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Abstract
BACKGROUND Multispecialty clinical settings are increasingly prevalent because of the growing complexity in health care, revealing challenges with overlaps in expertise. We study hospitalists and inpatient specialists to gain insights on how physicians with shared expertise may differentiate themselves in practice. PURPOSE The aim of this study was to explore how hospitalists differentiate themselves from other inpatient physicians when treating patient cases in areas of shared expertise, focusing on differences in patient populations, practice patterns, and performance on cost and quality metrics. METHODOLOGY We use mixed-effects multilevel models and mediation models to analyze medical records and disaggregated billing data for admissions to a large urban pediatric hospital from January 1, 2009, to August 31, 2015. RESULTS In areas of shared physician expertise, patients with more ambiguous diagnoses and multiple chronic conditions are more likely to be assigned to a hospitalist. Controlling for differences in patient populations, hospitalists order laboratory tests and medications at lower rates than specialists. Hospitalists' laboratory testing rate had a significant mediating role in their lower total charges and lower odds of their patients experiencing any nonsurgical adverse events compared to specialists, though hospitalists did not differ from specialists in 30- and 90-day readmission rates. PRACTICE IMPLICATIONS Physicians with shared expertise, such as hospitalists and inpatient specialists, differentiate their roles through assignment to ambiguous diagnoses and multisystem conditions, and practice patterns such as laboratory and medication orders. Such differentiation can improve care coordination and establish professional identity when roles overlap.
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Freeman MH, Shinn JR, Fernando SJ, Totten D, Lee J, Malenke JA, Wood CB, Langerman AJ, Mannion K, Sinard RJ, Rohde SL. Impact of Preoperative Risk Factors on Inpatient Stay and Facility Discharge After Free Flap Reconstruction. Otolaryngol Head Neck Surg 2021; 166:454-460. [PMID: 34399644 DOI: 10.1177/01945998211037541] [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: 11/15/2022]
Abstract
OBJECTIVE To determine the preoperative risk factors most predictive of prolonged length of stay (LOS) or admission to a skilled nursing facility (SNF) or inpatient rehabilitation center (IPR) after free flap reconstruction of the head and neck. STUDY DESIGN Retrospective cohort study. SETTING Tertiary academic medical center. METHODS Retrospective review of 1008 patients who underwent tumor resection and free flap reconstruction of the head and neck at a tertiary referral center from 2002 to 2019. RESULTS Of 1008 patients (65.7% male; mean age of 61.4 years, SD 14.0 years), 161 (15.6%) were discharged to SNF/IPR, and the median LOS was 7 days. In multiple linear regression analysis, Charlson Comorbidity Index (CCI; P < .001), American Society of Anesthesiologists (ASA) classification (P = .021), female gender (P = .023), and inability to tolerate oral diet preoperatively (P = .006) were statistically significantly related to increased LOS, whereas age, body mass index (BMI), modified frailty index (MFI), a history of prior radiation or chemotherapy, and home oxygen use were not. Multiple logistic regression analysis demonstrated that CCI (odds ratio [OR] = 1.119, confidence interval [CI] 1.023-1.223), age (OR = 1.082, CI 1.056-1.108), and BMI <19.0 (OR = 2.141, CI 1.159-3.807) were the only variables statistically significantly related to posthospital placement in an SNF or IPR. CONCLUSION Common tools for assessing frailty and need for additional care may be inadequate in a head and neck reconstructive population. CCI appears to be the best of the aggregate metrics assessed, with significant relationships to both LOS and placement in SNF/IPR.
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Affiliation(s)
- Michael Hartley Freeman
- Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Justin R Shinn
- Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Otolaryngology, Head and Neck Surgery, University of Texas Southwestern, Dallas, TX
| | - Shanik J Fernando
- Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Douglas Totten
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jaclyn Lee
- Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jordan A Malenke
- Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - C Burton Wood
- Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Otolaryngology, Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Alexander J Langerman
- Division of Head and Neck, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kyle Mannion
- Division of Head and Neck, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert J Sinard
- Division of Head and Neck, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah L Rohde
- Division of Head and Neck, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Lai YF, Leow SY, Lee SYF, Xiong J, Lim CW, Ong BC. General medicine at the frontline of acute care delivery: Comparison with family medicine hospitalist model implementation in Singapore. PROCEEDINGS OF SINGAPORE HEALTHCARE 2021. [DOI: 10.1177/2010105820937747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction This mixed methods study seeks to assess the clinical outcomes and qualitative insights associated with the pragmatic implementation of a general medicine (GM) physician-led inpatient care model, first at Alexandra Hospital (AH) and then at Sengkang General Hospital (SKH), and to compare them with findings reported in an earlier implementation of the family medicine (FM) hospitalist model in Singapore. Methods Anonymous quantitative demographic and clinical data including length of stay, 30-day readmission rate, inpatient mortality rate and gross cost of hospitalisation bills were extracted from the hospital information system. Comparative analyses with the FM hospitalist model and usual care were made. Secondary qualitative data that were gathered focused on increased understanding of the proposed model, its perceived challenges and future opportunities for its implementation. Results The adapted GM care model implemented first at AH and then at SKH seemed to suggest that such a model run by physicians from various backgrounds was capable of producing similarly superior outcomes when compared with the FM hospitalist model piloted in 2011, which was juxtaposed with usual care. With regard to qualitative insights, three findings were reported: (a) perception of and mindset in relation to generalists, which illustrates the barriers to implementing GM; (b) education and training of generalists, which underlines the current lack of adequate supply of GM specialists; and (c) operational issues of care model implementation, which highlights the current mismatches between the prevailing healthcare philosophy and the requirements for successful implementation of the GM care model. Conclusion The success of a GM care model hinges on how it is operationalised. With clear protocols, definitions, and a high level of protocol compliance by healthcare team members, the intended outcomes show promise for replication at other interested sites.
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Affiliation(s)
- Yi Feng Lai
- Office for Healthcare Transformation, Ministry of Health, Singapore
- National University of Singapore, Singapore
- Alexandra Hospital, Singapore
| | | | | | - Jun Xiong
- National University of Singapore, Singapore
| | - Cher Wee Lim
- Office for Healthcare Transformation, Ministry of Health, Singapore
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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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Komulainen H, Mertaniemi E, Lunkka N, Jansson N, Meriläinen M, Wiik H, Suhonen M. Persuasive speech in multi-professional change facilitation meetings. J Health Organ Manag 2019; 33:396-412. [DOI: 10.1108/jhom-12-2018-0366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this paper is to describe persuasive speech and discourses in multi-professional organizational change facilitation meetings at a hospital through rhetorical discourse analysis. Previous research has often considered organizational change to be a managerial issue, with other employees given the rather passive role of implementators. This study takes an alternative approach in assuming that organizational change could benefit by involving those who are most familiar with the tasks to be changed.
Design/methodology/approach
The study employed a qualitative, case study approach and focused on the construction of a hospitalist model within multi-professional change facilitation meetings. Eight videos of these multi-professional change facilitation meetings – which occurred between January and September 2017 – were observed and the material was analyzed by rhetorical discourse analysis. An average of 10–20 actors from different professional groups participated in the meetings. The change actors comprised physicians, nursing staff and nursing managers, along with a secretary and hospitalist. The meetings were conducted by a change facilitator.
Findings
The persuasive speech in the analyzed organizational change meetings occurred within five distinct discourses: constructing the change together, positive feedback, strategic change in speech, patient perspective and driving change. The content of these discourses revealed topics that are relevant to persuading members of healthcare organizations to adopt a planned change.
Originality/value
The presented research provides new knowledge about how persuasive speech is used in organizational change and describes the discourses in which persuasive speech is used in a healthcare context.
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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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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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Seiler A, Visintainer P, Brzostek R, Ehresman M, Benjamin E, Whitcomb W, Rothberg MB. Patient satisfaction with hospital care provided by hospitalists and primary care physicians. J Hosp Med 2012; 7:131-6. [PMID: 22042532 DOI: 10.1002/jhm.973] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 08/04/2011] [Accepted: 08/13/2011] [Indexed: 11/10/2022]
Abstract
BACKGROUND Compared to hospital care provided by primary care physicians (PCPs), the hospitalist model provides equal-to-superior efficiency and outcomes; however, little is known about how the model affects patient satisfaction. METHODS Random patient satisfaction telephone interviews were conducted on discharged adult medicine inpatients at 3 Massachusetts hospitals between 2003 and 2009. Questionnaires included variables assessing patient satisfaction with various physician care domains. Patient age, gender, admission year, education level, language, illness severity, emergency room admission status, institution, and attending physician type were extracted from billing records. We used adjusted multivariable models to compare patient satisfaction with hospitalists and PCPs for domains of: physician care quality, physician behavior, pain management, communication. RESULTS Inpatients completed discharge surveys for 8295 encounters (3597 hospitalist, 4698 PCP). Multivariate-adjusted satisfaction scores for physician care quality were slightly higher for PCPs than hospitalists (4.24 vs 4.20, P = 0.04); there was no statistical difference at any individual hospital, and no difference among different hospitalist groups. Patient ratings of hospitalists and PCPs for behavior, pain control, and communication were equivalent (all P values >0.23). In multivariable models, hospitalists and PCPs had similar adjusted proportions in the highest satisfaction category (79.2% vs 80.5%, respectively, P = 0.17) and lowest category (5.1% vs 4.5%, respectively, P = 0.19). Quality ratings of both groups improved equivalently (P slope interaction = 0.47) but significantly over time (PCP 4.21 (2003) to 4.36 (2009), hospitalist 4.11 to 4.33, P Δ <0.001). CONCLUSIONS Patients appear similarly satisfied with inpatient care provided by several hospitalist models and by primary care physicians.
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Affiliation(s)
- Adrianne Seiler
- Division of Healthcare Quality, Baystate Medical Center, Springfield, MA 01199, 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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Kimmel B, Sullivan MM, Rushakoff RJ. Survey on transition from inpatient to outpatient for patients on insulin: what really goes on at home? Endocr Pract 2011; 16:785-91. [PMID: 20350914 DOI: 10.4158/ep10013.or] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To identify the diabetes-specific, posthospital discharge issues that may arise for patients sent home on insulin therapy. METHODS We designed and conducted a telephone survey covering predischarge issues such as survival skill education and insulin discharge instructions, postdischarge logistical problems such as obtaining diabetes medications and supplies, and overall glucose control. The questionnaire was administered by telephone 1 week after discharge from the hospital to adult patients sent home on long-acting insulin. RESULTS We attempted to contact 61 patients who were eligible for the study. Eleven patients were unable to be reached by telephone despite multiple attempts. Forty-seven of 50 patients contacted agreed to be interviewed. Nearly 100% of patients received appropriate "survival skills" training, including instruction regarding self-monitoring of blood glucose, insulin administration, and treatment of hypoglycemia. Once discharged, 10 patients (21%) had difficulty obtaining diabetes medications and supplies. Thirty-seven patients (79%) felt that their blood glucose control was "good" in the week after they left the hospital compared with author perception of 25 patients having good glucose control (53%) on the basis of pre-defined criteria. Although patients received instruction on insulin dosing and when and who to call for problems and questions, specific guidelines on how to manage insulin in the setting of changing glucocorticoid dosages were not communicated to patients. CONCLUSIONS On the basis of our findings, we anticipate implementing improvements in diabetes-specific discharge prescriptions, new guidelines on when patients should call for assistance, and specific orders on how to adjust insulin for changes in glucocorticoid dosages.
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Affiliation(s)
- Bonnie Kimmel
- Division of Endocrinology and Metabolism, University of California-San Francisco, San Francisco, California 94115 , 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: 83] [Impact Index Per Article: 6.4] [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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Hock Lee K, Yang Y, Soong Yang K, Chi Ong B, Seong Ng H. Bringing generalists into the hospital: outcomes of a family medicine hospitalist model in Singapore. J Hosp Med 2011; 6:115-21. [PMID: 21387546 DOI: 10.1002/jhm.821] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
PURPOSE The aim of this study was to assess a newly introduced hospitalist care model in a Singapore hospital. Clinical outcomes of the family medicine hospitalists program were compared with the traditional specialists-based model using the hospital's administrative database. METHODS Retrospective cohort study of hospital discharge database for patients cared for by family medicine hospitalists and specialists in 2008. Multivariate analysis models were used to compare the clinical outcomes and resource utilization between patients cared for by family medicine hospitalists and specialist with adjustment for demographics, and comorbidities. RESULTS Of 3493 hospitalized patients in 2008 who met the criteria of the study, 601 patients were under the care of family medicine hospitalists. As compared with patients cared for by specialists, patients cared for by family medicine hospitalists had a shorter hospital length of stay (adjusted LOS, geometric mean, GM, 4.4 vs. 5.3 days; P < 0.001) and lower hospitalization costs (adjusted cost, GM, $2250.7 vs. $2500.0; P= 0.003), but a similar in-patient mortality rate (4.2% vs. 5.3%, P= 0.307) and 30-day all-cause unscheduled readmission rate (7.5% vs. 8.4%, P= 0.231) after adjustment for age, ethnicity, gender, intensive care unit (ICU) admission, numbers of organ failures, and comorbidities. CONCLUSION The family medicine hospitalist model was associated with reductions in hospital LOS and cost of care without adversely affecting mortality or 30-day all-cause readmission rate. These findings suggest that the hospitalist care model can be adapted for health systems outside North America and may produce similar beneficial effects in care efficiency and cost savings.
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Affiliation(s)
- Kheng Hock Lee
- Family Medicine and Continuing Care, Singapore General Hospital, Singapore.
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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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Chen LM, Freitag MH, Franco M, Sullivan CD, Dickson C, Brancati FL. Natural history of late discharges from a general medical ward. J Hosp Med 2009; 4:226-33. [PMID: 19388081 DOI: 10.1002/jhm.413] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Slow hospital discharges reduce efficiency and compromise care for patients awaiting a bed. Although efficient discharge is a widely held goal, the natural history of the discharge process has not been well studied. OBJECTIVE To describe the discharge process and identify factors associated with longer and later discharges. DESIGN Prospective cohort study. SETTING A general medicine ward without house-staff coverage, in a tertiary care hospital (The Johns Hopkins Hospital) in Baltimore, Maryland, from January 1, 2005 to April 30, 2005. PATIENTS Two hundred and nine consecutively discharged adult inpatients. MEASUREMENTS Discharge time (primary outcome) and discharge duration (secondary outcome). RESULTS Median discharge time was 3:09 PM (25th% to 75th%: 1:08 to 5:00 PM). In adjusted analysis, discharge time was associated with ambulance used on discharge (1.5 hours), prescriptions filled prior to discharge (1.4 hours), subspecialty consult prior to discharge (1.2 hours), and procedure prior to discharge (1.1 hours). Median duration of the discharge process was 7 hours 34 minutes (25th% to 75th%: 4.0 to 22.0 hours). Discharge duration was associated with discharge to a location other than home (28.9 hours), and with need for consultation (14.8 hours) or a procedure (13.4 hours) prior to discharge (all P values <0.05). CONCLUSIONS Discharge time and duration have wide variability. Longer and later discharges were associated with procedures and consults. Successful efforts to decrease time of discharge will require broad institutional effort to improve delivery of interdepartmental services.
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Affiliation(s)
- Lena M Chen
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, 150 S.Huntington Ave., Boston, MA 02130, 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: 178] [Impact Index Per Article: 11.9] [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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Edwards N, Webber J, Mill J, Kahwa E, Roelofs S. Building capacity for nurse-led research. Int Nurs Rev 2009; 56:88-94. [DOI: 10.1111/j.1466-7657.2008.00683.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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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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Resident physician and hospital pharmacist familiarity with patient discharge medication costs. ACTA ACUST UNITED AC 2009; 31:195-201. [DOI: 10.1007/s11096-009-9280-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2008] [Accepted: 12/28/2008] [Indexed: 11/27/2022]
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O'Leary MD KJ, Williams MD MV. The evolution and future of hospital medicine. ACTA ACUST UNITED AC 2008; 75:418-23. [DOI: 10.1002/msj.20078] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Balla U, Malnick S, Schattner A. Early readmissions to the department of medicine as a screening tool for monitoring quality of care problems. Medicine (Baltimore) 2008; 87:294-300. [PMID: 18794712 DOI: 10.1097/md.0b013e3181886f93] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
With growing awareness of medical fallibility, researchers need to develop tools to identify and study medical mistakes. We examined the utility of hospital readmissions for this purpose in a prospective case-control study in a large academic medical center in Israel. All patients with nonelective readmissions to 2 departments of medicine within 30 days of discharge were interviewed, and their medical records were carefully examined with emphasis on the index admission. Patient data were compared to data for age- and sex-matched controls (n = 140) who were not readmitted. Medical records of readmitted and control patients were blindly evaluated by 2 senior clinicians who independently identified potential quality of care (QOC) problems during the index admission. Inhospital and late mortality was determined 6 months after discharge.Over a period of 3 months there were 1988 urgent admissions; 1913 discharges and subsequently 271 unplanned readmissions occurred (14.1% of discharges). Readmissions occurred an average of 10 days after discharge, and readmitted patients were sicker than controls (mean, 4.3 vs. 3.3 diagnoses per patient), although their length of stay was similarly short (3.4 +/- 2.8 d). Analysis of all readmissions revealed QOC problems in 90/271 (33%) of readmissions, 4.5% of hospitalizations. All were deemed preventable. Interobserver agreement was good (83%, kappa = 0.67). Among matched controls, only 8/140 admissions revealed QOC problems (6%, p < 0.001) (k = 0.77). The preventable readmissions mostly involved a vascular event or congestive heart failure; they occurred within a mean of 10 +/- 8 days of the index admission, and their inpatient mortality was 6.7% vs. 1.7% among readmissions that had no QOC problems (odds ratio, 4.1; 95% confidence interval, 1.0-16.7). The main pitfalls identified during the index admission included incomplete workup (33%), too short hospital stay (31%), inappropriate medication (44%), diagnostic error (16%), and disregarding a significant laboratory result (12%). In many patients more than 1 pitfall was identified (mean, 1.5 per patient). Risk factors for preventable readmission include older age and living in an institution (p < 0.05). Almost two-thirds of the readmitted patients with QOC problems were discharged after spending 2 days or fewer at the hospital. In conclusion, unplanned readmissions within 30 days of discharge are frequent, more prevalent in sicker patients, and possibly associated with increased mortality. In a third of readmitted patients a QOC problem can be identified, and these problems are preventable. Thus, readmission may be used as a screening tool for potential QOC problems in the department of medicine. Routine monitoring of all readmissions may provide a simple cost-effective means of identifying and addressing medical mistakes.
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Affiliation(s)
- Uri Balla
- From Department of Medicine, Kaplan Medical Centre, Rehovot; Hebrew University Hadassah Medical School, Jerusalem, Israel
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Vansaghi LM, Stites SW, Pingleton SK, Turner S, Hansen C. Evolution of an academic hospitalist program: clinical, educational, and financial value. Am J Med 2008; 121:349-54. [PMID: 18374695 DOI: 10.1016/j.amjmed.2007.11.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2007] [Revised: 07/20/2007] [Accepted: 11/29/2007] [Indexed: 10/22/2022]
Affiliation(s)
- Lisa M Vansaghi
- University of Kansas Medical Center, Kansas City, KS 66160, USA.
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Southern WN, Berger MA, Bellin EY, Hailpern SM, Arnsten JH. Hospitalist care and length of stay in patients requiring complex discharge planning and close clinical monitoring. ACTA ACUST UNITED AC 2007; 167:1869-74. [PMID: 17893308 PMCID: PMC2838181 DOI: 10.1001/archinte.167.17.1869] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Academic medical centers are increasingly employing hospitalists to staff teaching wards. Although studies have demonstrated reduced lengths of stay (LOSs) associated with hospitalist care, it is unclear which patients are most likely to benefit. We sought to determine whether patients with specific diagnoses or discharge needs account for the association between hospitalist care and reduced LOS. METHODS Hospital admissions were divided into the following 2 groups based on type of attending physician: teaching hospitalist (full-time faculty hospitalist with no outpatient responsibilities) vs nonhospitalist (full-time or voluntary faculty contributing 1 or 2 months of teaching service per year). We included all patients discharged from an academic teaching service for a 2-year period. Data were extracted from the Montefiore Medical Center's clinical information system and the Social Security Death Registry. RESULTS Mean LOS was lower for teaching hospitalists than for nonhospitalists (5.01 vs 5.87 days [P < .02]). The reduction in LOS was greatest for patients requiring close clinical monitoring (patients with congestive heart failure, stroke, asthma, or pneumonia) and for those requiring complex discharge planning. There were no significant differences between the groups in readmission, in-hospital mortality, or 30-day mortality. CONCLUSION Teaching hospitalist care was associated with shorter LOS in patients requiring close clinical monitoring and complex discharge planning, without adversely affecting readmission or mortality rates.
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Affiliation(s)
- William N Southern
- Department of Medicine, Weiler Hospital of Albert Einstein College of Medicine, 1825 Eastchester Rd, Bronx, NY 10461, USA.
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Mistiaen P, Poot E. Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home. Cochrane Database Syst Rev 2006; 2006:CD004510. [PMID: 17054207 PMCID: PMC6823218 DOI: 10.1002/14651858.cd004510.pub3] [Citation(s) in RCA: 124] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND It is known that many patients encounter a variety of problems in the first weeks after they have been discharged from hospital to home. In recent years many projects have addressed discharge planning, with the aim of reducing problems after discharge. Telephone follow-up (TFU) is seen as a good means of exchanging information, providing health education and advice, managing symptoms, recognising complications early, giving reassurance and providing quality aftercare service. Some research has shown that telephone follow-up is feasible, and that patients appreciate such calls. However, at present it is not clear whether TFU is also effective in reducing postdischarge problems. OBJECTIVES To assess the effects of follow-up telephone calls in the first month post discharge, initiated by hospital-based health professionals, to patients discharged from hospital to home. SEARCH STRATEGY We searched the following databases from their start date to July 2003, without limits as to date of publication or language: the Cochrane Consumers and Communication Review Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), PubMed, EMBASE (OVID), BiomedCentral, CINAHL, ERIC (OVID), INVERT (Dutch nursing literature index), LILACS, Picarta (Dutch library system), PsycINFO/PsycLIT (OVID), the Combined Social and Science Citation Index Expanded (SCI-E), SOCIOFILE. We searched for ongoing research in the following databases: National Research Register (http://www.update-software.com/nrr/); Controlled Clinical Trials (http://www.controlled-trials.com/); and Clinical Trials (http://clinicaltrials.gov/). We searched the reference lists of included studies and contacted researchers active in this area. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of TFU initiated by a hospital-based health professional, for patients discharged home from an acute hospital setting. The intervention was delivered within the first month after discharge; outcomes were measured within 3 months after discharge, and either the TFU was the only intervention, or its effect could be analysed separately. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion and for methodological quality. The methodological quality of included studies was assessed using the criteria from the Cochrane Effective Practice and Organisation of Care Review Group. The data-extraction form was based on the template developed by the Cochrane Consumers and Communication Review Group. Data was extracted by one review author and checked by a second author. For as far it was considered that there was enough clinical homogeneity with regard to patient groups and measured outcomes, statistical pooling was planned using a random effects model and standardised mean differences for continuous scales and relative risks for dichotomous data, and tests for statistical heterogeneity were performed. MAIN RESULTS We included 33 studies involving 5110 patients. Predominantly, the studies were of low methodological quality. TFU has been applied in many patient groups. There is a large variety in the ways the TFU was performed (the health professionals who undertook the TFU, frequency, structure, duration, etc.). Many different outcomes have been measured, but only a few were measured across more than one study. Effects are not constant across studies, nor within patient groups. Due to methodological and clinical diversity, quantitative pooling could only be performed for a few outcomes. Of the eight meta-analyses in this review, five showed considerable statistical heterogeneity. Overall, there was inconclusive evidence about the effects of TFU. AUTHORS' CONCLUSIONS The low methodological quality of the included studies means that results must be considered with caution. No adverse effects were reported. Nevertheless, although some studies find that the intervention had favourable effects for some outcomes, overall the studies show clinically-equivalent results between TFU and control groups. In summary, we cannot conclude that TFU is an effective intervention.
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Affiliation(s)
- P Mistiaen
- NIVEL, Netherlands Institute for Healthcare Services Research, PO Box1568, Utrecht, Netherlands.
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Roy A, Heckman MG, Roy V. Associations between the hospitalist model of care and quality-of-care-related outcomes in patients undergoing hip fracture surgery. Mayo Clin Proc 2006; 81:28-31. [PMID: 16438475 DOI: 10.4065/81.1.28] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To investigate the relationship between the hospitalist consultant model of care and both length of hospital stay (LOS) and hospital cost for patients undergoing hip fracture surgery. PATIENTS AND METHODS We retrospectively studied 118 consecutive patients admitted with hip fracture (diagnosis related groups 79.35 and 81.52) between January 1, 2002, and December 31, 2002, at a community-based academic medical center. For each patient, consultations for preoperative medical evaluation and management of postoperative complications were performed by a hospitalist or a traditional medical consultant (nonhospitalist). We defined "hospitalist" as dedicated hospital-based physicians who provide their maximum professional time in inpatient health care delivery and who are completely free of outpatient responsibilities. Time to consultation (TTC), time to surgery (TTS), LOS, and total hospital costs were determined for each patient by review of the medical records and were compared between hospitalist and nonhospitalist consultants. RESULTS Both TTC and TTS were significantly lower for hospitalist patients (P < .001 and P = .004, respectively). Although not statistically significant, cost and LOS also were lower for patients receiving hospitalist care. In the hospitalist group, median cost was an estimated dollar 1777 less, and median LOS was 1 day less than in the nonhospitalist group. CONCLUSION Hospitalist Involvement in the medical management of patients undergoing hip fracture surgery may be associated with decreases in TTC, TTS, LOS, and total hospital cost. The results of this study have implications for consultative medical care of patients undergoing urgent surgery and their health outcomes.
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Affiliation(s)
- Archana Roy
- Division of Hospital Internal Medicine, Mayo Clinic College of Medicine, 4500 San Pablo Rd, Jacksonville, FL 32224, USA.
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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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Abstract
The hospitalist "specialty" is sweeping the inpatient setting with numbers of physicians choosing this specialty expected to exceed 20,000 by 2010. Yet, little is known about the involvement of nursing in the design, implementation, and evaluation of a hospitalist initiative. The author suggests the chief nursing officer's pivotal role in proactively encouraging the design and implementation of a hospitalist-nurse manager patient-centered care delivery model. The chief nursing officer can create an environment to foster research designed to identify outcomes from this partnership of hospitalist and clinical (nurse) manager.
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Affiliation(s)
- Lynda Olender
- Bronx VA Medical Center, Bronx, New York 10468, 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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Scheurer DB, Miller JG, Blair DI, Pride PJ, Walker GM, Cawley PJ. Hospitalists and Improved Cost Savings in Patients With Bacterial Pneumonia at a State Level. South Med J 2005; 98:607-10. [PMID: 16004167 DOI: 10.1097/01.smj.0000157532.78673.2f] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Danielle B Scheurer
- Department of Internal Medicine, Hospitalist Program, Medical University of South Carolina, Charleston, SC 29425, USA.
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Carey MR, Sheth H, Braithwaite RS. A prospective study of reasons for prolonged hospitalizations on a general medicine teaching service. J Gen Intern Med 2005; 20:108-15. [PMID: 15836542 PMCID: PMC1490052 DOI: 10.1111/j.1525-1497.2005.40269.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Delays in the care of hospitalized patients may lead to increased length of stay, iatrogenic complications, and costs. No study has characterized delays among general medicine inpatients in the current prospective payment era of care. OBJECTIVE To quantify and characterize delays in care which prolong hospitalizations for general medicine inpatients. DESIGN Prospective survey of senior residents. SETTING Urban tertiary care university-affiliated teaching hospital. PARTICIPANTS Sixteen senior residents were surveyed regarding 2,831 patient-days. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data were collected on 97.6% (2,762) of patient-days eligible for evaluation. Three hundred seventy-three patient-days (13.5% of all hospital days) were judged unnecessary for acute inpatient care, and occurred because of delays in needed services. Sixty-three percent of these unnecessary days were due to nonmedical service delays and 37% were due to medical service delays. The vast majority of nonmedical service delays (84%) were due to difficulty finding a bed in a skilled nursing facility. Medical service delays were most often due to postponement of procedures (54%) and diagnostic test performance (21%) or interpretation (10%), and were significantly more common on weekend days (relative risk [RR], 1.49; P=.02). Indeed, nearly one fourth of unnecessary patient-days (24% overall, 88 patient-days) involved an inability to access medical services on a weekend day (Saturday or Sunday). CONCLUSIONS At our institution, a substantial number of hospital days were judged unnecessary for acute inpatient care and were attributable to delays in medical and nonmedical services. Future work is needed to develop and investigate measures to decrease delays.
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Affiliation(s)
- Mark R Carey
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Rifkin WD, Holmboe E, Scherer H, Sierra H. Comparison of hospitalists and nonhospitalists in inpatient length of stay adjusting for patient and physician characteristics. J Gen Intern Med 2004; 19:1127-32. [PMID: 15566442 PMCID: PMC1494784 DOI: 10.1111/j.1525-1497.2004.1930415.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine the independent effect of hospitalist status upon inpatient length of stay after controlling for case mix, as well as patient-level and provider-level variables such as age, years since physician medical school graduation, and volume status of provider. DESIGN Observational retrospective cohort study employing a hierarchical random intercept logistic regression model. SETTING Tertiary-care teaching hospital. PATIENTS All admissions during 2001 to the department of medicine not sent initially to the medical intensive care unit or coronary care unit. MEASUREMENTS Observed length of stay (LOS) compared to principle diagnosis related group (DRG)-specific mean LOS for hospitalist and nonhospitalist patients adjusting for patient age, gender, years since physician graduation from medical school, and physician volume status. MAIN RESULTS The 9 hospitalists discharged 2,027 patients while the nonhospitalists discharged 9,361 patients. On average, hospitalist patients were younger, 63.3 versus 73.3 years (P < .0001). Hospitalists were more recently graduated from medical school, 13.8 versus 22.5 years (P= .02). Each year of patient age was found to increase the likelihood of an above average LOS (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.01 to 1.02; P < .001). In unadjusted analysis, hospitalists were less likely to have an above average LOS (OR, 0.51; 95% CI, 0.28 to 0.93; P= .03). Adjustment for effects of patient age and gender, physician gender, years since medical school graduation, and quintile of physician admission volume did not appreciably change the point estimate that hospitalist patients remained less likely to have above average LOS (OR, 0.60; 95% CI, 0.32 to 1.11; P= .11). CONCLUSIONS For a given principle DRG, hospitalist patients were less likely to exceed the average LOS than were nonhospitalist patients. This effect was rather large, in that hospitalist status reduced the likelihood of above average LOS by about 49%. Adjustment for patient age, years since physician graduation, and admission volume did not significantly alter this finding. Further research should focus on identifying specific practices that account for hospitalism's effects.
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Affiliation(s)
- William D Rifkin
- Department of Medicine, Yale University School of Medicine and Yale Primary Care Residency Program, CT, USA.
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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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Whelan A, Appel J, Alper EJ, De Fer TM, Dickinson TA, Fazio SB, Friedman E, Kuzma MA, Reddy S. The future of medical student education in internal medicine. Am J Med 2004; 116:576-80. [PMID: 15063829 DOI: 10.1016/j.amjmed.2004.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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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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Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med 2003; 18:646-51. [PMID: 12911647 PMCID: PMC1494907 DOI: 10.1046/j.1525-1497.2003.20722.x] [Citation(s) in RCA: 523] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine the prevalence of medical errors related to the discontinuity of care from an inpatient to an outpatient setting, and to determine if there is an association between these medical errors and adverse outcomes. PATIENTS Eighty-six patients who had been hospitalized on the medicine service at a large academic medical center and who were subsequently seen by their primary care physicians at the affiliated outpatient practice within 2 months after discharge. DESIGN Each patient's inpatient and outpatient medical record was reviewed for the presence of 3 types of errors related to the discontinuity of care from the inpatient to the outpatient setting: medication continuity errors, test follow-up errors, and work-up errors. MEASUREMENTS Rehospitalizations within 3 months after the initial postdischarge outpatient primary care visit. MAIN RESULTS Forty-nine percent of patients experienced at least 1 medical error. Patients with a work-up error were 6.2 times (95%confidence interval [95% CI], 1.3 to 30.3) more likely to be rehospitalized within 3 months after the first outpatient visit. We did not find a statistically significant association between medication continuity errors (odds ratio [OR], 2.5; 95%CI, 0.7 to 8.8) and test follow-up errors (OR, 2.4; 95%CI, 0.3 to 17.1) with rehospitalizations. CONCLUSION We conclude that the prevalence of medical errors related to the discontinuity of care from the inpatient to the outpatient setting is high and may be associated with an increased risk of rehospitalization.
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Affiliation(s)
- Carlton Moore
- Division of General Internal Medicine, Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA.
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Edlich RF, Hill LG, Heather CL. A national epidemic of unassigned patients: is the hospitalist the solution? J Emerg Med 2002; 23:297-300. [PMID: 12426021 DOI: 10.1016/s0736-4679(02)00535-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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