The authors review Geographic Cohorting of Adult Inpatient Teams: A Scoping Review, recently published in the Journal of Hospital Medicine (doi:10.1002/ jhm.70096).
Geographic cohorting (GCh) refers to the assignment of patients and their clinician team to a specific hospital unit. This approach has been adopted broadly, with 64% of hospitalists reporting participation in geographic localization in a pre-pandemic survey.1 GCh adoption has been driven by a desire to improve communication and workflow efficiency through proximity and by enabling collaborative care teams.2 However, data on patient outcomes and workflow efficiency are mixed and limited by study methodology, while the heterogeneity of interventions further complicates the assessment of results.3
In their comprehensive review, Kashiwagi et al. examined published studies that deployed GCh interventions for adult patients to physician-based units prior to July 2024.4 Their goal was to identify specific aims, implementation strategies, methods, and measured outcomes of cohorting hospitalized patients and their clinician teams.
Of the 30 studies reviewed, 25 or 92.6% were set at academic medical centers. All were in the U.S., with the majority (26, or 96.3%) located in non-intensive-care units, and most included general medicine patients. Twenty-five of the studies included details of their clinician teams; 23 included attending physicians, 10 included advanced practice practitioners, and 18 studies included resident physicians. About half of the studies used pre-post analysis at a single center, while the rest had various other designs. The aims were wide-ranging, from a single specific outcome, e.g., the number of pages received, to broader high-level outcomes, e.g., patient experience.
The authors identified four key implementation styles: (1) standalone GCh; (2) accountable care units (ACU) which contained elements of structured interprofessional bedside rounds, established registered nurse-physician partners as unit leaders, and accountability of unit teams for their metrics; (3) GCh + multiple elements separate from ACU; and (4) enhanced ACU that included additional processes. The spread of implementation styles was relatively equal for the first three, while only two studies used the enhanced ACU intervention. Process measures were limited in that the majority reported post-intervention measurement of GCh, a quarter reported target goals for the percentage of patients cohorted, and only three studies measured the fidelity of implementation of GCh or the uptake of ACU elements.
Outcome measures were sorted into eight categories: healthcare utilization (patient clinical outcomes such as length of stay and readmissions), patient safety (falls, hospital acquired infections, mortality), patient experience (patient satisfaction scores), workflow (efficiency metrics such as rounding times, time of discharge), workload (relative value units), clinical experience (participant opinions), communication or teamwork, and cost. Outcomes differed by implementation strategies, such that 67% of stand-alone GCh interventions measured workflow outcomes, while 67% of ACU interventions measured patient safety, and 60% of bundled non-ACU interventions measured healthcare utilization. Cost was the least reported, and unintended consequences, such as longer length of stay and increased interruptions, were described by just a few studies.
Why it Matters for Hospitalists
While geographic localization is not a new strategy for hospitalist practices to potentially enhance workflow efficiency, clinician satisfaction, and even patient outcomes, the heterogeneity in aims, implementation strategies, and outcome measures makes the data difficult to interpret. The varied needs and makeup of hospitalist practices also challenge the reproducibility of prior studies. Although a recent narrative review and perspectives on geographic localization summarized key patient and provider outcomes, Kashiwagi et al. provide a thorough and well-structured synopsis of the last 15 years’ work on geographic localization, focusing on the aim, implementation strategies, and outcomes of various interventions, as well as providing insight into opportunities to learn more about GCh practices.2,3
One notable finding from the review is that more than two-thirds of the studies used a bundled intervention that included other components in addition to GCh. This raises questions about whether GCh alone can produce meaningful clinical outcomes, which specific elements within the bundle have the greatest impact, or whether it is the interaction between GCh and those other elements that drives the clinical effect. Very few studies attempted to quantify the impact or degree of implementation of the individual bundled elements. The variability in aims, implementation strategies, and outcome measures suggests that there is not a one-size-fits-all solution when adapting GCh or its bundled elements. The authors recognized that a careful approach in future studies could help delineate the individual impact of bundle elements, allowing for a more tailored design for different practice needs. Similarly, not enough studies reported balancing measures or unintended consequences of GCh, which would also help inform practices in choosing their strategy.
Cautions and Considerations
While they are comprehensive, some caution is warranted in interpreting the data presented in the review. As the authors noted, most studies employed a pre-post analysis, with no study using a randomized controlled design, thus limiting direct causal linkage between GCh and its measured outcomes. Admittedly, implementing a multicenter RCT using GCh or a bundled GCh intervention faces substantial real-world barriers from the daily and varying operational demands of hospitals. In helping hospitalists weigh the different GCh interventions, we would have liked to see outcome measures aggregated by similar intervention styles or a general synthesis of the outcomes data. The scoping review, due to its broad nature and design, falls short of providing the same level of insight that a systematic review may offer into the potential clinical consequences of geographic cohorting.
Additionally, most studies were conducted at academic medical centers, which contrasts significantly with the scale, scope, and participant makeup of smaller community hospitals that make up the majority of hospitalist practices. In the case of our hospital system, we were able to implement and sustain GCh for hospitalist patients at the primary academic site, but for the smaller community site, our hospitalists opted, after a several-month GCh trial, to break geography in favor of fewer patient handoffs. Understanding the outcomes from the aims and implementation styles may bring us closer to a tailored guide for geographic localization. While we await future studies with more robust methodology, this comprehensive review may help steer practices looking to implement GCh towards studies with similar aims or practice characteristics and provide guidance on how to measure impact.
Bottom Line
This review provides a timely and thorough update on the geographic localization of patients to physician units, in an era of increased hospital crowding and consolidation that places pressure on hospitalist practices to work more efficiently and move patients through the hospital faster. There is no one-size-fits-all solution; thus, understanding the data in terms of objectives, methodology, and implementation strategies, as well as outcomes, can provide hospitalist practices with practical approaches to geographic localization. However, more robust studies are needed to better predict the appropriate implementation strategy and the full impact of geographic cohorting.
Dr. Nguyen
Dr. Schram
Dr. Nguyen is a hospitalist at the University of Chicago, director of triage for the section of hospital medicine, the patient logistics medical director, and senior medical director for throughput and efficiency for UChicago Medicine, and the hospitalist quality improvement director at UChicago Medicine’s Ingalls Memorial Hospital, all in Chicago. Dr. Schram is a hospitalist at the University of Chicago, the director of throughput and efficiency for the UChicago Medicine’s section of hospital medicine, senior medical director for throughput and efficiency for UChicago Medicine, and medical director at UChicago Medicine’s Mitchell Hospital Hyde Park, all in Chicago.
Key Points
- Geographic cohorting is a common practice.
- There may not be a one-size-fits-all solution, and it is tough to understand the impact of geographic cohorting, especially with bundled interventions.
- More structured studies with robust methodologies may help delineate intervention and impact.
References
1. Kara A, et al. Hospital-based clinicians’ perceptions of geographic cohorting: identifying opportunities for improvement. Am J Med Qual. 2018;33(3):303-312. doi: 10.1177/1062860617745123.
2. Kara A, et al. Closer to or farther away from an ideal model of care? Lessons learned from geographic cohorting. J Gen Intern Med. 2022;37(12):3162-3165. doi: 10.1007/ s11606-022-07560-y.
3. Bressman E, et al. Geographic cohorting by clinical care team: a narrative review. Ann Palliat Med. 2023;12(4):855-862. doi: 10.21037/apm22-1400.
4. Kashiwagi DT, et al. Geographic cohorting of adult inpatient teams: A scoping review. J Hosp Med. 2025. doi: 10.1002/jhm.70096