Acceptance of recommendations by inpatient pharmacy case managers: unintended consequences of hospitalist and specialist care.

STUDY OBJECTIVE: To determine whether recommendations made by pharmacists and accepted by hospital physicians resulted in fewer postdischarge readmissions and urgent care visits compared with recommendations that were not implemented. DESIGN: Prospective substudy of pharmacist recommendations. SETTING: Tertiary care academic medical center and private community-based physician practices and community pharmacies. PATIENTS: A total of 192 patients aged 18 years or older who were a subsample of a randomized, prospective study, who were admitted with a previous diagnosis of one of nine cardiovascular or pulmonary diseases or diabetes mellitus or had received oral anticoagulation therapy and who were discharged to community-based care provided by private physicians and community pharmacists. MEASUREMENTS AND MAIN RESULTS: Pharmacy case managers performed evaluations for patients and made recommendations to inpatient physicians. Patients received drug therapy counseling, a drug therapy list, and a wallet card at discharge. Data were collected from patients and private physicians for 90 days after discharge. Pharmacy case managers made 546 recommendations to inpatient physicians for 187 patients (97%). Overall, 260 (48%) of the 546 recommendations were accepted. The acceptance rate was lower for patients who had an urgent care visit compared with the other patients (33.6% vs 52.2%, p=0.033). High acceptance rates were noted for updating the record after medication reconciliation (36 patients [78%]) and when there was an actual allergy (2 [100%] of 2 patients) or medication error (2 [100%] of 2 patients). Physicians were less likely to accept recommendations related to drug indications (p<0.001), drug efficacy (p=0.041), and therapeutic drug and disease state monitoring (p=0.011). Recommendations made for patients with a relatively greater number of drugs were also less likely to be accepted (p=0.003). CONCLUSION: Recommendations to reconcile medications or address actual drug allergies or medication errors were frequently accepted. However, only 48% of all recommendations were accepted by inpatient physicians, and there was no impact on health care use 90 days after discharge. This study suggests that recommendations by pharmacy case managers were underused, and the low acceptance rate may have reduced the potential to avoid readmissions.

Dissecting the "CHF admission": an evidence-based review of the evaluation and management of acute decompensated heart failure for the hospitalist.

Acute decompensated heart failure (ADHF) is one of the most common conditions managed by hospitalists. Here we review the most recent evidence applicable to hospitalists for the diagnosis, risk stratification, and management of patients presenting with ADHF. By following a structured approach based on the patient's symptoms, history, physical examination, and laboratory testing, the clinician can make the diagnosis of heart failure efficiently. Because patients exhibit a wide spectrum of risk for adverse outcomes, both in the hospital and after discharge, assessing for clinical factors associated with these outcomes is essential. Congestion should be managed primarily with diuretics, and vasodilators may be helpful in certain patients. Given high rates of readmission, hospitalists should ensure that patients received evidence-based therapy, heart failure education is performed, and follow-up is in place before discharge.

Results of a retrospective observational study of intermediate care staffed by hospitalists: impact on mortality, co-management, and teaching.

BACKGROUND: Hospitalized patients are complex and institutions have to face the high cost of critical care and the limited resources of the ward. Intermediate care appears as an attractive strategy to provide rational care according to patient needs. It is an interesting scenario to expand co-management and teaching. STUDY DESIGN: Retrospective observational study. SETTING: Intermediate care unit (ImCU) of a single academic hospital. PATIENTS AND METHODS: 456 patients admitted from April 2006 to April 2010 were included in the study. Demographics, admission physiologic parameters and in-hospital mortality were recorded. We used the Simplified Acute Physiology Score II (SAPS II) as prognostic score system. Co-management with medical and surgical teams, and the number of training residents were evaluated. RESULTS: In-hospital mortality was 20.6%, whereas the expected mortality was 23.2% based on SAPS II score. The correlation between SAPS II predicted and observed death rates was accurate and statistically significant (Rho = 1.0, p < 0.001). Co-management was performed with several medical and surgical teams, with an increase in perioperative comanagement of 22.7% (p = 0.014). The number of training residents in ImCU increased from 4.3% to 30.4% (p = 0.002) CONCLUSIONS: An ImCU led by hospitalists showed encouraging results regarding patient survival and SAPS II is an useful tool for prognostic evaluation in this population. Intermediate care serves as an expansion of role for hospitalists; and clinicians, trainees and patients may benefit from co-management and teaching opportunities at this unique level of care.

Pediatric hospitalists' influences on education and career plans.

BACKGROUND: Pediatric hospitalist (PH) presence is rapidly increasing, yet little is known about pediatric resident exposure to hospitalists, or how this affects resident education/career decisions. OBJECTIVES: To determine resident exposure to pediatric hospitalists; examine resident opinions regarding hospitalists' roles; examine resident opinion of hospital medicine career training needs; explore how resident exposure to hospitalists affects career choices. METHODS: Survey of random sample of 300 residents from the American Academy of Pediatrics Section on Residents database. RESULTS: Two-hundred seventy-nine pediatric residents surveyed; 120(43%) responded with variance by question; 90% work with hospitalists during residency. Of this national sample, 82% cite hospitalists as enhancing education. A majority (64%) believe pediatric hospitalists are better than primary care physicians at caring for complex inpatients; 28% felt PH provided better care for routine admissions. Over one-third surveyed are considering a career in Pediatric Hospital Medicine (PHM); 7% plan to enter the field upon graduation. Residents cited opportunities to participate in education, flexible hours, and better salaries as the top 3 reasons to become a hospitalist. Ten percent felt there was no difference between resident and hospitalist positions; 21% see PHM as a short-term job without long-term potential. Of residents entering Primary Care, a majority (59%) stated that the availability of hospitalists would positively influence their choice of a practice position; 7% said they were "less likely to choose to practice Primary Care Pediatrics because of hospitalists." CONCLUSIONS: PH have a role in physician training. While PHM has become a career consideration for trainees, more work needs to be done to improve the perception of PHM as a viable long-term career.

The relationship between time spent communicating and communication outcomes on a hospital medicine service.

BACKGROUND: Quality care depends on effective communication between caregivers, but it is unknown whether time spent communicating is associated with communication outcomes. OBJECTIVE: To assess the association between time spent communicating, agreement on plan of care, and patient satisfaction. DESIGN: Time-motion study with cross-sectional survey. SETTING: Academic medical center. PARTICIPANTS: Physicians, patients, and nurses on a hospital medicine service. MEASUREMENTS: Hospitalists' forms of communication were timed with a stopwatch. Physician-nurse agreement on the plan of care and patient satisfaction with physician communication were assessed via survey. RESULTS: Eighteen hospitalists were observed caring for 379 patients. On average, physicians spent more time per patient on written than verbal communication (median: 9.2 min. vs. 6.3 min, p<0.001). Verbal communication was greatest with patients (mean time 5.3 min, range 0-37 min), then other physicians (1.4 min), families (1.1 min), nurses (1.1 min), and case managers (0.4 min). There was no verbal communication with nurses in 30% of cases. Nurses and physicians agreed most about planned procedures (87%), principal diagnosis (74%), tests ordered (73%), anticipated discharge date (69%) and least regarding medication changes (59%). There was no association between time spent communicating and agreement on plan of care. Among 123 patients who completed surveys (response rate 32%), time physicians spent talking to patients was not correlated with patients' satisfaction with physician communication (Pearson correlation coefficient = 0.09, p=0.30). CONCLUSIONS: Hospitalists vary in the amount of time they spend communicating, but we found no association between time spent and either patient satisfaction or nurse-physician agreement on plan of care.

Inpatient staffing within pediatric residency programs: work hour restrictions and the evolving role of the pediatric hospitalist.

OBJECTIVE: In October 2010, the Accreditation Council for Graduate Medical Education (ACGME) mandated new standards that will further restrict resident work hours. There is growing concern surrounding the impact these restrictions will have on the staffing of inpatient services. The objective of this study was to survey the landscape of pediatric resident coverage of noncritical care inpatient teaching services prior to the implementation of these guidelines. In addition, we sought to explore how changes in work hour restrictions might affect the role of pediatric hospitalists in training programs. METHODS: In January 2010, an institutional review board (IRB)-approved electronic survey was sent to 196 US residency training programs via the Association of Pediatric Program Directors (APPD) listserve. RESULTS: One hundred twenty responses were received representing 5201 pediatric residents. Of the programs that responded, 84% have hospitalists. At programs with hospitalists (n = 97), 24% have pediatric hospitalist attendings in-house at night. Nearly a quarter of responding programs (22%) reported having no attending physicians in-house at night. At the time of our survey, 31% of programs anticipated the addition of 24-hour in-house hospitalist coverage within the next 5 years. When the additional work hour restrictions are implemented, 70% of programs anticipated the need to add additional hospitalist coverage at night. CONCLUSIONS: Significant variation exists in how pediatric teaching services provide overnight coverage. While hospitalists are prevalent in pediatric training programs (84% overall, 67% day only), their role in direct patient care during the overnight hours has been limited thus far. New work hour restrictions will promote the need for more hospitalists.

Development of a pediatric hospitalist sedation service: training and implementation.

OBJECTIVE: There is growing demand for safe and effective procedural sedation in pediatric facilities nationally. Currently, these needs are being met by a variety of providers and sedation techniques, including anesthesiologists, pediatric intensivists, emergency medicine physicians, and pediatric hospitalists. There is currently no consensus regarding the training required by non-anesthesiologists to provide safe sedation. We will outline the training method developed at St. Louis Children's Hospital. METHODS: In 2003, the Division of Pediatric Anesthesia at St. Louis Children's Hospital approached the Division of Pediatric Hospitalist Medicine as a resource to provide pediatric sedation outside of the operating room. Over the last seven years, Pediatric Hospitalist Sedation services have evolved into a three-tiered system of sedation providers. The first tier provides sedation services in the emergency unit (EU) and the Center for After Hours Referral for Emergency Services (CARES). The second tier provides sedation throughout the hospital including the EU, CARES, inpatient units, Ambulatory Procedure Center (APC), and Pediatric Acute Wound Service (PAWS); it also provides night/weekend sedation call for urgent needs. The third tier provides sedation in all of the second-tier locations, as well as utilizing propofol in the APC. RESULTS: This training program has resulted in a successful pediatric hospitalist sedation service. Based on fiscal year 2009 billing data, the division performed 2,471 sedations. We currently have 43 hospitalists providing Tier-One sedation, 18 Tier-Two providers, and six Tier-Three providers. CONCLUSIONS: A pediatric hospitalist sedation service with proper training and oversight can successfully augment sedation provided by anesthesiologists.

Mentorship, productivity, and promotion among academic hospitalists.

BACKGROUND: United States academic hospitals have rapidly adopted the hospitalist model of care. Academic hospitalists have taken on much of the clinical and teaching responsibilities at many institutions, yet little is known about their academic productivity and promotion. OBJECTIVE: We sought to discover the attitudes and attributes of academic hospitalists regarding mentorship, productivity, and promotion. DESIGN: We performed a web-based email survey of academic hospitalists consisting of 61 questions. PARTICIPANTS: Four hundred and twenty academic hospitalists. MAIN MEASURES: Demographic details, scholarly production, presence of mentorship and attitudes towards mentor, academic rank KEY RESULTS: Two hundred and sixty-six (63%) of hospitalists responded. The majority were under 41 (80%) and had been working as hospitalists for <5 years (62%). Only 42% of academic hospitalists had a mentor. Forty-four percent of hospitalists had not presented a poster or abstract at national meeting; 51% had not been first author on a peer-reviewed publication. Factors positively associated with publication of a peer-reviewed first author paper included: 1) male gender, AOR = 2.38 (95% CI 1.30, 4.33), 2) >20% "protected" time, AOR = 1.92 (95% CI 1.00, 3.69), and 3) a better-than-average understanding of the criteria for promotion, AOR = 3.66 (95% CI 1.76, 7.62). A lack of mentorship was negatively associated with producing any peer-reviewed first author publications AOR = 0.43 (95% CI 0.23, 0.81); any non-peer reviewed publications AOR = 0.45 (95% CI 0.24, 0.83), and leading a teaching session at a national meeting AOR = 0.41 (95% CI 0.19, 0.88). Most hospitalists promoted to the level of associate professor had been first author on four to six peer-reviewed publications. CONCLUSIONS: Most academic hospitalists had not presented a poster at a national meeting, authored an academic publication, or presented grand rounds at their institution. Many academic hospitalists lacked mentorship and this was associated with a failure to produce scholarly activity. Mentorship may improve academic productivity among hospitalists.

Evaluating the performance of a hospitalist system in Taiwan: a pioneer study for nationwide health insurance in Asia.

BACKGROUND: The national health insurance (NHI) in Taiwan covers almost the entire population and controls medical costs. However, there is increasing patient admission and shortage of inpatient care staff. The hospitalist system may be a solution. OBJECTIVE: To study the efficiency of the hospitalist system under the NHI in Taiwan. DESIGN: Prospective observational study. METHODS: Under the NHI, a hospitalist-run ward (HW) was set-up in a medical referral center for patients admitted from the emergency department. The cohort was observed and compared to the internist-run wards (IWs) in terms of performance. RESULTS: From November 2009 to January 2010, 377 patients admitted to the HW and 433 to the IWs were enrolled. Patients in the HW were older and had poorer functional status and more underlying comorbidities. The HW group also had lower admission costs and shorter lengths of hospital stay (LOS) than the IW group. Due to different demographics, propensity analysis was performed on 101 matched pairs of patients, which showed significantly lower cost and shorter LOS in HW patients despite similar mortality and readmission rates. CONCLUSIONS: The hospitalist system has higher efficiency than the internist-run general wards under the NHI system in terms of costs and length of hospitalization. It may serve as an alternative model to address rising admissions and staff shortages.

Hospitalists assess the causes of early hospital readmissions.

BACKGROUND: Hospital readmissions are receiving increasing attention as an indicator of health care quality and waste. Hospitalists provide a unique perspective on the underlying processes that result in acute care readmissions and the extent to which readmissions can be prevented. OBJECTIVE: The study assessed the views of hospitalists on the preventability of readmissions and the most important ways to prevent future readmissions. DESIGN AND MEASUREMENTS: A group of 17 hospitalists serving four community hospitals reviewed the details of 300 consecutive 21-day readmissions. Each used a structured data collection form to code information from inpatient and outpatient charts on patient characteristics, process measures, preventability, and potential interventions. RESULTS: Overall, 15% of readmissions were rated as overtly preventable, but with wide variation among hospitalists in their ratings of preventability. Perceptions of preventability appear to be a function of readmission timing, the similarity of diagnoses between admissions, medication issues, and the presence of certain chronic diseases (eg, chronic obstructive pulmonary disease [COPD]). Hospitalists were more likely to recommend familiar interventions under their control for a readmissions termed preventable, such as extending the initial hospital stay or addressing medications and patient education at discharge. They less often identified outpatient case management, home services, or physician nursing home visits as viable prevention strategies. CONCLUSIONS: The study points to the multifactorial nature of interventions needed to prevent readmissions, the tradeoffs between hospital length of stay and readmission, and the importance of fostering a culture of optimism and engagement to outpatient components of the health system to reduce hospital readmissions.

Tried and true: a survey of successfully promoted academic hospitalists.

BACKGROUND: Academic hospital medicine is a new and rapidly growing field. Hospitalist faculty members often fill roles not typically held by other academic faculty, maintain heavy clinical workloads, and participate in nontraditional activities. Because of these differences, there is concern about how academic hospitalists may fare in the promotions process. OBJECTIVE: To determine factors critical to the promotion of successfully promoted hospitalists who have achieved the rank of either associate professor or professor. DESIGN: A cross-sectional survey. PARTICIPANTS: Thirty-three hospitalist faculty members at 22 academic medical centers promoted to associate professor rank or higher between 1995 and 2008. MEASUREMENTS: Respondents were asked to describe their institution, its promotions process, and the activities contributing to their promotion. We identified trends across respondents. RESULTS: Twenty-six hospitalists responded, representing 20 institutions (79% response rate). Most achieved promotion in a nontenure track (70%); an equal number identified themselves as clinician-administrators and clinician educators (40%). While hospitalists were engaged in a wide range of activities in the traditional domains of service, education, and research, respondents considered peer-reviewed publication to be the most important activity in achieving promotion. Qualitative responses demonstrated little evidence that being a hospitalist was viewed as a hindrance to promotion. CONCLUSIONS: Successful promotion in academic hospital medicine depends on accomplishment in traditional academic domains, raising potential concerns for academic hospitalists with less traditional roles. This study may provide guidance for early-career academic hospitalists and program leaders.

Using observed structured teaching exercises (OSTE) to enhance hospitalist teaching during family centered rounds.

BACKGROUND: "Rounds" are the organizing structure for academic hospitalist-trainee teams. Family centered rounds (FCR) are endorsed by the Institute of Medicine and by the American Academy of Pediatrics, however, rounds are often conducted in the privacy of the conference room where patients and families are not privy to the decision-making process used to determine their diagnosis and management. Less than half of pediatric hospitalists reported conducting FCR, citing concerns about inefficiency and diminished teaching. OBJECTIVE: The aim of this study was to design and implement a faculty development program to address the need of hospitalists to efficiently teach during FCR. DESIGN: Scoring templates were developed to measure evidence-based teaching behaviors to optimize orientation, feedback, clinical reasoning, assessing physical exam findings, and promoting resident leadership during FCR. Hospitalists were scored by Standardized Learners and Standardized Parents during 4 Observed Structured Teaching Exercises (OSTEs) before and after focused workshops. RESULTS: Fourteen of 14 hospitalist participants had 17 months ± 14 months of experience; 71% were female; none had previous training in the areas proposed in the study. The differences between pre- and post-OSTEs for the 4 stations were statistically significant (P < .0001). Particular improvements were noted in the correction of incorrect clinical reasoning (new patient diagnosis) (56% pre, 86% post) and orientation (65% pre, 95% post). CONCLUSIONS: We found incorporating OSTEs into a FCR faculty development program to be an effective strategy for improving faculty teaching behavior. Additional study is needed to determine if this strategy results in sustained improvements in conducting FCRs in real inpatient settings.

Frequently asked questions by hospitalists managing pain in adults with sickle cell disease.

Pain is the predominant medical presentation to hospitalists for patients with sickle cell disease (SCD). Dramatic treatment gains of SCD in childhood have resulted in more adults now requiring hospitalization than children. This has created new challenges to improve the quality of hospital care for SCD. The evidence base for pain management in SCD is lacking. We therefore offer some evidence and our informed opinion to answer frequently asked questions (FAQs) about pain management by hospitalists caring for adults with SCD. The most common questions center around defining a crisis; selecting and managing opioids; distinguishing between opioid tolerance, physical dependence, and addiction or misuse; determining appropriateness of discharge; and avoiding lengthy or recurrent hospitalizations.

Patient satisfaction with a hospitalist procedure service: is bedside procedure teaching reassuring to patients?

BACKGROUND: In recent years, hospital medicine programs have adopted "procedure teams" that supervise residents in performing invasive bedside procedures. The effect of procedure teams on patient satisfaction is unknown. OBJECTIVE: We sought to measure patient satisfaction with procedures performed by a hospitalist-supervised, intern-based procedure service (HPS) with a focus on patient perception of bedside communication. DESIGN: This was a prospective survey. METHODS: We surveyed all patients referred to the HPS for bedside thoracentesis, paracentesis, lumbar puncture, and arthrocentesis at a single academic medical center. Following each procedure, surveys were administered to English-speaking patients who could provide informed consent. Survey questions focused on patients' satisfaction with specific aspects of procedure performance as well as the quality and impact of communication with the patient and between members of the team. RESULTS: Of 95 eligible patients, 65 (68%) completed the survey. Nearly all patients were satisfied or very satisfied with the overall experience (100%), explanation of informed consent (98%), pain control (92%), and expertise (95%) of physicians. The majority of patients were satisfied with procedure duration (88%) and in those with therapeutic procedures most (89%) were satisfied with improvement in symptoms. Hearing physicians discuss the procedure at the bedside was reassuring to most patients (84%), who felt this to be a normal part of doing a procedure (94%). CONCLUSIONS: Patients are highly satisfied with procedure performance by supervised trainees, and many patients were reassured by physician communication during the procedure. These results suggest that patient experience and teaching can be preserved with a hospitalist-supervised procedure service.

Bringing generalists into the hospital: outcomes of a family medicine hospitalist model in Singapore.

PURPOSE: The aim of this study was to assess a newly introduced hospitalist care model in a Singapore hospital. Clinical outcomes of the family medicine hospitalists program were compared with the traditional specialists-based model using the hospital's administrative database. METHODS: Retrospective cohort study of hospital discharge database for patients cared for by family medicine hospitalists and specialists in 2008. Multivariate analysis models were used to compare the clinical outcomes and resource utilization between patients cared for by family medicine hospitalists and specialist with adjustment for demographics, and comorbidities. RESULTS: Of 3493 hospitalized patients in 2008 who met the criteria of the study, 601 patients were under the care of family medicine hospitalists. As compared with patients cared for by specialists, patients cared for by family medicine hospitalists had a shorter hospital length of stay (adjusted LOS, geometric mean, GM, 4.4 vs. 5.3 days; P < 0.001) and lower hospitalization costs (adjusted cost, GM, $2250.7 vs. $2500.0; P= 0.003), but a similar in-patient mortality rate (4.2% vs. 5.3%, P= 0.307) and 30-day all-cause unscheduled readmission rate (7.5% vs. 8.4%, P= 0.231) after adjustment for age, ethnicity, gender, intensive care unit (ICU) admission, numbers of organ failures, and comorbidities. CONCLUSION: The family medicine hospitalist model was associated with reductions in hospital LOS and cost of care without adversely affecting mortality or 30-day all-cause readmission rate. These findings suggest that the hospitalist care model can be adapted for health systems outside North America and may produce similar beneficial effects in care efficiency and cost savings.

A comparison of outcomes of general medical inpatient care provided by a hospitalist-physician assistant model vs a traditional resident-based model.

BACKGROUND: Residency reform in the form of work hour restrictions has forced academic medical centers to develop alternate models of care to provide inpatient care. One such model is the use of physician assistants (PAs) with hospitalists. However, these models of care have not been widely evaluated. OBJECTIVE: To compare the outcomes of inpatient care provided by a hospitalist-PA (H-PA) model with the traditional resident based model. DESIGN, SETTING AND PATIENTS: We conducted a retrospective cohort study of 9681 general medical (GM) hospitalizations between January 2005 and December 2006 using a hospital administrative database. We used multivariable mixed models to adjust for a wide variety of potential confounders and account for multiple patient visits to the hospital to compare the outcomes of 2171 hospitalizations to H-PA teams with those of 7510 hospitalizations to resident teams (RES). MEASUREMENTS: Length of stay (LOS), charges, readmission within 7, 14, and 30 days and inpatient mortality. RESULTS: Inpatient care provided by H-PA teams was associated with a 6.73% longer LOS (P = 0.005) but charges, risk of readmission at 7, 14, and 30 days and inpatient mortality were similar to resident-based teams. The increase in LOS was dependent on the time of admission of the patients. CONCLUSIONS: H-PA team-based GM inpatient care was associated with a higher LOS but similar charges, readmission rates, and inpatient mortality to traditional resident-based teams, a finding that persisted in sensitivity analyses.

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

BACKGROUND: Academic hospital medicine (AHM) groups continue to grow rapidly, driven largely by clinical demands. While new hospitalist faculty usually have strong backgrounds in clinical medicine, they often lack the tools needed to achieve excellence in the other aspects of a faculty career, including teaching, research, quality improvement, and leadership skills. OBJECTIVE: To develop and implement a Faculty Development (FD) Program that improves the knowledge, skills, attitudes, and scholarly output of first-year faculty. INTERVENTION: We created a vision and framework for FD that targeted our new faculty but also engaged our entire Division of Hospital Medicine. New faculty participated in a dedicated coaching relationship with a more senior faculty member, a core curriculum, a teaching course, and activities to meet a set of stated scholarly expectations. All faculty participated in newly established divisional Grand Rounds, a lunch seminar series, and venues to share scholarship and works in progress. RESULTS: Our FD programmatic offerings were rated highly overall on a scale of 1 to 5 (5 highest): Core Seminars 4.83 ± 0.41, Coaching Program 4.5 ± 0.84, Teaching Course 4.5 ± 0.55, Grand Rounds 4.83 ± 0.41, and Lunch Seminars 4.5 ± 0.84. Compared to faculty hired in the 2 years prior to our FD program implementation, new faculty reported greater degrees of work satisfaction, increased comfort with their skills in a variety of areas, and improved academic output. CONCLUSION: Building FD programs can be effective to foster the development and satisfaction of new faculty while also creating a shared commitment towards an academic mission.