Expanding the roles of hospitalist physicians to include public health

Efficiency of the Japanese Hospitalist System for Patients with Urinary Tract Infection: A Propensity-matched Analysis

Objective The hospitalist system in the United States has been considered successful in terms of the quality of care and cost effectiveness. In Japan, however, its efficacy has not yet been extensively examined. This study examined the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population using treatment of urinary tract infection as an example. Methods We analyzed 271 patients whose most resource-consuming diagnosis at admission was urinary tract infection between April 2017 and March 2019. Propensity-matched analyses were performed to compare health care economics and the quality of care between the hospitalist system and the conventional system. Results In matched pairs, care by the hospitalist system was associated with a significantly shorter length of stay than that by the conventional system. The quality of care (oral antibiotics switch rate, rate of appropriate antibiotics change based on urine or blood culture results, detection rate of urinary tract infection etiology and the number of laboratory tests) was also considered to be favorably impacted by the hospitalist system. Although not statistically significant, hospital costs tended to be lower with the hospitalist system than with the conventional system. The mortality rate and 30-day readmission were also not significantly different between the groups. Conclusion The hospitalist system had a favorable impact on the quality of care and length of stay without increasing readmission in patients with urinary tract infection. This study is further evidence of the strong potential for the positive impact of an implemented hospitalist system in Japan.

Capturing the Rest: Inpatient Mammography for Nonadherent Hospitalized Women

INTRODUCTION

More than a third of hospitalized women are overdue or nonadherent to breast cancer screening guidelines, and almost a third of them are also at high risk for developing breast cancer. The purpose of this study is to evaluate the feasibility of coordinating inpatient breast cancer screening mammography for these women before their discharge from the hospital.

METHODS

A prospective intervention study was conducted among 101 nonadherent women aged 50-74 years who were hospitalized to a general medicine service. Sociodemographic, reproductive history, family history of breast cancer, and medical comorbidities data were collected for all patients from January 2015 to October 2016. The data were analyzed in March 2018. Fisher's exact tests and unpaired t-tests were utilized to compare the characteristics of the study population.

RESULTS

Of the 101 women enrolled who were nonadherent to breast cancer screening recommendations, their mean age was 59.3 (SD=6) years, the mean 5-year Gail risk score was 1.63 (SD=0.69), and 29% of the women were African American. Almost 80% (n=79) underwent inpatient screening mammography. All women who underwent screening mammography during their inpatient stay were extremely satisfied with the experience. The convenience of having screening mammography while hospitalized was reported to be a major facilitator of completing the overdue screening. All nurses (100%) taking care of these women believed that this practice should become part of the standard of care, and most hospitalist physicians (66%) agreed that this practice is feasible.

CONCLUSIONS

This study shows that it is possible to coordinate mammography for hospitalized women who were overdue for screening and at high risk for developing breast cancer.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT04164251.

Quality Improvement Project to Promote Identification and Treatment of Children With Obesity Admitted to Hospital

Among children hospitalized for acute problems, comorbid obesity is commonly unaddressed. The objective was to improve identification and initial management of obesity among hospitalized children. In collaboration with nurses and dietitians, pediatric hospitalists of 2 children's hospitals conducted a quality improvement project to improve body mass index (BMI) documentation, obesity diagnosis, diet, and nutrition consultation through clinician education, development of computerized clinical decision-support system tools, and workflow modifications. Participants received monthly performance feedback. Among those with elevated BMI, diagnosis rose to 70.2%; a documented obesity diagnosis was associated with being 35 times more likely (P < .001) to receive at least 1 intervention while hospitalized. Participants reported an increase in skill in (27%), comfort with (27%), and knowledge of (33%) obesity management. Improvement in health care provider recognition and management of obesity in the inpatient setting is achievable. Additional work is needed to identify how best to sustain desired practice patterns.

Linking care of patients with obesity to outpatient weight control clinics following acute hospitalizations

Despite obesity impacting over one-third of US adults, guideline recommendations have not been effectively utilized by health care providers in hospital settings. Initiation of weight loss plans for obese patients during hospitalizations followed by linkage of care to weight control centers may improve compliance with the guidelines. Provider recognition and awareness that obesity is a chronic condition that warrants inpatient counsel and management with appropriate arrangement of postdischarge follow-up care will be critical to guideline implementation.

Predictors of Non-Adherence to Breast Cancer Screening among Hospitalized Women

Objective

Disparities in screening mammography use persists among low income women, even those who are insured, despite the proven mortality benefit. A recent study reported that more than a third of hospitalized women were non-adherent with breast cancer screening. The current study explores prevalence of socio-demographic and clinical variables associated with non-adherence to screening mammography recommendations among hospitalized women.

Patients and Methods

A cross sectional bedside survey was conducted to collect socio-demographic and clinical comorbidity data thought to effect breast cancer screening adherence of hospitalized women aged 50–75 years. Logistic regression models were used to assess the association between these factors and non-adherence to screening mammography.

Results

Of 250 enrolled women, 61% were of low income, and 42% reported non-adherence to screening guidelines. After adjustment for socio-demographic and clinical predictors, three variables were found to be independently associated with non-adherence to breast cancer screening: low income (OR = 3.81, 95%CI; 1.84–7.89), current or ex-smoker (OR = 2.29, 95%CI; 1.12–4.67), and history of stroke (OR = 2.83, 95%CI; 1.21–6.60). By contrast, hospitalized women with diabetes were more likely to be compliant with breast cancer screening (OR = 2.70, 95%CI 1.35–5.34).

Conclusion

Because hospitalization creates the scenario wherein patients are in close proximity to healthcare resources, at a time when they may be reflecting upon their health status, strategies could be employed to counsel, educate, and motivate these patients towards health maintenance. Capitalizing on this opportunity would involve offering screening during hospitalization for those who are overdue, particularly for those who are at higher risk of disease.

Use of Nutrition Standards to Improve Nutritional Quality of Hospital Patient Meals: Findings from New York City's Healthy Hospital Food Initiative

BACKGROUND

Most hospital patient meals are considered regular-diet meals; these meals are not required to meet comprehensive nutrition standards for a healthy diet. Although programs exist to improve nutrition in hospital food, the focus is on retail settings such as vending machines and cafeterias vs patient meals. New York City's Healthy Hospital Food Initiative (HHFI) provides nutrition standards for regular-diet meals that hospitals can adopt, in addition to retail standards.

OBJECTIVE

This study was undertaken to describe regular-diet patient menus before and after implementation of the HHFI nutrition standards.

DESIGN

The study involved pre- and post- menu change analyses of hospitals participating in the HHFI between 2010 and 2014.

PARTICIPANTS/SETTING

Eight New York City hospitals, selected based on voluntary participation in the HHFI, were included in the analyses.

MAIN OUTCOME MEASURES

Nutritional content of regular-diet menus were compared with the HHFI nutrition standards.

STATISTICAL ANALYSES PERFORMED

Nutrient analysis and exact Wilcoxon signed-rank tests were used for the analysis of the data.

RESULTS

At baseline, no regular-diet menu met all HHFI standards, and most exceeded the daily limits for percentage of calories from fat (n=5), percentage of calories from saturated fat (n=5), and milligrams of sodium (n=6), and they did not meet the minimum grams of fiber (n=7). Hospitals met all key nutrient standards after implementation, increasing fiber (25%, P<0.01) and decreasing sodium (-19%, P<0.05), percentage of calories from fat (-24%, P<0.01), and percentage of calories from saturated fat (-21%, P<0.05). A significant increase was seen in fresh fruit servings (667%, P<0.05) and decreases in full-fat and reduced-fat milk servings (-100%, P<0.05), refined grain servings (-35%, P<0.05), and frequency of desserts (-92%, P<0.05).

CONCLUSIONS

Regular diet menus did not comply with the HHFI nutrition standards at baseline. Using the HHFI framework, hospitals significantly improved the nutritional quality of regular-diet patient menus. The standards were applied across hospitals of varying sizes, locations, menu types, and food service operations, indicating feasibility of this framework in a range of hospital settings.

What do hospitalists think about inpatient mammography for hospitalized women who are overdue for their breast cancer screening?

BACKGROUND

A recent study showed that many hospitalized women are nonadherent with breast cancer screening recommendations, and that a majority of these women would be amenable to inpatient screening if it were offered.

OBJECTIVE

Explore hospitalists' views about the appropriateness of inpatient breast cancer screening and their concerns about related matters.

METHODS

A cross-sectional study was conducted among 4 hospitalist groups affiliated with Johns Hopkins Medical Institution. χ(2) and t-test statistics were used to identify hospitalist characteristics that were associated with being supportive of inpatient screening mammography.

RESULTS

The response rate was 92%. Sixty-two percent of respondents believed that hospitalists should not be involved in breast cancer screening. In response to clinical scenarios describing hospitalized women who were overdue for screening, only one-third of hospitalists said that they would order a screening mammogram. Lack of follow-up on screening mammography results was cited as the most common concern related to ordering the test.

CONCLUSIONS

Future studies are needed to evaluate the feasibility and potential barriers associated with inpatient screening mammography.

Hospitalized women's willingness to pay for an inpatient screening mammogram

Lower rates for breast cancer screening persist among low income and uninsured women. Although Medicare and many other insurance plans would pay for screening mammograms done during hospital stays, breast cancer screening has not been part of usual hospital care. This study explores the mean amount of money that hospitalized women were willing to contribute towards the cost of a screening mammogram. Of the 193 enrolled patients, 72% were willing to pay a mean of $83.41 (95% CI, $71.51-$95.31) in advance towards inpatient screening mammogram costs. The study's findings suggest that hospitalized women value the prospect of screening mammography during the hospitalization. It may be wise policy to offer mammograms to nonadherent hospitalized women, especially those who are at high risk for developing breast cancer.

Improving utilization of antimicrobial drugs among physician assistants in the ED

OBJECTIVE

This study examines the effectiveness of an educational intervention that used audit and feedback to influence physician assistant (PA) antimicrobial utilization in an emergency department (ED).

METHODS

Twelve ED PAs participated in this pre- and postintervention study. Their prescribing patterns were retrospectively reviewed and classified as appropriate, effective but inappropriate, or inappropriate using a previously developed methodology. A hospitalist physician conducted a 1-hour academic detailing intervention session with each PA that reviewed inappropriate prescribing practices and provided feedback for improvement based on current guidelines. After the meetings, the prescribing patterns of the providers were followed prospectively and comparisons were made between the proportions of antimicrobials prescribed appropriately and inappropriately before and after the intervention.

RESULTS

The percentage of appropriate prescriptions increased from 64% (95% CI, 58-72) to 81% (95% CI, 75-86), whereas the proportion of inappropriate prescriptions decreased from 36% (95% CI, 31-43) to 19% (95% CI, 14-23) across the study periods (both P < .001).

CONCLUSION

PA antimicrobial utilization was responsive to an academic detailing initiative that relied heavily on audit and feedback of past performance. Targeting PAs in quality improvement initiatives may be a highly effective way to influence change in health care utilization.

Addressing obesity in the hospitalized patient: a needs assessment

OBJECTIVE

To perform a needs assessment to determine the extent to which hospitalist providers recognize and intervene upon obese patients in the hospital setting.

METHODS

A chart review was performed for patients admitted to the hospitalist service at Johns Hopkins Bayview Medical Center between September 1 and October 1, 2008. Patient charts were reviewed for documentation of obesity and treatment plans were ordered and implemented. Demographic data for patients and hospitalist providers was also collected. Providers were also surveyed about their documentation practices related to obesity and any perceived barriers.

RESULTS

Forty-nine percent (136/276) of admitted patients were obese. Obesity was documented in 19% (26/136) of admission notes and a discrete plan was made to address obesity 7% (10/136) of the time. Hospitalist providers were more likely to document obesity in patients <60 years old (85% versus 55% respectively, P <0.007), and in patients with body mass indices (BMI) >or= 35 (77% versus 44% respectively, P < 0.004). Provider survey results suggest that providers do not document obesity because it is not considered to be an acute issue (67%), and they elect not to address obesity because they lack the time (63%), skill (37%), and they believe that their efforts will be unsuccessful (33%).

CONCLUSION

Documentation of obesity by hospitalist providers is poor. Because an inpatient admission has been characterized as a teachable moment when patients are willing to reflect on behavior change, this may be an ideal time to counsel and educate obese patients.

Utilizing audit and feedback to improve hospitalists' performance in tobacco dependence counseling

INTRODUCTION

Hospitalized smokers benefit from smoking cessation counseling and nicotine replacement therapy (NRT). However, inpatient providers who care for hospitalized patients carry out these preventive measures inconsistently.

METHODS

We designed a peer-led audit and feedback intervention to improve (a) the frequency of smoking cessation counseling and (b) the appropriateness of the prescribing of NRT by hospitalist practitioners in our hospital. Documentation of tobacco cessation counseling in progress notes and discharge summaries and the ordering and dosing of NRT were assessed for 30 hospitalists before and after an intervention. This intervention included specific feedback on their counseling and prescribing practices as well as education and was delivered as part of a one-on-one academic detailing session.

RESULTS

Five hundred and forty five and 1,119 patient-days were considered for this analysis in the pre- and postperiods, respectively. Documentation of tobacco dependence counseling in progress notes increased from 36% to 44% (p = .002) and from 7.5% to 46.8% in discharge summaries (p < .0001) following the intervention. The appropriateness of NRT dosing increased from 26% (before) to 64% (after) the intervention (p < .0001).

DISCUSSION

A peer-led audit and feedback intervention for hospitalists significantly increases the frequency of smoking cessation counseling and the adequacy of NRT prescribing for hospitalized smokers.

Hospitalist physician leadership skills: perspectives from participants of a leadership conference

OBJECTIVE

To characterize how the use of behavioral contracts may serve to focus individuals' intentions to grow as leaders.

METHODS

Between 2007 and 2008, participants of the Society of Hospital Medicine Leadership Academy courses completed behavioral contracts to identify 4 action plans they wanted to implement based on things learned at the Academy. Contracts were independently coded by 2 investigators and compared for agreement. Content analysis identified several major themes that relate to professional growth as leaders. Follow-up surveys assessed fulfillment of personal goals.

RESULTS

The majority of respondents were male (84; 70.0%), and most were hospitalist leaders (76; 63.3%). Their median time practicing as hospitalists was 4 years, 14 (11.7%) were Assistant Professors, and 80 (66.7%) were in private practice. Eight themes emerged from the behavioral contracts, revealing ways in which participants wished to develop: improving communication and interpersonal relations; refining vision and goals for strategic planning; developing intrapersonal leadership; enhancing negotiation skills; committing to organizational change; understanding business drivers; establishing better metrics to assess performance; and strengthening interdepartmental relationships. At follow-up, all but 1 participant had achieved at least 1 of their personal goals.

CONCLUSIONS

Understanding the areas that hospitalist leaders identify as "learning edges" may inform the personal learning plans of those hoping to take on leadership roles in hospital medicine.

Role of hospitalists in an offsite alternate care center (ACC) for pandemic flu

Recent concerns about an influenza pandemic have highlighted the need to plan for offsite Alternate Care Centers (ACCs). The likelihood of a successful response to patient surges will depend on the local health systems' ability to prepare well in advance of an influenza pandemic. Our health system has worked closely with our state's medical biodefense network to plan the establishment of an ACC for an influenza pandemic. As hospitalists have expanded their roles in their local health systems, they are poised to play a major role in planning for the next influenza pandemic. Hospitalists should work with their health system's administration in developing an ACC plan.

Tobacco, alcohol, and drug use among hospital patients: concurrent use and willingness to change

BACKGROUND

Data are limited on concurrent smoking and substance use among hospital patients. To better inform hospital-based intervention strategies, we evaluated the prevalence and concurrent use of these behaviors. This study evaluated the association between tobacco, alcohol, and other drug use, compared willingness to quit smoking among patients with and without substance use, and evaluated the relationship between willingness to quit smoking and readiness to change substance use.

METHODS

This study was a cross-sectional survey of non-Intensive Care Unit hospital patients at 2 public hospitals (a 464-bed tertiary-care hospital and a 100-bed community hospital) by bedside interview. Severity of use and willingness to change behavior was determined. We evaluated the association between smoking and substance use by multivariable methods.

RESULTS

Of 7,391 patients with known smoking status, 2,684 (36%) were current smokers. Among them, 1,376 hospitalized smokers (51%) had concurrent substance use. Among the 1,972 patients with at-risk alcohol or drug use, the prevalence of smoking was 70% compared to 24% for non-substance users (P < .01). Compared to other patients who smoked, substance-dependent patients were more likely (Prevalence Rate Ratio = 1.4, 95% Confidence Interval = 1.1-1.9) to be moderate to heavy smokers. Regardless of substance use pattern, most patients (60%) expressed a desire to immediately quit smoking.

CONCLUSION

Hospital patients who describe at-risk substance use are likely to smoke and express willingness to quit smoking. Given the prevalence of concurrent smoking and substance use and patients' desire to change both behaviors, there is a need for coordination of substance use and smoking cessation interventions.

Underutilized time for health education of hospitalized patients

BACKGROUND

Our anecdotal observations suggested that hospitalized patients had considerable time during the day when they were not occupied with diagnostic testing or other activities. Accordingly, we sought to quantify the fraction of free time that hospitalized patients had available to participate in health educational activities and if and when during their hospitalization they were interested in participating in these activities and felt capable of doing so.

METHODS

From June 25 through August 15, 2005, randomly selected consenting patients admitted to the Internal Medicine service of an academic safety-net hospital became subjects of a time-motion study that was conducted from admission to discharge or to hospital Day 6. Another randomly selected group received daily surveys, and patients in a third group were interviewed on Day 2 or 3 of their hospitalization.

RESULTS

Time-motion data, surveys, and interviews were obtained from 13, 138, and 15 patients, respectively. Of the 316 patient-hours observed, 71% were classified as downtime. More than 80% of patients either "strongly agreed" or "agreed" that they were interested in and capable of being educated on all days of their hospitalization. The themes generated from the interviews included the desire to know more about self-management, prevention of disease recurrence or progression, and their primary illness.

CONCLUSIONS

Adult medical inpatients have considerable time and strong motivation to participate in health educational activities throughout their hospitalization. The current structure for educating hospitalized patients should be supplemented to take these findings into account.

Improving antibiotic utilization among hospitalists: a pilot academic detailing project with a public health approach

BACKGROUND

Inappropriate use of antibiotics is a major clinical problem and public health concern. We developed and implemented a pilot hospitalist-delivered academic detailing intervention to improve the patterns of antibiotic prescribing for inpatients.

OBJECTIVE

To improve antibiotic prescribing patterns on the hospitalist service of an academic medical center.

DESIGN, SETTING, AND PARTICIPANTS

Hospitalist practitioners were recruited to participate in this pre- and postintervention pilot study at Johns Hopkins Bayview Medical Center (JHBMC). Public health principles for creating a conceptual framework based on behavioral change theory were used in developing the intervention.

METHODS

Antibiotic prescribing patterns of 17 hospitalist practitioners were retrospectively reviewed. Antimicrobial prescriptions were classified as appropriate, effective but inappropriate, or inappropriate. A profile was assembled for each hospitalist, and an academic detailing intervention session was arranged. The session reviewed inappropriate prescribing practices as well as current practice guidelines. After the detailing meeting, the prescribing patterns of the hospitalists were followed prospectively.

MAIN OUTCOME MEASURES

The main outcome measures were the proportions of antibiotics prescribed inappropriately before the intervention, during the detailing period, and after the intervention.

RESULTS

Seventeen hospitalist practitioners who participated in the study. A total of 247 prescriptions were reviewed in the preintervention and 129 prescriptions in the postintervention period. Prior to academic detailing, 43% (95% CI 37%-49%) of the prescriptions were appropriate and 57% (95% CI 51%-63%) were inappropriate. After the intervention, 74% (95% CI 65%-81%) of the prescriptions were appropriate and 26% (95% CI 19%-35%) were inappropriate; P < .0001.

CONCLUSIONS

A carefully planned and methodically executed intervention can result in behavior change, even among busy hospitalists. The academic detailing intervention, which included a practice-based learning component, improved antibiotic prescribing practices of hospitalists at JHBMC.