Use Of Hospitalists Research Articles

Hospitalist programs in academic medical centers

The use of hospitalists in the care of in‐patients is a relatively new phenomenon in the USA – hospitalists are delivering medical care to patients in private practice, public hospitals, and academic medical centers. Several obstacles hinder understanding of the characteristics of academic medical center‐based hospitalists. These include differences in definitions and nomenclature, differences in job descriptions, roles and administration across hospitalist programs, and in qualifications and credentialing of hospitalists versus other physicians. These differences derive from the heterogeneity of AMCs by bed size, level of local and regional competition, and cultural, utilization and referral patterns. The field needs an agreed definition of the term “hospitalist”. Assuming a good definition, one could take advantage of already good descriptive data on AMCs to quantify hospitalists within AMCs and to study how hospitalist programs vary by AMC characteristics.

Pediatric hospitalists fill varied roles in the care of newborns.

The use of hospitalists in the care of newborns appears to be increasing and may be advantageous for several reasons, including decreased cost, decreased length of stay, increased patient survival, increased availability, and greater experience among hospitalists. Research specific to the use of hospitalists in newborn medicine needs to be done to support this hypothesis. Non-clinical activities such as teaching, developing clinical guidelines, and taking an active role in hospital and academic leadership also may improve education and patient care. It is essential that hospitalists who provide care in nurseries work to smooth the transition to a PCP and not act as a barrier. Relatively speaking, the care provided by hospitalists is most often short-term, and the relationship between infants and their parents with the PCP should begin as soon as possible.

The hospitalist movement 5 years later.

We originally described the hospitalist model of inpatient care in 1996; since then, the model has experienced tremendous growth. This growth has important clinical, financial, educational, and policy implications. To review data regarding the effect of hospitalists on resource use, quality of care, satisfaction, and teaching; and to analyze the impact of hospitalists on the health care system and frame key issues facing the movement. We searched MEDLINE, BIOSIS, EMBASE, and the Cochrane Library from 1996 to September 2001 for studies comparing hospitalist care with an appropriate control group in terms of resource use, quality, or satisfaction outcomes. We extracted information regarding study design, nature of hospitalist and control groups, analytical strategies, and key outcomes. Most studies found that implementation of hospitalist programs was associated with significant reductions in resource use, usually measured as hospital costs (average decrease, 13.4%) or average length of stay (average decrease, 16.6%). The few studies that failed to demonstrate reductions usually used atypical control groups. Although several studies found improved outcomes, such as inpatient mortality and readmission rates, these results were inconsistent. Patient satisfaction was generally preserved, while limited data supported positive effects on teaching. Although concerns about inpatient-outpatient information transfer remain, recent physician surveys indicate general acceptance of the model. Empirical research supports the premise that hospitalists improve inpatient efficiency without harmful effects on quality or patient satisfaction. Education may be improved. In part catalyzed by these data, the clinical use of hospitalists is growing rapidly, and hospitalists are also assuming prominent roles as teachers, researchers, and quality leaders. The hospitalist field has now achieved many of the attributes of traditional medical specialties and seems destined to continue to grow.

Friend or foe? How primary care physicians perceive hospitalists.

Increased use of hospitalists is redefining the role of primary care physicians. Whether primary care physicians welcome this transition is unknown. We examined primary care physicians' perceptions of how hospitalists affect their practices, their patient relationships, and overall patient care. A mailed survey of randomly selected general internists, general pediatricians, and family practitioners with experience with hospitalists practicing in California. Physicians' self-reports of hospitalists' effects on quality of patient care and on their own practices. Seven hundred eight physicians were eligible for this study, and there was a 74% response rate. Of the 524 physicians who responded, 34% were internists, 38% were family practitioners, and 29% were pediatricians. Of the 524 respondents, 335 (64%) had hospitalists available to them and 120 (23%) were required to use hospitalists for all admissions. Physicians perceived hospitalists as increasing (41%) or not changing (44%) the overall quality of care and perceived their practice style differences as neutral or beneficial. Twenty-eight percent of primary care physicians believed that the quality of the physician-patient relationship decreased; 69% reported that hospitalists did not affect their income; 53% believed that hospitalists decreased their workload; and 50% believed that hospitalists increased practice satisfaction. In a multivariate model predicting physician perceptions, internists, physicians who attributed loss of income to hospitalists, and physicians in mandatory hospitalist systems viewed hospitalists less favorably. Practicing primary care physicians have generally favorable perceptions of hospitalists' effect on patients and on their own practice satisfaction, especially in voluntary hospitalist systems that decrease the workload of primary care physicians and do not threaten their income. Primary care physicians, particularly internists, are less accepting of mandatory hospitalist systems. Arch Intern Med. 2000;160:2902-2908

The presence of hospitalists in medical education.

The presence of hospitalists in medical education.

The hospitalist model: perspectives of the patient, the Internist, and internal medicine.

The use of hospitalists has implications for patients, for internists, and for the specialty of internal medicine. For patients, the greatest concern is interrupting the continuity of a supportive relationship with their regular physican. For many internists, the hospitalist model is attractive, but they are concerned that health plans will compel physicians to transfer their patients to a hospitalist at the time of admission to the hospital (mandatory hand-off). Thus, the hospitalist could become the means to exclude internists from hospital care and deprive them of an important source of professional satisfaction. The specialty of internal medicine is very concerned about the mandatory hand-off because it threatens the internist's identity as the physician who can care for the sickest patients in any venue, making it harder for patients and health plans to distinguish the internist from family physicians and nurse practitioners. The hospitalist movement has much to offer internal medicine. To enjoy the benefits and avoid the harms associated with the hospitalist model, internal medicine must resist the imposition of the mandatory hand-off and use the hospitalist's focus on excellent inpatient care to improve the practice of medicine by all internists.

The hospitalist: new boon for internal medicine or retreat from primary care?

The growing reliance on hospitalists in the United States has implications for several areas of internal medicine, including patient care, administration, clinical practice, and medical education. This paper discusses some of the potential advantages and disadvantages of the use of hospitalists in each of these areas. The new hospitalist practice mode highlights long-standing tensions about the role and direction of internal medicine, tensions that affect generalist and specialty care in both outpatient and hospital settings. The career trajectory of hospitalists will depend on whether burnout is a problem and on whether hospitalists will be able to compete effectively with sub-specialists, such as cardiologists and physicians specializing in AIDS. Clearly, hospitalism meets a clinical need and expands opportunities for internists, but it is important that it not overreach, forfeiting primary care turf and distorting medical education. This new field warrants close monitoring because of its potential effects and because-unlike related fields, such as emergency medicine and intensive care--its birth was strongly influenced by system-wide financial considerations.

The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital.

Hospitalists are increasingly being used for inpatient care. To investigate whether the use of hospitalists is beneficial. Retrospective cohort study. Inpatient medical service of a 500-bed community teaching hospital. 1620 patients in the study group, seen during the hospitalist year; 1679 patients from the same outpatient practice as the study group, seen during the previous year (prehospitalist year); an unselected comparison group of 3413 patients seen during the prehospitalist year and 3223 patients seen during the hospitalist year; and a subset of the unselected comparison group, cared for by outpatient practices, who had a prehospitalist length of stay similar to that of the study group (743 patients in the prehospitalist year and 786 in the hospitalist year). Full-time faculty hospitalists cared for the study group, were in the hospital during normal working hours, and made decisions throughout the day. In the prehospitalist year and in the comparison groups, primary care physicians managed their own hospitalized patients. Length of stay; cost of care; costs of hematology and chemistry evaluation, pharmacy, and radiology; and readmissions were determined for the prehospitalist and hospitalist years. In the study group, median length of stay decreased from 6.01 to 5.01 days (P < 0.001). Median cost of care decreased from $4139 to $3552 (P < 0.001), and the 14-day readmission rate decreased from 9.9 to 4.64 readmissions per 100 admissions (P < 0.001). In the comparison groups, length of stay decreased but both cost of care and readmission rates increased. Hospitalists may improve the efficiency of inpatient care. Further study in various settings is needed to verify these findings.