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Published On May 3, 2012

CLINICAL CARE

Enter Hospitalists

Becoming ubiquitous, thes on-the-spot physicians provide immediate care and may cut hospital costs. The jury's still out on quality.

A DECADE AGO, A MORNING VISIT TO CHECK ON HOSPITAL PATIENTS was a way of life for most primary care physicians. But these days, when someone is admitted to the hospital, someone else—a hospitalist—is likely to take charge. Shawn Lee, one of 18 hospitalists at Overlake Hospital Medical Center, a 330-bed community facility in Bellevue, Wash., is trained as a physician in internal medicine and has broad knowledge of the maladies he’s apt to see during a typical day. One morning last December, for example, his 15 patients had conditions ranging from pneumonia and complications from a stroke to gastrointestinal problems and dementia. One needed surgery.

Unlike other hospital physicians, in the emergency room or in critical care units, hospitalists coordinate all aspects of patients’ treatment during their entire hospital stays. Lee may make a diagnosis, order tests and medications, consult with specialists, visit the patient and keep family members informed. Though he shares some of those duties with another Overlake hospitalist who takes over on the night shift, Lee is in charge of his patients until they’re discharged, at which point their primary care physicians take over again.

Sick elderly patients with multiple problems tend to dominate Lee’s daily roster, and his ability to provide what he terms “almost instant” feedback helps them get prompt treatment that may involve several people. “I’m in the hospital all day, and everything happens in real time,” Lee says. “I order a test, get results back in several hours and can start additional testing or therapy, if necessary.”

All of that should translate to better care, and it can also lead to early discharges. Hospitalist care has been shown to reduce the average length of patients’ hospital stays, and because of the way Medicare and other insurers pay for care, shorter stays are a financial benefit for hospitals. Moreover, hospitalists increasingly take a role in managing hospital programs for quality improvement, patient safety and efficiency, and some now are involved in doctor training programs and in doing research on hospitalist care. Lee has been working with colleagues to develop best practices for prescribing in the hospital. “Ten years ago, when I started, I wasn’t expected to be part of these quality initiatives,” he says.

With hospitalists playing many roles, they’re much in demand, and their ranks have grown from approximately 1,000 nationwide in the mid-1990s to more than 34,000 today, according to the Society of Hospital Medicine (SHM). Nearly two-thirds of U.S. hospitals, including some 90% that have at least 200 beds, now use these specialists. “Within 10 years, virtually every hospital will have hospitalists,” says Robert Wachter, chief of hospital medicine at the University of California, San Francisco. And the U.S. health reform law could further speed up this trend. Starting this year, hospitals risk financial penalties for excessive readmissions, medical errors and other operating inefficiencies, and hospitalists are expected to emerge as leaders of efforts to meet the new standards.

For now, with the switch to this model of hospital care in full swing, hospitals face an array of challenges. Though hospitalist programs have delivered short-term savings, it’s not clear whether that trend will hold up in the long run. Designing an effective, efficient hospitalist program can present problems with scheduling, patient records and coordination of care, and securing adequate funding for hospitalists can be difficult when budgets are tight. And there’s no consensus yet on whether having hospitalists on staff actually improves care. Still, Wachter remains convinced of the benefits. “There are growing pains, but hospitalists fill a lot of unmet needs,” he says, such as caring for patients who can no longer be handled by residents because of new duty-hour limits.

IN 1996, WACHTER AND THEN-UCSF COLLEAGUE LEE GOLDMAN, now dean of the Faculties of Health Sciences and Medicine at the Columbia University College of Physicians and Surgeons, coined the term hospitalist in a New England Journal of Medicine article, which argued that hospitalized patients need the care of a physician who spends all day, every day in the hospital. Though some health systems were already experimenting with that model, the article is generally credited with launching hospital medicine.

At first, there was little enthusiasm for the approach. The medical community worried that handing off patients to hospitalists would disrupt the old-fashioned familiarity between patients and their doctors. “You should be ashamed,” one physician told Wachter. “My father would be turning over in his grave,” said another. Still, in the decade and a half since the article appeared, pressures on hospitals and physicians to be more efficient and effective have only grown stronger, and the move to a hospitalist model of care has gained momentum.

EVER SINCE THE INTRODUCTION OF MEDICARE’S PROSPECTIVE PAYMENT SYSTEM for hospital services in the 1980s, hospitals have been looking for ways to discharge patients as quickly as is safely possible. Under prospective payment, the amount the government pays is based on each patient’s diagnosis, not the length of hospital stay, so getting a heart attack patient home early should bring a financial benefit. And early data on hospitalists showed that their patients seemed to leave the hospital sooner than other patients. In an article in the Journal of the American Medical Association in 2002, Wachter reviewed 19 hospitalist studies and found that having these specialists on staff shortened patient stays by an average of 16.6% and cut hospital costs by 13.4%. And in a 2009 Mayo Clinic Proceedings review evaluating nearly three dozen academic studies of hospitalist care during the past decade, the authors found that the trends of shorter stays and lower costs continued throughout that period.

At the same time, concerns about quality of hospital care and patient safety were growing, and hospitalists have been seen as one way to address those problems, in part by taking an active role in improving hospital systems. An informal survey by SHM indicated that 97% of hospitalist programs now are involved with quality improvement initiatives and 58% have some responsibility for patient satisfaction. In addition, new regulations restricting resident duty hours in 2003 and again last year have in many cases left hospitalists taking care of large numbers of patients previously handled by residents.

Meanwhile, more stringent regulations and advances in technology have made it increasingly difficult for physicians with office practices to keep abreast of hospitals’ tests and procedures. “Many primary care physicians have become less comfortable with the clinical and organizational aspects of hospital care, while hospitalists have developed skill sets based on continuous exposure to acutely ill, hospitalized patients,” Wachter says.

IN THE RAPID SHIFT TO A HOSPITALIST MODEL, most hospitals seem convinced that it’s better for patients to have a physician who’s always around. But so far, there’s not a lot of research to support that notion. A study of 45 hospitals nationwide, published in 2007 in the New England Journal of Medicine, for example, found that although hospitals staffed by hospitalists had lower costs and shorter average stays by patients, there was no difference in clinical outcomes. “I think the most conservative statement is that hospitalists don’t have obviously worse outcomes,” says David Meltzer, chief of the University of Chicago’s division of hospital medicine.

But new research suggests that even that claim may be unwarranted. An analysis of inpatient Medicare claims by the Sealy Center on Aging at the University of Texas Medical Branch at Galveston, published last year in Annals of Internal Medicine, cited evidence that hospitalist care may be resulting in cost shifting—while hospitalists save hospitals money by discharging patients quickly, those patients are more likely to be readmitted, costing Medicare more in the long run. Analyzing the records of 58,000 Medicare patients admitted at 454 hospitals from 2001 to 2006, the study’s authors found that although patients who remained under the care of primary care physicians spent an extra half day or so in the hospital, costing Medicare an extra $282 per patient, hospitalists’ patients were more likely to end up in a nursing home or back in the hospital, at an additional cost of $332 per person.

Though some experts have criticized the design and analysis of the Texas research, few dispute its main findings. “The study raises issues that are very important, particularly that we need to do a better job coordinating care among hospitalists, primary care physicians and hospital systems,” says Wachter. The results also underscore the challenge hospitalists face in establishing rapport with patients—a quality-of-care issue that can lead directly to readmissions and higher costs. “My biggest worry is that older patients, who tend to be very medically complex, are repeatedly admitted to the hospital and every time they come in, they get a different physician who doesn’t know their full medical histories as well as their primary care physician does,” Meltzer says. A hospitalist who’s not up to speed on the problems of a particular patient may be more likely to make a misdiagnosis or to prescribe a treatment that has already failed. In a paper published last year, Meltzer argued that a new model of care in which physicians care for high-risk patients in both the inpatient and outpatient settings might reduce potential miscommunication and other continuity-of-care problems.

Some hospitalist programs are attempting to address the issue of excessive readmissions. One part of the problem is how long it takes hospital discharge summaries to reach a patient’s primary care doctor; another is that the summaries tend to be short on information about a patient’s test results, medications and follow-up plans. Until a year ago at UCSF, for example, it often took as long as two weeks for primary care physicians to receive discharge summaries, according to Michelle Mourad, director of quality for the hospital’s division of hospital medicine. The hospital’s electronic medical records system also lacked applications for including vital signs, laboratory results and medications in the discharge summary.

Mourad led a quality improvement project that created a template that includes such essential components as medication changes and pending tests. It is used not only to note daily events but also, ultimately, as the discharge summary. The increased efficiency afforded by the template has helped reduce the average time for completing discharge summaries from nine days to less than two, and along with other changes has helped to reduce readmissions for patients over age 65—from a rate of 16.5% in 2008 to 13.2% in 2010.

In 2008, responding to a study showing that one in five Medicare patients was rehospitalized within 30 days, at an annual cost of $17.4 billion, SHM launched Project BOOST—Better Outcomes for Older Adults through Safe Transition—which has now expanded to 102 sites. Hospitals get a tool kit of forms and procedures for standardizing and improving the discharge process, with the goal of reducing readmissions.

Hospitalists in a 40-bed unit at Morton Plant Hospital, a 687-bed community hospital in Clearwater, Fla., have been experimenting with BOOST tools since 2009. The hospital has adopted a one-page “patient friendly” discharge form and a standard script for nurses to read from in going over medication changes with patients. The hospital hasn’t yet seen a reduction in readmissions—it’s awaiting a broader implementation of the tools—but patient satisfaction related to the discharge process has already improved.

 

AS CRUCIAL AS IT MAY BE TO IMPROVE HOSPITALIST SYSTEMS AND CARE, such concerns show no sign of slowing the shift to this new model of care. And though hospitalists aren’t yet officially specialists, last year the American Board of Internal Medicine took a first step in differentiating the field, implementing a program, including an exam, that lets general internists earn Maintenance of Certification in Internal Medicine with a Focused Practice in Hospital Medicine. Hospitalists also have their own professional society and a peer-reviewed journal, and there are now senior residency tracks and fellowship programs for hospital medicine at 42 institutions.

It’s clear that hospitalists are not only here to stay but also likely to expand into new settings. Specialties including neurology, general surgery, obstetrics, psychiatry, pediatrics and cardiology are adopting the hospitalist model, and some nursing homes and rehabilitation facilities are also beginning to hire hospitalists. “With all the pressures on reducing costs and readmissions, the demand for hospitalist specialists from these facilities is going to be huge,” says Adam Singer, founder and chairman of IPC The Hospitalist Company, which places hospitalists in more than 800 hospitals and other facilities. “There are more than 15,000 nursing homes in this country, and there are hardly any physicians managing those patients.”

Yet even as hospitalists move into new areas, there continue to be questions about how to improve transitions of care and communication with patients and primary care physicians, and about what will happen as health care reform changes hospital care. “After a period of such rapid growth, now people are going to expect a lot more from hospitalists,” says Joseph Li, SHM president and director of hospital medicine at Beth Israel Deaconess Medical Center in Boston. “The big question is, will we be able to deliver on our promises? I’m confident we will.”

 

DOSSIER

1. State of Hospital Medicine: 2011 Report Based on 2010 Data, published by the Society of Hospital Medicine and the Medical Group Management Association. The most comprehensive source of information about trends in the field.

2. “Association of Hospitalist Care With Medical Utilization After Discharge: Evidence of Cost Shift From a Cohort Study,” by Yong-Fang Kuo and James S. Goodwin, Annals of Internal Medicine, Aug. 2, 2011. In this national study of nearly 60,000 Medicare patients, care by hospitalists was associated with shorter lengths of stay and lower hospital charges compared with inpatient care by primary care physicians. But these savings were eaten up by increased costs within 30 days after discharge.

3. “The Hospitalist: Better Value in Inpatient Care?” Issue Brief No. 842, National Health Policy Forum, March 30, 2011. This analysis examines the effect of hospitalists on the quality and efficiency of care delivery, the outlook for the physician workforce and the development of new models such as accountable care organizations.

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