Trends in market demand for internal medicine 1999 to 2004: an analysis of physician job advertisements

The Effect of Geographic Cohorting of Inpatient Teaching Services on Patient Outcomes and Resident Experience

BACKGROUND

Geographic cohorting is a hospital admission structure in which every patient on a given physician team is admitted to a dedicated hospital unit. Little is known about the long-term impact of this admission structure on patient outcomes and resident satisfaction.

OBJECTIVE

To evaluate the effect of geographic cohorting on patient outcomes and resident satisfaction among inpatient internal medicine teaching services within an academic hospital.

DESIGN AND INTERVENTION

We conducted an interrupted time series analysis examining patient outcomes before and after the transition to geographic cohorting of our 3 inpatient teaching services within a 520-bed academic hospital in November 2017. The study observation period spanned from January 2017 to October 2018, allowing for a 2-month run-in period (November-December 2017).

PARTICIPANTS

We included patients discharged from the inpatient teaching teams during the study period. We excluded patients admitted to the ICU and observation admissions.

MAIN MEASURES

Primary outcome was 6-month mortality adjusted for patient age, sex, race, insurance status, and Charlson Comorbidity Index (CCI) analyzed using a linear mixed effects model. Secondary outcomes included hospital length of stay (LOS), 7-day and 30-day readmission rate, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, and resident evaluations of the rotation.

KEY RESULTS

During the observation period, 1720 patients (mean age 64, 53% female, 56% white, 62% Medicare-insured, mean CCI 1.57) were eligible for inclusion in the final adjusted model. We did not detect a significant change in 6-month mortality, LOS, and 7-day or 30-day readmission rates. HCAHPS scores remained unchanged (77 to 80% top box, P = 0.19), while resident evaluations of the rotation significantly improved (mean overall score 3.7 to 4.0, P = 0.03).

CONCLUSIONS

Geographic cohorting was associated with increased resident satisfaction while achieving comparable patient outcomes to those of traditional hospital admitting models.

Evolving practice of hospital medicine and its impact on hospital throughput and efficiencies

Hospitalists are uniquely positioned to implement strategies to improve patient flow and efficiency. Hospital leaders have stated they expect hospitalists to comanage surgical patients, participate in observation units, and screen medical admissions, in addition to providing inpatient care for medical patients. We review how the hospitalists' role in acute inpatient care, surgical comanagement, short stay units, chest pain units, and active bed management has improved throughput and patient flow.

Job characteristics, satisfaction, and burnout across hospitalist practice models

BACKGROUND

Nearly two-thirds of hospitals in the United States are served by hospitalist physicians. How hospitalist work patterns and job satisfaction vary across various practice models is unknown.

METHODS

We administered the Hospitalist Worklife Survey to a randomized stratified sample of 3105 potential hospitalists and 662 hospitalist members of 3 multistate hospitalist companies. Details about respondents' hospitalist group characteristics, their work patterns, and satisfaction with 2 global and 11 domain measures were assessed. Factors influencing job satisfaction were also solicited. These factors, job characteristics, job satisfaction, and burnout were compared across predefined practice models.

RESULTS

The adjusted response rate was 25.6%. Among the respondents, 44% were employed by a hospital, 15% by a multispecialty physician group, 14% by a multistate hospitalist group, 14% by a university or medical school, 12% by a local hospitalist group, and 2% by other. Hospitalists of local groups reported more clinical shifts per month, and hospitalists of local and multistate groups reported more billable encounters per shift compared to other practice models. Academic hospitalists reported fewer night shifts, fewer billable encounters per shift, more nonclinical work hours, and lower earnings compared to other practice models. Differences in clinical and nonclinical responsibilities, and differences in factors most important to job satisfaction, were noted across the 5 models. Despite these differences, levels of global job satisfaction and burnout were similar across the practice models.

CONCLUSIONS

Work patterns, compensation, and hospitalists' priorities varied significantly across practice models. Overall job satisfaction and burnout were similar across models, despite these differences.

Unintended consequences of a standard admission order set on venous thromboembolism prophylaxis and patient outcomes

BACKGROUND

Standard order sets often increase the use of desirable interventions for patients likely to benefit from them. Whether such order sets also increase misuse of these interventions in patients potentially harmed by them is unknown. We measured the association between a paper-based standard admission order set with a venous thromboembolism pharmacoprophylaxis (VTEP) module and use of VTEP for patients likely to benefit from it as well as patients with unclear benefit or potential harm from it.

METHODS

We conducted a retrospective cohort study using administrative and pharmacy charge data of patients admitted between 1 July 2005 and 31 December 2008 to two medical and three surgical services that implemented a standard admission order set in August 2006. The primary outcome was use of VTEP in patients with likely benefit, unclear benefit, and potential harm from VTEP prior to and following order set implementation.

KEY RESULTS

A total of 8,429 patients (32%) were admitted prior to and 17,635 (68%) following order set implementation. There was a small unadjusted rise in overall VTEP use after implementation (51% to 58%, p < 0.001). In multivariable models with interrupted time series analysis, patients with potential harm from VTEP had the largest increase in VTEP use at the time of implementation [adjusted odds ratio = 1.58; 95% confidence interval (CI), 1.12-2.22]. The increased likelihood of receiving VTEP in this subgroup gradually returned to baseline (adjusted odds ratio per month = 0.98; 95% CI, 0.96-0.99).

CONCLUSIONS

Implementation of a standard admission order set transiently increased VTEP in patients with potential harm from it. Order set and guideline success should be judged based on the degree to which they successfully target patients likely to benefit from the intervention without inadvertently targeting patients potentially harmed.

Investing in the future: building an academic hospitalist faculty development program

BACKGROUND

Academic hospital medicine (AHM) groups continue to grow rapidly, driven largely by clinical demands. While new hospitalist faculty usually have strong backgrounds in clinical medicine, they often lack the tools needed to achieve excellence in the other aspects of a faculty career, including teaching, research, quality improvement, and leadership skills.

OBJECTIVE

To develop and implement a Faculty Development (FD) Program that improves the knowledge, skills, attitudes, and scholarly output of first-year faculty.

INTERVENTION

We created a vision and framework for FD that targeted our new faculty but also engaged our entire Division of Hospital Medicine. New faculty participated in a dedicated coaching relationship with a more senior faculty member, a core curriculum, a teaching course, and activities to meet a set of stated scholarly expectations. All faculty participated in newly established divisional Grand Rounds, a lunch seminar series, and venues to share scholarship and works in progress.

RESULTS

Our FD programmatic offerings were rated highly overall on a scale of 1 to 5 (5 highest): Core Seminars 4.83 ± 0.41, Coaching Program 4.5 ± 0.84, Teaching Course 4.5 ± 0.55, Grand Rounds 4.83 ± 0.41, and Lunch Seminars 4.5 ± 0.84. Compared to faculty hired in the 2 years prior to our FD program implementation, new faculty reported greater degrees of work satisfaction, increased comfort with their skills in a variety of areas, and improved academic output.

CONCLUSION

Building FD programs can be effective to foster the development and satisfaction of new faculty while also creating a shared commitment towards an academic mission.

California hospital leaders' views of hospitalists: meeting needs of the present and future

BACKGROUND

Hospital medicine has grown rapidly, but hospital leaders' perceptions of current and future drivers of hospitalist growth are unknown.

OBJECTIVE

: To determine hospital executives' perceptions of factors leading to hospitalist implementation and their vision for hospitalists' work roles.

SETTING

Nonfederal, acute care hospitals in California.

PARTICIPANTS

California hospital leaders (eg, chief executive officers).

INTERVENTION

Cross-sectional survey from 2006 to 2007.

MEASUREMENTS

We asked California hospital leaders whether their hospitals had a hospitalist service and the prospects for growth. In addition, we examined factors responsible for implementation, scope of hospitalists' practices, and need for additional certification as perceived by hospital leaders.

RESULTS

We received surveys from 179 of 334 hospitals (response rate of 54%). Of the 64% of respondents that reported the use of hospitalists, none intended to decrease the size of their hospitalist group, and 57% expected growth over 2 years. The most common reasons for implementing a hospitalist program were to care for uncovered patients (68%) and improve cost/length of stay (63%). Respondents also indicated that demand from other physicians was an important factor. Leaders reported that hospitalists provide a wide range of services, with a majority involved in quality improvement projects (72%) and medical comanagement of surgical patients (66%). Most leaders favor additional certification for hospitalists.

CONCLUSIONS

There is widespread adoption of hospitalists in California hospitals, with an expectation of continued growth. The drivers of the field's growth are evolving and dynamic. In particular, attentiveness to quality performance and demand from other physicians are increasingly important reasons for implementation.

Effect of hospitalist attending physicians on trainee educational experiences: a systematic review

BACKGROUND

Trainees receive much of their inpatient education from hospitalists.

PURPOSE

To characterize the effects of hospitalists on trainee education.

DATA SOURCES

MEDLINE, Database of Reviews of Effectiveness (DARE), National Health Service (NHS) Economic Evaluation Database (EED), Health Technology Assessment (HTA), and the Cochrane Collaboration Database (last searched October 2008) databases using the term "hospitalist", and meeting abstracts from the Society of Hospital Medicine (SHM) (2002-2007), Society of General Internal Medicine (SGIM) (2001-2007), and Pediatric Academic Societies (PAS) (2000-2007).

STUDY SELECTION

Original English language research studies meeting all of the following: involvement of hospitalists; comparison to nonhospitalist attendings; evaluation of trainee knowledge, skills, or attitudes. 711 articles were reviewed, 32 retrieved, and 6 included; 7,062 meeting abstracts were reviewed, 9 retrieved, and 2 included.

DATA EXTRACTION

Two authors reviewed articles to determine study eligibility. Three authors independently reviewed included articles to abstract data elements and classify study quality.

DATA SYNTHESIS

Seven studies were quasirandomized one was a noncontemporaneous comparison. All citations only measured trainee attitudes. In all studies comparing hospitalists to nonhospitalists, trainees were more satisfied with hospitalists overall, and with other aspects of their teaching, but ratings were high for both groups. One of 2 studies that distinguished nonhospitalist general internists from specialists showed that trainees preferred hospitalists, but the other did not demonstrate a hospitalist advantage over general internists.

CONCLUSIONS

Trainees are more satisfied with inpatient education from hospitalists. Whether the increased satisfaction translates to improved learning is unclear.

Challenges and opportunities in academic hospital medicine: report from the academic hospital medicine summit

BACKGROUND

The field of hospital medicine is growing rapidly in academic medical centers. However, few organizations have explicitly considered the opportunities and barriers posed to hospital medicine's development as an academic field in internal medicine.

OBJECTIVE

To develop consensus around key areas limiting or facilitating hospital medicine's development as an academic discipline.

DESIGN

Consensus format conference of key stakeholders in academic hospital medicine.

RESULTS

The Consensus Group identified several issues impeding the development of academic hospital medicine as a recognized entity in academic settings, including extraordinarily rapid growth, increasingly preponderate non-teaching roles, and demands to perform non-clinical duties (such as quality improvement) not generally viewed as academic pursuits. The Consensus Group developed recommendations for addressing these concerns, specifically 1) characterizing the 'optimal' job description for an academic hospitalist, 2) developing better local and at-a-distance opportunities for training academic hospitalists in key aspects of early career success, 3) advocacy for development of fellows and junior faculty researchers in hospital medicine. Fostering academic hospital medicine will help address these issues more effectively and will help the field while also attracting the next generation of generalists needed to care for an increasingly complex inpatient population.

Challenges and opportunities in academic hospital medicine: report from the Academic Hospital Medicine Summit

BACKGROUND

The field of hospital medicine is growing rapidly in academic medical centers. However, few organizations have explicitly considered the opportunities for and barriers to hospital medicine's development as an academic field in internal medicine.

OBJECTIVE

The objective was to develop consensus around key areas limiting or facilitating hospital medicine's development as an academic discipline.

DESIGN

The design was a consensus format conference of key stakeholders in academic hospital medicine.

RESULTS

The consensus group identified several issues impeding the development of academic hospital medicine as a recognized entity in academic settings, including extraordinarily rapid growth, increasingly preponderant nonteaching roles, and demands to perform nonclinical duties (such as quality improvement) not generally viewed as academic pursuits. The consensus group developed recommendations for addressing these concerns, specifically: 1) characterizing the optimal job description for an academic hospitalist, 2) developing better local and at-a-distance opportunities for training academic hospitalists in key aspects of early career success, and 3) advocating for the development of fellows and junior faculty researchers in hospital medicine.

SUMMARY

Fostering academic hospital medicine will help address these issues more effectively and will help the field while also attracting the next generation of generalists needed to care for an increasingly complex inpatient population.

The state of hospital medicine in 2008

In the mid 1990s, a new model for hospital care began to take hold in the United States, in which a separate physician, who I dubbed a "hospitalist," assumed the responsibility for managing the inpatient stay in place of the primary care physician. A 2006 American Hospital Association survey indicated that there are more than 20,000 hospitalists in the United States, making this the fastest growing medical specialty in American medical history. In this article, I briefly trace the reasons for the field's remarkable growth, describe some of hospital medicine's key issues and concerns, and speculate about the future shape of the field.

Outcomes of care by hospitalists, general internists, and family physicians

BACKGROUND

The hospitalist model is rapidly altering the landscape for inpatient care in the United States, yet evidence about the clinical and economic outcomes of care by hospitalists is derived from a small number of single-hospital studies examining the practices of a few physicians.

METHODS

We conducted a retrospective cohort study of 76,926 patients 18 years of age or older who were hospitalized between September 2002 and June 2005 for pneumonia, heart failure, chest pain, ischemic stroke, urinary tract infection, acute exacerbation of chronic obstructive pulmonary disease, or acute myocardial infarction at 45 hospitals throughout the United States. We used multivariable models to compare the outcomes of care by 284 hospitalists, 993 general internists, and 971 family physicians.

RESULTS

As compared with patients cared for by general internists, patients cared for by hospitalists had a modestly shorter hospital stay (adjusted difference, 0.4 day; P<0.001) and lower costs (adjusted difference, $268; P=0.02) but a similar inpatient rate of death (odds ratio, 0.95; 95% confidence interval [CI], 0.85 to 1.05) and 14-day readmission rate (odds ratio, 0.98; 95% CI, 0.91 to 1.05). As compared with patients cared for by family physicians, patients cared for by hospitalists had a shorter length of stay (adjusted difference, 0.4 day; P<0.001), and the costs (adjusted difference, $125; P=0.33), rate of death (odds ratio, 0.95; 95% CI, 0.83 to 1.07), and 14-day readmission rate (odds ratio, 0.95; 95% CI, 0.87 to 1.04) were similar.

CONCLUSIONS

For common inpatient diagnoses, the hospitalist model is associated with a small reduction in the length of stay without an adverse effect on rates of death or readmission. Hospitalist care appears to be modestly less expensive than that provided by general internists, but it offers no significant savings as compared with the care provided by family physicians.