Association Between Physician Part-time Clinical Work and Patient Outcomes.

Importance: Despite the growing number of physicians who reduce clinical time owing to research, administrative work, and family responsibilities, the quality of care provided by these physicians remains unclear. Objective: To examine the association between the number of days worked clinically per year by physicians and patient mortality. Design, Setting, and Participants: This cross-sectional analysis was completed on a 20% random sample of Medicare fee-for-service beneficiaries 65 years and older who were admitted to the hospital with an emergency medical condition and treated by a hospitalist in 2011 through 2016. Because hospitalists typically work in shifts, hospitalists' patients are plausibly quasirandomized to hospitalists based on the hospitalists' work schedules (natural experiment). The associations between hospitalists' number of days worked clinically per year and 30-day patient mortality and readmission rates were examined, adjusting for patient and physician characteristics and hospital fixed effects (effectively comparing physicians within the same hospital). Data analysis was conducted from July 1, 2020, to July 2, 2021. Exposures: Physicians' number of days worked clinically per year. Main Outcomes and Measures: The primary outcome was 30-day patient mortality, and the secondary outcome was 30-day patient readmission. Results: Among 392 797 hospitalizations of patients treated by 19 170 hospitalists (7482 female [39.0%], 11 688 male [61.0%]; mean [SD] age, 41.1 [8.8] years), patients treated by physicians with more days worked clinically exhibited lower mortality. Adjusted 30-day mortality rates were 10.5% (reference), 10.0% (adjusted risk difference [aRD], -0.5%; 95% CI, -0.8% to -0.2%; P = .002), 9.5% (aRD, -0.9%; 95% CI, -1.2% to -0.6%; P < .001), and 9.6% (aRD, -0.9%; 95% CI, -1.2% to -0.6%; P < .001) for physicians in the first (bottom), second, third, and fourth (top) quartile of days worked clinically, respectively. Readmission rates were not associated with the numbers of days a physician worked clinically (adjusted 30-day readmissions for physicians in the bottom quartile of days worked clinically per year vs those in the top quartile, 15.3% vs 15.2%; aRD, -0.1%; 95% CI, -0.5% to 0.3%; P = .61). Conclusions and Relevance: In this cross-sectional study, hospitalized Medicare patients treated by physicians who worked more clinical days had lower 30-day mortality. Given that physicians with reduced clinical time must often balance clinical and nonclinical obligations, improved support by institutions may be necessary to maintain the clinical performance of these physicians.

Implementation of a triage nurse role and the effect on hospitalist workload.

OBJECTIVES: Hospital medicine groups vary staffing models to match available workforce with expected patient volumes and acuity. Larger groups often assign a single hospitalist to triage pager duty which can be burdensome due to frequent interruptions and multitasking. We introduced a new role, the Triage nurse, to hold the triage pager and distribute patients. We sought to determine the effect of this Triage Nurse on the perceived workload of hospitalists and frequency of pages. METHODS: We partnered with our patient throughput department to implement the Triage Nurse role who took the responsibility of tracking and distributing admissions among three admitting physicians along with coordinating report. We used the National Aeronautics and Space Administration-Task Load Index (NASA-TLX) to measure perceived workload and accessed pager logs of admitters for 3 months before and after implementation. RESULTS: Overall, 50 of an expected 67 NASA-TLX surveys (74.6%) were returned in the pre-intervention period and 64 of 92 (69.6%) were returned in the post-intervention period. We found a statistically significant reduction in the domains of physical demand, temporal demand, effort and frustration from pre- to post-intervention periods (p < 0.01). There was also a significant decrease in the performance domain (p = 0.01) with a lower number indicative of better perceived performance. There was a significant reduction in the mean number of pages received by admitting hospitalists over their 9-h shifts (81.3 + 17.3 vs 52.4 + 7.3; p < 0.01). CONCLUSION: The implementation of the Triage Nurse role was associated with a significant decrease in the perceived workload of admitting hospitalists. Our findings are important because workload and interruptions can contribute to errors and burnout. Future studies should test interventions to improve hospitalist workload and evaluate their effect on patient outcomes and physician wellness.

The scope of hospital medicine practice at night: a national survey of night shift hospitalists.

Introduction: Although in-person hospitalist presence, increasingly staffed by dedicated nocturnists, has become the norm overnight in the hospital, the scope of nocturnist practice and typical workload has not been defined. This study examines the clinical responsibilities and patient safety perceptions of hospitalists who work night shifts in the United States.Methods: In the fall of 2019, a cross-sectional, web-based survey was administered to physician and nurse practitioner/physician assistant (NP/PA) hospitalists who work night shifts. The questionnaire assessed night staffing structure, typical responsibilities, patient volume, perceptions of safety overnight, as well as demographic information. The survey was posted on the Society of Hospital Medicine (SHM) Hospital Medicine Exchange (HMX) Online Discussion Forum. Additionally, the survey was distributed by 'snowball method' by respondents to other night hospitalists. Responses were collected anonymously.Results: Of the 167 respondents, 157 reported working night shifts. There was at least one respondent from 32 different states. In addition to performing admissions to medicine services and covering inpatients, night hospitalists cover ICU patients, participate in RRT/Code teams and procedure teams, perform consults, participate in medical education, and take outpatient calls. Across institutions, there was a large distribution in numbers of patients covered in a night shift; however, patient volume fell into typical ranges: 5-10 admissions for physicians, 0-6 admissions for NP/PAs, and 25-75 patient cross-coverage census. When physicians perform more than five admissions per night, hospitalists were less likely to agree that they could provide safe care (88% vs. 63%, p = 0.0006).Conclusions: This is the first national study to examine the clinical responsibilities of hospitalists working overnight. Overnight responsibilities are heterogeneous across institutions. As hospitals are increasingly employing nocturnists, more research is needed to guide night staffing and optimize patient safety.

Surgical Comanagement by Hospitalists: Continued Improvement Over 5 Years.

Surgical comanagement (SCM), in which surgeons and hospitalists share responsibility of care for surgical patients, has been increasingly utilized. In August 2012, we implemented SCM in Orthopedic and Neurosurgery services in which the same Internal Medicine hospitalists are dedicated year round to each of these surgical services to proactively prevent and manage medical conditions. In this article, we evaluate if SCM was associated with continued improvement in patient outcomes between 2012 and 2018 in Orthopedic and Neurosurgery services at our institution. We conducted regression analysis on 26,380 discharges to assess yearly change in our outcomes. Since 2012, the odds of patients with ≥1 medical complication decreased by 3.8% per year (P = .01), the estimated length of stay decreased by 0.3 days per year (P < .0001), and the odds of rapid response team calls decreased by 12.2% per year (P = .001). Estimated average direct cost savings were $3,424 per discharge.

A Quality Collaboration in Heart Failure and Pneumonia Inpatient Care at Novant Health: Standardizing Hospitalist Practices to Improve Patient Care and System Performance.

BACKGROUND: Heart failure and pneumonia are among the most measured and expensive conditions to treat in the United States across all payer types and are top of mind for value-driven hospital organizations and payers seeking to not only improve the quality of care for patients but also reduce unnecessary spending. Care standardization potentially leads to better patient outcomes and reduced excess costs but is a difficult objective to achieve. METHODS: A pre-post analysis of clinical practice, patient outcomes, and cost was designed to determine if serial measurement and feedback using simulated patients improves patient care quality and reduces costs for two common conditions cared for by hospitalists: pneumonia and heart failure. Care decisions measured using the simulations were compared to patient-level data collected by the system. RESULTS: Intrafacility care variation seen among Novant Health's 11 facilities employing hospitalists decreased from 14.9% to 8.5%, and overall quality-of-care scores by individual providers improved by 14.6 percentage points from study start to end. Overall, care changes (for example, troponin usage, palliative care consults, beta blocker orders) documented in the simulated patients matched the available patient-level data. Care standardization around evidence-based practices, as measured by the simulations, was associated with appreciable decreases in patient length of stay and readmissions, amounting to nearly $1.1 million in savings for Novant Health. CONCLUSION: An approach using simulated patients that includes serial measurement and feedback may help significantly reduce practice variation between different facilities in a health system and reduce costs substantially without negatively affecting outcomes.

The rise of hospitalists: an opportunity for infectious diseases investigators.

INTRODUCTION: Despite the essential role played by infectious diseases specialists in patient care, public health, cost-containment, and biomedical research, the field has a substantially higher percentage of vacant positions than other medicine sub-specialties. While much has been written about what this disturbing trend means for patient care, comparatively little attention has been focused on the dire implications for clinical research and the development of novel anti-infective therapy. Areas covered: We examine the ways that hospitalists and infectious disease specialists might collaborate to study emerging diagnostic platforms, novel antimicrobial agents, and strengthen antimicrobial stewardship programs to improve the delivery of high-quality health care. Through the use of PubMed, the manuscript reviews existing collaborations as well as those that might develop in the years to come. Expert commentary: In this paper, we propose potential strategies to confront this emerging problem, focusing on novel collaborations with the hospitalist - the specialist in inpatient medicine - to bolster the pipeline of funding for clinical infectious diseases investigators.

Improving Quality of Care for Seriously Ill Patients: Opportunities for Hospitalists.

As the shift to value-based payment accelerates, hospitals are under increasing pressure to deliver high-quality, efficient services. Palliative care approaches improve quality of life and family well-being, and in doing so, reduce resource utilization and costs. Hospitalists frequently provide palliative care interventions to their patients, including pain and symptom management and engaging in conversations with patients and families about the realities of their illness and treatment plans that align with their priorities. Hospitalists are ideally positioned to identify patients who could most benefit from palliative care approaches and often refer the most complex cases to specialty palliative care teams. Though hospitalists are frequently called upon to provide palliative care, most lack formal training in these skills, which have not typically been included in medical education. Additional training in communication, safe and effective symptom management, and other palliative care knowledge and skills are available in both in-person and online formats.

Exploration of a new model of care in a psychiatry unit.

The model established at Orillia Soldiers Memorial Hospital involves family physicians as the most responsible physician. They act as "admission gatekeeper" for all unattached patients who are admitted to the psychiatry in-patient unit. A PubMed, EBSCO, OVID Medline, Embase, CINAHL, and Web of Science database review of the last 10 years (2006-2016) was undertaken. A satisfaction survey was undertaken. An intensive literature review found this model to be unique. The model has proved to be extremely efficient and cost-effective.

Pediatric Hospitalist Comanagement Survey of Clinical and Billing Practices.

Surgical comanagement is an increasingly common practice in pediatric hospital medicine. Information about the structure and financing of such care is limited. The aim of the researchers for this study was to investigate pediatric hospitalist surgical comanagement models and to assess pediatric hospitalist familiarity with and patterns of billing for surgical patients. We conducted a cross-sectional cohort web-based survey of pediatric hospitalists using the American Academy of Pediatrics' Section on Hospital Medicine listserv. In our study (N = 133), we found wide variation in our cohort in surgical patient practice management, including program structure, individual billing practices, and knowledge regarding billing practices. Even for pediatric hospitalists with comanagement service agreements between surgeons and pediatric hospitalists, there was no increased awareness or knowledge about reimbursement or billing for surgical patients. This global lack of knowledge in our small but diverse sample suggests that billing resources and training for pediatric hospitalists practicing comanagement of surgical patients are needed.

New Models of Care.

The practice of obstetrics and gynecology continues to evolve. Changes in the obstetrician-gynecologists workforce, reimbursement, governmental regulations, and technology all drive new models of care. The advent of the obstetric hospitalist is one new model, and the development of team-based care is another. Increasingly, obstetrician-gynecologists are becoming employees of health care delivery systems, and others are focusing the scope of their practices to subspecialites. As new practice models emerge, the specialty of obstetrics and gynecology will continue to change to meet the health care needs of women.

No Variation in Patient Care Outcomes After Implementation of Resident Shift Work Duty Hour Limitations and a Hospitalist Model System.

This study examines whether implementing a resident shift work schedule (RSWS) alone or combined with a hospitalist-led model system (HMS/RSWS) affects patient care outcomes or costs at a pediatric tertiary care teaching hospital. A retrospective sample compared pre- and postintervention groups for the most common primary discharge diagnoses, including asthma and cellulitis (RSWS intervention) and inflammatory bowel disease and diabetic ketoacidosis (HMS/RSWS intervention). Outcome variables included length of stay, number of subspecialty consultations, and hospitalization charges. For the RSWS intervention, the preintervention (n = 107) and postintervention (n = 92) groups showed no difference in any of the outcome variables. For the HMS/RSWS intervention, the preintervention (n = 98) and postintervention (n = 69) groups did not differ in demographics or length of stay. However, subspecialty consultations increased significantly during postintervention from 0.83 to 1.52 consults/hospitalization ( P < .01) without significantly increasing hospitalization charges. Neither the RSWS nor HMS/RSWS intervention affected patient care outcomes at a pediatric tertiary care teaching hospital.

Hospitalist-vascular surgery comanagement: effects on complications and mortality.

OBJECTIVES: Hospitalized vascular surgery patients have multiple severe comorbidities, poor functional status, and high perioperative cardiac risk. Thus they may be ideal patients for a collaborative care model. However, there is little evidence for a comanagement model on clinical outcomes. METHODS: The two-year pre-post study consisted of a comanagement model where a hospitalist actively participated in the medical care of American Society of Anesthesiologist Physical Status Classification scale 3 or 4 vascular surgery patients. Outcomes were in-hospital mortality, length of stay, 30-day readmission rate, pain scores, and patient safety metrics. RESULTS: With comanagement, patient complications decreased from 3.5 to 2.2 events per 1000 patients. (p = 0.045). Mortality decreased from 2.01% to 1.00% (p = 0.049), corresponding to a decrease in the risk-adjusted observed to expected mortality rate ratio from 1.22 to 0.53 (p = 0.01). Patient reported pain scores improved; more patients in the comanagement cohort expressed no pain (72% vs 82.8%; p = 0.01) and there were reductions in reports of mild and moderate pain. There was no significant difference in the risk-adjusted length of stay (observed to expected ratio 0.83 to 0.88 for the pre-intervention and comanagement groups, respectively, p = 0.48). The 30-day readmission rate was unchanged (21.9 vs 20.6% p = 0.44). Patients in the intervention period were more clinically complex, as evidenced by the greater case mix index (2.21 vs 2.44). CONCLUSIONS: After two years of implementation, our comanagement service reduced complications, mortality, and pain scores among high-risk vascular surgery patients.

Collaborative Care on the Stroke Unit: A Cross-Sectional Outcomes Study.

OBJECTIVE: The aim of this study was to evaluate the economic and quality outcomes associated with a collaborative advanced practice nurse and hospitalist physician model of care on the inpatient stroke unit as compared with usual hospitalist physician-led care. BACKGROUND: High functioning collaborative teams are anticipated to be essential under value-based reimbursement. METHODS: Hospitalist nurse practitioners were assigned to the stroke unit in collaboration with hospitalist physicians to implement daily hospital management for patients with stroke and transient ischemic attack. To evaluate outcomes associated with the care model, a retrospective cross-sectional design was used with 100 patients in the collaborative advanced practice nurse and hospitalist physician care group and 100 patients in the usual hospitalist physician-led care group. Primary outcome measures were length of stay, 30-day readmissions, stroke core measure documentation, and patient experiences of care. Analysis of demographic characteristics assured that the samples were similar. RESULTS: The collaborative care group performed better on one of five stroke core quality measures and on two of three patient experiences of care measures. Mean length of stay and hospital readmissions were similar between groups. Five patients left the stroke unit against medical advice in the usual hospitalist physician-led care group, whereas there were no discharges against medical advice in the collaborative care group. CONCLUSION: Advanced practice nurse and hospitalist physician collaboration is a promising model for healthcare quality improvement during inpatient stroke care; results are likely generalizable to other adult medicine populations.

The Effects of a Hospitalist Comanagement Model for Joint Arthroplasty Patients in a Teaching Facility.

BACKGROUND: The goal of this study was to compare postoperative medical comanagement of total hip arthroplasty and total knee arthroplasty patients using a hospitalist (H) and nonhospitalist (NH) model at a single teaching institution to determine the clinical and economic impact of the hospitalist comanagement. METHODS: We retrospectively reviewed the records of 1656 patients who received hospitalist comanagement with 1319 patients who did not. The NH and H cohorts were compared at baseline via chi-square test for the American Society of Anesthesiologists classification, the t test for age, and the Wilcoxon test for the unadjusted Charlson Comorbidity Index score and the age-adjusted Charlson Comorbidity Index score. Chi-square test was used to compare the postoperative length of stay, readmission rate at 30 days after surgery, diagnoses present on admission, new diagnoses during admission, tests ordered postoperatively, total direct cost, and discharge location. RESULTS: The H cohort gained more new diagnoses (P < .001), had more studies ordered (P < .001), had a higher cost of hospitalization (P = .002), and were more likely to be discharged to a skilled nursing facility (P < .001). The H cohort also had a lower length of stay (P < .001), but we believe evolving techniques in both pain control and blood management likely influenced this. There was no significant difference in readmissions. CONCLUSION: Any potential benefit of a hospitalist comanagement model for this patient population may be outweighed by increased cost.

Laborist to Obstetrician/Gynecologist-Hospitalist: An Evolution or a Revolution?

The laborist model offers the best approach to standardize care and improve patient safety on the labor unit, improve physician well-being, and decrease physician dissatisfaction/burnout. The concept of the laborist was based on the hospitalist model. The laborist is free of the stresses of a private practice, works a constant and controllable schedule, and can have work shift limitations, thereby eliminating the issue of fatigue and impairment, and improving patient safety while decreasing the potential for adverse outcomes that may result in a liability action. This is what is being demanded both by patients and generation Y physicians.

Roles of Obstetrician-Gynecologist Hospitalists with Changes in the Obstetrician-Gynecologist Workforce and Practice.

Obstetrician-gynecologists (OB-GYNs) are the fourth largest group of physicians and the only specialty dedicated solely to women's health care. The specialty is unique in providing 24-hour inpatient coverage, surgical care and ambulatory preventive health care. This article identifies and reviews changes in the OB-GYN workforce, including more female OB-GYNs, an increasing emphasis on work-life balance, more sub-specialization, larger group practices with more employed physicians and, finally, an emphasis on quality and performance improvement. It then describes the evolution of the OB-GYN hospitalist movement to date and the role of OB-GYN hospitalists in the future with regard to these workforce changes.

Potential Impact of Obstetrics and Gynecology Hospitalists on Safety of Obstetric Care.

Staffing models are critical aspects of care delivery. Provider staffing on the labor and delivery unit has recently received heightened attention. Based on the general medicine hospitalist model, the obstetrics and gynecology hospitalist or laborist model of obstetric care was introduced more than a decade ago as a plausible model-of-care delivery to improve provider satisfaction, with the goal of also improving safety and outcomes through continuous coverage by providers whose sole focus was on the labor and delivery unit without other competing clinical duties. It is plausible that this model of provider staffing and care delivery will increase safety.

Obstetrics Hospitalists: Risk Management Implications.

The concept of having an in-house obstetrician (serving as an obstetrics [OB] hospitalist) available 24 hours a day, 7 days a week provides a safety net for OB events that many need immediate intervention for a successful outcome. A key precept of risk management, that of loss prevention, fits perfectly with the addition of an OB hospitalist role in the perinatal department. Inherent in the role of OB hospitalists are the patient safety and risk management principles of improved communication, enhanced readiness, and immediate availability.

Business and Organizational Models of Obstetric and Gynecologic Hospitalist Groups.

The growth of obstetric and gynecologic (OB/GYN) hospitalists throughout the United States has led to different organizational approaches, depending on the perception of what an OB/GYN hospitalist is. There are advantages of OB/GYN hospitalist practices; however, practitioners who do this as just 1 piece of their practice are not fulfilling the promise of what this new specialty can deliver. Because those with office practices have their own business models, this article is devoted to the organizational and business models of OB/GYN hospitalists for physicians whose practice is devoted to inpatient obstetrics with or without emergency room and/or inpatient gynecology coverage.