The number of patients admitted to acute care hospitals

Hospitalist Organizational Structures in the Baltimore-Washington Area and Outcomes: A Descriptive Study Christine Soong, MD, James A. Welker, DO, and Scott M. Wright, MD Abstract Background: Hospitalist groups are heterogeneous and the ideal model for inpatient care is not known. Organizational characteristics of hospitalists may impact outcomes. Objective: To describe and compare hospitalist groups at 5 hospitals. Design: Observational retrospective study using survey instruments. Participants: Hospitalist program leaders. Measurements: Characteristics collected include hospital volume and size; hospitalist age, gender, years in practice, board certification status, international medical graduate status, and involvement with quality improvement; and hospitalist group age, volume, work shift description, remuneration, and utilization of nurse practitioners, physician assistants, and case managers. Descriptive statistics summarized differences between hospitalist groups and association with patient outcomes. Results: The groups differed in patient volumes (2093 6022), continuity (maximum 5 vs. 10 consecutive days worked), physician-extender roles, and availability of in-house hospitalist overnight. Conclusions: Differences exist among hospitalist groups. Organizational characteristics may influence capacity, outcomes, and quality of care delivered on the inpatient services. Further study is needed to determine which organizational feature is associated with improved patient care. The number of patients admitted to acute care hospitals in the United States has steadily increased over the past decade, with more than 30 million adult discharges in 2006 [1]. With growing pressures to increase quality and decrease costs, hospitals are accountable for adherence to core quality measures and avoidance of adverse events. Integral to this process are hospitalists, who deliver much of the inpatient care provided in the country. Hospitalists represent the fastest growing physician specialty group in the United States and are present in 55% of hospitals with more than 200 beds [2]. Comparisons of hospitalist and non-hospitalist care have revealed modest benefits in efficiency without significant differences in patient outcomes such as mortality [3 8]; however, many studies were limited by small sample sizes and data collection from single institutions. Moreover, these studies focused largely on differences between hospitalists and non-hospitalists rather than examining variations between hospitalist groups. Seemingly, wide variations exist in the organizational structure of hospitalist groups, including patient volume, shift length, shift coverage structure, and use of mid-level providers and house staff [9]. However, detailed information on hospitalist organizational characteristics is not available. Staffing patterns in other acute care settings, such as the intensive care unit (ICU), have been strongly linked to patient outcomes. In these units, high-intensity physician staffing and lower nurse-patient ratios are associated with reduced in-hospital mortality and length of stay (LOS) [10,11]. Given the high penetration of hospitalist providers within hospitals and the supposed differences in how this care is organized and provided, we sought to describe the different models of hospitalist care and health care outcomes at these sites. Methods Setting and Participants Five hospitals in the Baltimore-Washington area that participate in the CareScience Care Data Exchange program, a peer-to-peer technology that enables the exchange of information between health care organizations, were identified for participation in the study. Adult patients older than 18 years were included in the analysis if they were admitted by a physician classified as a hospitalist at 1 of the 5 hospitals. Data Collection, Data Sources, and Data Analysis Patient demographics, health care outcomes, and clinical results were obtained from the CareScience database. This From the Johns Hopkins University, Baltimore, MD. www.jcomjournal.com Vol. 18, No. 3 March 2011 JCOM 107

hospitalist Groups data was amassed retrospectively from CareScience for eligible adult patients cared for by a hospitalist between 1 Jul 2008 and 30 Jun 2009. A single investigator conducted a 20-minute phone interview with the leader of each of the hospitalist groups to learn about the details of their group and how it functioned. In preparation for this data collection endeavor, a careful literature review was conducted to determine specific organizational characteristics that might affect patient outcomes. We also solicited input from hospitalist leaders at other institutions, as well as from individuals with expertise in survey design. The survey was pilot tested with hospitalist leaders not part of the study to assess for clarity, and questions to be asked on the data collection instrument were adjusted based on feedback. Descriptive statistics (proportions, mean, median, range and standard deviation) were used to summarize both the responses from the hospitalist leaders about their programs as well as the supplementary data that was imported from the CareScience database. The institutional review board at Johns Hopkins University approved the study. Results All 5 hospitalist group leaders agreed to the telephone survey (100% participation rate) and we were granted access to their CareScience outcomes data. Characteristics of Hospitalists Hospitalist characteristics are detailed in Table 1. The majority of hospitalists were male, with a median age of 34.5 years and a mean range of 3 to 8 years experience as a hospitalist. All hospitalist physicians at these 5 institutions were board certified. The proportion of international medical graduate hospitalists ranged from 25% to 80% across the 5 groups. Across the hospitals, the hospitalist physicians spent approximately 85% of their time in clinical care. Hospitalist Group Organizational Structure Hospitalist group organizational structure is shown in Table 1. The hospitalist programs have been in existence for 4 to 13 years (mean, 8.6 years). Volumes of hospitalist service varied considerably, with annual hospitalist admissions ranging from 2093 to 6022 among the 5 hospitals. When factoring in the number of providers (physicians and physician-extenders), this translates into 299 to 502 admissions/provider annually. Mean reported daily patient census cared for by the hospitalist groups ranged from 20 to 77.5. There was a twofold difference in mean daily patient cap (maximum number of patients to be managed by a hospitalist daily) per hospitalist from 8 to 16 from lowest to highest groups. Hospitalist work structures differed among the 5 hospitals. Two hospitalist groups described a model of shift work with hospitalists rotating through day, night, and admitting shifts where each hospitalist has a distinct role. In contrast, the other 3 groups have their hospitalists perform a combination of activities and responsibilities every day (including admissions, follow-up care, and cross-coverage). The practice model for the 5 hospitalist groups involved daily rounds by hospitalist providers; no group systematically conducts rounds with nursing, and only 1 group rounds daily with a dedicated hospitalist case manager. The maximum number of allowable consecutive days to be worked by a hospitalist ranged from 5 to 10 days across sites, and all but 1 hospitalist group reported, presence of a hospitalist in the hospital 24 hours daily. Each hospitalist group reported that bonuses to salary were tied to productivity. Other variables that were linked to additional compensation at some of the sites included Joint Commission core measures adherence, length of stay, and patient satisfaction (Table 1). Turnover rates (defined as the number of hospitalists leaving over a 2-year period as a percentage of current total number of hospitalists) differed considerably, with rates as low as 17% and as high as 44% (Table 1). Hospital Characteristics All 5 hospitals were community teaching hospitals. Total number of hospital beds ranged from 300 to 700 (Table 1). Total admissions during the study period ranged from 18,064 to 42,626. Department of medicine admissions varied between 6500 and 19,643, with the hospitalist groups caring for 11% to 56% of these cases. Patient Characteristics Between July 2008 and June 2009, a total of 20,105 patients aged 18 years or older were admitted to the hospitalist service at the 5 hospitals. Patient mean age was 59.4 years and 45.2% were male. Patient characteristics across the 5 hospitals are shown in Table 2. The top 4 principal diagnoses prompting admissions were chest pain, chronic bronchitis, heart failure, and pneumonia. Outcomes The 5 hospitals differed in in-patient mortality rates and 14-day and 30-day readmission rates (all p < 0.05, Table 2). A total of 238 patients (1.2%) died in hospital and 1815 (9%) were readmitted within 14 days after discharge. Mean LOS was 2.84 days, and costs averaged $9911.40 across admissions. Rates of cardiac arrest and venous thromboembolism prophylaxis were not different among the groups (p > 0.05). 108 JCOM March 2011 Vol. 18, No. 3 www.jcomjournal.com

Table 1. Characteristics of Hospitalist Groups Characteristic Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital characteristics Hospital beds, n 379 300 310 700 926 Annual hospital admissions, n 30,000 18,064 20,746 22,675 42,626 Annual medicine admissions, n 18,256 12,163 6500 11,300 19,643 Hospitalist characteristics Number of physician hospitalists, n 9 12 9 24 14 Male, n (%) 7 (78) 10 (83) 6 (67) 12 (50) 7 (50) Age in years, median (range) 37.5 (30 45) 34.5 (28 50) 35 (30 45) 34 (29 40) 32 (28 50) Mean years practicing as a hospitalist 8.5 5 3 3.25 4 Board certification, % 100 100 100 100 99 International medical graduate, % 40 80 44 28 25 Hospitalists involved in quality improvement, n (%) Group organizational structure 4 (44) 5 (42) 1 (11) 1 (4) 7 (50) Age of hospitalist program in years 10 11 5 13 4 Current full-time equivalents (FTE), n 9 12 7.5 23 7 FTE 2 yrs ago, n 11 10.6 6 12 6 FTE 5 yrs ago, n 9 5 4 8 4 Patient volume Hospitalist admissions 2008 9, n 5954 6022 2362 3674 2093 Mean daily census, n 70 77.5 20 50 70 Mean daily patients per hospitalist, n 16 12 12.5 8 12 Shift description Duration, hr 11.5 8 12 10 12 Maximum continuous days worked, n 10 6 6 5 7 Mean number of providers seen by a patient per admission, n 2.5 3 2 2 1.5 24-hr in-hospital hospitalist Yes Yes Yes Yes No Rounds Daily by hospitalist Yes Yes Yes Yes Yes With nurse No No No No No With case manager No No No Yes No Housestaff supervision Yes Yes Yes Yes Yes Midlevel use Yes No Yes Yes No Dedicated case manager No No No Yes No Base salary, $ 143,000 162,500 130,000 120,000 140,000 Productivity bonus Yes Yes Yes Yes Yes Core measures bonus Yes Yes Yes No Yes Length of stay bonus Yes Yes Yes No Yes Pt satisfaction bonus Yes Yes Yes No No Turnover (number of hospitalists leaving over 2 years), n (%) 4 (44) 2 (17) 1.5 (17) 9 (38) 4 (28) www.jcomjournal.com Vol. 18, No. 3 March 2011 JCOM 109

hospitalist Groups Table 2. Patient Characteristics and Outcomes of Hospitalist Groups Characteristic/Outcome Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Patient characteristic Volume (2008 9), n 5954 6022 2362 3674 2093 Mean patient age, yr (SD) 59.7 (18.6) 60.0 (18.7) 57.7 (16.4) 61.7 (17.0) 58.1 (18.2) Male, n (%) 2603 (43.7) 2632 (43.7) 1106 (46.8) 1745 (47.5) 1002 (47.9) Outcome Mortality,* n (%) 70 (1.2) 83 (1.4) 16 (0.7) 25 (0.7) 44 (2.1) Length of stay, d (SD) 2.4 (2.31) 2.8 (2.15) 2.0 (2.09) 2.8 (3.48) 4.2 (2.33) 95% confidence interval 2.34 2.45 2.74 2.85 1.93 2.07 2.69 2.91 4.10 4.30 14-day readmissions,* n (%) 554 (9.3) 55 (10.9) 155 (6.6) 315 (9.5) 136 (6.5) 30-day readmissions,* n (%) 932 (15.7) 1,096 (18.2) 266 (11.3) 501 (16.3) 232 (11.1) Cardiac arrest, n (%) 17 (0.3) 23 (0.4) 4 (0.2) 9 (0.2) 11 (0.5) Venous thromboembolism prophylaxis, 4572 (76.8) 4327 (71.9) 1743 (73.8) 1980 (73.4) 1784 (85.2) n (%) Hospital charges, $ 6154 6711 6075 7045 23,572 *p < 0.05. Discussion Hospitalist organizational characteristics differed among the 5 hospitals studied. Of note, patient volumes, continuity (as determined by the number of unique providers seeing any single patient during a typical inpatient stay), and midlevel roles varied across hospitals. Inpatient outcomes were also significantly different between hospitals, particularly mortality and readmission rates. Some of these differences may be related to the ways that these hospitalist groups are organized and structured. To date, numerous published studies on hospitalists have focused on differences between hospitalist and non-hospitalist providers and the impact on cost-effectiveness and patient outcomes [3 5,8,12]. Review of the literature reveals a paucity of publications examining differences between hospitalist groups. Halasyamani and colleagues conducted a retrospective cohort study comparing LOS, costs, 30-day readmission rates, and mortality among an academic hospitalist service, a private hospitalist service, and a group of community physicians all working at a single hospital [13]. Academic hospitalists care was associated with statistically significant shorter LOS and lower costs compared with private hospitalists. Exploration of the hospitalist organizational characteristics was limited, but select differences were that the academic hospitalists utilized moonlighters for the majority of weekend coverage and they worked longer shifts. Meltzer reported that resource use and mortality improved as hospitalists gained experience over time working on hospital wards [14]. In our dataset, it also appeared as if the more established (ie, older) hospitalist programs achieved better outcomes with lower mortality and reduced LOS. A study by Lopez et al found improved performance on quality indicators for acute myocardial infarction, heart failure, and pneumonia in hospitals with hospitalists compared with those without. Differences between hospitalist groups were not examined [6]. Hospitalist group #5 had the longest hospital and ICU LOS, together with the highest in-hospital mortality and cardiac arrest rates. This group also saw fewer patients when adjusting for the number of providers in the group. Notable organizational characteristics were the lack of 24-hour inhospital hospitalist coverage, a less mature hospitalist program (4 years of experience to date), and a lower proportion of direct patient care provided by hospitalist (or more care delivered by physician extenders). At this site, moonlighters cover the patients overnight, potentially impacting outcomes through breaches in quality hand-offs. Dedicated overnight hospitalists may improve quality through continuity of care and in comparison to non-hospitalists. These associations highlight the need for further study to measure the effect of hospitalist organizational characteristics on clinical outcomes. Several limitations of this study should be considered. First, the results are largely descriptive as our sample size was not planned to be powered to detect statistical differences between hospitalist groups. Second, individual patient level data was not available from the system that outputs 110 JCOM March 2011 Vol. 18, No. 3 www.jcomjournal.com

means. Further, the nature of the outcome data did not allow for consideration of possible confounders. Third, we relied on self-report by the leader of each hospitalist group in the one-on-one interview as we collected details about the characteristics of their group. Finally, the hospitals were fairly homogeneous all located in 1 geographical region and all teaching community institutions thereby possibly limiting generalizability. In summary, hospitalist organizational structure and characteristics may influence health care outcomes in meaningful ways. Detailed quantitative examination of the relationship between hospitalist structure and patient outcomes is needed to determine the extent of these associations so as to identify best practices. Acknowledgments: The authors would like to thank Janet McIntyre and Jim Huang for their assistance in database creation. Corresponding author: Christine Soong, MD, Univ. of Toronto, Mt. Sinai Hospital, 600 University Ave., Rm. 428, Toronto, Ontario, Canada M5G 1X5, csoong@mtsinai.on.ca. Funding/support: Dr. Wright is a Miller-Coulson Family Scholar and is supported through the Johns Hopkins Center for Innovative Medicine. Financial disclosures: None. References 1. Association AH. Chartbook: Trends affecting hospitals and health systems Chapter 3: Utilization and volume. Accessed 5 Aug 2010 at www.aha.org/aha/research-and-trends/ chartbook/ch3.html. 2. Kralovec P, Miller J, Wellikson L, Huddleston J. The status of hospital medicine groups in the United States. J Hosp Med 2006;1:75 80. 3. Lindenauer P, Rotheberg M, Pekow P, et al. Outcomes of care by hospitalists, general internists, and family physicians. N Engl J Med 2007;357:2589 600. 4. Meltzer D, Shah M, Morrison J. Decreased length of stay, costs and mortality in a randomized trial of academic hospitalists. J Gen Intern Med 2001;16(Suppl):S208. 5. Diamond H, Goldberg E, Janosky J. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med 1998;129:197 203. 6. Lopez L, Hicks L, Cohen A, et al. Hospitalists and the quality of care in hospitals. Arch Intern Med 2009;169:1389 94. 7. Sehgal NL, Green A, Vidyarthi A, et al. Patient whiteboards as a communication tool in the hospital setting: a survey of practices and recommendations. J Hosp Med 2010;5:234 9. 8. Auerbach A, Wachter R, Katz P, 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 65. 9. Society of Hospital Medicine. 2007 2008 survey. Accessed 5 Aug 2010 at www.hospitalmedicine.org/am/template. cfm?section=survey&template=/cm/htmldisplay. cfm&contentid=18412. 10. Pronovost P, Angus D, Dorman T, et al. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA 2002;288:2151 62. 11. Pronovost P, Jenckes M, Dorman T. Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA 1999;281:1310 7. 12. Rifktin W, Holmboe E, Scherer H, Sierra H. Comparison of hospitalists and nonhospitalists in inpatient length of stay adjusting for patient and physician characteristics. J Gen Intern Med 2004;19:1127 32. 13. Halasyamani L, Valenstein P, Friedlander M, Cowen M. A comparison of two hospitalist models with traditional care in a community teaching hospital. Am J Med 2005;118:536 43. 14. Meltzer D, Manning W, Morrison J, 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 74. Copyright 2010 by Turner White Communications Inc., Wayne, PA. All rights reserved. www.jcomjournal.com Vol. 18, No. 3 March 2011 JCOM 111