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Exceed Acceptable


 

Armed with a cup of coffee, with my dogs walked and fed and the sun rising into view, I eased into my home office chair and contentedly folded open the pages of The Wall Street Journal.

My ritual early-morning glance at the local and national papers usually provides little more than a glum outlook for my favorite sports teams, a glummer view of my financial investments, and a few seeds to cultivate into elevator small talk.

This morning, however, I was struck by this headline: “‘Hospitalists’ Are Seen as Help.”1 I happily noted the subheading, which referred to us as “specialists.” I reveled in the general tone of the article, which indicated that we reduce hospital length of stay and costs.

The article reported the findings of a New England Journal of Medicine paper by Lindenauer, et al., that showed a 0.4-day reduction in length of stay (LOS) and a net savings of $268 per patient compared with non-hospitalist general internist providers.2 Good news for the field, indeed.

The promise of the hospital medicine movement is that hospitalists will do it better: cheaper, faster, and safer. If we accept this, then these new data appear to paint a picture of a movement that is chugging off course. I don’t think it’s that simple. Rather, this speaks to two key elements in the maturation process of the hospitalist field.

Or was it? What was not highlighted in The Wall Street Journal was that while hospitalists also reduced LOS 0.4 days versus non-hospitalist family physicians, there was no statistically significant reduction in cost versus this cohort. Further, there was no difference in hospital mortality or 14-day readmission rate versus either non-hospitalist set of providers.

While not the greatest markers of quality, mortality and readmission rate are two of the easiest and most recognized markers of effective care. Dr. Lindenauer’s paper found no benefit from the hospitalist model.

Granted, other studies have shown a benefit of the hospitalist model in areas such as co-management of orthopedic patients. But these effects were modest and primarily limited to process measures, not quality-of-care outcomes.

Another recent paper by Auerbach, et al., reported that general medical consultation by hospitalists on surgical patients did not result in better glycemic control, use of perioperative beta blockade, or venous thromboembolism prophylaxis versus surgical care alone.­

In a healthcare system that the Institute of Medicine claims is responsible for unfathomable rates of medication errors and upward of 100,000 avoidable inpatient deaths every year, it sounds as though hospitalists are missing the chance to fulfill their promise.

The promise of the hospital medicine movement is that hospitalists will do it better: cheaper, faster, and safer. If we accept this, then these new data appear to paint a picture of a movement that is chugging off course.

I don’t think it’s that simple. Rather, this speaks to two key elements in the maturation process of the hospitalist field.

First, changing the fundamentals of healthcare delivery is difficult work. This is especially true for a young group of providers, who struggle with overwhelming growth, constant understaffing, and a business model that favors patient encounters over process improvement.

On top of this, we are asked to change behavior in a complex system where instituting change often involves altering the practice of others outside your group, such as nurses or other physician groups.

Add to this significant undertraining in patient safety and process improvement, and a lack of time for quality improvement work or rewards to encourage it.

It’s little wonder we haven’t moved the quality needle much. Viewed through this lens, the fact that we have accomplished even modest improvements is impressive.

Second, we need to do a better job of measuring our benefit. Mortality and readmission are important outcomes, and we should always aim to improve these quality indicators. However, they’re both downstream markers that are easy to measure but difficult to budge.

We must acknowledge, however, that we haven’t done a good job of measuring our effect on the value-added aspects of hospital medicine: nursing happiness, hospital leadership, team work, staff education, patient satisfaction, protocol development, and our willingness to take on work others are not keen to do, such as unassigned emergency department call.

How do we put a price on the value of being available for a patient in extremis, a nurse with a question, a committee chairpersonship? How do we measure the downstream benefit of offloading our surgical and medical subspecialty colleagues so they can perform more procedures while we care for their recently proceduralized patients?

This is difficult material to measure, especially in a scientific manner. In this regard, it is incumbent on local leaders to ensure these data are collected and available for presentation to those who subsidize our practices.

Short of this, groups are exposed to a serious threat from a hospital chief financial officer armed with a directive to cut costs and the Dec. 20 edition of The Wall Street Journal.

Hospital medicine is a work in progress. We need to do a better job of measuring our value-added benefits. However, we should strive to exceed what is acceptable. While it is reasonable to accept little documented improvement in quality indicators today, it should not be acceptable in the near future.

The field will need to move toward improving, documenting, and rewarding improvements in clinical outcomes. This means elemental change toward developing practice standards and models of care for common disease states, standardizing care throughout the hospital and actively engaging in improving quality at every turn.

Hospitalists will need to agree to be measured, participate in measurement, and be held accountable for achieving quality benchmarks.

This transformation necessitates that hospitalist educators (both residency and post-residency) better prepare hospitalists to lead change in areas of quality improvement.

These educators must impart the basic tenets of change management, process improvement, and patient safety.

These changes will take provider time—time that will need to be supported by hospitals and group leaders in the form of accepting less revenue per provider, which will in turn require inspired leadership to negotiate this time and build a new sustainable business model centered around quality.

As the field matures it is becoming clearer that our business can no longer be predicated on cost savings and efficiency alone.

While we need to be ever mindful of these metrics, we need to evolve beyond this model to one with quality at its core.

We should expect and reward superior patient outcomes at the expense of quantity. Anything short of this squanders one of the purest opportunities to positively affect the U.S. healthcare system for generations to come. TH

Dr. Glasheen is associate professor of medicine at the University of Colorado 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. Levitz J. Hospitalists are seen as help. The Wall Street Journal. Dec. 20, 2007:D7.
  2. Lindenauer PK, Rothberg MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AD et al. Outcomes of care by hospitalists, general internists, and family physicians. N Engl J Med. 2007 Dec 20; 357(25):2589-2600.
  3. Auerbach AD, Rasic MA, Sehgal N, Ide B, Stone B, Maselli Jet al. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med. 2007 Nov. 26;167(21): 2338-2344.

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