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The Hospitalist Movement, 2004

The Hospitalist Movement, 2004. Eric M. Siegal, M.D. Assistant Professor of Medicine (CHS) Director, Hospitalist Program University of Wisconsin es2@medicine.wisc.edu. Objectives. Recent history of the hospitalist movement

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The Hospitalist Movement, 2004

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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 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

  3. Disclosure This talk has not been sponsored by any organization. No pharmaceutical representatives were harmed in the making of this presentation.

  4. 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

  5. Workforce Composition • 88% Medicine trained • 83% GIM • 5% medical subspecialists • 12% Peds and Family Medicine SHM Hospitalist Productivity and Compensation Survey, 2002

  6. 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

  7. 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

  8. 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

  9. 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.

  10. 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

  11. 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

  12. 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

  13. 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

  14. UWHC Case Mix Index 07/97 – 09/03

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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 ofInpatient Care. Washington, DC: Advisory Board Company; 1998:1-59.

  20. 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

  21. Hospitalists Can: • Make PCPs and specialists more productive • Allow specialists to concentrate on their specialties • Help their colleagues enjoy their careers

  22. 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

  23. 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

  24. 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

  25. 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?

  26. 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”

  27. Is the Proliferation of Hospitalists a Good Thing?

  28. Why it Could be Bad Discontinuous care of hospitalized patients: • Misinformed caregivers • Nobody knows patients’ wishes or social situation • Fumbled handoffs

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

  35. “ 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

  36. 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

  37. 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

  38. 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.

  39. 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

  40. 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

  41. 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

  42. 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)

  43. “Hospital Medicine”? • “Hospitology”? • “Hospiturgery”? • “Overgrown interns”

  44. 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

  45. 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

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