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1.
BMJ ; 364: l121, 2019 Jan 30.
Artigo em Inglês | MEDLINE | ID: mdl-30700408

RESUMO

OBJECTIVES: To evaluate the changes in productivity when scribes were used by emergency physicians in emergency departments in Australia and assess the effect of scribes on throughput. DESIGN: Randomised, multicentre clinical trial. SETTING: Five emergency departments in Victoria used Australian trained scribes during their respective trial periods. Sites were broadly representative of Australian emergency departments: public (urban, tertiary, regional referral, paediatric) and private, not for profit. PARTICIPANTS: 88 physicians who were permanent, salaried employees working more than one shift a week and were either emergency consultants or senior registrars in their final year of training; 12 scribes trained at one site and rotated to each study site. INTERVENTIONS: Physicians worked their routine shifts and were randomly allocated a scribe for the duration of their shift. Each site required a minimum of 100 scribed and non-scribed shifts, from November 2015 to January 2018. MAIN OUTCOME MEASURES: Physicians' productivity (total patients, primary patients); patient throughput (door-to-doctor time, length of stay); physicians' productivity in emergency department regions. Self reported harms of scribes were analysed, and a cost-benefit analysis was done. RESULTS: Data were collected from 589 scribed shifts (5098 patients) and 3296 non-scribed shifts (23 838 patients). Scribes increased physicians' productivity from 1.13 (95% confidence interval 1.11 to 1.17) to 1.31 (1.25 to 1.38) patients per hour per doctor, representing a 15.9% gain. Primary consultations increased from 0.83 (0.81 to 0.85) to 1.04 (0.98 to 1.11) patients per hour per doctor, representing a 25.6% gain. No change was seen in door-to-doctor time. Median length of stay reduced from 192 (interquartile range 108-311) minutes to 173 (96-208) minutes, representing a 19 minute reduction (P<0.001). The greatest gains were achieved by placing scribes with senior doctors at triage, the least by using them in sub-acute/fast track regions. No significant harm involving scribes was reported. The cost-benefit analysis based on productivity and throughput gains showed a favourable financial position with use of scribes. CONCLUSIONS: Scribes improved emergency physicians' productivity, particularly during primary consultations, and decreased patients' length of stay. Further work should evaluate the role of the scribe in countries with health systems similar to Australia's. TRIAL REGISTRATION: ACTRN12615000607572 (pilot site); ACTRN12616000618459.


Assuntos
Serviço Hospitalar de Emergência , Avaliação de Desempenho Profissional/métodos , Médicos Hospitalares , Secretárias de Consultório Médico , Corpo Clínico Hospitalar , Administração de Recursos Humanos em Hospitais/métodos , Austrália , Análise Custo-Benefício , Eficiência , Serviço Hospitalar de Emergência/classificação , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Médicos Hospitalares/normas , Médicos Hospitalares/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Secretárias de Consultório Médico/organização & administração , Secretárias de Consultório Médico/normas , Corpo Clínico Hospitalar/educação , Corpo Clínico Hospitalar/normas , Corpo Clínico Hospitalar/estatística & dados numéricos , Melhoria de Qualidade , Tempo para o Tratamento/normas , Tempo para o Tratamento/estatística & dados numéricos
2.
J Hosp Med ; 14(1): 16-21, 2019 01 08.
Artigo em Inglês | MEDLINE | ID: mdl-30379136

RESUMO

BACKGROUND: Given the national emphasis on affordability, healthcare systems expect that their clinicians are motivated to provide high-value care. However, some hospitalists are reimbursed with productivity bonuses, and little is known about the effects of these reimbursements on the local culture of high-value care delivery. OBJECTIVE: To evaluate if hospitalist reimbursement models are associated with high-value culture in university, community, and safety-net hospitals. DESIGN, SETTING, PATIENTS: Internal medicine hospitalists from 12 hospitals across California completed a cross-sectional survey assessing their perceptions of high-value care culture within their institutions. Sites represented university, community, and safety-net centers with different performances as reflected by the Centers of Medicare and Medicaid Service's Value-based Purchasing (VBP) scores. MEASUREMENT: Demographic characteristics and High-Value Care Culture Survey (HVCCSTM) scores were evaluated using descriptive statistics, and associations were assessed through multilevel linear regression. RESULTS: Of the 255 hospitalists surveyed, 147 (57.6%) worked in university hospitals, 85 (33.3%) in community hospitals, and 23 (9.0%) in safety-net hospitals. Across all 12 sites, 166 (65.1%) hospitalists reported payment with salary or wages, and 77 (30.2%) with salary plus productivity adjustments. The mean HVCCS score was 50.2 (SD 13.6) on a 0-100 scale. Hospitalists reported lower mean HVCCS scores if they reported payment with salary plus productivity (ß = -6.2, 95% CI -9.9 to -2.5) than if they reported payment with salary or wages. CONCLUSIONS: Hospitalists paid with salary plus productivity reported lower high-value care culture scores for their institutions than those paid with salary or wages. High-value care culture and clinician reimbursement schemes are potential targets of strategies for improving quality outcomes at low cost.


Assuntos
Eficiência , Médicos Hospitalares/estatística & dados numéricos , Medicina Interna , Planos de Incentivos Médicos/estatística & dados numéricos , Melhoria de Qualidade , Adulto , California , Estudos Transversais , Feminino , Hospitais Comunitários/estatística & dados numéricos , Hospitais Universitários/estatística & dados numéricos , Humanos , Masculino , Medicare , Provedores de Redes de Segurança/estatística & dados numéricos , Estados Unidos , Aquisição Baseada em Valor/estatística & dados numéricos
3.
J Hosp Med ; 14(1): 9-15, 2019 01 08.
Artigo em Inglês | MEDLINE | ID: mdl-30534642

RESUMO

BACKGROUND: Hospitals are complex adaptive systems within which multiple components such as patients, practitioners, facilities, and technology interact. A careful approach to optimization of this complex system is needed because any change can result in unexpected deleterious effects. One such approach is discrete event simulation, in which what-if scenarios allow researchers to predict the impact of a proposed change on the system. However, studies illustrating the application of simulation in optimization of general internal medicine (GIM) team inpatient operations are lacking. METHODS: Administrative data about admissions and discharges, data from a time-motion study, and expert opinion on workflow were used to construct the simulation model. Then, the impact of four changes: aligning medical teams with nursing units, adding a hospitalist team, adding a nursing unit, and adding both a nursing unit and hospitalist team with higher admission volume were modeled on key hospital operational metrics. RESULTS: Aligning medical teams with nursing units improved team metrics for aligned teams but shifted patients to unaligned teams. Adding a hospitalist team had little benefit, but adding a nursing unit improved system metrics. Both adding a hospitalist team and a nursing unit would be required to maintain operational metrics with increased patient volume. CONCLUSION: Using simulation modeling, we provided data on the implications of four possible strategic changes on GIM inpatient units, providers, and patient throughput. Such analyses may be a worthwhile investment to study strategic decisions and make better choices with fewer unintended consequences.


Assuntos
Simulação por Computador , Previsões , Medicina Interna , Eficiência Organizacional , Feminino , Médicos Hospitalares/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Humanos , Masculino , Admissão do Paciente/estatística & dados numéricos , Equipe de Assistência ao Paciente/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Estudos de Tempo e Movimento
4.
J Telemed Telecare ; 25(4): 213-220, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-29498301

RESUMO

INTRODUCTION: Since 2010, more than 75 rural hospitals have closed in the USA and more than one-third are at risk of closure due to lower patient volumes, lower funding levels, decreased hospital revenue and lower physician employment pools. Telemedicine can provide new models of care delivery that maintain quality and reduce cost of healthcare in rural populations. The purpose of this project was to evaluate a cross-organizational pilot program by comparing a NP/telemedicine physician hospitalist programme with a traditional physician hospitalist model to assess effects on length of patient stay, mortality rates, readmission rate, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) ratings of provider communication, and total hospital costs. METHODS: The Standard for Quality Improvement Reporting Excellence (SQUIRE) guidelines were followed. Using a one-year retrospective chart review, average length of stay, mortality rates, 30-day readmission rates and provider communication ratings were compared between hospitalists that were nurse practitioners working with physicians through telemedicine support and physicians alone. RESULTS: There was no statistically significant variance in average length of stay, mortality rates, 30-day readmission rates, or provider communication ratings on HCAHPS surveys compared to the NP or physician hospitalist. DISCUSSION: This new model of care demonstrates that telemedicine can be used to provide safe and efficient physician support from a regional hub medical centre to nurse practitioners practising as hospitalists in rural Critical Access Hospitals at up to 58% cost savings while maintaining quality of care and increasing access to community-based physicians.


Assuntos
Médicos Hospitalares/estatística & dados numéricos , Profissionais de Enfermagem/estatística & dados numéricos , Telemedicina/estatística & dados numéricos , Serviços Urbanos de Saúde/organização & administração , Feminino , Custos Hospitalares/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos
6.
J Hosp Med ; 13(11): 764-769, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30484779

RESUMO

BACKGROUND: Twitter-based journal clubs are intended to connect clinicians, educators, and researchers to discuss recent research and aid in dissemination of results. The Journal of Hospital Medicine (JHM) began producing a Twitter-based journal club, #JHMChat, in 2015. OBJECTIVE: To describe the implementation and assess the impact of a journal-sponsored, Twitter-based journal club on Twitter and journal metrics. INTERVENTION: Each #JHMChat focused on a recently published JHM article, was moderated by a social media editor, and included one study author or guest. MEASUREMENTS: The total number of participants, tweets, tweets/participant, impressions, page views, and change in the Altmetric score were assessed after each session. Thematic analysis of each article was conducted, and post-chat surveys of participating authors and participant responses to continuing medical education surveys were reviewed. RESULTS: Seventeen Twitter-based chats were held: seven (47%) focused on value, six (40%) targeted clinical issues, and four (27%) focused on education. On average, we found 2.17 (±0.583 SD) million impressions/session, 499 (± 129 SD) total tweets/session, and 73 (±24 SD) participants/session. Value-based care articles had the greatest number of impressions (2.61 ± 0.55 million) and participants (90 ± 12). The mean increase in the Altmetric score was 14 points (±12), with medical education-themed articles garnering the greatest change (mean increase of 32). Page views were noted to have increased similarly to levels of electronic Table of Content releases. Authors and participants believed #JHMChat was a valuable experience and rated it highly on post-chat evaluations. CONCLUSIONS: Online journal clubs appear to increase awareness and uptake of journal article results and are considered a useful tool by participants.


Assuntos
Medicina Hospitalar/educação , Médicos Hospitalares/estatística & dados numéricos , Disseminação de Informação , Publicações Periódicas como Assunto/estatística & dados numéricos , Mídias Sociais/estatística & dados numéricos , Educação Médica Continuada , Humanos , Comunicação Acadêmica
7.
J Am Board Fam Med ; 31(5): 680-681, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30201663

RESUMO

Based on a 2016 survey of family physicians who were then three years out of residency training, we found that almost 9 percent self-identified as hospitalists. These family physician hospitalists were significantly more likely than their non-hospitalist peers to be male, work longer hours, be better paid, and be more satisfied with their work. These attributes may attract more family physicians to hospital medicine, with negative implications for the supply of primary care physicians. (J Am Board Fam Med 2018;31:680-681.).


Assuntos
Médicos Hospitalares/estatística & dados numéricos , Médicos de Família/estatística & dados numéricos , Feminino , Humanos , Masculino
8.
BMJ ; 362: k3640, 2018 09 26.
Artigo em Inglês | MEDLINE | ID: mdl-30257919

RESUMO

OBJECTIVE: To investigate whether the US News & World Report (USNWR) ranking of the medical school a physician attended is associated with patient outcomes and healthcare spending. DESIGN: Observational study. SETTING: Medicare, 2011-15. PARTICIPANTS: 20% random sample of Medicare fee-for-service beneficiaries aged 65 years or older (n=996 212), who were admitted as an emergency to hospital with a medical condition and treated by general internists. MAIN OUTCOME MEASURES: Association between the USNWR ranking of the medical school a physician attended and the physician's patient outcomes (30 day mortality and 30 day readmission rates) and Medicare Part B spending, adjusted for patient and physician characteristics and hospital fixed effects (which effectively compared physicians practicing within the same hospital). A sensitivity analysis employed a natural experiment by focusing on patients treated by hospitalists, because patients are plausibly randomly assigned to hospitalists based on their specific work schedules. Alternative rankings of medical schools based on social mission score or National Institute of Health (NIH) funding were also investigated. RESULTS: 996 212 admissions treated by 30 322 physicians were examined for the analysis of mortality. When using USNWR primary care rankings, physicians who graduated from higher ranked schools had slightly lower 30 day readmission rates (adjusted rate 15.7% for top 10 schools v 16.1% for schools ranked ≥50; adjusted risk difference 0.4%, 95% confidence interval 0.1% to 0.8%; P for trend=0.005) and lower spending (adjusted Part B spending $1029 (£790; €881) v $1066; adjusted difference $36, 95% confidence interval $20 to $52; P for trend <0.001) compared with graduates of lower ranked schools, but no difference in 30 day mortality. When using USNWR research rankings, physicians graduating from higher ranked schools had slightly lower healthcare spending than graduates from lower ranked schools, but no differences in patient mortality or readmissions. A sensitivity analysis restricted to patients treated by hospitalists yielded similar findings. Little or no relation was found between alternative rankings (based on social mission score or NIH funding) and patient outcomes or costs of care. CONCLUSIONS: Overall, little or no relation was found between the USNWR ranking of the medical school from which a physician graduated and subsequent patient mortality or readmission rates. Physicians who graduated from highly ranked medical schools had slightly lower spending than graduates of lower ranked schools.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Faculdades de Medicina/estatística & dados numéricos , Faculdades de Medicina/normas , Idoso , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Feminino , Pesquisa sobre Serviços de Saúde , Mortalidade Hospitalar , Médicos Hospitalares/economia , Médicos Hospitalares/normas , Médicos Hospitalares/estatística & dados numéricos , Humanos , Masculino , Medicare/estatística & dados numéricos , Qualidade da Assistência à Saúde/economia , Resultado do Tratamento , Estados Unidos/epidemiologia
9.
J Healthc Manag ; 63(4): e43-e58, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29985257

RESUMO

EXECUTIVE SUMMARY: As part of the provisions of the 2010 Affordable Care Act, the Centers for Medicare & Medicaid Services adjusts payments made to hospitals through its Hospital Value-Based Purchasing (HVBP) program. In light of the increasing aim to improve efficiency, healthcare organizations are exploring innovative strategies for care delivery, including the use of hospitalists. Supporters of the hospitalist model suggest use of these specialists offers several advantages over the traditional model of physician care in the inpatient setting, including improved coordination, reduced costs, and improved quality indicator scores. This study explores the effect of hospitalists on hospitals' scores in the four domains of the fiscal year 2016 HVBP program: clinical process of care, patient experience of care (PEOC), outcome, and efficiency. Data from the 2015 HVBP database, the 2015 Medicare Final Rule Standardizing File, and the 2015 American Hospital Association database were used for the analysis. The study used multivariate regression analysis in Stata 12. Results from this study suggest that hospitals employing a higher percentage of hospitalists see related improvement in their overall total performance score. In light of improvements within the PEOC, outcome, and efficiency scores, it would appear that hospitalists are primarily providing linking services, which helps provide better coordination of care that is otherwise lacking in more traditionally fragmented approaches to care.


Assuntos
Gastos em Saúde/estatística & dados numéricos , Médicos Hospitalares/economia , Medicaid/economia , Medicare/economia , Patient Protection and Affordable Care Act/economia , Aquisição Baseada em Valor/economia , Aquisição Baseada em Valor/estatística & dados numéricos , Adulto , Feminino , Médicos Hospitalares/estatística & dados numéricos , Humanos , Masculino , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act/estatística & dados numéricos , Estados Unidos
10.
J Hosp Med ; 13(10): 702-705, 2018 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-29964277

RESUMO

Wide variability exists in the clinical workload of pediatric hospitalists without an accepted standard for benchmarking purposes. By using data obtained from interviews of pediatric hospital medicine (PHM) program leaders, we describe the clinical workload of university-based programs and report on the program sustainability perceived by PHM program leaders. The median clinical hours reported for a full-time pediatric hospitalist were 1800 hours per year, with a median of 15 weekends worked per year. Furthermore, program leaders reported an ideal number of clinical hours as 1700 hours per year. Half of the interviewed program leaders perceived their current models as unsustainable. Programs perceived as unsustainable were more likely than those perceived as sustainable to require a higher number of weekends worked per year or to be university employed. Further research should focus on establishing benchmarks for the workloads of pediatric hospitalists and on evaluating factors that can affect sustainability.


Assuntos
Médicos Hospitalares/estatística & dados numéricos , Hospitais Pediátricos/estatística & dados numéricos , Carga de Trabalho/estatística & dados numéricos , Administração Hospitalar , Hospitais Universitários , Humanos
12.
J Arthroplasty ; 33(8): 2387-2391, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29691166

RESUMO

BACKGROUND: We developed an orthopedic hospitalist fellowship program for our total joint replacement program at a large urban academic medical center. The goal of the program was to improve patient outcomes, quality, and healthcare value through collaborative perioperative care and improved care coordination. This study evaluates the implementation and impact of our modified Hospitalist-Orthopaedic Team Co-management model on quality and performance metrics. METHODS: We reviewed our Quality Institute data using 3 databases for the 16 months before (PreOH) and 18 months after (PostOH) implementation. Procedural volume was identical during period 1 (1100 cases) vs period 2 (1119 cases). Metrics included mean LOS (length of stay), % patients discharged home, mean observed and expected LOS and LOS index, LOS variance, % ICU (intensive care unit) admissions, mean ICU days, % cases with complications, % mortality, 30-day readmission rate, and Hospital Consumer Assessment of Healthcare Providers and Systems scores. Statistical analysis was performed using the software imbedded in the database software. RESULTS: Statistically significant improvements occurred in multiple performance and quality metrics including mean hospital LOS for total knee replacement, percentage of total knee replacement patients discharged home, and percentage of patients discharged home for primary total hip arthroplasty, complication rate, and 30-day readmission rate. Reductions in % ICU admission and ICU LOS were seen but not statistically significant. HCAPHS scores improved in 6 of 8 categories, and was statistically significant in 3 of 8. CONCLUSION: The results of this study demonstrate that the modified Hospitalist-Orthopaedic Team Co-management model described above improves quality, cost effectiveness, and value for elective total joint replacement patients in comparison to the traditional consultation only model.


Assuntos
Artroplastia de Quadril/normas , Artroplastia do Joelho/normas , Médicos Hospitalares/estatística & dados numéricos , Ortopedia/normas , Assistência Perioperatória/normas , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/estatística & dados numéricos , Artroplastia do Joelho/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos , Feminino , Hospitais , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Ortopedia/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente , Assistência Perioperatória/estatística & dados numéricos , Fatores de Tempo
13.
Scand J Trauma Resusc Emerg Med ; 26(1): 26, 2018 Apr 05.
Artigo em Inglês | MEDLINE | ID: mdl-29622029

RESUMO

BACKGROUND: Hospital at home (HaH) is an alternative to acute admission for elderly patients. It is unclear if should be cared for a primarily by a hospital intern specialist or by the patient's own general practitioner (GP). The study assessed whether a GP based model was more effective than a hospital specialist based model at reducing number of hospital admissions without affecting the patient's recovery or number of deaths. METHODS: Pragmatic, randomised, open-labelled multicentre parallel group trial with two arms in four municipalities, four emergency departments and 150 GPs in Southern Denmark, including + 65 years old patients with an acute medical condition that required acute hospital in-patient care. The patients were randomly assigned to hospital specialist based model or GP model of HaH care. Five physical and cognitive performance tests were performed at inclusion and after 7 days. Primary outcome was number of hospital admissions within 7 days. Secondary outcomes were number of admissions within 14, 21 and 30 days, deaths within 30 and 90 days and changes in performance tests. RESULTS: Sixty seven patients were enrolled in the GP model and 64 in the hospital specialist model. 45% in the hospital specialist arm versus 24% in the GP arm were admitted within 7 days (effect size 2.7, 95% CI 1.3-5.8; p = 0.01) and this remained significant within 30 days. No differences were found in death or changes in performance tests from day 0-7 days between the two groups. CONCLUSIONS: The GP based HaH model was more effective than the hospital specialist model in avoiding hospital admissions within 7 days among elderly patients with an acute medical condition with no differences in mental or physical recovery rates or deaths between the two models. REGISTRATION: No. NCT02422849 Registered 27 March 2015. Retrospectively registered.


Assuntos
Clínicos Gerais/estatística & dados numéricos , Médicos Hospitalares/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Dinamarca/epidemiologia , Feminino , Idoso Fragilizado , Humanos , Masculino , Modelos Organizacionais
14.
Am J Manag Care ; 24(3): 152-156, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29553278

RESUMO

OBJECTIVES: To describe the characteristics and outcomes of patients discharged from the emergency department (ED) by hospitalist physicians. STUDY DESIGN: Retrospective cohort study at a tertiary academic medical center. METHODS: We used consultation Current Procedural Technology codes to identify patients discharged from the ED after referral for hospitalist admission from April 2011 to April 2014. We report patient demographics and primary diagnoses. Main outcome measures included return to the ED, hospitalization, or mortality, all within 30 days. RESULTS: There were 710 discharges from the ED for 670 patients referred for hospitalist admission; 21.7% returned to the ED, 12.3% were hospitalized, and 0.4% died within 30 days. Chest pain was the most common diagnosis (38.2%); 18.1% of these patients returned to the ED within 30 days. Patients with the following 3 diagnoses returned to the ED most frequently: sickle cell disease (82.4%), alcohol-related diagnoses (43.5%), and abdominal pain (35.7%). In multivariate analysis, abdominal pain (odds ratio [OR], 3.2; P <.001) and alcohol dependence (OR, 3.1; P = .003) increased the odds of ED revisits, whereas syncope (OR, 0.23; P = .049) reduced the odds. Chest pain reduced the odds of hospitalization (OR, 0.37; P = .005). CONCLUSIONS: A majority of patients discharged from the ED after referral for hospitalist admission did not return to the ED within 30 days, and the 30-day hospitalization rate was low. Our data suggest that hospitalists can safely aid patients by reducing the costs and adverse outcomes associated with unnecessary hospitalization.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Médicos Hospitalares/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Centros Médicos Acadêmicos , Adulto , Feminino , Hospitais com mais de 500 Leitos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores Socioeconômicos
16.
JAMA Netw Open ; 1(8): e185658, 2018 12 07.
Artigo em Inglês | MEDLINE | ID: mdl-30646280

RESUMO

Importance: Pediatric hospital medicine is a relatively new and growing specialty. However, research remains inconclusive on outcomes for inpatients cared for by pediatric hospitalists compared with those cared for by general pediatricians. Objective: To analyze outcomes, adverse events (AEs), and types of AEs associated with care provided for pediatric patients by hospitalists vs general pediatricians. Design, Setting, and Participants: This cross-sectional study used data from the medical records of a US urban academic children's hospital comprising 1423 hospitalizations between January 1, 2009, and August 31, 2015, for 57 diagnoses of patients cared for by either a hospitalist or general pediatrician. General pediatricians worked primarily in the hospital's outpatient clinic, serving a few inpatient weeks per year, and were not the patients' primary care physician. Data analysis was performed from July 1, 2017, to October 10, 2018. Main Outcomes and Measures: Outcomes were length of stay, total costs, 30-day readmission rates, and AEs. Adverse events were documented by International Classification of Diseases, Ninth Revision, Clinical Modification codes determined by review of medical records. Adverse event categories were drug events, infections, and device-related AEs. Generalized linear models were used to analyze patient outcomes, with standard errors clustered by physician. Models were adjusted for patient characteristics, including Chronic Condition Indicators. Models were estimated with and without adjustment for physician characteristics. Results: The data set contained 1423 hospitalizations among 726 female patients and 697 male patients (mean [SD] age, 6.1 [6.3] years). Hospitalists cared for 870 patients, and general pediatricians cared for 553 patients. Among the physicians, there were 57 women and 38 men; physicians were a mean (SD) 11.1 (8.1) years out of medical school. Patients cared for by general pediatricians were younger than those cared for by hospitalists (mean [SD] age, 5.4 [6.0] vs 6.5 [6.4] years; P = .001) but had similar mean (SD) Chronic Condition Indicator scores (1.5 [1.0] vs 1.5 [1.0]). A total of 33 of 56 general pediatricians (58.9%) and 24 of 39 hospitalists (61.5%) were women (P = .006), and general pediatricians were in practice twice as long as hospitalists on average (mean [SD], 16.0 [10.3] vs 7.9 [3.8] years out of medical school; P < .001). In multivariate models adjusting for patient-level features, there were no significant differences between general pediatricians and hospitalists for mean length of stay (4.7 vs 4.6 days), total costs ($14 490 vs $15 200), and estimated 30-day readmission rate (8.9% vs 6.4%), and results were similar with adjustments for physician characteristics. Device-related AEs were higher among hospitalists (3.0% vs 1.1%; odds ratio, 0.34; 95% CI, 0.12-1.00); this association became nonsignificant after adjusting for physician experience. Conclusions and Relevance: General pediatrician and hospitalist inpatient care had similar length of stay, total costs, and readmission rates. However, AEs differed between hospitalists and general pediatricians, with device-related AEs more common among hospitalists, which may be associated with hospitalists' fewer years in practice. Such findings can inform hospitals in planning their inpatient staffing and patient safety oversight.


Assuntos
Infecção Hospitalar/epidemiologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Médicos Hospitalares/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Pediatras/estatística & dados numéricos , Criança , Pré-Escolar , Estudos Transversais , Assistência à Saúde/estatística & dados numéricos , Equipamentos e Provisões/efeitos adversos , Equipamentos e Provisões/estatística & dados numéricos , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Qualidade da Assistência à Saúde , Centros de Atenção Terciária/estatística & dados numéricos , Resultado do Tratamento
17.
JAMA Netw Open ; 1(3): e180876, 2018 07 06.
Artigo em Inglês | MEDLINE | ID: mdl-30646042

RESUMO

Importance: The share of the population covered by accountable care organizations (ACOs) is growing, but the association between this increase and physician employment is unknown. Objective: To investigate the association between the growth of ACOs and changes in physician work hours, probability of being self-employed, and probability of working in a hospital. Design, Setting, and Participants: A fixed-effects design was used in this cross-sectional study to compare changes in physician employment in hospital referral regions with high vs low ACO growth. A nationally representative 1% sample of all working US physicians obtained annually from 2011 through 2015 from the American Community Survey (N = 49 582) was included. Data analysis was conducted from March 28, 2017, to April 10, 2018. Main Outcomes and Measures: Physician hours worked per week, probability of being self-employed, and probability of working in a hospital. Results: Of the 49 582 physicians included in the study, 63.5% were men; the mean (SD) age of sampled physicians was 46.01 (11.59) years. In 2011, sampled physicians worked a mean (SD) of 52.2 (16.1) hours per week, 24.43% were self-employed, and 42.03% worked in a hospital. A 10-percentage point increase in ACO enrollment in a hospital referral region was associated with a statistically significant reduction of 0.82 (95% CI, -1.52 to -0.13; P = .02) work hours in men and a decrease of 2% (95% CI, -3.8% to -0.1%; P = .04) in the probability of all physicians being self-employed. The association with self-employment was strongest (-5.0%; 95% CI, -8.7% to -1.4%; P = .006) in physicians aged 50 to 69 years, who were also more likely (4.0%; 95% CI, 1.0% to 6.9%; P = .009) to work in a hospital. Conclusions and Relevance: The growth of ACOs within hospital referral regions appears to be associated with a reduction in hours of work and self-employment among physicians. These results suggest that ACOs may affect physician employment patterns.


Assuntos
Organizações de Assistência Responsáveis/estatística & dados numéricos , Emprego/estatística & dados numéricos , Médicos Hospitalares/estatística & dados numéricos , Médicos/estatística & dados numéricos , Adulto , Idoso , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Estados Unidos
18.
J Hosp Med ; 13(7): 470-475, 2018 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-29261820

RESUMO

BACKGROUND: Individual provider performance drives group metrics, and increasingly, individual providers are held accountable for these metrics. However, appropriate attribution can be challenging, particularly when multiple providers care for a single patient. OBJECTIVE: We sought to develop and operationalize individual provider scorecards that fairly attribute patient-level metrics, such as length of stay and patient satisfaction, to individual hospitalists involved in each patient's care. DESIGN: Using patients cared for by hospitalists from July 2010 through June 2014, we linked billing data across each hospitalization to assign "ownership" of patient care based on the type, timing, and number of charges associated with each hospitalization (referred to as "provider day weighted "). These metrics were presented to providers via a dashboard that was updated quarterly with their performance (relative to their peers). For the purposes of this article, we compared the method we used to the traditional method of attribution, in which an entire hospitalization is attributed to 1 provider, based on the attending of record as labeled in the administrative data. RESULTS: Provider performance in the 2 methods was concordant 56% to 75% of the time for top half versus bottom half performance (which would be expected to occur by chance 50% of the time). While provider percentile differences between the 2 methods were modest for most providers, there were some providers for whom the methods yielded dramatically different results for 1 or more metrics. CONCLUSION: We found potentially meaningful discrepancies in how well providers scored (relative to their peers) based on the method used for attribution. We demonstrate that it is possible to generate meaningful provider-level metrics from administrative data by using billing data even when multiple providers care for 1 patient over the course of a hospitalization.


Assuntos
Médicos Hospitalares/estatística & dados numéricos , Pacientes Internados/estatística & dados numéricos , Assistência ao Paciente/estatística & dados numéricos , Hospitalização , Humanos , Satisfação do Paciente
19.
J Hosp Med ; 13(1): 6-12, 2018 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-29240847

RESUMO

BACKGROUND: Intensivist shortages have led to increasing hospitalist involvement in critical care delivery. OBJECTIVE: To characterize the practice of hospitalists practicing in the intensive care unit (ICU) setting. DESIGN: Survey of hospital medicine physicians. SETTING: This survey was conducted as a needs assessment for the ongoing efforts of the Critical Care Task Force of the Society of Hospital Medicine Education Committee. PARTICIPANTS: Hospitalists in the United States. INTERVENTION: An iteratively developed, 25-item, webbased survey. MEASUREMENTS: Results were compiled from all respondents then analyzed in subgroups. Various items were examined for correlations. RESULTS: A total of 425 hospitalists completed the survey. Three hundred and twenty-five (77%) provided critical care services, and 280 (66%) served as primary physicians in the ICU. Hospitalists were significantly more likely to serve as primary physicians in rural ICUs (85% of rural respondents vs 62% of nonrural; P < .001 for association). Half of the rural hospitalists who were primary physicians for ICU patients felt obliged to practice beyond their scope, and 90% at least occasionally perceived that they had insufficient support from board-certified intensivists. Among respondents serving as primary physicians for ICU patients, 67% reported at least moderate difficulty transferring patients to higher levels of ICU care. Difficulty transferring patients was the only item significantly correlated with the perception of being expected to practice beyond one's scope (P < .05 for association). CONCLUSIONS: Hospitalists frequently deliver critical care services without adequate training or support, most prevalently in rural hospitals. Without major changes in intensivist staffi ng or patient distribution, this is unlikely to change.


Assuntos
Cuidados Críticos/métodos , Médicos Hospitalares/psicologia , Médicos Hospitalares/estatística & dados numéricos , Unidades de Terapia Intensiva , Determinação de Necessidades de Cuidados de Saúde , Humanos , Internet , Qualidade da Assistência à Saúde , Serviços de Saúde Rural , Inquéritos e Questionários , Estados Unidos
20.
Acad Pediatr ; 18(2): 200-207, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-28502710

RESUMO

OBJECTIVE: In October 2016, the American Board of Medical Specialties approved the petition for pediatric hospital medicine (PHM) to become the newest pediatric subspecialty. Knowledge about residents entering the PHM workforce is needed to inform certification and fellowship accreditation. This study describes the characteristics of graduating pediatric residents with PHM positions and identifies factors associated with postresidency position choices. METHODS: We analyzed data from the American Academy of Pediatrics Annual Survey of Graduating Residents, 2006-2015. Chi-square tests were used to compare responses between residents entering PHM to those entering subspecialty fellowships, and to compare residents entering PHM at community and tertiary-care hospitals. We used multivariable logistic regression to identify associations between resident and training characteristics and position choices. RESULTS: A total of 5969 respondents completed the survey (60.6% response rate); 593 (10.3%) reported that they were entering PHM and 1954 (33.9%) reported subspecialty fellowships. Of residents entering PHM, 345 (60.7%) reported positions at tertiary-care hospitals and 194 (34.2%) reported positions at community hospitals. Seventy percent of residents entering PHM envisioned long-term PHM careers, with PHM career goals more frequently reported among residents entering community hospitalist positions (P < .01). In multivariable analysis, residents entering PHM were significantly more likely to be female, to have children, to report that family factors limited their job selection, and to have higher levels of educational debt than residents entering fellowships. CONCLUSIONS: Factors associated with postresidency PHM positions, including substantial educational debt and sociodemographic characteristics, may influence the development of the field as the specialty pursues fellowship accreditation.


Assuntos
Escolha da Profissão , Bolsas de Estudo , Médicos Hospitalares/educação , Pediatria/educação , Adulto , Emprego , Feminino , Mão de Obra em Saúde , Médicos Hospitalares/estatística & dados numéricos , Hospitais Comunitários/estatística & dados numéricos , Humanos , Renda , Modelos Logísticos , Masculino , Análise Multivariada , Pediatria/estatística & dados numéricos , Admissão e Escalonamento de Pessoal , Área de Atuação Profissional , Pesquisa , Fatores Sexuais , Inquéritos e Questionários , Ensino , Centros de Atenção Terciária/estatística & dados numéricos , Apoio ao Desenvolvimento de Recursos Humanos/estatística & dados numéricos
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