What effect does inpatient physician specialty and experience have on clinical outcomes and resource utilization on a general medical service?

Survey of Inpatient Consultations with General Internal Medicine Physicians in a Tertiary Hospital: A Retrospective Observational Study

Purpose

The general internal medicine (GIM) department can be an effective diagnostic coordinator for undiagnosed outpatients. We investigated the contribution of GIM consultations to the diagnosis of patients admitted to specialty departments in hospitals in Japan that have not yet adopted a hospitalist system.

Patients and Methods

This single-center, retrospective observational study was conducted at a university hospital in Japan. GIM consultations from other departments on inpatients aged ≥20 years, from April 2016 to March 2021, were included. Data were extracted from electronic medical records, and consultation purposes were categorized into diagnosis, treatment, and diagnosis and treatment. The primary outcome was new diagnosis during hospitalization for patients with consultation purpose of diagnosis or diagnosis and treatment. The secondary outcomes were the purposes of consultation with the Diagnostic and Generalist Medicine department.

Results

In total, 342 patients were included in the analysis. The purpose of the consultations was diagnosis for 253 patients (74%), treatment for 60 (17.5%), and diagnosis and treatment for 29 patients (8.5%). In 282 consultations for diagnosis and diagnosis and treatment, 179 new diagnoses were established for 162 patients (57.5%, 95% confidence interval [CI], 51.5-63.3).

Conclusion

The GIM department can function as a diagnostic consultant for inpatients with diagnostic problems admitted to other specialty departments in hospitals where hospitalist or other similar systems are not adopted.

Generalist vs specialist acute medical admissions - What is the impact of moving towards acute medical subspecialty admissions on efficacy of care provision?

INTRODUCTION

The discussion surrounding generalist versus specialist acute medical admissions continues to stimulate debate and patients with certain conditions benefit from specialist care.

AIM

To determine whether a specialty medical admission program would reduce inpatient length of stay (LOS), mortality and readmission rates.

DESIGN/METHODS

A prospective cohort study of inpatients admitted under a general internal medicine (GIM) service before and after introduction of a specialty-directing programme. We hypothesized that early transfer of patient care to a specialty suited to their presenting complaint would reduce LOS and a specialty-directing early redistribution of care programme was introduced. Seven of the ten clinical teams participating in the GIM roster adopted the programme. On the morning following a specialty-directing team being on call for all new GIM admissions during a 24-hour period, specialty-directing teams were allocated one patient appropriate to their specialty.

RESULTS

5,144 patient-care episodes were analysed over the two-year study period. LOS increased by greater than 15%, one year after introducing the specialty-directing programme (8.5±8.4 vs 7.3±7.5 days, p < 0.001). LOS did not differ between teams that participated and those who did not (8.4±8.1 vs 8.1±7.9 days, p = 0.298). No differences were found in the proportion of patients who were discharged home, died while an inpatient or re-admitted within 30 days of discharge. The proportion of patients aged greater than 80 years increased significantly also - from 24.7% in 2017 to 27.9% in 2019(p == 0.009).

CONCLUSION

Widespread adoption of specialist care may not be beneficial for all medical inpatients and physicians should continue to undergo dual specialist and GIM training.

Readmissions on Teaching Versus Non-Teaching Services: Are They Any Different?

Introduction There is a paucity of comparative data on readmissions between teaching services (TS) and nonteaching services (NTS). Therefore, we designed this study to determine if there are any differences in readmissions between the two services. Materials and methods A unique cohort of 384 readmissions during one year was retrospectively examined at Hunter Holmes McGuire Veterans Medical Center. The data on patient demographics, baseline characteristics, comorbid illnesses, length of stay (LOS), and reasons for readmission within 30 days were extracted. Results There were no differences in readmission rates (8.2% vs. 10.2%; P = .135), LOS during index admission (4.2 ± 4.8 vs. 4.1 ± 3.5; P = .712), and age-adjusted Charlson Comorbid Index Score (6.1 ± 3.0 vs. 6.8 ± 2.8; P = .037) between the TS and NTS groups. However, the reasons for readmissions between the two groups were statistically significantly different (P < .01). Specifically, these differences were found between system issues and new diagnoses. The NTS showed higher rates of readmissions secondary to new diagnoses and systems issues, whereas the TS showed higher rates of secondary to clinician issues and disease progression. Conclusions We have a new understanding of the difference in reasons for readmissions between TS and NTS; it possibly results from the different structures of the two teams, which may help us address readmissions in a different light to improve overall readmission rate.

Comparative Impact of C-Reactive Protein Testing in Hospitalized Patients with Acute Respiratory Tract Infection: A Retrospective Cohort Study

INTRODUCTION

Evidence-based data on the usefulness of C-reactive protein (CRP) monitoring in patient outcomes are lacking. CRP testing in patients with acute respiratory tract infections (ARTIs) showed wide variability between internal medicine wards in our hospital network. In this study we aimed to investigate whether repetitive CRP tests might influence the switch of antibiotic therapy from intravenous (IV) to oral (PO) route and whether CRP measurements affect the combined outcome of readmission and in-hospital mortality.

METHODS

This was a retrospective cohort study conducted in two internal medicine wards selected in a network of five teaching hospitals on the basis of their CRP prescription frequency. Clinical and laboratory data of 296 patients with ARTIs and admitted from 1 January to 31 December 2016 were analyzed.

RESULTS

The mean ± SD of CRP tests/patient and the in-hospital length of antibiotic therapy (days) in the low-CRP (L-CRP) vs the high-CRP (H-CRP) wards were 1.14 ± 0.62 vs 3.43 ± 1.54 (p < 0.001) and 7.1 ± 2.6 vs 7.5 ± 3.2 (p = 0.298), respectively. The probability of antibiotic switching was higher in the L-CRP ward (HR 2.90, 95% CI 1.69-4.95, p < 0.001) correlating with the lower number of CRP determinations (HR 1.20, 95% CI 1.01-1.41, p = 0.034). In-hospital readmissions and mortality rates did not significantly differ between the two wards (L-CRP 17.1% vs H-CRP 10.0%, p = 0.133). The number of CRP determinations affected the combined outcome (OR 1.38, 95% CI 1.01-1.90, p = 0.043).

CONCLUSIONS

Repetitive CRP testing in ARTIs offers no added value to either antibiotic switch or patient outcomes in hospitalized patients in internal medicine wards.

Computer-Assisted Antimicrobial Recommendations for Optimal Therapy: Analysis of Prescribing Errors in an Antimicrobial Stewardship Trial

Clinician education and prospective audit and feedback interventions, deployed separately and concurrently, did not reduce antimicrobial use errors or rates compared to a control group of general medicine inpatients at our public hospital. Additional research is needed to define the optimal scope and intensity of hospital antimicrobial stewardship interventions. Infect Control Hosp Epidemiol 2017;38:857-859.

The ratio of nurse consultation and physician efficiency index of senior rheumatologists is significantly higher than junior physicians in rheumatology residency training: A new efficiency measure in a cohort, exploratory study

To elucidate the difference between ratios of nurse consultation sought by senior rheumatologists and junior physicians in rheumatology residency training, and also to evaluate physician efficiency index respecting patients with rheumatoid arthritis (RA).Data regarding outpatient visits for RA patients between November 2013 and 2015 were extracted. The mean interval (day) between consultations, the nurse/physician visits ratio, and physician efficiency index (nurse/physician visits ratio × mean interval) for each senior and junior physicians were calculated. Disease Activity Score in 28 joints-C-Reactive Protein (DAS28-CRP) and Health Assessment Questionnaire (HAQ) scores were used to monitor treatment outcome. Therefore, DAS28 and HAQ scores were measured 3 times: firstly at physician consultation, then after nurse consultation, and finally at the third visit, either at a nurse or physician consultation.Of 6046 visits, 3699 visits, planned by 11 physicians (4 specialists and 7 junior physicians), were included. These numbers of visits belonged to 672 RA patients, among which 431 (64.1%) patients were female, the mean age being 64.9 ± 14.1 years, and DAS28 at baseline was 4.5 ± 1.2. The nurse/physician visits ratio (P = .01) and mean efficiency index (P = .04) of senior rheumatologists were significantly higher than that of junior physicians. Regression analysis showed a positive correlation between physician postgraduate experience and physician efficiency index adjusted for DAS28 at baseline and number of patients for each physician (regression coefficient 5.427, 95% confidence interval 1.068-9.787, P = .022). There was a high correlation between physicians' postgraduate experience (year) and the ratio of nurse/physician visits (r = 0.91, P < .001), and also physician efficiency index (r = 0.94, P < .001). Nurse consultation did not contribute to worsening treatment outcome, since DAS28 and HAQ scores were significantly decreased if physician visits were followed by nurse visits (P = .004 for DAS28 and P = .025 for HAQ).If junior physicians are supervised to refer RA patients with milder and sufficient treatment plan to nurses, the entire department operates more efficiently, leading to prevent additional expenses (due to the differences in yearly salary of physicians and nurses) and human resource waste. Quality of care should be monitored by markers of disease activity and CRP.

Physician experience and outcomes among patients admitted to general internal medicine teaching wards

BACKGROUND

Physician scores on examinations decline with time after graduation. However, whether this translates into declining quality of care is unknown. Our objective was to determine how physician experience is associated with negative outcomes for patients admitted to hospital.

METHODS

We conducted a retrospective cohort study involving all patients admitted to general internal medicine wards over a 2-year period at all 7 teaching hospitals in Alberta, Canada. We used files from the Alberta College of Physicians and Surgeons to determine the number of years since medical school graduation for each patient's most responsible physician. Our primary outcome was the composite of in-hospital death, or readmission or death within 30 days postdischarge.

RESULTS

We identified 10 046 patients who were cared for by 149 physicians. Patient characteristics were similar across physician experience strata, as were primary outcome rates (17.4% for patients whose care was managed by physicians in the highest quartile of experience, compared with 18.8% in those receiving care from the least experienced physicians; adjusted odds ratio [OR] 0.88, 95% confidence interval [CI] 0.72-1.06). Outcomes were similar between experience quartiles when further stratified by physician volume, most responsible diagnosis or complexity of the patient's condition. Although we found substantial variability in length of stay between individual physicians, there were no significant differences between physician experience quartiles (mean adjusted for patient covariates and accounting for intraphysician clustering: 7.90 [95% CI 7.39-8.42] d for most experienced quartile; 7.63 [95% CI 7.13-8.14] d for least experienced quartile).

INTERPRETATION

For patients admitted to general internal medicine teaching wards, we saw no negative association between physician experience and outcomes commonly used as proxies for quality of inpatient care.

Treating patients with colon cancer liver metastasis: a nationwide analysis of therapeutic decision making

BACKGROUND

Criteria for resectability of colon cancer liver metastases (CLM) are evolving, yet little is known about how physicians choose a therapeutic strategy for potentially resectable CLM.

METHODS

Physicians completed a national Web-based survey that consisted of varied CLM conjoint tasks. Respondents chose among three treatment strategies: immediate liver resection (LR), preoperative chemotherapy followed by surgery (C → LR), or palliative chemotherapy (PC). Data were analyzed by multinomial logistic regression, yielding odds ratios (OR).

RESULTS

Of 219 respondents, 79 % practiced at academic centers and 63 % were in practice ≥10 years. Median number of cases evaluated was four per month. Surgical training varied: 51 % surgical oncology, 44 % hepato-pancreato-biliary/transplantation, 5 % no fellowship. Although each factor affected the choice of CLM therapy, the relative effect differed. Hilar lymph node disease predicted a strong aversion to LR with surgeons more likely to choose C → LR (OR 8.92) or PC (OR 49.9). Solitary lung metastasis also deterred choice of LR, with respondents favoring C → LR (OR 4.43) or PC (OR 6.97). After controlling for clinical factors, surgeons with more years in practice were more likely to choose PC over C → LR (OR 1.94) (P = 0.005). Surgical oncology-trained surgeons were more likely than hepatobiliary/transplant-trained surgeons to choose C → LR (OR 2.53) or PC (OR 4.15) (P < 0.001).

CONCLUSIONS

This is the first nationwide study to define the relative impact of key clinical factors on choice of therapy for CLM. Although clinical factors influence choice of therapy, surgical subspeciality and physician experience are also important determinants of care.

Competence in patient safety: a multifaceted experiential educational intervention for resident physicians

BACKGROUND

The need to provide efficient, effective, and safe patient care is of paramount importance. However, most physicians receive little or no formal training to prepare them to address patient safety challenges within their clinical practice.

METHODS

We describe a comprehensive Patient Safety Learning Program (PSLP) for internal medicine and medicine-pediatrics residents. The curriculum is designed to teach residents key concepts of patient safety and provided opportunities to apply these concepts in the "real" world in an effort to positively transform patient care. Residents were assigned to faculty expert-led teams and worked longitudinally to identify and address patient safety conditions and problems. The PSLP was assessed by using multiple methods.

RESULTS

Resident team-based projects resulted in changes in several patient care processes, with the potential to improve clinical outcomes. However, faculty evaluations of residents were lower for the Patient Safety Improvement Project rotation than for other rotations. Comments on "unsatisfactory" evaluations noted lack of teamwork, project participation, and/or responsiveness to faculty communication. Participation in the PSLP did not change resident or faculty attitudes toward patient safety, as measured by a comprehensive survey, although there was a slight increase in comfort with discussing medical errors.

CONCLUSIONS

Development of the PSLP was intended to create a supportive environment to enhance resident education and involve residents in patient safety initiatives, but it produced lower faculty evaluations of resident for communication and professionalism and did not have the intended positive effect on resident or faculty attitudes about patient safety. Further research is needed to design or refine interventions that will develop more proactive resident learners and shift the culture to a focus on patient safety.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

U.S. trends in hospitalization and generalist physician workforce and the emergence of hospitalists

BACKGROUND

General internists and other generalist physicians have traditionally cared for their patients during both ambulatory visits and hospitalizations. It has been suggested that the expansion of hospitalists since the mid-1990s has "crowded out" generalists from inpatient care. However, it is also possible that declining hospital utilization relative to the size of the generalist workforce reduced the incentives for generalists to continue providing hospital care.

OBJECTIVE

To examine trends in hospital utilization and the generalist workforce before and after the emergence of hospitalists in the U.S. and to investigate factors contributing to these trends.

DESIGN

Using data from 1980-2005 on inpatient visits from the National Hospital Discharge Survey, and physician manpower data from the American Medical Association, we identified national trends before and after the emergence of hospitalists in the annual number of inpatient encounters relative to the number of generalists.

RESULTS

Inpatient encounters relative to the number of generalists declined steadily before the emergence of hospitalists. Declines in inpatient encounters relative to the number of generalists were driven primarily by reduced hospital length of stay and increased numbers of generalists.

CONCLUSIONS

Hospital utilization relative to generalist workforce declined before the emergence of hospitalists, largely due to declining length of stay and rising generalist workforce. This likely weakened generalist incentives to provide hospital care. Models of care that seek to preserve dual-setting generalist care spanning ambulatory and inpatient settings are most likely to be viable if they focus on patients at high risk of hospitalization.

Hospitalists as emerging leaders in patient safety: lessons learned and future directions

OBJECTIVE

To examine the results of a multi-institution, hospitalist-centered consortium designed to disseminate knowledge of best practices relevant to patient safety and to facilitate institutional innovation around such practices.

METHODS

The Hospitalists as Emerging Leaders in Patient Safety (HELPS) consortium consisted of a hospitalist lead and a patient safety representative from each of 9 health care systems in southeastern Michigan. The consortium's aim was to provide rapid dissemination of best practices in patient safety through regular group meetings and to facilitate implementation and analysis of hospitalist-led patient safety initiatives. Key safety targets included prevention of device-related infections, creating a culture of safety, care transitions, medication safety, fall prevention, perioperative care, intensive care unit safety, and end-of-life care. Participating institutions were free to implement any of the best practices and had access to the expertise of the HELPS coordinating site. Surveys were used to assess knowledge dissemination among participants.

RESULTS

Participating institutions described their patient safety initiative and identified several key barriers and facilitators encountered during implementation. Common themes emerged among both barriers and facilitators. In postmeeting surveys to measure dissemination, consortium participants answered a mean of 84.2% (SD = 19.2) of the questions correctly.

CONCLUSIONS

The HELPS consortium successfully disseminated knowledge regarding best practices and identified common barriers and facilitators faced by hospitalists and institutions attempting to improve safety. The next step is to transform the consortium into a robust quality collaborative that leverages key facilitators and prospectively addresses barriers to implementing high-impact interventions in a multihospital setting.

Hospitalist involvement in internal medicine residencies

CONTEXT

The ways hospitalists interact with and contribute to internal medicine residencies in the United States have been described locally, but have not been documented on a national level.

OBJECTIVES

To describe the penetration of hospitalists into medicine residency faculty nationally, and document their contributions to teaching activities.

DESIGN, SETTING, AND PARTICIPANTS

Survey of all 386 internal medicine residency directors in the United States in 2005 (272 respondents) and 2007 (236 respondents).

MEASUREMENTS

Number of teaching hospitals utilizing hospitalists, number of programs utilizing hospitalists to teach, hospitalist teaching duties, and number with hospitalist tracks.

RESULTS

In 2005, program directors recalled 54% of teaching hospitals employed hospitalists before and 73% after implementation of work-hour limitations. Of those employing hospitalists, 92% of programs in the Northeast and West used them to teach. Two years later, the Midwest (78%) and South (76%) continued to lag behind in the proportion of teaching hospitalists. Specific teaching activities of hospitalists included: attending on teaching service (92%), conducting rounds (81%), observation of clinical skills (67%), lectures (68%), and morning report (52%). Seven percent of program directors reported other duties of hospitalists, including: supervising procedures, reviewing night float patients, serving as associate program directors, and writing curricula. Eleven percent of training programs had hospitalist tracks.

CONCLUSIONS

As hospitalists have become prevalent and have become efficient clinicians in community and university hospitals, the majority of internal medicine residencies have enlisted them to provide rounds, lectures, and bedside teaching. A small number of residencies are beginning to develop tracks to facilitate this new career option for graduates.

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

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

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

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

Health care utilization and the proportion of primary care physicians

BACKGROUND

The impact of primary care physicians on health care utilization remains controversial. Some have hypothesized that primary care physicians decrease health care utilization through enhanced coordination of care and a preventive care focus.

METHODS

Using data from the Area Resource File (a Health Resources and Services Administration US county-level database) for the years 1990, 1995, and 1999, we performed a retrospective cross-sectional analysis with generalized estimating equations to determine if measures of health care utilization (inpatient admissions, outpatient visits, emergency department visits, and surgeries) were associated with the proportion of primary care physicians to total physicians within metropolitan statistical areas.

RESULTS

The average proportion of primary care physicians in each metropolitan statistical area was 0.34 (SD 0.46, range 0.20-0.54). Higher proportions of primary care physicians were associated with significantly decreased utilization, with each 1% increase in proportion of primary care physicians associated with decreased yearly utilization for an average-sized metropolitan statistical area of 503 admissions, 2968 emergency department visits, and 512 surgeries (all P <.03). These relationships were consistent each year studied.

CONCLUSIONS

Increased proportions of primary care physicians appear to be associated with significant decreases in measures of health care utilization across the 1990s. National efforts aimed at limiting health care utilization may benefit from focusing on the proportion of primary care physicians relative to specialists in this country.

Evidence that supports the value of social work in hospitals

The value of hospital social work is supported by one hospital's tracking system that monitored social work discharge services and compared outcome with non-social work discharges. The sample consisted of a total of 64,722 patients admitted to the "med-surg" hospital unit over a two and one-half year time period from 2002 to 2004. Of the total patients in the sample, 15.7% (n = 10,156) had social work involvement. Sixty percent of the social worker patients were age 70 or over compared with the mean age of the sample of 56.2 years. The mean length of stay for social work served patients was 11.4 days (sd = 13.9) compared to 4.3 days (sd = 6.3) non-social work patients, a difference that was significant (t =-68.3; p = .000). The authors attribute the longer lengths of stay to social workers' receiving older and more difficult-to-place patients. An evidence-based case is made for the cost-containment value of social workers in hospitals and for the creation of a tracking infrastructure to aid in monitoring the daily achievements of medical/surgical social workers.