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

Current Status of Hospitalist Practice and Factors Influencing Job Satisfaction in Korea

BACKGROUND

Although the roles and responsibilities of hospitalists have grown considerably in recent years, research on the current job status and satisfaction levels of Korean hospitalists is lacking.

OBJECTIVE

We investigate the present state of Korean hospitalists and the factors influencing their job satisfaction 6 years after the pilot program's launch.

DESIGN

This cross-sectional analysis was based on an online survey conducted from January 30 to February 18, 2023.

PARTICIPANTS

Korean hospitalists (N = 303) MAIN MEASURES: The survey encompassed participant demographics, hospital information, education, clinical practice, research involvement, and job satisfaction. We employed multiple logistic regression analyses to identify determinants of satisfaction as a hospitalist.

KEY RESULTS

The analysis was based on 79 hospitalists' responses (response rate 26%). Respondents had a median age of 39 years; approximately half were male internal medicine specialists, possessing over 3 years of hospitalist experience. Most respondents were interested in clinical work (94.4%), with only 21.5% interested in research and evidence-based medicine. Over two-thirds indicated that non-clinical duties occupied less than 20% of their time. Overall, job satisfaction among hospitalists averaged 51.9%. Notably, the availability of a research mentor was significantly associated with job satisfaction (P = .011). While hospitalists with more than 3 years of experience, more hospitalists per facility, and autonomy were associated with increased job satisfaction, these associations were not statistically significant. Furthermore, there was no association between night shift work, work type, or work hours and job satisfaction.

CONCLUSIONS

Although Korean hospitalists primarily focus on clinical practice, our study underscores the positive impact of mentorship from research mentors on job satisfaction, supported by comprehensive univariate and multivariate analyses. These findings signal a progressive transformation in the role of Korean hospitalists, as they increasingly engage in research alongside patient care.

Standardizing Generalist Definitions to Improve Evidence in General Medicine: Addressing Diverse Interpretations and Lack of Consistency

Purpose

There has been growing interest in generalists in Japan in recent years. However, due to the diverse use of the term "generalist", the specific roles of these physicians remain ambiguous. Consequently, the target population for research on generalists is unclear, making it challenging to conduct studies within the generalist practice framework. Therefore, a literature search was conducted to examine how generalists are defined and classified in research worldwide.

Methods

We conducted a literature search that focused exclusively on articles written in English and used keywords related to generalists, general medicine (GM), primary care, and family medicine. Based on the results, six physicians working in GM reviewed the findings and discussed the identified issues and their potential solutions.

Results

The definition of generalists in studies targeting GM, family medicine, and primary care conducted worldwide, including Japan, varies. Generalists exhibit diverse roles even within university hospitals in Japan. No studies provide a precise categorization or definition of generalists based on specific medical practices or roles, except for hospitalists, who are primarily involved in inpatient management in the United States.

Conclusion

The definition of GM was unclear based on the results of the literature search, and the lack of uniformity in backgrounds has rendered the target population unclear. Consequently, in healthcare settings where medical systems vary by country or region, evidence from studies targeting generalists cannot readily apply to actual practice. Clarifying generalists through an explicit definition based on clinical practice will allow for a more precise target population for research on generalists and enable the accumulation of evidence related to well-defined groups of generalists, contributing to the advancement of GM. Therefore, future research is required to develop new indicators to precisely classify and define generalists.

Hospitalists as Facilitators of Surge and Contingency Medical Operations and Planning

Hospital medicine, a specialty encompassing physicians and advanced practice providers in internal medicine, pediatrics, and family medicine, has been a core and rapidly growing component of civilian health care for the past two decades. More recently, hospitalists have been taking on key roles during surge and contingency planning and operations, most notably during the COVID-19 pandemic which necessitated marked changes in inpatient care across the United States. The military health system has been slower to incorporate hospitalists into clinical care and planning than civilian organizations due to its unique features. However, an increasing focus on future distributed operations in contested environments, pandemic care, and humanitarian assistance/disaster response requires new consideration of their role in military medicine. This stems from hospitalists' value as clinicians who include triage, resource utilization stewardship, medical inpatient care, pre-/post-operative management of surgical patients, and high acuity patient stabilization and management within their scope, often working collaboratively with other specialists such as emergency medicine physicians, surgeons, and intensivists. Just as importantly, hospitalists are system-level facilitators and leaders of patient capacity expansion and/or clinical process changes when needed for response to incidents in a variety of acute care scenarios. With uniformed billets being increasingly targeted to military platform requirements, there is now an opportunity to revisit the value of hospitalists in military medicine. In this Commentary, we review the roles that hospitalists can fill in hospital and operational medical settings, with a focus on surge and contingency operations. To demonstrate this capability, we present here the experience of two operational units employing hospitalists for high acuity patient management and two civilian hospitals implementing surge operations during the 2022-2023 "tripledemic" of viral respiratory infections in the United States. Their innovations facilitated the care of higher acuity and higher volume during times when medical care requirements were limited by traditional staffing models. We end by reviewing opportunities and challenges related to expanding hospitalist use within the military health system and describing efforts that are underway to address the challenges.

How Do We Establish the Utility and Evidence of General Medicine in Japan?

Hospital Medicine in the United States has achieved significant progress in the accumulation of evidence. This development has influenced the increasing societal demand for General Medicine in Japan. Generalists in Japan actively engage in a wide range of interdisciplinary clinical practices, education, and management. Furthermore, Generalists have also contributed to advances in research. However, there is limited evidence regarding the benefits of General Medicine in Japan in all these areas, with most of the evidence derived from single-center studies. In Japan, the roles of Generalists are diverse, and the comprehensive definition of General Medicine makes it difficult to clearly delineate its scope. This results in an inadequate accumulation of evidence regarding the benefits of General Medicine, potentially making it less attractive to the public and younger physicians. Therefore, it is necessary to categorize General Medicine and collect clear evidence regarding its benefits.

Evaluating Outcomes and Time Delays of a Non-Trainee-Driven Hospitalist Procedure Service

BACKGROUND AND OBJECTIVES

Ultrasound guidance has become standard of care in hospital medicine for invasive bedside procedures, especially central venous catheter placement. Despite ultrasound-guided bedside procedures having a high degree of success, only a few hospitalists perform them. This is because these are usually performed by radiologists or in the setting of trainee-run procedure teams. We sought to determine the impact of a non-trainee driven , hospitalist-run procedure service relative to time from consult to procedure.

METHODS

The University of Alabama at Birmingham Hospital (UAB), Department of Hospital Medicine, trained 8 non-trainee hospitalist physicians (from existing staff) to implement the ultrasound-guided procedure service. This study examines consult to procedure completion time since the implementation of the procedure service (2014 to 2020). Univariate analyses are used to analyze pre-implementation (2012-2014), pilot (2014-2016), and post-implementation data (2016-2018 initial, and 2018-2020 sustained).

RESULTS

Results suggest a 50% reduction in time from consult to procedure completion when compared with the period before implementation of the nontrainee hospitalist procedure service.

CONCLUSIONS

A hospitalist procedure service, which does not include trainees, results in less time lag from consult to procedure completion time, which could increase patient satisfaction and improve throughput. As such, this study has wide generalizability to community hospitals and other nonacademic medical centers that may not have trainees.

Does Hospitalist Care Enhance Palliative Care and Reduce Aggressive Treatments for Terminally Ill Patients? A Propensity Score-Matched Study

BACKGROUND

Information on the use of palliative care and aggressive treatments for terminally ill patients who receive care from hospitalists is limited.

METHODS

This three-year, retrospective, case-control study was conducted at an academic medical center in Taiwan. Among 7037 patients who died in the hospital, 41.7% had a primary diagnosis of cancer. A total of 815 deceased patients who received hospitalist care before death were compared with 3260 patients who received non-hospitalist care after matching for age, gender, catastrophic illness, and Charlson comorbidity score. Regression models with generalized estimating equations were performed.

RESULTS

Patients who received hospitalist care before death, compared to those who did not, had a higher probability of palliative care consultation (odds ratio (OR) = 3.41, 95% confidence interval (CI): 2.63-4.41), and a lower probability to undergo invasive mechanical ventilation (OR = 0.13, 95% CI: 0.10-0.17), tracheostomy (OR = 0.14, 95% CI: 0.06-0.31), hemodialysis (OR = 0.70, 95% CI: 0.55-0.89), surgery (OR = 0.25, 95% CI: 0.19-0.31), and intensive care unit admission (OR = 0.11, 95% CI: 0.08-0.14). Hospitalist care was associated with reductions in length of stay (coefficient (B) = -0.54, 95% CI: -0.62--0.46) and daily medical costs.

CONCLUSIONS

Hospitalist care is associated with an improved palliative consultation rate and reduced life-sustaining treatments before death.

Impact of hospitalist care model on patient outcomes in acute medical unit: a retrospective cohort study

OBJECTIVE

To assess a newly introduced, hospitalist-run, acute medical unit (AMU) care model at a tertiary care hospital in the Republic of Korea.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care hospital in the Republic of Korea.

PARTICIPANTS

We evaluated 6391 medical inpatients admitted through the emergency department (ED) from 1 June 2016 to 31 May 2017.

INTERVENTIONS

The study compared multiple outcomes among medical inpatients from the ED between the non-hospitalist group and the AMU hospitalist group.

OUTCOME MEASURES

In-hospital mortality (IHM), intensive care unit (ICU) admission rate, hospital length of stay (LOS), ED-LOS and unscheduled readmission rates were defined as patient outcomes and compared between the two groups.

RESULTS

Compared with the non-hospitalist group, the AMU hospitalist group had lower IHM (OR: 0.43, p<0.001), a lower ICU admission rate (OR: 0.72, p=0.013), a shorter LOS (coefficient: -0.984, SE: 0.318; p=0.002) and a shorter ED-LOS (coefficient: -3.021, SE: 0.256; p<0.001). There were no significant differences in the 10-day or 30-day readmission rates (p=0.974, p=0.965, respectively).

CONCLUSIONS

The AMU hospitalist care model was associated with reductions in IHM, ICU admission rate, LOS and ED-LOS. These findings suggest that the AMU hospitalist care model has the potential to be adopted into other healthcare systems to improve care for patients with acute medical needs.

Use of Obstetric and Gynecologic Hospitalists Is Associated With Decreased Severe Maternal Morbidity in the United States

OBJECTIVES

This study aimed to evaluate the prevalence of obstetric and gynecologic (Ob/Gyn) hospitalists and determine if an association exists between the presence of Ob/Gyn hospitalists and severe maternal morbidity (SMM).

METHODS

This observational study included data from hospitals listed in the USA TODAY 's 2019 article titled, "Deadly deliveries: Childbirth complication rates at maternity hospitals." Telephone and email surveys of staff in these hospitals identified the presence or absence of continuous providers in the hospital 24 hours, 7 days a week (24/7 coverage) and the types of providers who are employed, then compared these responses with the SMM cited by USA TODAY .

RESULTS

Eight hundred ten hospitals were contacted, with participation from 614 labor and delivery units for a response rate of 75.8%. Fifty-seven percent of units were staffed with 24/7 coverage, with 46% of hospitals' coverage primarily provided by an Ob/Gyn hospitalist and 54% primarily by a nonhospitalist OB/Gyn provider. The SMM and presence of 24/7 coverage increased with the level of neonatal care and delivery volume. Of hospitals with 24/7 coverage, those that primarily used Ob/Gyn hospitalists had a lower SMM for all mothers (1.7 versus 2.0, P = 0.014) and for low-income mothers (1.9 versus 2.30, P = 0.007) than those who primarily used nonhospitalist OB/Gyn providers.

CONCLUSIONS

Severe maternal morbidity increases with delivery volume, level of neonatal care, and 24/7 coverage. Of hospitals with 24/7 coverage, units that staff with Ob/Gyn hospitalists have lower levels of SMM than those that use nonhospitalist Ob/Gyn providers.

Building a thriving academic hospitalist workforce: A rapid qualitative analysis identifying key areas of focus in the field

BACKGROUND

The hospitalist workforce has been at the forefront of the pandemic and has been stretched in both clinical and nonclinical domains. We aimed to understand current and future workforce concerns, as well as strategies to cultivate a thriving hospital medicine workforce.

DESIGN, SETTING, AND PARTICIPANTS

We conducted qualitative, semistructured focus groups with practicing hospitalists via video conferencing (Zoom). Utilizing components from the Brainwriting Premortem Approach, attendees were split into small focus groups and listed their thoughts about workforce issues that hospitalists may encounter in the next 3 years, identifying the highest priority workforce issues for the hospital medicine community. Each small group discussed the most pressing workforce issues. These ideas were then shared across the entire group and ranked. We used rapid qualitative analysis to guide a structured exploration of themes and subthemes.

RESULTS

Five focus groups were held with 18 participants from 13 academic institutions. We identified five key areas: (1) support for workforce wellness; (2) staffing and pipeline development to maintain an adequate workforce to match clinical growth; (3) scope of work, including how hospitalist work is defined and whether the clinical skillset should be expanded; (4) commitment to the academic mission in the setting of rapid and unpredictable clinical growth; and (5) alignment between the duties of hospitalists and resources of hospitals. Hospitalists voiced numerous concerns about the future of our workforce. Several domains were identified as high-priority areas of focus to address current and future challenges.

A National Survey of the Infrastructure and Scope of Practice for Gastroenterology Hospitalists

BACKGROUND

Hospital-based specialty-trained physicians have become more prevalent with emerging data suggesting benefit in consult and procedure volume, reduced complication rates, and increased practice productivity. Interest in gastroenterology (GI) hospitalist programs has increased in recent years. However, little is known regarding the types of GI hospitalist models that currently exist.

AIMS

To characterize the infrastructure of GI hospitalist models across the USA.

METHODS

A 50-question survey was distributed to the GI Hospitalist Special Interest Group of the American Society for Gastrointestinal Endoscopy. Information on demographics, hospital infrastructure, and compensation were collected.

RESULTS

31 of 33 (94%) GI hospitalists completed the questionnaire. Respondents were mostly male (65%), white (48%) or Asian (42%). Most GI hospitalists spent at least half of their clinical time dedicated to the inpatient consultation service (73%), during which they had no other clinical duties. Most services had endoscopy suites with dedicated inpatient endoscopy rooms (66%), over 4 h allotted for procedures (83%), and were available on weekends (62%). Over half of GI hospitalists reported having outpatient duties, the most common being performance of direct access endoscopy (69%). Outside of clinical responsibilities, GI hospitalists were most frequently involved in clinical education or fellowship program leadership (48%). Most GI hospitalists were salaried with an incentive-based bonus based on work relative value units.

CONCLUSION

GI hospitalist programs are varied throughout the USA but key commonalities exist between most programs.

Comparing Japanese University Hospitals' and Community Healthcare Facilities' Research Contributions on PubMed

Purpose

Although research in general medicine is important, the contributions and characteristics of general medicine physicians (GMPs) in university hospitals (UH) and community healthcare facilities (CHF) remains unclear. Therefore, this study examines the popularity of research by affiliation, characteristics of journal publication, annual trends, and differences in impact factors (IFs) of journal publications.

Methods

This study is a secondary bibliometric analysis of articles in international journals published in PubMed over the past six years (2015-2020). The analysis compared English articles published by either UH- or CHF-affiliated GMPs in Japan in terms of, among other things, article type, research field, and IF.

Results

Of the 2372 articles analyzed, 1688 (71.2%) were published by physicians affiliated with UHs, 62.6% of which were original. Basic research, international collaboration, and ratio of IFs were significantly higher for such papers. In contrast, the number of CHF articles were significantly higher in the areas of clinical research and practice, with a greater proportion of case reports. There was no significant difference in IF between the disciplines within each affiliation, but the IF was the highest in experimental basic research and the lowest in medical and clinical education. In the six-year time series, the number of original papers by UHs and CHFs increased roughly twofold between 2015 and 2020, but the number of articles in the areas of medical education and healthcare quality and safety remained mostly unchanged.

Conclusion

The number of international papers published by Japanese GMPs has increased since 2015, particularly in terms of original papers and clinical research from UHs. However, there was no significant difference in the IF between UH and CHF publications. Our findings can guide the development of indicators, research, and education strategies regarding Japanese GMPs' research performance.

Best practices during COVID-19 pandemic in solid organ transplant programs in Spain

Clinical management of transplant patients abruptly changed during the first months of COVID-19 pandemic (March to May 2020). The new situation led to very significant challenges, such as new forms of relationship between healthcare providers and patients and other professionals, design of protocols to prevent disease transmission and treatment of infected patients, management of waiting lists and of transplant programs during state/city lockdown, relevant reduction of medical training and educational activities, halt or delays of ongoing research, etc. The two main objectives of the current report are: 1) to promote a project of best practices in transplantation taking advantage of the knowledge and experience acquired by professionals during the evolving situation of the COVID-19 pandemic, both in performing their usual care activity, as well as in the adjustments taken to adapt to the clinical context, and 2) to create a document that collects these best practices, thus allowing the creation of a useful compendium for the exchange of knowledge between different Transplant Units. The scientific committee and expert panel finally standardized 30 best practices, including for the pretransplant period (n = 9), peritransplant period (n = 7), postransplant period (n = 8) and training and communication (n = 6). Many aspects of hospitals and units networking, telematic approaches, patient care, value-based medicine, hospitalization, and outpatient visit strategies, training for novelties and communication skills were covered. Massive vaccination has greatly improved the outcomes of the pandemic, with a decrease in severe cases requiring intensive care and a reduction in mortality. However, suboptimal responses to vaccines have been observed in transplant recipients, and health care strategic plans are necessary in these vulnerable populations. The best practices contained in this expert panel report may aid to their broader implementation.

Research Trends and Impact Factor on PubMed Among General Medicine Physicians in Japan: A Cross-Sectional Bibliometric Analysis

Background

Japan created a specialty system for general medicine in 2018. However, Japanese academic generalists’ contribution to research remains unclear. This study examines the popularity of Japanese general medicine research, the characteristics of journal publications, annual trends, and the characteristics/differences among publications in journals with an impact factor (IF).

Methods

This bibliometric analysis extracted international, English-language, journal articles published on PubMed between January 1, 2015, and December 31, 2020. Analysis included articles with either the first, second, or last author in general medicine. We classified articles according to publication or article type and field of research. We obtained standard descriptive statistics for each publication type. Chi-squared test or Fisher’s exact test was used to compare nominal variables. For continuous variables, t-tests or Wilcoxon rank-sum tests were used, as appropriate.

Results

Of the 2372 articles analyzed, original articles were most common (56.3%), followed by case reports (30.1%), reviews (7.63%), and letters/others (5.9%). Publication volume increased 2.64-fold annually over 5 years. Clinical research (60.5%) was most common among original articles, followed by basic experimental research (17.5%) and public health/epidemiology (12.7%). Medical quality and safety (4.1%), medical and clinical education (3.1%), and health services (1.42%) received comparatively little attention. Eighty percent of articles were published in journals with IF; however, these journals rarely published case reports. Among original articles, the likelihood of publishing in journals with IF was high for basic laboratory medicine articles with higher IF (median IF 3.83, OR 1.71, 95% CI 2.20–5.95, p=0.044) and lower for clinical education research with the lowest IF (median IF 1.83, OR 0.56, 95% CI 01.8–0.75, p<0.001).

Discussion

General medicine physicians’ international research output is increasing in Japan; however, research achievements have not been generalized, but rather much influenced by clinical subspecialty backgrounds. This will likely continue unless an academic generalist discipline is established.

Organization of primary care

Strong primary care does not develop spontaneously but requires a well-developed organizational planning between levels of care. Primary care-oriented health systems are required to effectively tackle unmet health needs of the population, and efficient primary care organization (PCO) is crucial for this aim. Via strong primary care, health delivery, health outcomes, equity, and health security could be improved. There are several theoretical models on how primary care can be organized. In this position paper, the key aspects and benchmarks of PCO will be explored based on previously mentioned frameworks and domains. The aim of this position paper is to assist primary care providers, policymakers, and researchers by discussing the current context of PCO and providing guidance for implementation, development, and evaluation of it in a particular setting. The conceptual map of this paper consists of structural and process (PC service organization) domains and is adapted from frameworks described in literature and World Health Organization resources. Evidence we have gathered for this paper shows that for establishing a strong PCO, it is crucial to ensure accessible, continuous, person-centered, community-oriented, coordinated, and integrated primary care services provided by competent and socially accountable multiprofessional teams working in a setting where clear policy documents exist, adequate funding is available, and primary care is managed by dedicated units.

The Hospital Value-Based Purchasing Program: Do hospitalists improve health care value

INTRODUCTION

As healthcare organizations examine the associated benefits of employing a larger hospitalist workforce, there is a need to better understand the association with patients' quality, experience, and efficiency. However, there is a lack of information regarding how hospital use of hospitalists over time influences hospital scoring on quality programs, such as the Center for Medicare and Medicaid Services (CMS) Hospital Inpatient Value-Based Purchasing (HVBP) Program. This study examines the association between hospitalist staffing between 2014 and 2019 and HVBP scores.

METHODS

We used a cross-sectional panel study design. Total Performance Score (TPS) and its domains were obtained from CMS from 2014 to 2019 and merged with the American Hospital Association Annual Survey Database. We utilized random-effects multivariable panel regression models and zero-inflated negative binomial regression to examine the association between the hospitalist-staffing ratio and the HVBP Program. All models were adjusted for hospital characteristics.

RESULTS

A total of 2126 hospitals were included in the study. The average ratio of hospitalists per staffed bed was 0.06, with a standard deviation of 0.15. This study suggests that hospitals that employ a higher percentage of hospitalists see improvement in their overall TPS (β = 5.40; p < .001), Patient Experience (β = 2.49; p <.05), and Efficiency (incidence-rate ratio= 1.41; p < .001) domain. However, the Clinical Care domain was no different in organizations employing more hospitalists.

CONCLUSION

There are benefits associated with TPS, Patient Experience, and Efficiency from employing hospitalists. Managers should seek opportunities to leverage hospitalists' expertise in providing care, particularly in improving care processes.

Physician role differentiation: Patients, practice patterns, and performance

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.

Outcomes of a Neurohospitalist Program at an Academic Medical Center

Background and Purpose

The purpose is to determine the impact of an academic neurohospitalist service on clinical outcomes.

Methods

We performed a retrospective, quasi-experimental study of patients discharged from the general neurology service before (August 2010–July 2014) and after implementation of a full-time neurohospitalist service (August 2016–July 2018) compared to a control group of stroke patients. Primary outcomes were length of stay and 30-day readmission. Using the difference-in-difference approach, the impact of introducing a neurohospitalist service compared to controls was assessed with adjustment of patients’ characteristics. Secondary outcomes included mortality, in-hospital complications, and cost.

Results

There were 2706 neurology admissions (1648 general; 1058 stroke) over the study period. The neurohospitalist service was associated with a trend in reduced 30-day readmissions (ratio of ORs: .52 [.27, .98], P = .088), while length of stay was not incrementally changed in the difference-in-difference model (-.3 [-.7, .1], P = .18). However, descriptive results demonstrated a significant reduction in mean adjusted LOS of .7 days (4.5 to 3.8 days, P < .001) and a trend toward reduced readmissions (8.9% to 7.6%, P = .42) in the post-neurohospitalist cohort despite a significant increase in patient complexity, shift to higher acuity diagnoses, more emergent admissions, and near quadrupling of observation status patients. Mortality and in-hospital complications remained low, patient satisfaction was stable, and cost was not incrementally changed in the post-neurohospitalist cohort.

Conclusions

Implementation of a neurohospitalist service at an academic medical center is feasible and associated with a significant increase in patient complexity and acuity and a trend toward reduced readmissions.

A Study on the Evaluation of Polyenoic Vegetable Oils and Their Female Health Benefits Based on Time Series Analysis Model: The Case of Peony Seed Oil

Polyenoic vegetable oils mainly contain polyenoic acids such as linoleic acid and linolenic acid, as well as active ingredients such as VE, phytosterols, mineral elements, and squalene. Among them, schisandra oil, kiwi seed oil, grape seed oil, maitake fruit oil, and evening primrose seed oil all contain up to 80% or more polyenoic acids. Studies have shown that polygenic vegetable oils have the effects of assisting in lowering blood lipids, antioxidation, delaying ageing, anti-inflammation, sun protection, moisturizing, slimming and weight loss, etc. They can be widely used in nutritional and healthy edible oils, health food, skin care, and cosmetic products and have great prospects for development and utilization. This paper explores the application of artificial neural networks in the analysis of data. A nonlinear time series prediction method based on the BP algorithm is proposed. The prediction accuracy is much higher than that of the traditional method.

Comparison of inpatient spending and readmission rates for patients treated by male versus female physicians in China: An observational study

OBJECTIVE

To determine whether there are significant differences in costs of treatment and readmission rates for hospital consultations undertaken by female versus male physicians in China.

METHODS

Using data from the Urban Employee Basic Medical Insurance program from January 2018 through October 2019, we investigated spending patterns and clinical outcomes for patients at tertiary hospitals in one of the largest cities in China by the gender of the attending physician. Our sample included 79,085 hospitalizations treated by 3993 physicians in internal medicine departments. We examined the association between physician gender and visit cost using a multivariable linear model. We examined the association between physician gender and 30-days readmission rates using a multivariable probability model. We adjusted for a rich set of patient characteristics, primary diagnosis fixed effects, and hospital fixed effects. In addition, we used patient fixed effects in a robustness analysis.

RESULTS

Adjusting for primary diagnosis fixed effects, spending per visit was 4.1% higher for patients treated by male physicians than for those treated by female physicians, a statistically significant difference (95% CI [1.5%, 6.7%]). This pattern persisted after further adjusting for hospital fixed effects (3.2% [1.2%, 5.2%]), patient characteristics (3.2% [1.2%, 5.1%]), and patient fixed effects (4.2% [1.8%, 6.7%]). The difference is mainly driven by higher spending on drugs (8.7% [3.9%, 13.6%]) and out-of-pocket costs (3.9% [1.7%, 6.0%]). No statistically significant differences were observed in the readmission rates of patients treated by male and female physicians in any of our three model specifications.

CONCLUSIONS

Spending per visit was significantly higher among patients treated by male physicians than among those treated by female physicians, with the difference mainly driven by spending on drugs and out-of-pocket costs. No significant difference was observed in the hospital readmission rates of patients treated by male and female physicians. These findings have important implications for gender equality in medicine and health care quality and efficiency in developing countries.

Hospital at Home: An Evolving Model for Comprehensive Healthcare

Hospital at Home (HaH) is a sustainable, innovative, and next-generation model of healthcare. From the healthcare management point of view, this model provides cost benefits and quality improvement, and from the physicians' point of view, it helps in providing patient-centered medical care and keeps patients away from hospital admission and its complications. The HaH model was first introduced at John Hopkins in the United States in 1995, which showed very promising results in context to the length of stay, readmission rates, patient satisfaction, and hospital-acquired infections. The HaH model of care provides acute critical care to patients at home and reduces unnecessary hospitalization and related complications. The identified patients for this model of care are elderly patients with chronic conditions and multiple comorbidities. The emergence of technology in today's world and the impact of coronavirus disease 2019 (COVID-19) have increased the demand for the HaH model of care. Although there are many benefits and advantages, the HaH model of care has significant barriers and limitations, such as reimbursement for payment, physician and patient resistance, patient safety, and lack of quantifying research data to support the use of this model. Specific training for the physician, nursing, and other members of the HaH multidisciplinary team is necessary for HaH treatment protocols, along with patient and family caregiver education for those who elect the HaH model of care. HaH is the future of comprehensive healthcare services and helps in achieving the triple aim of access to healthcare, improved quality of care, and reduced cost for healthcare.

Interventions to Reduce Hospital Length of Stay in High-risk Populations: A Systematic Review

IMPORTANCE

Many strategies to reduce hospital length of stay (LOS) have been implemented, but few studies have evaluated hospital-led interventions focused on high-risk populations. The Agency for Healthcare Research and Quality (AHRQ) Learning Health System panel commissioned this study to further evaluate system-level interventions for LOS reduction.

OBJECTIVE

To identify and synthesize evidence regarding potential systems-level strategies to reduce LOS for patients at high risk for prolonged LOS.

EVIDENCE REVIEW

Multiple databases, including MEDLINE and Embase, were searched for English-language systematic reviews from January 1, 2010, through September 30, 2020, with updated searches through January 19, 2021. The scope of the protocol was determined with input from AHRQ Key Informants. Systematic reviews were included if they reported on hospital-led interventions intended to decrease LOS for high-risk populations, defined as those with high-risk medical conditions or socioeconomically vulnerable populations (eg, patients with high levels of socioeconomic risk, who are medically uninsured or underinsured, with limited English proficiency, or who are hospitalized at a safety-net, tertiary, or quaternary care institution). Exclusion criteria included interventions that were conducted outside of the hospital setting, including community health programs. Data extraction was conducted independently, with extraction of strength of evidence (SOE) ratings provided by systematic reviews; if unavailable, SOE was assessed using the AHRQ Evidence-Based Practice Center methods guide.

FINDINGS

Our searches yielded 4432 potential studies. We included 19 systematic reviews reported in 20 articles. The reviews described 8 strategies for reducing LOS in high-risk populations: discharge planning, geriatric assessment, medication management, clinical pathways, interdisciplinary or multidisciplinary care, case management, hospitalist services, and telehealth. Interventions were most frequently designed for older patients, often those who were frail (9 studies), or patients with heart failure. There were notable evidence gaps, as there were no systematic reviews studying interventions for patients with socioeconomic risk. For patients with medically complex conditions, discharge planning, medication management, and interdisciplinary care teams were associated with inconsistent outcomes (LOS, readmissions, mortality) across populations. For patients with heart failure, clinical pathways and case management were associated with reduced length of stay (clinical pathways: mean difference reduction, 1.89 [95% CI, 1.33 to 2.44] days; case management: mean difference reduction, 1.28 [95% CI, 0.52 to 2.04] days).

CONCLUSIONS AND RELEVANCE

This systematic review found inconsistent results across all high-risk populations on the effectiveness associated with interventions, such as discharge planning, that are often widely used by health systems. This systematic review highlights important evidence gaps, such as the lack of existing systematic reviews focused on patients with socioeconomic risk factors, and the need for further research.

Comparison of Patient Satisfaction in Inpatient Care Provided by Hospitalists and Nonhospitalists in South Korea

Background: A Korean hospitalist is a medical doctor in charge of inpatient care during hospital stays. The purpose of this study is to examine the patient satisfaction of hospitalist patients compared to non-hospitalist patients. Patient satisfaction is closely related to the outcome, quality, safety, and cost of care. Thus, seeking to achieve high patient satisfaction is essential in the inpatient care setting. Design, setting, and participants: This is a case-control study based on patient satisfaction survey by the Korean Health Insurance Review and Assessment Service. We measured patients’ satisfaction in physician accessibility, consultation and care service skills, and overall satisfaction through logistic regression analyses. A total of 3871 patients from 18 facilities responded to 18 questionnaires and had health insurance claim data. Results: Hospitalist patients presented higher satisfaction during the hospital stay compared to non-hospitalist patients. For example, as per accessibility, hospitalist patients could meet their attending physician more than twice a day (OR: 3.46, 95% CI: 2.82–4.24). Concerning consultation and care service skills, hospitalists’ explanations on the condition and care plans were easy to understand (OR: 2.33, 95% CI: 1.89–2.88). Moreover, overall satisfaction was significantly higher (β: 0.431, p < 0.0001). Subgroup analyses were conducted by medical division and region. Hospitalist patients in the surgical department and the rural area had greater patient satisfaction in all aspects of the survey than non-hospitalist patients. Conclusions: Hospitalists’ patients showed higher satisfaction during the hospital stay. Our study discovered that hospitalists could provide high-quality care as they provide onsite care continuously from admission to discharge.

Improved Inpatient Care through Greater Patient-Doctor Contact under the Hospitalist Management Approach: A Real-Time Assessment

Objective: To examine the difference between hospitalist and non-hospitalist frequency of patient–doctor contact, duration of contact, cumulative contact time, and the amount of time taken by the doctor to resolve an issue in response to a medical call. Research Design and Measures: Data from 18 facilities and 36 wards (18 hospitalist wards and 18 non-hospitalist wards) were collected. The patient–doctor contact slip and medical call response slips were given to each inpatient ward to record. A total of 28,926 contacts occurred with 2990 patients, and a total of 8435 medical call responses occurred with 3329 patients. Multivariate logistic regression analyses and regression analyses were used for statistical analyses. Results: The average frequency of patient–doctor contact during a hospital stay was 10.0 times per patient for hospitalist patients. Using regression analyses, hospitalist patients had more contact with the attending physician (β = 5.6, standard error (SE) = 0.28, p < 0.0001). Based on cumulative contact time, hospitalists spent significantly more time with the patient (β = 32.29, SE = 1.54, p < 0.0001). After a medical call to resolve the issue, doctors who took longer than 10 min were 4.14 times (95% CI 3.15–5.44) and those who took longer than 30 min were 4.96 times (95% CI 2.75–8.95) more likely to be non-hospitalists than hospitalists. Conclusion: This study found that hospitalists devoted more time to having frequent encounters with patients. Therefore, inpatient care by a hospitalist who manages inpatient care from admission to discharge could improve the care quality.

Hospitalists, two decades later: Which US hospitals utilize them?

Hospitalists, or specialists of hospital medicine, have long been practicing in Canada and Europe. However, it was not until the mid-1990s, when hospitals in the U.S. started widespread adoption of hospitalists. Since then, the number of hospitalists has grown exponentially in the U.S. from a few hundred to over 50,000 in 2016. Prior studies on hospitalists have well documented benefits hospitals gain from adopting this innovative staffing strategy. However, there is a dearth of research documenting predictors of hospitals' adoption of hospitalists. To fill this gap, this longitudinal study (2003-2015) purposes to determine organizational and market characteristics of U.S. hospitals that utilize hospitalists. Our findings indicate that private not-for-profit, system affiliated, teaching, and urban hospitals, and those located in higher per capita income markets have a higher probability of utilizing hospitalists. Additionally, large or medium, profitable hospitals, and those that treat sicker patients have a higher probability of adoption. Finally, hospitals with a high proportion of Medicaid patients have a lower probability of utilizing hospitalists. Our results suggest that hospitals with greater slack resources and those located in munificent counties are more likely to use hospitalists, while their under-resourced counterparts may experience more barriers in adopting this innovative staffing strategy.

Burden and Outcomes of Fragmentation of Care in Hospitalized Patients With Inflammatory Bowel Diseases: A Nationally Representative Cohort

BACKGROUND

Fragmentation of care (FoC) may adversely impact health care quality in patients with chronic diseases. We conducted a US nationally representative cohort study to evaluate the burden and outcomes of FoC in hospitalized patients with inflammatory bowel disease (IBD).

METHODS

Using Nationwide Readmissions Database 2013, we created 2 cohorts of superutilizer patients with IBD with 2 hospitalizations (cohort 1: FoC, defined as readmission to nonindex hospital vs no FoC) or 3 hospitalizations (cohort 2: multiple episodes of fragmentation vs single episode of fragmentation vs no FoC) between January and June 2013, which were followed through December 2013. We evaluated burden, pattern, and outcomes of fragmentation (6-month risk of readmission, risk of surgery, and inpatient mortality).

RESULTS

In cohort 1, of 6073 patients with IBD with 2 admissions within 6 months, 1394 (23%) experienced FoC. Fragmentation of care was associated with modestly higher risk of readmission within 6 months (31% vs 28%, P < 0.01; adjusted relative risk, 1.11 [1.01-1.21]), without differences in risk of surgery (2.8% vs 4.3%, P = 0.19) or in-hospital mortality (0.2% vs 0.5%, P = 0.22). In cohort 2, of 1717 patients with 3 hospitalizations within 6 months, the number of patients with multiple episodes of fragmentation was associated with higher risk of readmission compared with patients with single episode of fragmentation or no FoC (52% vs 49% vs 43%, P = 0.03).

CONCLUSIONS

In a US cohort study, FoC is associated with a modestly higher risk of readmission, without higher risk of surgery or mortality in superutilizer patients with IBD. Future studies focusing on impact of outpatient care and postdischarge coordination are warranted in superutilizer patients.

Prospects for the Korean model of the surgical hospitalist system

To meet the increasing social demand for improved patient safety and quality medical care in Korea, a pilot project of the hospitalist system in the field of internal medicine and surgery was initiated in 2016. Since the hospitalist system in the field of surgery in Korea should be based on the specific Korean medical environment, it is difficult to adopt a precedent model from other countries, and therefore a uniquely Korean operational model is necessary. Surgical hospitalists (surgeons working only within wards) in Korea are in charge of advanced primary care, perioperative care, and medical system care. Surgical hospitalists are able to care for older adult patients who have undergone a major operation to treat a highly severe condition. For inpatient care, the axis will need to shift from a trainee-centered structure to a surgical hospitalist-centered structure. This change will make possible the improvement of patient safety and quality medical care. The role of surgical hospitalists will extend not only to medical care, but also to education, academic activities, research, and related administrative aspects. To build a more stable and sustainable system, it is necessary to create a systemic operational foundation for proceeding with this new surgical hospitalist system.

Hospitalists staffing levels and hospital performance

OBJECTIVE (OR STUDY QUESTION)

To examine the association between hospitalists staffing levels and contract type with CMS Total Performance Score (TPS).

DATA SOURCES/STUDY SETTING

Total performance scores were obtained from CMS, hospital-level data from the 2015 American Hospital Association Annual Survey Database, and unemployment rates from the Area Resource Health File.

STUDY DESIGN

We used cluster analysis to classify hospitals based on the distribution of various hospitalist contracts, and we used regression analysis to examine the association between TPS and hospitalist staffing levels and contract distributions. Hospital-level predictors included hospitalists staffing levels, RN staffing levels, and Magnet status. Market-level variables were unemployment rates and competition.

PRINCIPAL FINDINGS

Higher staffing levels of employed hospitalists or hospitalists with a group contract are associated with higher TPS (with coefficient estimates of 0.85 and 0.83, respectively, and the same standard error of 0.22). Higher staffing levels of hospitalists under individual contract are negatively associated with TPS (with coefficient estimate of -0.43 and standard error of 0.21). Based on the regression analysis using hospital clusters as independent variables, hospitals with individual contracts or without hospitalists providing care had significantly worse TPS compared to hospitals that predominantly employ hospitalists (with coefficient estimate of -1.80 and standard error of 0.61). Magnet status, RN staffing levels, and small and medium size were positively associated with TPS. Medicare share of inpatient days, teaching status, AMCs, and for-profit and public nonfederal ownership were negatively associated with TPS.

CONCLUSIONS

Adequate hospitalist staffing level is important for hospitals to achieve better performance. Hospitals need to consider the mix of arrangements or contracts that they have with hospitalists.

Communication with Diverse Patients: Addressing Culture and Language

Effective communication is key when providing quality health care. The dynamics of communication within the health care team and with the patient and family can be challenging. These challenges stem from the sharing of complex information, highly emotional topics, and health literacy barriers. Linguistic and cultural barriers can further aggravate these challenges. This section provides an overview of linguistic and cultural challenges related to patient-provider communication, strategies for effective communication with patients with limited English Proficiency via the use of interpreter services, and tips for how to teach these skills to health care providers.

Family Medicine Patients Have Shorter Length of Stay When Cared for on a Family Medicine Inpatient Service

Introduction: Hospitalists have been shown to have shorter lengths of stays than physicians with concurrent outpatient practices. However, hospitalists at academic medical centers may be less aware of local resources that can support the hospital to home transition for local primary care patients. We hypothesized that local family medicine patients admitted to a family medicine inpatient service have shorter length of stay than those admitted to general hospitalist services which also care for tertiary patients at an academic medical center. Methods: A retrospective cohort study was conducted at an academic medical center with a department of family medicine providing primary care to over 80 000 local patients. A total of 3100 consecutive family medicine patients admitted to either the family medicine inpatient service or a general medicine inpatient service over 3 years were studied. The primary outcome was length of stay, which was adjusted using multivariate linear regression for demographics, prior utilization, diagnosis, and disease severity. Results: Adjusted length of stay was 33% longer (95% CI 24%-44%) for local family medicine patients admitted to general medicine inpatient services as compared with the family medicine inpatient service. Readmission rates within 30 days were not different (19% vs 16%, P = .14). Conclusions: Local primary care patients were safely discharged from the hospital sooner on the family medicine inpatient service than on general medicine inpatient services. This is likely because the family physicians staffing their inpatient service are more familiar with outpatient resources that can be effectively marshaled to help local patients with the transition from hospital to home.

Hospital risk-based payments and physician employment: Impact on financial performance

BACKGROUND

Hospital involvement in risk-based payment and employment of physicians can have a large impact on their profitability. Risk-based reimbursement approaches with third-party payers and provider-sponsored insurance products hold hospital organizations financially accountable for a range of patient services. Direct employment of physicians can add new revenue sources for the hospital but comes at the high cost of physician compensation packages.

PURPOSE

Risk bearing and physician employment have multifaceted effects on hospital profitability. The objective of this study is to assess overall financial implications of these arrangements.

METHODOLOGY

Fixed-effects estimation with American Hospital Association, Centers for Medicare & Medicaid Services, and Area Health Resource File data are used for the period 2012-2015. Key measures include indicators of hospital involvement in risk-based payments and the number of employed physicians by specialty. Hospital and market factors that could affect profitability are controlled in the analysis.

RESULTS

Increases in employed hospitalists for hospitals with risk-based payment arrangements had a beneficial effect on their profitability. No significant association existed between profits and increased physician employment for hospitals lacking such payment arrangements and for increased nonhospitalist physician employment in hospitals with these arrangements.

CONCLUSIONS

Hospitals that hold some degree of financial responsibility for patient care have learned how to deploy employed hospitalists to their financial advantage. The unique role of hospitalists in expediting and coordinating patient care may yield the cost control that hospitals need to succeed under risk-based payment arrangements.

PRACTICE IMPLICATIONS

Hospitals are still on a learning curve in determining how to structure incentives for their nonhospitalist employed physicians. To the extent that employment of these nonhospitalist physicians has not yet had a detrimental effect on hospital profits, a window of opportunity exists for hospitals to develop enhanced approaches to align primary care and specialist physicians to achieve financial aims.

Incorporating Continuity in a 7-On 7-Off Hospitalist Model and the Correlation With Patient Handoffs and Length of Stay

Little research in hospital medicine examines the effects of hospitalist continuity on patient outcomes. This study implemented a novel staffing model with approximately half of rounding teams starting their 7-day workweek on Monday and the others on Friday. Teams admitted their own patients on their first 4 days with additional nighttime admissions handed off to those teams. No admissions were given to teams on their last 3 days. Length of stay was significantly reduced from 6.34 days in 2015 to 5.7 days in 2016 (P < .002) with a significant decrease in handoffs. There was an increase in odds ratio of death (1.37, SE = .128) with each additional hospitalist involved in a patient's care while adjusting for year and number of patient diagnoses (P < .001). There was no statistical difference in charges, 30-day readmissions, or mortality between years.

Adverse Events and Patient Outcomes Among Hospitalized Children Cared for by General Pediatricians vs Hospitalists

IMPORTANCE

Pediatric hospital medicine is a relatively new and growing specialty. However, research remains inconclusive on outcomes for inpatients cared for by pediatric hospitalists compared with those cared for by general pediatricians.

OBJECTIVE

To analyze outcomes, adverse events (AEs), and types of AEs associated with care provided for pediatric patients by hospitalists vs general pediatricians.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the medical records of a US urban academic children's hospital comprising 1423 hospitalizations between January 1, 2009, and August 31, 2015, for 57 diagnoses of patients cared for by either a hospitalist or general pediatrician. General pediatricians worked primarily in the hospital's outpatient clinic, serving a few inpatient weeks per year, and were not the patients' primary care physician. Data analysis was performed from July 1, 2017, to October 10, 2018.

MAIN OUTCOMES AND MEASURES

Outcomes were length of stay, total costs, 30-day readmission rates, and AEs. Adverse events were documented by International Classification of Diseases, Ninth Revision, Clinical Modification codes determined by review of medical records. Adverse event categories were drug events, infections, and device-related AEs. Generalized linear models were used to analyze patient outcomes, with standard errors clustered by physician. Models were adjusted for patient characteristics, including Chronic Condition Indicators. Models were estimated with and without adjustment for physician characteristics.

RESULTS

The data set contained 1423 hospitalizations among 726 female patients and 697 male patients (mean [SD] age, 6.1 [6.3] years). Hospitalists cared for 870 patients, and general pediatricians cared for 553 patients. Among the physicians, there were 57 women and 38 men; physicians were a mean (SD) 11.1 (8.1) years out of medical school. Patients cared for by general pediatricians were younger than those cared for by hospitalists (mean [SD] age, 5.4 [6.0] vs 6.5 [6.4] years; P = .001) but had similar mean (SD) Chronic Condition Indicator scores (1.5 [1.0] vs 1.5 [1.0]). A total of 33 of 56 general pediatricians (58.9%) and 24 of 39 hospitalists (61.5%) were women (P = .006), and general pediatricians were in practice twice as long as hospitalists on average (mean [SD], 16.0 [10.3] vs 7.9 [3.8] years out of medical school; P < .001). In multivariate models adjusting for patient-level features, there were no significant differences between general pediatricians and hospitalists for mean length of stay (4.7 vs 4.6 days), total costs ($14 490 vs $15 200), and estimated 30-day readmission rate (8.9% vs 6.4%), and results were similar with adjustments for physician characteristics. Device-related AEs were higher among hospitalists (3.0% vs 1.1%; odds ratio, 0.34; 95% CI, 0.12-1.00); this association became nonsignificant after adjusting for physician experience.

CONCLUSIONS AND RELEVANCE

General pediatrician and hospitalist inpatient care had similar length of stay, total costs, and readmission rates. However, AEs differed between hospitalists and general pediatricians, with device-related AEs more common among hospitalists, which may be associated with hospitalists' fewer years in practice. Such findings can inform hospitals in planning their inpatient staffing and patient safety oversight.

The effects of substitution of hospital ward care from medical doctors to physician assistants on non-adherence to guidelines on medication prescribing

AIM

This study determined the effect of substitution of inpatient care from medical doctors (MDs) to physician assistants (PAs) on non-adherence to guidelines on medication prescribing.

METHODS

A multicenter matched-controlled study was performed comparing wards on which PAs provide medical care in collaboration with MDs (PA/MD model), with wards on which only MDs provide medical care (MD model). A set of 17 quality indicators to measure non-adherence to guidelines on medication prescribing by PAs and MDs was composed by 14 experts in a modified Delphi procedure. The indicators covered different pharmacotherapeutic subjects, such as gastric protection in case of use of NSAID or prevention of obstipation in case of use of opioids. These indicators were expressed in proportions by dividing the number of patients in which the prescriber did not adhere to a guideline, by all patients that were applicable. Multivariable regression analysis was performed in order to adjust for potential confounders.

RESULTS

1021 patients from 17 hospital wards in the 'PA/MD model' group and 1286 patients from 17 hospital wards in the 'MD model' group were included. Two of the 17 quality indicators showed significantly less non-adherence to guidelines for the PA/MD model; the indicators concerning prescribing gastric protection in case of use of NSAID in combination with corticosteroids (OR 0.42, 95% CI 0.19-0.90) and in case of use of NSAID in patients older than 70 years (OR 0.47, 95% 0.23-0.95). For none of the other quality indicators for prescribing of medication a difference between the MD model and the PA/MD model was found.

CONCLUSION

This study suggests that the non-adherence to guidelines on medication prescribing on wards with the PA/MD model does not differ from wards with traditional house staffing by MDs only. Further research is needed to determine quality, efficiency and safety of prescribing behavior of PAs.

Implementation of a seven-day hospitalist program to improve the outcomes of the weekend admission: A retrospective before-after study in Taiwan

Objective

Patients admitted during weekends may have worse outcomes than those during weekdays. Adjusting the practice of senior physicians over weekends may reduce the weekend effect.

Design

A controlled before-after study, with propensity score matching (PSM) for potential confounding variables, to compare outcomes between weekday and weekend admissions.

Setting

A 2000-bed medical centre in Taiwan

Participants

Hospitalised general medicine patients cared for by traditional internal medicine teams (pre-intervention cohort) and those cared for by hospitalists after introducing a seven-day hospitalist program in the first six-month (post-intervention cohort) and following three-year periods.

Main outcome measures

Proportion of intensive care unit (ICU) admissions, cardiopulmonary resuscitation (CPR) events, and in-hospital mortality.

Results

The pre-intervention cohort included 982 patients. Significantly higher mortality rates (11.3% vs. 6.2%, p = 0.032) were recorded in the case of weekend admissions, with similar proportions of ICU admission and CPR events. The post-intervention cohort included 601 patients. No significant difference was recorded in any of the main outcomes between weekday and weekend admissions. PSM for pre-intervention and post-intervention cohort showed shorter LOS after intervention, with no difference in ICU admission, CPR, and morality for the weekday and weekend admissions, respectively. The three-year cohort that followed, consisting of 3315 patients, showed no difference of outcomes between weekday and weekend admissions. After PSM, there were no significant differences in ICU admission rates (1.0% vs. 1.8%), CPR (0.3% vs. 0.2%) events and hospital mortality rates (8.1% vs. 8.5%), when weekday and weekend admissions were compared.

Conclusions

The seven-day hospitalist program shows potential in providing equally safe care for both weekday and weekend general medicine admissions with sustainable development.

Comparing an on-site nurse practitioner with telemedicine physician support hospitalist programme with a traditional physician hospitalist programme

INTRODUCTION

Since 2010, more than 75 rural hospitals have closed in the USA and more than one-third are at risk of closure due to lower patient volumes, lower funding levels, decreased hospital revenue and lower physician employment pools. Telemedicine can provide new models of care delivery that maintain quality and reduce cost of healthcare in rural populations. The purpose of this project was to evaluate a cross-organizational pilot program by comparing a NP/telemedicine physician hospitalist programme with a traditional physician hospitalist model to assess effects on length of patient stay, mortality rates, readmission rate, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) ratings of provider communication, and total hospital costs.

METHODS

The Standard for Quality Improvement Reporting Excellence (SQUIRE) guidelines were followed. Using a one-year retrospective chart review, average length of stay, mortality rates, 30-day readmission rates and provider communication ratings were compared between hospitalists that were nurse practitioners working with physicians through telemedicine support and physicians alone.

RESULTS

There was no statistically significant variance in average length of stay, mortality rates, 30-day readmission rates, or provider communication ratings on HCAHPS surveys compared to the NP or physician hospitalist.

DISCUSSION

This new model of care demonstrates that telemedicine can be used to provide safe and efficient physician support from a regional hub medical centre to nurse practitioners practising as hospitalists in rural Critical Access Hospitals at up to 58% cost savings while maintaining quality of care and increasing access to community-based physicians.

Transformation of the Health Care Industry: Curb Your Enthusiasm?

Policy Points: Policymakers seek to transform the US health care system along two dimensions simultaneously: alternative payment models and new models of provider organization. This transformation is supposed to transfer risk to providers and make them more accountable for health care costs and quality. The transformation in payment and provider organization is neither happening quickly nor shifting risk to providers. The impact on health care cost and quality is also weak or nonexistent. In the longer run, decision makers should be prepared to accept the limits on transformation and carefully consider whether to advocate solutions not yet supported by evidence.

CONTEXT

There is a widespread belief that the US health care system needs to move "from volume to value." This transformation to value (eg, quality divided by cost) is conceptualized as a two-fold movement: (1) from fee-for-service to alternative payment models; and (2) from solo practice and freestanding hospitals to medical homes, accountable care organizations, large hospital systems, and organized clinics like Kaiser Permanente.

METHODS

We evaluate whether this transformation is happening quickly, shifting risk to providers, lowering costs, and improving quality. We draw on recent evidence on provider payment and organization and their effects on cost and quality.

FINDINGS

Data suggest a low prevalence of provider risk payment models and slow movement toward new payment and organizational models. Evidence suggests the impact of both on cost and quality is weak.

CONCLUSIONS

We need to be patient in expecting system improvements from ongoing changes in provider payment and organization. We also may need to look for improvements in other areas of the economy or to accept and accommodate prospects of modest improvements over time.

Era of hospitalists

Hospitalists, known as physicians, are an emerging group in the medical field that is focused on the general medical care of hospitalized patients. Specializing in hospital medicine, they often attract a mix of appreciation and criticism. In the present manuscript, we review the pros and cons of a hospitalist in the health-care system. Although experts agree that hospitalists add value to the health-care system by reducing costs, streamlining administrative processes, and contributing to improved health-care outcomes, there is a large degree of disagreement regarding the extent of hospitalist contribution to overall improvements on health-care outcomes. In this paper, new strategies to overcome reported shortcomings and to further improve the quality of health care are discussed. Abbreviations: SHM: Society of Hospital Medicine; BOOST: Better Outcomes by Optimizing Safe Transitions; RED: Re-Engineered Discharge; CHF: chronic heart failure; MI: myocardial infarction; ICU: intensive care unit; PACT: post-acute care transitions; MRSA: methicillin-resistant Staphylococcus aureus; CINAHL: The Cumulative Index to Nursing and Allied Health Literature; PCP: primary care physician.

A Qualitative Study of Hospitalists' Perceptions of Patient Satisfaction Metrics on Pain Management

Hospital initiatives to promote pain management may unintentionally contribute to excessive opioid prescribing. To better understand hospitalists' perceptions of satisfaction metrics on pain management, the authors conducted 25 interviews with hospitalists. Transcribed interviews were systematically analyzed to identify emergent themes. Hospitalists felt institutional pressure to earn high satisfaction scores for pain, which they perceived influenced practices toward opioid prescribing. They felt tying compensation to satisfaction scores commoditized pain. Hospitalists believed satisfaction would improve with increased time spent at the bedside. Focusing on methods to improve patient-physician communication, while maintaining efficiency in clinical practice, may promote both patient-centered pain management and satisfaction.

The "Surgeon on Service" Model for Timely, Economically Viable Inpatient Care of Tracheostomy Patients in Academic Pediatric Otolaryngology

Importance

The traditional practice model for pediatric otolaryngologists at high-volume academic centers is to simultaneously balance outpatient care responsibilities with those of the inpatient service, emergency department, and ambulatory care clinics. This model leads to challenges with care coordination, timeliness of nonemergency operative care, and consistent participation in care and consultation at the attending surgeon level. The "surgeon on service" (SOS) model-where faculty members rotate to manage the inpatient service in lieu of outpatient responsibilities-has been described as one method to address this conundrum. The operational and economic feasibility of the SOS model has been demonstrated; however, its impact on care coordination, time from consultation to surgical care, and length of stay (LOS) have not been evaluated.

Objective

To determine the impact of the SOS model on the quality principles of timeliness and efficiency of tracheostomy tube placement and to determine if the SOS model is fiscally feasible in an academic pediatric otolaryngology practice.

Design, Setting, and Participants

Medical record review of patients undergoing tracheostomy in a pediatric academic medical center and survey of their treating physician trainees, comparing the 6-month SOS pilot phase (postimplementation, January-June 2016) with the 6-month preimplementation period (January-June 2015).

Intervention

Implementation of the SOS model.

Main Outcomes and Measures

Time to tracheostomy, frequency of successful coordination of tracheostomy with gastrostomy tube placement, total LOS, productivity measured in work relative value units, and responses to trainee surveys.

Results

Of the 41 patients included in the study (24 boys and 17 girls; mean age, 3 years; range, 3 months to 17 years), 15 were treated before SOS implementation, and 26 after. Also included were 21 trainees. Before SOS implementation, median time to tracheostomy was 7 days (range, 2-20 days); after SOS implementation, it was 4 days (range, 1-10 days) (difference between the medians, before to after, -3 days; 95% CI, -5 to 0 days). There was no significant difference in overall LOS or ability to coordinate tracheostomy with gastrostomy tube placement. Preimplementation trainee surveys cited dissatisfaction with the communication channels to the primary team when the consulting surgeon was not immediately available to perform tracheostomy. No challenges were reported after implementation. Productivity was comparable to that in the outpatient setting.

Conclusions and Relevance

In this study, the presence of a rotating inpatient pediatric otolaryngologist was a productive approach to patient care associated with more timely performance of tracheostomy. Other benefits were an improved balance of service with education to trainees and a better perception of communication with consulting services.

Hospitals' use of hospitalists: Implications for financial performance

BACKGROUND

Hospitalists, or physicians specializing in hospital-based practice, have grown significantly since they were first introduced in the United States in the mid-1990s. Prior studies on the impact of hospitalists have focused on costs and length of stay. However, there is dearth of research exploring the relationship between hospitals' use of hospitalists and organizational performance.

PURPOSE

Using a national longitudinal sample of acute care hospitals operating in the United States between 2007 and 2014, this study explores the impact of hospitalists staffing intensity on hospitals' financial performance.

METHODOLOGY

Data sources for this study included the American Hospital Association Annual Survey, the Area Health Resources File, and the Centers for Medicare & Medicaid Services' costs reports and Case Mix Index files. Data were analyzed using a panel design with facility and year fixed effects regression.

RESULTS

Results showed that hospitals that switched from not using hospitalists to using a high hospitalist staffing intensity had both increased patient revenues and higher operating costs per adjusted patient day. However, the higher operating costs from high hospitalist staffing intensity were offset by increased patient revenues, resulting in a marginally significant increase in operating profitability (p < .1).

PRACTICE IMPLICATIONS

These findings suggest that the rise in the use of hospitalists may be fueled by financial incentives such as increased revenues and profitability in addition to other drivers of adoption.

Impact of an Obstetrical Hospitalist Program on the Safety Events in a Mid-Sized Obstetrical Unit

Objective

Because internal medicine hospitalist programs were developed to address issues in medicine such as a need to improve quality, improve efficiency, and decrease healthcare cost, obstetrical (OB) hospitalist models were developed to address needs specific to the obstetrics and gynecology field. Our objective was to compare outcomes measured by occurrence of safety events before and after implementation of an OB hospitalist program in a mid-sized OB unit.

Methods

From July 2012 to September 2014, 11 safety events occurred on the labor and delivery floor. A full-time OB hospitalist program was implemented in October 2014.

Results

From October 2014 to December 2016, there was 1 safety event associated with labor and delivery.

Conclusion

It has been speculated that implementation of an OB hospitalist model would be associated with improved maternal and neonatal outcomes; our regional OB referral hospital demonstrated a statistically significant decrease in OB safety events after the OB hospitalist program implementation.

Patients Negatively Impacted by Discontinuity of Nursing Care During Acute Hospitalization

BACKGROUND

Continuity of nursing care in hospitals remains poor and not prioritized, and we do not know whether discontinuous nursing care is negatively impacting patient outcomes.

OBJECTIVES

This study aims to examine nursing care discontinuity and its effect on patient clinical condition over the course of acute hospitalization.

RESEARCH DESIGN

Retrospective longitudinal analysis of electronic health records (EHR). Average point-in-time discontinuity was estimated from time of admission to discharge and compared with theoretical predictions for optimal continuity and random nurse assignment. Mixed-effects models estimated within-patient change in clinical condition following a discontinuity.

SUBJECTS

A total of 3892 adult medical-surgical inpatients were admitted to a tertiary academic medical center in the Eastern United States during July 1, 2011 and December 31, 2011.

MEASURES

Exposure: discontinuity of nursing care was measured at each nurse assessment entry into a patient's EHR as assignment of the patient to a nurse with no prior assignment to that patient.

OUTCOME

patient's clinical condition score (Rothman Index) continuously tracked in the EHR.

RESULTS

Discontinuity declined from nearly 100% in the first 24 hours to 70% at 36 hours, and to 50% by the 10th postadmission day. Discontinuity was higher than predicted for optimal continuity, but not random. Each instance of discontinuity lead to a 0.12-0.23 point decline in the Rothman Index score, with more pronounced effects for older and high-mortality risk patients.

CONCLUSIONS

Discontinuity in acute care nurse assignments was high and negatively impacted patient clinical condition. Improved continuity of provider-patient assignment should be advocated to improve patient outcomes in acute care.

Length of stay for patients undergoing invasive electrode monitoring with stereoelectroencephalography and subdural grids correlates positively with increased institutional profitability

OBJECTIVE

Lowering the length of stay (LOS) is thought to potentially decrease hospital costs and is a metric commonly used to manage capacity. Patients with epilepsy undergoing intracranial electrode monitoring may have longer LOS because the time to seizure is difficult to predict or control. This study investigates the effect of economic implications of increased LOS in patients undergoing invasive electrode monitoring for epilepsy.

METHODS

We retrospectively collected and analyzed patient data for 76 patients who underwent invasive monitoring with either subdural grid (SDG) implantation or stereoelectroencephalography (SEEG) over 2 years at our institution. Data points collected included invasive electrode type, LOS, profit margin, contribution margins, insurance type, and complication rates.

RESULTS

LOS correlated positively with both profit and contribution margins, meaning that as LOS increased, both the profit and contribution margins rose, and there was a low rate of complications in this patient group. This relationship was seen across a variety of insurance providers.

SIGNIFICANCE

These data suggest that LOS may not be the best metric to assess invasive monitoring patients (i.e., SEEG or SDG), and increased LOS does not necessarily equate with lower or negative institutional financial gain. Further research into LOS should focus on specific specialties, as each may differ in terms of financial implications.

Association of Physician Specialty with Hospice Referral for Hospitalized Nursing Home Patients with Advanced Dementia

OBJECTIVES

Hospitalists hospice referral patterns have been unstudied. This study aims to examine hospice referral rates by attending type for hospitalized nursing home (NH) residents with advanced cognitive impairment (ACI) at the time of discharge between 2000 and 2010.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Hospitalized NH residents age ≥66 drawn from the 20% sample of Medicare beneficiaries with ACI, 4 or more activities of daily living (ADL) impairments on last minimum data set (MDS) assessment completed within 120 days of admission (n = 128,989).

MEASUREMENTS

Hospice referral was defined as referral to hospice within 1 day after hospital discharge. Attending physician type was determined by Part B physician billing for 100% of the billings during that admission. Continuity of care was defined as the hospital physician also billing for an outpatient visit within 120 days of that hospital admission. Number of ADL impairments, cognitive measures, pre-admission illnesses and illness severity were derived from the MDS.

RESULTS

Of the 105,329 hospitalized patients with ACI that survived to discharge (72.3% white, 30.6% male), the hospice referral rate at the time of hospital discharge increased from 2.8% in 2000 to 11.2% in 2010. Using a multivariate, hospital fixed effects model examining changes in the distribution of inpatient attending physicians, hospitalists compared to generalist physicians were more likely to refer these patients to hospice at discharge (AOR 1.17, 95% CI 1.09-1.26). Continuity of physician care from the outpatient setting to the hospital was associated with lower hospice referral (AOR 0.78, 95% CI 0.73-0.85).

CONCLUSION

Hospice referrals for NH-dwelling persons with ACI admitted to the hospital increased between 2000 and 2011 and disproportionately so when the attending physician was a hospitalist.

Utilization Management in a Large Community Hospital

The utilization management of laboratory tests in a large community hospital is similar to academic and smaller community hospitals. There are numerous factors that influence laboratory utilization. Outside influences like hospitals buying physician practices, increasing numbers of hospitalists, and hospital consolidation will influence the number and complexity of the test menu that will need to be monitored for over and/or under utilization in the central laboratory and reference laboratory. CLIA’88 outlines the four test categories including point-of-care testing (waived) and provider-performed microscopy that need laboratory test utilization management. Incremental cost analysis is the most efficient method for evaluating utilization reduction cost savings. Economies of scale define reduced unit cost per test as test volume increases. Outreach programs in large community hospitals provide additional laboratory tests from non-patients in physician offices, nursing homes, and other hospitals. Disruptive innovations are changing the present paradigms in clinical diagnostics, like wearable sensors, MALDI-TOF, multiplex infectious disease panels, cell-free DNA, and others. Obsolete tests need to be universally defined and accepted by manufacturers, physicians, laboratories, and hospitals, to eliminate access to their reagents and testing platforms.

Determinants of the sustained employment of physician assistants in hospitals: a qualitative study

OBJECTIVES

To identify determinants of the initial employment of physician assistants (PAs) for inpatient care as well as of the sustainability of their employment.

DESIGN

We conducted a qualitative study with semistructured interviews with care providers. Interviews continued until data saturation was achieved. All interviews were transcribed verbatim. A framework approach was used for data analysis. Codes were sorted by the themes, bringing similar concepts together.

SETTING

This study was conducted between June 2014 and May 2015 within 11 different hospital wards in the Netherlands. The wards varied in medical speciality, as well as in hospital type and the organisational model for inpatient care.

PARTICIPANTS

Participant included staff physicians, residents, PAs and nurses.

RESULTS

The following themes emerged to be important for the initial employment of PAs and the sustainability of their employment: the innovation, individual factors, professional interactions, incentives and resources, capacity for organisational change and social, political and legal factors.

CONCLUSIONS

10 years after the introduction of PAs, there was little discussion among the adopters about the added value of PAs, but organisational and financial uncertainties played an important role in the decision to employ and continue employment of PAs. Barriers to employ and continue PA employment were mostly a consequence of locally arranged restrictions by hospital management and staff physicians, as barriers regarding national laws, PA education and competencies seemed absent.