In the course of my work with hospitalist practices around the country, I end up speaking with a lot of primary-care physicians (PCPs) who refer patients to hospitalists. I nearly always hear the same three frustrations or complaints from them:
- “I’m not reliably notified when my patient is admitted or discharged.”
- “The hospitalists too often make unnecessary or unhelpful changes in patients’ chronic medicines, because they either never get an accurate home medicine list to begin with, or too liberally adjust chronic therapy that should be left to me.”
- “I wish the hospitalists were more open to directly admitting some patients from my office, to save the patient the stress and expenses of an unnecessary stop in the ED.”
I’ve listed them in ascending order of what I think is difficulty to fix. The first of these can be difficult but not impossible to fix, while the last one—direct admissions—is really tricky to “fix” to the satisfaction of both hospitalists and most PCPs.
Direct Admissions and HM Reluctance
When explaining why they resist direct admissions, most hospitalists raise concerns that I too share. They typically begin with an anecdote, often from years ago, of a patient the PCP described as stable, but was in extremis when arriving to the floor bed and required emergent transfer to the ICU. In fact, I suspect this has happened at least once or twice to nearly every hospitalist. Much to the frustration of PCPs, hospital leaders, and some patients, this concern has led a number of HM groups to adopt a policy of never accepting direct admissions. They insist that all patients are seen first in the ED, which typically means that the ED physician, rather than the hospitalist, is the first doctor the patient encounters at the hospital.
Other reasons cited for reluctance or refusal to accept direct admissions include the longer time required to get test results like blood work or chest X-rays when ordered from the floor versus the ED. And because the patient’s precise time of arrival can’t be known, it is tricky for some groups to determine in advance which hospitalist will be seeing the patient, resulting in a complicated handoff.
Some PCPs, especially those who have practiced for decades, might be remembering the rationale and process for admitting patients years ago and inappropriately request direct admission for a patient who might not even need the hospital. But while it seems clear this happens occasionally, hospitalists could have a bias, leading them to feel like it is a much more common problem than it really is.
All of these are legitimate concerns, though in most settings I don’t think they justify setting a firm rule of “no direct admissions.”
Dearth of Meaningful Data to Guide Policy
There are seemingly an endless number of studies about things like the effects of resident work-hours and the value of handoff communication, so the literature must be full of studies about direct admissions. Surely some of the risks are offset by improvements in safety and fewer handoffs (by eliminating the ED doctor). But sadly, there aren’t any studies to go on. I couldn’t find a single one. (If you know of one or more studies that directly examine direct admissions from PCP offices, please let me know.)
The Agency for Healthcare Research and Quality (AHRQ) has a 2008 case study titled “Is It Safe to Be Direct?” (www.webmm.ahrq.gov/case.aspx?caseID=178) that describes and comments on a direct-admit case that didn’t go well, but it is an opinion piece without empiric data.1