A Novel Hospital Medicine Training Track for Internal Medicine Residents: Description and Program Evaluation of the First 15 Years.

Background: The growth of hospital medicine has resulted in a parallel growth of hospital medicine training within internal medicine residency programs (IMRPs), but the experience and outcomes of these training offerings have not yet been described. Objective: To describe the first dedicated hospitalist track and the program evaluation data. Methods: The University of Colorado Hospitalist Training Track (HTT) is a 3-year track within the IMRP with robust inpatient clinical training, specialized didactics, experiential improvement work, and career mentorship. We collected data on graduates' current practices and board certification pass rates. To further evaluate the track, we electronically sent a cross-sectional survey to 124 graduates from 2005 to 2019 to identify current practice settings, graduate roles, and assessment of the training track. Results: Among 124 graduates, 97 (78.2%) practice hospital medicine, and the board certification pass rate was slightly higher than the overall IMRP pass rate for those graduating classes. Sixty-two (50%) graduates responded to the survey. Among respondents, 50 (80.6%) currently practice hospital medicine and 34 (54.8%) practice in an academic setting. The majority (50, 80.6%) hold leadership roles and are involved in a variety of scholarship, educational, and operational projects. Dedicated clinical training, didactics, and mentorship were valued by respondents. Conclusions: This represents the first description and program evaluation of a HTT for IM residents. A dedicated HTT produces graduates who choose hospital medicine careers at high rates and participate in a wide variety of leadership and nonclinical roles.

Characteristics, satisfiers, development needs, and barriers to success for early-career academic hospitalists.

BACKGROUND: Academic hospitalists engage in many non-clinical domains. Success in these domains requires support, mentorship, protected time, and networks. To address these non-clinical competencies, faculty development programs have been implemented. We aim to describe the demographics, job characteristics, satisfiers, and barriers to success of early-career academic hospitalists who attended the Academic Hospitalist Academic (AHA), a professional development conference from 2009 to 2019. METHODS: Survey responses from attendees were evaluated; statistical analyses and linear regression were performed for numerical responses and qualitative coding was performed for textual responses. RESULTS: A total of 965 hospitalists attended the AHA from 2009 to 2019. Of those, 812 (84%) completed the survey. The mean age of participants was 34 years and the mean time in hospitalist practice was 3.2 years. Most hospitalists were satisfied with their job, and teaching and clinical care were identified as the best parts of the job. The proportion of female hospitalists increased from 42.2% in 2009 to 60% in 2019 (p = 0.001). No other demographics or job characteristics significantly changed over the years. Lack of time and confidence in individual skills were the most common barriers identified in both bedside teaching and providing feedback, and providing constructive feedback was an additional challenge identified in giving feedback. CONCLUSIONS: Though early-career hospitalists reported high levels of job satisfaction driven by teaching and clinical care, barriers to success include time constraints and confidence. Awareness of these factors of satisfaction and barriers to success can help shape faculty development curricula for early-career hospitalists.

The Institute for Health care Quality, Safety, and Efficiency: A Comprehensive Approach to Improving Organization-Level Quality Performance.

Despite decades of effort to drive quality improvement, many health care organizations still struggle to optimize their performance on quality metrics. The advent of publicly reported quality rankings and ratings allows for greater visibility of overall organizational performance, but has not provided a roadmap for sustained improvement in these assessments. Most quality training programs have focused on developing knowledge and skills in pursuit of individual and project-level improvements. To date, no training program has been associated with improvements in overall organization-level, publicly reported measures. In 2012, the Institute for Health care Quality, Safety, and Efficiency was launched, which is an integrated set of quality and safety training programs, with a focus on leadership development and support of performance improvement through data analytics and intensive coaching. This effort has trained nearly 2000 individuals and has been associated with significant improvement in organization-level quality rankings and ratings, offering a framework for organizations seeking systematic, long-term improvement.

Real-time electronic health record mortality prediction during the COVID-19 pandemic: a prospective cohort study.

OBJECTIVE: To rapidly develop, validate, and implement a novel real-time mortality score for the COVID-19 pandemic that improves upon sequential organ failure assessment (SOFA) for decision support for a Crisis Standards of Care team. MATERIALS AND METHODS: We developed, verified, and deployed a stacked generalization model to predict mortality using data available in the electronic health record (EHR) by combining 5 previously validated scores and additional novel variables reported to be associated with COVID-19-specific mortality. We verified the model with prospectively collected data from 12 hospitals in Colorado between March 2020 and July 2020. We compared the area under the receiver operator curve (AUROC) for the new model to the SOFA score and the Charlson Comorbidity Index. RESULTS: The prospective cohort included 27 296 encounters, of which 1358 (5.0%) were positive for SARS-CoV-2, 4494 (16.5%) required intensive care unit care, 1480 (5.4%) required mechanical ventilation, and 717 (2.6%) ended in death. The Charlson Comorbidity Index and SOFA scores predicted mortality with an AUROC of 0.72 and 0.90, respectively. Our novel score predicted mortality with AUROC 0.94. In the subset of patients with COVID-19, the stacked model predicted mortality with AUROC 0.90, whereas SOFA had AUROC of 0.85. DISCUSSION: Stacked regression allows a flexible, updatable, live-implementable, ethically defensible predictive analytics tool for decision support that begins with validated models and includes only novel information that improves prediction. CONCLUSION: We developed and validated an accurate in-hospital mortality prediction score in a live EHR for automatic and continuous calculation using a novel model that improved upon SOFA.

Real-Time Electronic Health Record Mortality Prediction During the COVID-19 Pandemic: A Prospective Cohort Study.

BACKGROUND: The SARS-CoV-2 virus has infected millions of people, overwhelming critical care resources in some regions. Many plans for rationing critical care resources during crises are based on the Sequential Organ Failure Assessment (SOFA) score. The COVID-19 pandemic created an emergent need to develop and validate a novel electronic health record (EHR)-computable tool to predict mortality. RESEARCH QUESTIONS: To rapidly develop, validate, and implement a novel real-time mortality score for the COVID-19 pandemic that improves upon SOFA. STUDY DESIGN AND METHODS: We conducted a prospective cohort study of a regional health system with 12 hospitals in Colorado between March 2020 and July 2020. All patients >14 years old hospitalized during the study period without a do not resuscitate order were included. Patients were stratified by the diagnosis of COVID-19. From this cohort, we developed and validated a model using stacked generalization to predict mortality using data widely available in the EHR by combining five previously validated scores and additional novel variables reported to be associated with COVID-19-specific mortality. We compared the area under the receiver operator curve (AUROC) for the new model to the SOFA score and the Charlson Comorbidity Index. RESULTS: We prospectively analyzed 27,296 encounters, of which 1,358 (5.0%) were positive for SARS-CoV-2, 4,494 (16.5%) included intensive care unit (ICU)-level care, 1,480 (5.4%) included invasive mechanical ventilation, and 717 (2.6%) ended in death. The Charlson Comorbidity Index and SOFA scores predicted overall mortality with an AUROC of 0.72 and 0.90, respectively. Our novel score predicted overall mortality with AUROC 0.94. In the subset of patients with COVID-19, we predicted mortality with AUROC 0.90, whereas SOFA had AUROC of 0.85. INTERPRETATION: We developed and validated an accurate, in-hospital mortality prediction score in a live EHR for automatic and continuous calculation using a novel model, that improved upon SOFA. TAKE HOME POINTS: Study Question: Can we improve upon the SOFA score for real-time mortality prediction during the COVID-19 pandemic by leveraging electronic health record (EHR) data?Results: We rapidly developed and implemented a novel yet SOFA-anchored mortality model across 12 hospitals and conducted a prospective cohort study of 27,296 adult hospitalizations, 1,358 (5.0%) of which were positive for SARS-CoV-2. The Charlson Comorbidity Index and SOFA scores predicted all-cause mortality with AUROCs of 0.72 and 0.90, respectively. Our novel score predicted mortality with AUROC 0.94.Interpretation: A novel EHR-based mortality score can be rapidly implemented to better predict patient outcomes during an evolving pandemic.

Teaching Students to Transform: The Health Innovations Scholars Program 6 Years Later.

Training in leadership and health system transformation is increasingly important in undergraduate medical education in order to develop a pipeline of engaged physicians dedicated to transforming health care. Despite this growing need, it is unclear whether current leadership training methods have long-term impact on students' career trajectory. The authors analyzed career outcomes from 6 years of the Health Innovations Scholars Program (HISP) to better understand how the program affected the 46 graduates' future involvement in health system transformation and leadership. Eighty-eight percent of the graduates remained involved in quality improvement, 70% held leadership positions, 31% participated in health innovation, and 15% participated in patient safety initiatives. Project involvement of the graduates represented both primary and secondary catalysts for health system change, leading to 28 unique catalyst events. HISP is a model for directing trainees' career trajectory toward engagement in health system leadership and redesign.

Hospital Medicine Resident Training Tracks: Developing the Hospital Medicine Pipeline.

BACKGROUND: Hospital medicine (HM) is rapidly evolving into new clinical and nonclinical roles. Traditional internal medicine (IM) residency training likely does not optimally prepare residents for success in HM. Hospital medicine residency training tracks may offer a preferred method for specialized HM education. METHODS: Internet searches and professional networks were used to identify HM training tracks. Information was gathered from program websites and discussions with track directors. RESULTS: The 11 HM tracks at academic medical centers across the United States focus mostly on senior residents. Track structure and curricular content are determined largely by the structure and curricula of the IM residency programs in which they exist. Almost all tracks feature experiential quality improvement projects. Content on healthcare economics and value is common, and numerous track leaders report this content is expanding from HM tracks into entire residency programs. Tracks also provide opportunities for scholarship and professional development, such as workshops on abstract creation and job procurement skills. Almost all tracks include HM preceptorships as well as rotations within various disciplines of HM. CONCLUSIONS: HM residency training tracks focus largely on quality improvement, health care economics, and professional development. The structures and curricula of these tracks are tightly linked to opportunities within IM residency programs. As HM continues to evolve, these tracks likely will expand to bridge clinical and extra-clinical gaps between traditional IM training and contemporary HM practice. Journal of Hospital Medicine 2017;12:173-176.

Impact of state medicaid expansion status on length of stay and in-hospital mortality for general medicine patients at US academic medical centers.

BACKGROUND: Medicaid is often associated with longer hospitalizations and higher in-hospital mortality than other insurance types. OBJECTIVE: To characterize the impact of state Medicaid expansion status under the Affordable Care Act (ACA) on payer mix, length of stay (LOS), and in-hospital mortality. DESIGN/SETTING/PATIENTS: Retrospective cohort study of general medicine patients discharged from academic medical centers (AMCs) within the University HealthSystem Consortium from October 1, 2012 to September 30, 2015. INTERVENTION/MEASUREMENTS: Hospitals were stratified according to state Medicaid expansion status. The proportion of discharges by primary payer, LOS index, and mortality index were compared between Medicaid-expansion and nonexpansion hospitals before and after ACA implementation. ACA implementation was defined as January 1, 2014, for all states except Michigan, New Hampshire, Pennsylvania, and Indiana, which had unique dates of Medicaid expansion. RESULTS: We identified 3,144,488 discharges from 156 hospitals in 24 Medicaid-expansion states and Washington, DC, and 1,114,464 discharges from 55 hospitals in 14 nonexpansion states during the study period. Hospitals in Medicaid-expansion states experienced a significant 3.7% increase in Medicaid discharges (P = 0.013) and a 2.9% decrease in uninsured discharges (P < 0.001) after ACA implementation, whereas hospitals in nonexpansion states saw no significant change in payer mix. In a difference-in-differences analysis, the changes in LOS and mortality indices pre- to post-ACA implementation did not differ significantly between hospitals in Medicaid-expansion versus nonexpansion states. CONCLUSIONS: The differential shift in payer mix between Medicaid-expansion and nonexpansion states under the ACA did not influence LOS or in-hospital mortality for general medicine patients at AMCs in the United States. Journal of Hospital Medicine 2015;11:847-852. © 2015 Society of Hospital Medicine.

Visiting professorship in hospital medicine: An innovative twist for a growing specialty.

INTRODUCTION: As an emerging and rapidly growing specialty, academic hospitalists face unique challenges in career advancement. Key mentoring needs, especially developing reputation and relationships outside of their institution are often challenging. METHODS: We describe the structure of a novel Visiting Professorship in Hospital Medicine Program. It utilizes reciprocal exchanges of hospitalist faculty at the rank of late assistant to early associate professor. The program is designed explicitly to facilitate spread of innovation between institutions through a presentation by the visiting professor and exposure to an innovation at the host hospital medicine group. It provides a platform to advance the career success of both early- and midcareer hospitalist faculty through 1-on-1 coaching sessions between the visiting professor and early-career faculty at the host institution and commitment by visiting professors to engage in mentoring after the visit. RESULTS: Five academic hospitalist groups participated. Seven visiting professors met with 29 early-career faculty. Experience following faculty exchange visits demonstrates program effectiveness, as perceived by both early-career faculty and the visiting professors, in advancing the goals of mentorship and career advancement. One-year follow-up suggests that 62% of early-career faculty will engage in subsequent interactions with the visiting professor, and half report spread of innovation between academic hospital medicine groups. CONCLUSIONS: The Visiting Professorship in Hospital Medicine offers a low-cost framework to promote collaboration between academic hospital medicine groups and facilitate interinstitutional hospitalist mentoring. It is reported to be effective for the goal of professional development for midcareer hospitalists. Journal of Hospital Medicine 2016;11:714-718. © 2016 Society of Hospital Medicine.

Pharmacist and Physician Collaborative Practice Model Improves Vancomycin Dosing in an Intensive Care Unit.

OBJECTIVE: A pharmacist and physician collaborative practice intervention to improve the initial dosing of vancomycin was implemented with the goal of decreasing the number of subtherapeutic first troughs and increasing the number of therapeutic troughs. METHODS: Using the best available evidence, a nomogram was created to determine the initial vancomycin dose. The nomogram utilized actual bodyweight and glomerular filtration rate (eGFR) estimated with the MDRD4 equation. The dose was based on the 2009 ASHP/IDSA/SIDP guidelines, which recommended 15-20 mg/kg every 8-12 hours. Providers ordered "vancomycin IV dosed per pharmacy". RESULTS: The pre- (n = 75) and post-intervention (n = 108) cohorts had similar age, gender distribution, weight, and eGFR. The median total daily vancomycin dose was similar in pre- and post-intervention groups (2000 mg), although the median first trough was higher following the intervention (13.0 vs. 14.8 mcg/ml, p = 0.03). Following the intervention, the proportion of first troughs under 10 mcg/ml decreased (32% to 13%, p = 0.003), while the proportion of troughs in the 10 - 20 mcg/ml therapeutic range increased (50.7% vs. 69.4%, p= 0.01). There was no difference in the proportion of troughs over 20 mcg/ml (17.3% vs. 17.6%, p= 0.96). CONCLUSIONS: A multi-disciplinary intervention utilizing a nomogram-based pharmacy collaborative practice model significantly improves the proportion of therapeutic initial vancomycin troughs and decreases the number of subtherapeutic troughs by half.

The Health Innovations Scholars Program: A Model for Accelerating Preclinical Medical Students' Mastery of Skills for Leading Improvement of Clinical Systems.

Dramatic changes in health care require physician leadership. Efforts to instill necessary skills often occur late in training. The Heath Innovations Scholars Program (HISP) provided preclinical medical students with experiential learning focused on process improvement. Students led initiatives to improve the discharge process for stroke patients. All students completed an aptitude survey and Quality Improvement Knowledge Assessment Test (QIKAT) before and after the program. Significant improvements occurred across subject areas of leadership (18.4%, P < .001), quality and safety (14.7%, P < .001), and health care systems operations (21.2%, P < .008), and in the domains of knowledge (25.9%, P < .001) and skills (25.2%, P < .001). Average cumulative QIKAT results improved significantly (8.33 to 9.83, P = .04). Three of 4 recommended interventions were implemented. Furthermore, students engaged in other process improvement work on return to their home institutions. The HISP successfully advanced preclinical medical students' ability to lead clinical systems improvement.

Changes in Payer Mix and Physician Reimbursement After the Affordable Care Act and Medicaid Expansion.

Although uncompensated care for hospital-based care has fallen dramatically since the implementation of the Affordable Care Act and Medicaid expansion, the changes in hospital physician reimbursement are not known. We evaluated if payer mix and physician reimbursement by encounter changed between 2013 and 2014 in an academic hospitalist practice in a Medicaid expansion state. This was a retrospective cohort study of all general medicine inpatient admissions to an academic hospitalist group in 2013 and 2014. The proportion of encounters by payer and reimbursement/inpatient encounter were compared in 2013 versus 2014. A sensitivity analysis determined the relative contribution of different factors to the change in reimbursement/encounter. Among 37 540 and 40 397 general medicine inpatient encounters in 2013 and 2014, respectively, Medicaid encounters increased (17.3% to 30.0%, P < .001), uninsured encounters decreased (18.4% to 6.3%, P < 0.001), and private payer encounters also decreased (14.1% to 13.3%, P = .001). The median reimbursement/encounter increased 4.2% from $79.98/encounter in 2013 to $83.36/encounter in 2014 (P < .001). In a sensitivity analysis, changes in length of stay, proportions in encounter type by payer, payer mix, and reimbursement for encounter type by payer accounted for -0.7%, 0.8%, 2.0%, and 2.3% of the reimbursement change, respectively. From 2013 to 2014, Medicaid encounters increased, and uninsured and private payer encounters decreased within our hospitalist practice. Reimbursement/encounter also increased, much of which could be attributed to a change in payer mix. Further analyses of physician reimbursement in Medicaid expansion and non-expansion states would further delineate reimbursement changes that are directly attributable to Medicaid expansion.

Understanding predictors of prolonged hospitalizations among general medicine patients: A guide and preliminary analysis.

Targeting patients with prolonged hospitalizations may represent an effective strategy for reducing average hospital length of stay (LOS). We sought to characterize predictors of prolonged hospitalizations among general medicine patients to guide future improvement efforts. We conducted a retrospective cohort study using administrative data of general medicine patients discharged from inpatient status from our academic medical center between 2012 and 2014. Multivariable logistic regression was performed to assess the association between sociodemographic and clinical variables with prolonged LOS, defined as >21 days. Of 18,363 discharges, 416 (2.3%) demonstrated prolonged LOS. Prolonged hospitalizations accounted for 18.6% of total inpatient days and contributed 0.8 days to an average LOS of 4.8 days during the study period. Prolonged hospitalizations were associated with younger age (odds ratio [OR]: 0.80 per 10-year increase in age, 95% confidence interval [CI]: 0.73-0.87) and Medicaid insurance (OR: 1.99, 95% CI: 1.29-3.05, REF = Medicare). Compared to patients without prolonged LOS, prolonged LOS patients were more likely to have methicillin-resistant Staphylococcus aureus septicemia (OR: 8.83, 95% CI: 1.72-45.36); require a palliative care consult (OR: 4.63, 95% CI: 2.86-7.49), ICU stay (OR: 6.66, 95% CI: 5.22-8.50), or surgery (OR: 5.04, 95% CI: 3.90-6.52); and be discharged to a post-acute-care facility (OR: 10.37, 95% CI: 6.92-15.56). Prolonged hospitalizations in a small proportion of patients were an important contributor to overall LOS and particularly affected Medicaid enrollees with complex hospital stays who were not discharged home. Further studies are needed to determine the reasons for discharge delays in this population.

The Quality and Safety Educators Academy: fulfilling an unmet need for faculty development.

Educating physician trainees in the principles of quality improvement (QI) and patient safety (PS) is a national imperative. Few faculty are trained in these disciplines, and few teaching institutions have the resources and infrastructure to develop faculty as instructors of these skills. The authors designed a 3-day, in-person academy to provide medical educators with the knowledge and tools to integrate QI and PS concepts into their training programs. The curriculum provided instruction in quality and safety, curriculum development and assessment, change management, and professional development while fostering peer networking, mentorship, and professional development. This article describes the characteristics, experiences, and needs of a cross-sectional group of faculty interested in acquiring skills to help them succeed as quality and safety educators. It also describes the guiding principles, curriculum blueprint, program evaluation, and lessons learned from this experience which could be applied to future faculty development programs in quality and safety education.

Understanding and execution of discharge instructions.

Discharge from the acute care hospital is increasingly recognized as a time of heightened vulnerability for lapses in safety and quality. The capacity of patients to understand and execute discharge instructions is critical to promote effective self-care. This study explores factors that predict understanding and execution of discharge instructions in a sample of 237 recently discharged older adults. A study nurse conducted a postdischarge home visit to ascertain patient understanding and assess execution of instructions. Health literacy, cognition, and self-efficacy were important predictors of successful understanding and execution of instructions. Neither discharge diagnosis nor complexity of discharge instructions was found to be a significant predictor of these outcomes. Results indicate a need to implement reliable protocols that identify patients at risk for poor understanding and execution of hospital discharge instructions and provide customized approaches to meet them at their respective levels.

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.

Evaluation of a hospitalist-run acute care for the elderly service.

BACKGROUND: Comprehensive care for frail older inpatients may improve selected outcomes and reduce harm. OBJECTIVE: To evaluate a Hospitalist-run Acute Care for the Elderly (Hospitalist-ACE) service. DESIGN: Quasi-randomized, controlled trial. SETTING: Urban academic medical center. PATIENTS: Medical inpatients age ≥70 years. INTERVENTION: Hospitalist-ACE service components: 1) selected hospitalist attendings; 2) daily interdisciplinary rounds; 3) standardized geriatric assessment; 4) clinical focus on mitigating harm and discharge planning; 5) novel inpatient geriatrics curriculum. MEASURES: The primary outcome was recognition of abnormal functional status by the primary medical team. Secondary outcomes included: recognition of abnormal cognitive status and delirium by the primary medical team; use of physical restraints and sleep aids; documentation of code status; hospital charges, length of stay, readmission rates, discharge location, and falls. RESULTS: One hundred twenty-two Hospitalist-ACE patients were compared to 95 usual care patients. Hospitalist-ACE patients had significantly greater recognition of abnormal functional status (65% vs 32%, P < 0.0001), and abnormal cognitive status (57% vs 36%, P = 0.02), and greater use of "Do Not Attempt Resuscitation" orders (39% vs 26%, P = 0.04). There were no differences in use of physical restraints, or sleep aids, falls, or discharge location. Hospitalist-ACE patients and usual care patients had similar mean lengths of stay in days (3.4 ± 2.7 vs 3.1 ± 2.7, P = 0.52), mean charges ($24,617 ± $15,828 vs $21,488 ± $13,407, P = 0.12), and 30-day readmission rates (12% vs 10%, P = 0.50). CONCLUSIONS: A Hospitalist-ACE service may improve care processes without significantly increasing resource consumption. No impact on key clinical outcomes was observed.