteristics. J Am Geriatr Soc 2010; 58:1649-57. [PMID: 20863324 DOI: 10.1111/j.1532-5415.2010.03007.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To assess how shorter length of stay (LOS) associated with hospitalist care than with care by other physicians varied according to patient and hospital characteristics and to explore whether these differences in LOS changed over time in the Medicare population. DESIGN Retrospective cohort study using data from a 5% national sample of Medicare beneficiaries. SETTING Hospital. PARTICIPANTS To examine temporal trends, 1,981,654 Medicare admissions in 2001 to 2006 at 5,036 U.S. hospitals were used. To examine the influence of patient and hospital characteristics, 314,590 admissions in 2006 were used. MEASUREMENTS Hospital LOS. RESULTS In multivariable analyses controlling for patient and hospital characteristics, differences in LOS associated with hospitalist care increased from 0.02 fewer days in 2001/02 to 0.22 days in 2003/04 to 0.35 days in 2005/06. For 2006 admissions, differences in LOS were greater in older patients and patients with a higher diagnosis-related group (DRG) weight. The differences were three times as great for medical as for surgical DRGs, with greater differences in LOS at nonprofit than for-profit hospitals and at community than teaching hospitals. CONCLUSION The shorter LOS associated with hospitalist care would appear to be greatest in older, complicated, nonsurgical patients cared for at community hospitals.
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Affiliation(s)
- Yong-Fang Kuo
- Department of Internal Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas, USA.
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Kuo YF, Sharma G, Freeman JL, Goodwin JS. Growth in the care of older patients by hospitalists in the United States. N Engl J Med 2009; 360:1102-12. [PMID: 19279342 PMCID: PMC2977939 DOI: 10.1056/nejmsa0802381] [Citation(s) in RCA: 185] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND National and population-based information on the increase in patient care by hospitalists in the United States is lacking. METHODS Using a 5% sample of Medicare beneficiaries in 1995, 1997, 1999, and the period from 2001 through 2006, we identified 120,226 physicians in general internal medicine who were providing care to older patients in 5800 U.S. hospitals. We defined hospitalists as general internists who derived 90% or more of their Medicare claims for evaluation-and-management services from the care of hospitalized patients. We then calculated the percentage of all inpatient Medicare services provided by hospitalists and identified patient and hospital characteristics associated with the receipt of hospitalist services. RESULTS The percentage of physicians in general internal medicine who were identified as hospitalists increased from 5.9% in 1995 to 19.0% in 2006, and the percentage of all claims for inpatient evaluation-and-management services by general internists that were attributed to hospitalists increased from 9.1% to 37.1% during this same period. Accompanying the increase in care by hospitalists was an increase in the percentage of all hospitalized Medicare patients who were treated by general internists (both hospitalists and traditional, non-hospital-based general internists), from 46.4% in 1995 to 61.0% in 2006. In a multilevel, multivariable analysis controlling for patient and hospital characteristics, the odds of receiving care from a hospitalist increased by 29.2% per year from 1997 through 2006. In 2006, there was marked geographic variation in the rates of care provided by hospitalists, with rates of more than 70% in some hospital-referral regions. CONCLUSIONS These analyses of data from Medicare claims showed a substantial increase in the care of hospitalized patients by hospitalist physicians from 1995 to 2006.
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Affiliation(s)
- Yong-Fang Kuo
- Department of Internal Medicine and the Sealy Center on Aging, University of Texas Medical Branch, Galveston 77555-0460, USA.
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Salottolo K, Slone DS, Howell P, Settell A, Bar-Or R, Craun M, Bar-Or D. Effects of a nonsurgical hospitalist service on trauma patient outcomes. Surgery 2009; 145:355-61. [PMID: 19303983 DOI: 10.1016/j.surg.2008.12.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2008] [Accepted: 12/15/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND The American College of Surgeons criteria for Level I trauma centers calls for >90% of trauma patients to be admitted directly by a trauma surgeon or surgical subspecialist; however, the efficiency of the trauma system may be increased if patients presenting with comorbid conditions and minor injuries are treated by a hospitalist team (nonsurgical Trauma MEDical [TMED] service). We hypothesized outcomes would be equivalent for patients treated under TMED versus a surgical service. METHODS This retrospective review compared mortality, hospital length of stay (LOS), Emergency Department (ED) LOS, placement to rehabilitation facilities, and complication rates for patients who could have been treated by TMED as identified by an algorithm. The study population for 2003 (pre-TMED) was compared with the study population for 2006 (post-TMED). Univariate analyses and multivariate logistic and linear regression were used to identify outcomes that were different for patients treated in 2003 versus 2006. Sensitivity, specificity, and percent kappa agreement were calculated for patients who were treated by the TMED team in 2006 versus patients in 2006 who were identified using the algorithm. RESULTS The algorithm had reasonable sensitivity (78%) and specificity (90%); the kappa agreement was excellent (0.88). No differences were found in mortality (P = .31), rate of complications (P = .08), ED LOS (P = .77), or placement to rehabilitation facilities (P = .29) for patients identified in 2003 versus 2006. Hospital LOS was increased in 2006 (3.7 vs 4.1 days; P = .02). CONCLUSION These data support admission of trauma patients with nonsevere, single-system injuries to a nonsurgical hospitalist service. We hypothesize that overall system efficiency may be improved by applying this alternative model in other trauma centers.
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Affiliation(s)
- Kristin Salottolo
- Trauma Research Department, Swedish Medical Center, Englewood, CO 80113, USA
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Bishop TF, Kathuria N. Economic and healthcare forces of hospitalist movement. ACTA ACUST UNITED AC 2009; 75:424-9. [PMID: 18828163 DOI: 10.1002/msj.20069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
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.
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Glasheen JJ, Siegal EM, Epstein K, Kutner J, Prochazka AV. Fulfilling the promise of hospital medicine: tailoring internal medicine training to address hospitalists' needs. J Gen Intern Med 2008; 23:1110-5. [PMID: 18612754 PMCID: PMC2517911 DOI: 10.1007/s11606-008-0646-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Categorical internal medicine (IM) residency training has historically effectively prepared graduates to manage the medical needs of acutely ill adults. The development of the field of hospital medicine, however, has resulted in hospitalists filling clinical niches that have been traditionally ignored or underemphasized in categorical IM training. Furthermore, hospitalists are increasingly leading inpatient safety, quality and efficiency initiatives that require understanding of hospital systems, multidisciplinary care and inpatient quality assessment and performance improvement. Taken in this context, many graduating IM residents are under-prepared to practice as effective hospitalists. In this paper, we outline the rationale for targeted training in hospital medicine and discuss the content and methods for delivering this training.
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Affiliation(s)
- Jeffrey J Glasheen
- Internal Medicine Residency Training Program, University of Colorado Denver School of Medicine, Aurora, CO, USA.
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Kho AN, Hui S, Kesterson JG, McDonald CJ. Which observations from the complete blood cell count predict mortality for hospitalized patients? J Hosp Med 2007; 2:5-12. [PMID: 17274042 PMCID: PMC3692736 DOI: 10.1002/jhm.143] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Information on the prognostic utility of the admission complete blood count (CBC) and differential count is lacking. OBJECTIVE To identify independent predictors of mortality from the varied number and morphology of cells in the complete blood count defined as a hemogram, automated five cell differential count and manual differential count. DESIGN Retrospective cohort study and chart review. SETTING Wishard Memorial Hospital, a large urban primary care hospital. PATIENTS A total of 46,522 adult inpatients admitted over 10 years to Wishard Memorial Hospital-from January 1993 through December 2002. INTERVENTION None. MEASUREMENTS Thirty-day mortality measured from day of admission as determined by electronic medical records and Indiana State death records. RESULTS Controlling for age and sex, the multivariable regression model identified 3 strong independent predictors of 30-day mortality-nucleated red blood cells (NRBCs), burr cells, and absolute lymphocytosis-each of which was associated with a 3-fold increase in the risk of death within 30 days. The presence of nucleated RBCs was associated with a 30-day mortality rate of 25.5% across a range of diagnoses, excluding patients with sickle-cell disease and obstetric patients, for whom NRBCs were not associated with increased mortality. Having burr cells was associated with a mortality rate of 27.3% and was found most commonly in patients with renal or liver failure. Absolute lymphocytosis predicted poor outcome in patients with trauma and CNS injury. CONCLUSIONS Among patients admitted to Wishard Memorial Hospital, the presence of nucleated RBCs, burr cells, or absolute lymphocytosis at admission was each independently associated with a 3-fold increase in risk of death within 30 days of admission.
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Mourad O, Redelmeier DA. Clinical teaching and clinical outcomes: teaching capability and its association with patient outcomes. MEDICAL EDUCATION 2006; 40:637-44. [PMID: 16836536 DOI: 10.1111/j.1365-2929.2006.02508.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND There is little research on the impact of medical education on patient outcome. We studied whether teaching capability is associated with altered short-term patient outcomes. METHODS We performed a multicentre retrospective cross-sectional study involving 40 clinician teachers who had attended on the general internal medicine services in hospitals affiliated with the University of Toronto along with the clinical outcomes of consecutive patients treated for community-acquired pneumonia, congestive heart failure, chronic obstructive pulmonary disease and gastrointestinal bleeding (n = 4377) between 1999 and 2001. Doctors were characterised by teaching effectiveness scores (n = 677) as high-rated or low-rated according to house staff ratings. RESULTS There was no correlation between the teaching effectiveness scores and the mean length of stay for those patients treated for community-acquired pneumonia (high-rated = 10.3 versus low-rated = 8.1 days, P = 0.058), congestive heart failure (high-rated = 10.1 versus low-rated = 9.9 days, P = 0.978), chronic obstructive pulmonary disease (high-rated = 9.4 versus low-rated = 9.9 days, P = 0.419) and gastrointestinal bleeding (high-rated = 6.3 versus low-rated = 6.8 days, P = 0.741). In addition, we observed no significant correlation between teaching effectiveness scores and 7-day, 28-day and 1-year readmission rates for all pre-specified diagnoses. CONCLUSION There is no large correlation between teaching effectiveness scores and short-term patient outcomes, suggesting that doctor teaching capabilities, as perceived by house staff, does not generally impact clinical care.
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Affiliation(s)
- Ophyr Mourad
- St Michael's Hospital, Toronto, Ontario, Canada.
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Ettner SL, Kotlerman J, Afifi A, Vazirani S, Hays RD, Shapiro M, Cowan M. An alternative approach to reducing the costs of patient care? A controlled trial of the multi-disciplinary doctor-nurse practitioner (MDNP) model. Med Decis Making 2006; 26:9-17. [PMID: 16495196 DOI: 10.1177/0272989x05284107] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Susan L Ettner
- School of Medicine, Division of General Internal Medicine and Health Services Research, UCLA School of Medicine, 911 Broxton Plaza, Room 106, Los Angeles, CA 90095, USA.
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Coffman J, Rundall TG. The impact of hospitalists on the cost and quality of inpatient care in the United States: a research synthesis. Med Care Res Rev 2005; 62:379-406. [PMID: 16049131 DOI: 10.1177/1077558705277379] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Parekh V, Saint S, Furney S, Kaufman S, McMahon L. What effect does inpatient physician specialty and experience have on clinical outcomes and resource utilization on a general medical service? J Gen Intern Med 2004; 19:395-401. [PMID: 15109336 PMCID: PMC1492253 DOI: 10.1111/j.1525-1497.2004.30298.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To examine the effects of internal medicine specialty and physician experience on inpatient resource use and clinical outcomes on an academic general medicine service. DESIGN A 1-year retrospective cohort study. SETTING The University of Michigan Hospitals, Ann Arbor, Michigan. PATIENTS Two thousand six hundred seventeen admissions to the general medicine service from July 2001 to June 2002, excluding those for whom data were incomplete (n = 18). MEASUREMENTS AND MAIN RESULTS Length of stay (LOS) and total hospital costs were used to measure resource utilization. Hospital mortality and 14-day and 30-day readmission rates were used to measure clinical outcomes. Adjusted mean LOS was significantly greater for rheumatologists (0.56 days greater; P =.002) and endocrinologists (0.38 days greater; P =.03) compared to general internists. Total costs were lower for general internists compared to endocrinologists ($1100 lower; P =.01) and rheumatologists ($431 lower; P =.07). Hospitalists showed a trend toward reduced LOS compared to all other physicians (0.31 days lower; P =.06). The top two deciles of physicians stratified by recent inpatient general medical experience showed significantly reduced LOS compared to all other physicians (0.35 days lower; P =.04). No significant differences were seen in readmission rates or in-hospital mortality among the various physician groups. CONCLUSIONS General internists had lower lengths of stay and costs compared to endocrinologists and rheumatologists. Hospitalists showed a trend toward reduced LOS compared to all other physicians. Recent inpatient general medicine experience appears to be a determinant of reduced inpatient resource use.
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Affiliation(s)
- Vikas Parekh
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan 48109-0376, USA.
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Abstract
OBJECTIVE To compare evaluations of teaching effectiveness among hospitalist, general medicine, and subspecialist attendings on general medicine wards. DESIGN Cross-sectional. SETTING A large, inner-city, public teaching hospital. PARTICIPANTS A total of 423 medical students and house staff evaluating 63 attending physicians. MEASUREMENTS AND MAIN RESULTS We measured teaching effectiveness with the McGill Clinical Tutor Evaluation (CTE), a validated 25-item survey, and reviewed additional written comments. The response rate was 81%. On a 150-point composite measure, hospitalists' mean score (134.5 [95% confidence interval (CI), 130.2 to 138.8]) exceeded that of subspecialists (126.3 [95% CI, 120.4 to 132.1]), P =.03. General medicine attendings (135.0 [95% CI, 131.2 to 138.8]) were also rated higher than subspecialists, P =.01. Physicians who graduated from medical school in the 1990s received higher scores (136.0 [95% CI, 133.0 to 139.1]) than did more distant graduates (129.1 [95% CI, 125.1 to 133.1]), P =.006. These trends persisted after adjusting for covariates, but only year of graduation remained statistically significant, P =.05. Qualitative analysis of written remarks revealed that trainees valued faculty who were enthusiastic teachers, practiced evidence-based medicine, were involved in patient care, and developed a good rapport with patients and other team members. These characteristics were most often noted for hospitalist and general medicine attendings. CONCLUSIONS On general medicine wards, medical students and residents considered hospitalists and general medicine attendings to be more effective teachers than subspecialists. This effect may be related to the preferred faculty members exhibiting specific characteristics and behaviors highly valued by trainees, such as enthusiasm for teaching and use of evidence-based medicine.
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Affiliation(s)
- Sunil Kripalani
- Division of General Medicine, Emory University School of Medicine, Atlanta, GA 30303, USA.
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Abstract
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.
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Affiliation(s)
- Robert M Wachter
- Department of Medicine, University of California Medical Center, Box 0120, Room M-994, 505 Parnassus Avenue, San Francisco, CA 94143-0120, USA.
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Palmer HC, Armistead NS, Elnicki DM, Halperin AK, Ogershok PR, Manivannan S, Hobbs GR, Evans K. The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. Am J Med 2001; 111:627-32. [PMID: 11755506 DOI: 10.1016/s0002-9343(01)00976-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To evaluate the impact of implementing a hospitalist service with a nurse discharge planner in an academic teaching hospital. SUBJECTS AND METHODS Inpatient medicine service was provided by hospitalists, general internists, and specialists. Service personnel were identical except that the hospitalist service also had a nurse discharge planner. Hospitalists attended 4 months per year (compared with the 1 month by most other attending physicians) and had no outpatient responsibilities during the ward months. Patients were admitted alternately based on resident call schedule. Major outcomes included average costs of hospitalization, length of stay, and resource utilization. Quality measures included inpatient mortality, 30-day readmission rates, and satisfaction of patients, residents and students. RESULTS Hospitalist-attended services had lower mean (+/- SD) inpatient costs per patient ($4289 +/- $6512) compared with specialist-staffed services ($6066 +/- $7550, P < 0.0001), with a trend toward lower costs when compared with generalist-attended services ($4850 +/- $7027, P = 0.11). Hospitalist services had shorter mean lengths of stay (4.4 +/- 4.0 days), compared with generalists (5.2 +/- 5.2 days) and specialists (6.0 +/- 5.5 days, P < 0.0001 for hospitalists vs. both groups). Readmission rates were similar in all groups. Mortality rates were higher in the specialist group [5.0% (44 of 874)] compared with hospitalists [2.2% (18 of 829)] and generalists [2.6% (20 of 761), P = 0.002 for specialists vs. both groups, P = 0.09 for generalists vs hospitalists]. Satisfaction results were uniformly high in all groups, with no significant differences. CONCLUSION Hospitalist services with a nurse discharge planner were associated with lower average cost and shorter average length of hospital stay, without any apparent compromise in clinical outcomes or patient satisfaction.
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Affiliation(s)
- H C Palmer
- Department of Medicine, West Virginia University, Morgantown, Pennsylvania, USA
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