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1. The Hospitalist Movement, 2004 Eric M. Siegal, M.D.
Assistant Professor of Medicine (CHS)
Director, Hospitalist Program
University of Wisconsin
2. Objectives Recent history of the hospitalist movement
Impact of hospitalists on health care: what we do, dont and should know
Where the hospitalist movement is going
Hospitalists at the University of Wisconsin
4. Disclosure This talk has not been sponsored by any organization.
No pharmaceutical representatives were harmed in the making of this presentation.
5. What is a Hospitalist? Hospitalist first coined in 1996 by Wachter and Goldman
Hospitalists are physicians whose primary professional focus is the general medical care of hospitalized patients. They may engage in clinical care, teaching, research or leadership in the field of general hospital medicine.
Wachter, Goldman: NEJM, 1996; 335:514-7
6. Workforce Composition
88% Medicine trained
5% medical subspecialists
12% Peds and Family Medicine
SHM Hospitalist Productivity and Compensation Survey, 2002
7. Is This Really a New Idea? Not entirely:
Canada, Britain, Australia and NZ have maintained hospitalist-like models for decades.
Redelmeier. A Canadian Perspective on the American Hospitalist Movement. Arch Intern Med.1999;159:1665-1668
Bindman, Majeed. Organisation of primary care in the United States. BMJ. 2002; 326: 631-634
8. Explosive Growth NAIP/SHM founded in 1997 at a breakout session of the ACP meeting
1997: 23 members
2003: 3,900 members
Currently 7-8,000 hospitalists
Potential size: 20,000 30,000
There are about 20,000 cardiologists in the United States
Lurie et al. The Potential Size of the Hospitalist Workforce in the United States. Am J Med. 1999; 106:441-5
9. Inpatient Services, PC Denver, CO hospitalist practice
Founded in 1998 by 4 physicians at 2 hospitals seeing 35 encounters per day
As of 12/03: 22 physicians at 4 hospitals seeing 190 encounters per day
This is happening across the country
10. Why is the Hospitalist Movement Growing so Fast?
Physicians (PCPs & specialists)
Third party payers
Increasing numbers of physicians perceive hospital medicine as a viable long-term career.
11. New Hospitals in Denver Three new hospitals opening across metro Denver in 2004
All three hospitals plan to contract hospitalist groups to provide inpatient coverage from day one
Why: Many community physicians (PCPs and specialists) made patient referrals contingent upon having pre-existing hospitalist groups on site
13. Whats Fueling Physician Demand for Hospitalists?
Inpatient medicine is becoming more demanding and difficult
Physicians are increasingly concerned about lifestyle issues
Unassigned / ER call
Financial pressures are driving physicians to look for more efficient ways to deliver health care
14. Is Inpatient Medicine Becoming More Difficult?
+ Increasing co-morbidities
+ Care shifting to ambulatory setting
Sicker patients in the hospital
Sicker patients inevitably demand more physician time and expertise
15. Sicker Patients at UWHC Case Mix Index: A numerical score of blended patient acuity:
1: minor 2: moderate 3: major 4: extreme
From 7/97 9/03, CMI at UWHC increased from 1.65 to 1.79 (p <.0001)
CMI has been increasing by .01 every four months for the past six years
16. UWHC Case Mix Index 07/97 09/03
17. Sicker Patients Nationally 18.2 million CA inpatients (1993-97)
Acuity index: 1.69 ? 1.79
By 2025: A.I. 2.50 (40% increase)
Institute for Health and Socio-economic Policy: California Healthcare: Sicker Patients, Fewer Nurses, Fewer Staffed Beds; 1999
18. Physician Lifestyle Physicians are increasingly concerned about balancing lifestyle and practice
Juggling inpatient and outpatient medical practice is stressful and time-consuming
The more primary care physicians practice inpatient medicine, the more they are likely to express job dissatisfaction and burnout.
Saint et al. What Effect Does Increasing Inpatient Time Have on Outpatient-oriented Internist Satisfaction? JGIM. 2003; 18: 725-729
19. The Unassigned Call Crisis Management of unassigned patients is reaching crisis levels across the nation
Unassigned patients are typically difficult: No access to pre-hospital primary care, difficult follow-up, higher rates of substance abuse, noncompliance
Reimbursement is generally poor
Unassigned patients have become problematic for all parties: Internists, ERs, hospitals and patients
Hospitalists are increasingly perceived as the solution
Edlich et al. A National Epidemic of Unassigned Patients: Is the Hospitalist the Solution? J. Emerg Med. 2002; 23: 297-300
20. Financial Pressures Inpatient/outpatient medical practices are generally inefficient
Divided attention interrupts efficiency in the clinic
Some large practices rotate inpatient call
One physician manages everyones inpatients
This is really a quasi-hospitalist model
21. Financial Bottom Line
Hospitalists may improve generalists bottom line by $40,000 by allowing increased outpatient productivity
Falk CT, Miller C. Hospitalist Programs: Towards a New Practice of Inpatient Care. Washington, DC: Advisory Board Company; 1998:1-59.
22. Why Do Specialists Like Hospitalists?
I think, therefore I am ---undercompensated
Doing pays way better than thinking
30-74 min. critical care = 4.00 RVUs
single-vessel PTCA = 14.84 RVUs
In areas with shortages of specialists, hospitalists can fill some of the voids, allowing specialists to concentrate on the most complicated patients
Specialists would rather practice their specialites
23. Hospitalists Can: Make PCPs and specialists more productive
Allow specialists to concentrate on their specialties
Help their colleagues enjoy their careers
25. Why Do Hospitals Want Hospitalists?
Do more with less:
Worsening staffing shortages
24:7 in-hospital attending coverage may become mandatory
26. Quality / Safety Crisis 44,000-98,000 inpatient deaths per year attributed to medical errors
8th leading cause of death, exceeding MVA, breast cancer and AIDS
Cost: $17-29 billion per year
Major system flaws and failures are endemic to hospitals
To Err is Human: Building a Safer Health System: Institute of Medicine, 2000
27. Hospitalists are Uniquely Positioned to Champion Patient Safety and Quality Improvement Initiatives
Nobody knows the hospital better than a hospitalist
Hospitalists are uniquely invested: the hospital is our home
28. Why Are Physicians Attracted to Hospital Medicine? Why is a career that offers unpredictable days, weird hours and perpetual treatment as a house officer becoming so popular? SupplySupply
29. Because Logical transition from I.M. residency
High-acuity, interesting cases
Daily interaction with subspecialists
Alternative to primary care for people who dont want to subspecialize
Its why I became an internist
30. Is the Proliferation of Hospitalists a Good Thing?
31. Why it Could be Bad Discontinuous care of hospitalized patients:
Nobody knows patients wishes or social situation
32. Why it Could be Bad - II Could increase the sense of marginalization already felt by many primary care physicians
Could precipitate a schism in Internal Medicine by creating discrete specialties in outpatient and inpatient practice
33. Why it Could be Good Discontinuity of care isnt always bad
Internal Medicine might actually benefit from differentiating outpatient and inpatient tracks
Physicians who focus solely on hospital care might do it better than physicians who dont
Hospitals might function better
Could actually increase the allure and prestige of a generalist career
Christakis, Wachter. Does Continuity of Care Matter? West Med. 2001; 175: 174-75
34. How Do We Decide? User satisfaction:
Hospitals and staff
Resource utilization and outcomes
Impact upon General Internal Medicine
Impact upon Medicine as a whole
35. Do We Have Enough Data to Decide?
No Studies to date are small and limited in scope and power
Ongoing areas of research:
36. Do Hospitalists Improve Patient Satisfaction?
No large, well-designed studies to date
Patient concern about abandonment by their PCP when theyre sick may be offset by greater availability and attentiveness from hospitalists
Patients are deeply concerned that their PCPs are informed and involved in their care. They are less concerned whether or not the PCP is making the day to day decisions
37. Do Hospitalists Improve Nurses Job Satisfaction?
Again, no published studies
Anecdotally, nurses love hospitalists.
Are readily available
Understand hospital protocols and systems
Probably know the RNs on a first-name basis
Attuned to the team-based care model that is central to nursing care
38. From a nursing perspective, it is hard to imagine the Hospitalist role as anything but a dream come true.
Elizabeth Henneman, PhD, RN.
Clinical Specialist, MICU, UCLA
39. Do Hospitalists Improve PCP Job Satisfaction? 708 PCPs surveyed: 524 responded (74%)
62% of physicians surveyed had hospitalists available to them
PCPs with experience with hospitalists believed that hospitalists:
Had no effect on their income (69%)
Decreased their workload (53%)
Increased their practice satisfaction (50%)
Decreased the quality of their relationships with their patients (28%)
Fernandez et al. Friend or Foe? How Primary Care Physicians Perceive Hospitalists. Arch Int Med. 2000; 160: 2902-2908
41. Are Hospitalists Better Than General Internists at Inpatient Care?
High volume and subspecialization improve outcomes and efficiency (surgery, cardiology, critical care)
It makes intuitive sense that this should apply to hospital medicine as well
42. Do Hospitalists Improve Resource Utilization? 19 studies comparing hospitalists and generalists
15 studies: Hospitalists significantly decreased costs (average: 13.4%) and lengths of stay (average: 16.6%)
Outcomes were at least neutral
Limitations: Many of these studies were small and retrospective
Wachter, Goldman. The Hospitalist Movement 5 Years Later. JAMA.2002;287:487-494.
43. How About Quality of Care? Two recent studies: One at a community hospital, the other at an academic center
Short-term relative risk of death for patients admitted to hospitalist services was about 0.7
Auerbach 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
Meltzer 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
44. Intriguing Results, but Hardly Definitive
Very limited scope: 7 hospitalists at 2 hospitals Difficult to generalize this to the entire medical community
Stay tuned more data are coming
45. What Can We Say About Hospitalists in 2004?
Probably utilize inpatient resources more efficiently than generalists
Probably do not adversely affect outcomes and might improve them
May improve hospital staff satisfaction
Should improve physician satisfaction in a voluntary system
Effect on patient satisfaction unclear
47. Could Hospitalism be a Distinct Medical Subspecialty? Not until we come up with a better name than Hospitalism
(Hospitalism first coined in 1869 to describe unhygienic conditions in old, overcrowded hospitals)
49. What Defines a Specialty? Physicians who self-identify and organize as a distinct group
Distinct scholarly activity
Distinct body of knowledge
Demonstrable value in specialization
50. Physicians Who Self-Identify and Organize as a Distinct Group Growing number of pure hospitalist practices
Society of Hospital Medicine
National and regional hospitalist meetings that are rapidly increasing in size, scope and sophistication
51. Growing Number of Pure Hospitalist Practices Lawrence Wellikson, MD, SHM Hospitalist Productivity and Compensation Survey, 2002
52. Distinct Scholarly Activity National journal: The Hospitalist
Hospital medicine textbook
Fellowships in Hospital Medicine
Novel research in patient safety, quality, hospital systems and best practices
53. Distinct Body of Knowledge?(Isnt this what categorical Medicine residents have been learning for decades?)
Palliative / end of life care
Rehabilitation / sub-acute care
54. Precedents Quasi-specialties:
55. Demonstrable Value?
Is medicine better due to the presence of hospitalists?
57. Controversies and Problems
Moving target phenomenon
Hospitalists in the ICU
Longevity and Burnout
Impact on General Internal Medicine
58. Moving Target: As Hospitalists Make Everyone Else Better, They Make Themselves Look Worse
Hospitalists improve hospital quality, systems and efficiencies: This affects everyone who practices
The generalists who choose to remain in the hospital are usually the ones who are most motivated to do it well
59. Hospitalists Cant Generate Their Own Incomes 80-85% of all hospitalist practices receive financial support
Poor reimbursement for cognitive specialties
Adverse payer mixes
Unbillable time spent coordinating care
ROI for hospitals that support hospitalists groups is 3-5:1
60. Hospitalists Dont Belong in the ICU When compared to generalists, intensivists lower ICU mortality
Unfortunately, there arent enough of them:
22% shortfall by 2020
35% by 2030
Not every ICU patient needs an intensivist
We need to decide how to share the burden of caring for patients in the ICU
Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease. Can we meet the requirements of an aging population? JAMA. 2000;284:2762-2770.
61. Longevity and Burnout How many 55 year old cardiologists, surgeons or intensivists do you regularly see rounding in the hospital?
Inpatient physicians tend to work weird hours, weekends and holidays
Lack of control over day
Most specialists can shift to outpatient practices as they get olderhospitalists cant
62. Longevity and Burnout Recognize that this is a high-stress job and plan accordingly
Embrace shift work as a necessary component and build systems to make it work well
Respect circadian rhythms
Emergency Medicine may provide a template
63. Hospitalists are Bad for GIM Hospitalists are overwhelmingly generalists
Generalist (primary care) careers are losing appeal
Hospital medicine is the only generalist specialty that is growing (briskly!)
Hospital medicine is breathing new life into general medicine
64. Can We (Should We?) Train Internists to Become Expert in Both Inpatient and Outpatient Medicine in 3 Years?
65. One Potential Model All Medicine residents train identically in PG-1 and PG-2 years
PG-3: Either Inpatient or Outpatient Medicine / Primary Care track
If practice environment demands both skill sets, can take both tracks and do a four year residency
If subspecializing, can pick track most appropriate to the specialty
67. What Issues Have Hospitalists Been Asked to Tackle at UW? UWHC
Improve integration of care across disciplines
Fill voids left by a contracting housestaff program
Improve resource utilization and LOS
More effective deployment of specialists Meriter
24/7 & emergency coverage
Referrals from outlying areas
Support those PCPs who no longer want to do inpatient medicine
68. The Future of Hospitalists at UW Internists are tightly woven into the fabric of inpatient health care
Hospitalists bring a new level of service and responsiveness to the medical staff
Hospitalists drive progressive systemic improvements in efficiency, quality, safety and outcomes
The hospital becomes a living laboratory for novel healthcare outcomes research
Develop a unique educational curriculum (fellowship?) in hospital medicine
Become role models for housestaff and students