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• Filed under: Columns, Quality, From the Editor’s Desk

• Keywords: quality of care, patient outcomes, teaching tools, training, CME continuing medical education

Promise or Insanity?

From: The Hospitalist, June 2008

by Jeff Glasheen, MD

Insanity is doing the same thing over and over again and expecting different results.—Albert Einstein

A hospitalist is defined as a provider whose primary professional focus is the general medical care of hospitalized patients.1

While this allows a concise, usable characterization of a hospitalist, it’s not the whole story. If it were, medical residents, nurses, and inpatient pharmacists all would be hospitalists.

Indeed, a traditional internist with a large hospital practice could reasonably deem him or herself a hospitalist. What defines what a hospitalist does, or should be doing—and how, if at all, is that different than what a traditional internist does in the hospital?

Education Deficiencies

Early data suggested a stark difference between outcomes attributed to hospitalists and general internists who rotated between the clinic and the hospital.

An early experience from the academic environment showed a hospitalist teaching model, when compared with a traditional teaching service, resulted in a 0.6-day length-of-stay (LOS) reduction and a cost savings of $700 per patient with no decrement in the quality of care, clinical outcomes, or satisfaction of provider, housestaff, or patient.2

Similar findings were revealed when community teaching and non-teaching hospitals transitioned to the hospitalist model.3-5 A 2002 review of 19 hospitalist studies revealed an average decreased LOS of 17% coupled with a 1% reduction in hospital costs per case.6

The year 2002 also saw, for the first time, published data that the hospitalist model could reduce in-hospital and 30-day mortality rates.7,8 Together with a 2004 paper showing reductions in minor post-operative complications with hospitalist comanagement of orthopedic patients, these studies suggested hospitalists’ care transcended mere cost savings, improving quality measures as well.9

As one of Albert Einstein’s most famous maxims warns, hospitalists on a mission to improve quality of care will be poorly served by repeating training patterns of dubious value.

More recently, however, Lindenauer, et al., found important but less robust differences between hospitalists and non-hospitalists.10 As compared with traditional internists, hospitalists reduced LOS 0.4 days and cost per patient by $268.

While these moderate reductions in LOS and cost versus traditional internists are statistically and clinically significant, they are less vigorous than previous findings. Despite some methodological concerns, this largest investigation—in terms of hospital sites (45), patients (76,926) and hospitalists (284)—revealed no demonstrable improvements in the quality outcomes measured.

Similarly, another recent publication found consultation, provided by medical subspecialists or hospitalists, did not improve glycemic control, rate of appropriate venous thromboembolism (VTE) prophylaxis or perioperative beta-blocker use compared with patients cared for by surgeons alone.11,12

While it is tempting to think hospitalists have re-engineered the systems of care to the point that any provider can fluently and adroitly care for patients, continued reports of less-than-optimal hospital outcomes do not support this hypothesis. More likely, the variance in the early and recent studies relates to the egress from the hospital of less capable or engaged non-hospitalist providers such that more recent findings reflect a comparator group that more closely approximates, in terms of clinical volume, hospitalists.

It’s time to reconsider how we document the merit of hospitalists. Continuing to benchmark hospitalists against non-hospitalists will not tell us if inpatient care is becoming safer, only how one group is doing compared with another. Nor will it necessarily lead to improvements in the quality of care.

To fulfill the promise of the hospitalist model, we need to ensure hospitalists are doing it better, not just better than an external comparator group. As such, it would be more valuable to evaluate hospitalists today versus those five years ago. If, as I suspect, there would be little difference in the clinical outcomes between a new hospitalist (or one in practice for three years) in 2003 and one in 2008 and we accept that hospitalist care has yet to achieve its pinnacle then we must adopt a new path. This will require redesigning the way we train hospitalists.

The ineffectiveness of our current training system is playing out in Dr. Lindenauer’s New England Journal of Medicine paper last year. He found hospitalist outcomes are only marginally better than their similarly trained traditional internist colleagues. To expect differences is to succumb to Albert Einstein’s definition of insanity. We simply cannot expect hospitalists to improve the quality of care with the same set of tools that didn’t allow our predecessors to do so.

Hospitalist-Focused Curricula

Several studies have evaluated the gap between internal medicine (IM) training and hospital medicine practice. A 2007 paper reported that nearly 30% of a community hospitalist practice consisted of areas of under emphasis in traditional IM training.13

These include consultative medicine (6.4% of practice) and the care of the patients with neurological (13.4%), orthopedic (6.4%), or general surgical (2.2%) issues. Additionally, nearly 50% of their practice consisted of patients older than 65, with the largest subset of patients ages 75-84.

Yet, most IM residency training programs do not adequately train housestaff to care for these types of patients and problems. Plauth, et al., documented areas of educational deficiencies by surveying several hundred IM-trained hospitalists about their preparedness to practice hospital medicine following residency training.14

The respondents reported feeling unprepared to care for the type and amount of neurology, geriatrics, palliative care and consultative and perioperative medicine they encountered.

Additionally, they were ill-equipped for the myriad quality improvement and systems and transitions-of-care issues they faced daily.

The “2005-2006 SHM Survey: State of the Hospital Medicine Movement” further highlighted the level of hospitalist non-clinical work, showing that 86% of hospitalist groups engage in quality improvement, 72% contribute practice guidelines, 54% work in utilization review, and 54% are involved in developing electronic medical records and provider order entry.15

For the hospitalist model to deliver outcomes superior to our traditional care model, we will need to create training programs that provide hospitalists with the skills current IM graduates do not possess.

Training programs must evolve to include the necessary clinical and non-clinical aspects of this new medical specialty. Hospitalists have populated the American healthcare landscape for more than a decade, yet very few training programs support innovation in the field of hospital medicine.

It is past time for IM educators, many of whom are hospitalists, to bridge this educational chasm through curricular reform. Short of this, the hospital medicine movement will achieve its pinnacle well short of its promise. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. Society of Hospital Medicine. General information about SHM. Available at: www.hospitalmedicine.org/Content/NavigationMenu/AboutSHM/GeneralInformation/General_Information.htm. Accessed April 25, 2008.
2. Wachter RB, Katz P, Showstack J, Bindman AB, Goldman L. Reorganizing an academic medical service. JAMA. 1998;279:1560-1565.
3. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1998;129:197-203.
4. Freese RB. The Park Nicollet experience in establishing a hospitalist system. Ann Intern Med. 1999;130:350-354.
5. Craig DE, Hartka L, Likosky WH, Caplan WM, Litsky P, Smithey J. Implementation of a hospitalist system in a large health maintenance organization: The Kaiser Permanente experience. Ann Intern Med. 1999;130:355-359.
6. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
7. Meltzer D, Manning W, Morrison J, et al. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
8. Auerbach AD, Wachter RM, Katz P, et al. Implementation of a voluntary hospitalist service at a community teaching hospital: Improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-865.
9. Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee arthroplasty. Ann Intern Med. 2004;141:28-38.
10. Lindenauer PK, Rothber MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AD. Outcomes of care by hospitalist, general internists, and family physicians. N Engl J Med. 2007;357:2589-600.
11. Dr Andrew Auerbach, personal communication, January 7, 2008.
12. Auerbach AD, Rasic MA, Sehgal N, Ide B, Stone B, Maselli J. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med. 2007;167:2338-2344.
13. Glasheen JJ, Epstein KR, Siegal E, Kutner J, Prochazka AV. The spectrum of community-based hospitalist practice, a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7):727-728.
14. Plauth WH, Pantilat SZ, Wachter RM et al. Hospitalist’s perceptions of their residency training needs: Results of a national survey. Am J Med. 2001;111:247-254.
15. Society of Hospital Medicine. 2005-2006 SHM Survey: State of the Hospital Medicine Movement. Available at: http://dev.hospitalmedicine.org/AM/Template.cfm?Section=Survey&Template=/CM/ContentDisplay.cfm&ContentID=14352. Accessed April 28, 2008.