The Hospitalist Movement, 2004

1. The Hospitalist Movement, 2004 Eric M. Siegal, M.D. Assistant Professor of Medicine (CHS) Director, Hospitalist Program University of Wisconsin es2@medicine.wisc.edu

2. Objectives Recent history of the hospitalist movement Impact of hospitalists on health care: what we do, don’t 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 83% GIM 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? Demand: Physicians (PCPs & specialists) Hospitals Third party payers Supply: 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. What’s 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? Aging population + 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 Travel time Divided attention interrupts efficiency in the clinic Some large practices rotate inpatient call One physician manages everyone’s 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: Sicker patients Worsening staffing shortages Decreasing reimbursement Prospective payment Unassigned patients 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 Fast-pace High-acuity, interesting cases Daily interaction with subspecialists Alternative to primary care for people who don’t want to subspecialize “It’s 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: Misinformed caregivers Nobody knows patients’ wishes or social situation Fumbled handoffs

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 isn’t 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 don’t 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: PCP/specialists Patients 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: User satisfaction Resource utilization Outcomes

36. Do Hospitalists Improve Patient Satisfaction? No large, well-designed studies to date My impression: Patient concern about abandonment by their PCP when they’re 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. 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 Retrospective 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)

48. “Hospital Medicine”? “Hospitology”? “Hospiturgery”? “Overgrown interns”

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?(Isn’t this what categorical Medicine residents have been learning for decades?) New skills: QA/QI Operations Systems improvement Team-based medicine Established skills: Medical consultation Palliative / end of life care Medical ethics Critical care Rehabilitation / sub-acute care

54. Precedents Quasi-specialties: Geriatric Medicine GIM Site-specific specialties: Critical Care Emergency Medicine

55. Demonstrable Value? Is medicine better due to the presence of hospitalists?

57. Controversies and Problems Moving target phenomenon Income 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 Can’t 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 Don’t Belong in the ICU When compared to generalists, intensivists lower ICU mortality Unfortunately, there aren’t 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 older—hospitalists can’t

62. Longevity and Burnout Recognize that this is a high-stress job and plan accordingly Limit workloads 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 Unattached patients!!! 24/7 & emergency coverage Referrals from outlying areas Improve quality 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