Transcript Hospitalists in 2003 (How I Learned to Stop Worrying and

The Hospitalist Movement, 2004
Eric M. Siegal, M.D.
Assistant Professor of Medicine (CHS)
Director, Hospitalist Program
University of Wisconsin
[email protected]
Objectives
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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
Disclosure
This talk has not been sponsored by any organization.
No pharmaceutical representatives were harmed in the
making of this presentation.
What is a Hospitalist?
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“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
Workforce Composition
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88% Medicine trained
83% GIM
 5% medical subspecialists
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12% Peds and Family Medicine
SHM Hospitalist Productivity and Compensation Survey, 2002
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
Explosive Growth
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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
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
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Why is the Hospitalist
Movement Growing so Fast?
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Demand:
 Physicians (PCPs & specialists)
 Hospitals
 Third party payers
Supply:
Increasing numbers of physicians perceive
hospital medicine as a viable long-term
career.
New Hospitals in Denver
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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
What’s Fueling Physician
Demand for Hospitalists?
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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
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
Sicker Patients at UWHC
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Case Mix Index: A numerical score of
blended patient acuity:
1: minor 2: moderate 3: major 4: extreme
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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
UWHC Case Mix Index 07/97 – 09/03
Sicker Patients Nationally
18.2 million CA inpatients (1993-97)
Acuity index: 1.69  1.79
 By 2025: A.I. 2.50 (40% increase)
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Institute for Health and Socio-economic Policy: California Healthcare:
Sicker Patients, Fewer Nurses, Fewer Staffed Beds; 1999
Physician Lifestyle
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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
The Unassigned Call Crisis
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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
Financial Pressures
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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
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.
Why Do Specialists Like
Hospitalists?
 “I think, therefore I am ---undercompensated”
Doing pays way better than thinking
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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
Hospitalists Can:
Make PCPs and specialists more
productive
 Allow specialists to concentrate on their
specialties
 Help their colleagues enjoy their careers
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Why Do Hospitals Want
Hospitalists?
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Do more with less:
 Sicker patients
 Worsening staffing shortages
 Decreasing reimbursement
Prospective payment
Unassigned patients
24:7 in-hospital attending coverage may
become mandatory
Quality / Safety Crisis
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44,000-98,000 inpatient deaths per year
attributed to medical errors
th
 8 leading cause of death, exceeding MVA,
breast cancer and AIDS
 Cost: $17-29 billion per year
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Major system flaws and failures are endemic
to hospitals
“To Err is Human: Building a Safer Health System”: Institute of Medicine, 2000
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
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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?
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”
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Is the Proliferation of
Hospitalists a Good Thing?
Why it Could be Bad
Discontinuous care
of hospitalized
patients:
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Misinformed
caregivers
Nobody knows
patients’ wishes or
social situation
Fumbled handoffs
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
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Why it Could be Good
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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
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
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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
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Do Hospitalists Improve
Patient Satisfaction?
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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
Do Hospitalists Improve
Nurses’ Job Satisfaction?
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Again, no published studies
Anecdotally, nurses love hospitalists.
Hospitalists:
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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
“ 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
Do Hospitalists Improve PCP Job
Satisfaction?
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708 PCPs surveyed: 524 responded (74%)
62% of physicians surveyed had hospitalists
available to them
PCPs with experience with hospitalists believed that
hospitalists:
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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
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
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Do Hospitalists Improve
Resource Utilization?
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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.
How About Quality of Care?
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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
Intriguing Results, but Hardly
Definitive
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Retrospective
Very limited scope: 7 hospitalists at 2
hospitals – Difficult to generalize this to the
entire medical community
Stay tuned – more data are coming
What Can We Say About
Hospitalists in 2004?
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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
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)
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“Hospital
Medicine”?
“Hospitology”?
“Hospiturgery”?
“Overgrown interns”
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
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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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Growing Number of Pure
Hospitalist Practices
Lawrence Wellikson, MD, SHM Hospitalist Productivity and Compensation Survey, 2002
2002
2000
1997
Hospital owned
38%
33%
23%
Multispecialty group
17 %
24%
35%
University faculty
9%
10%
5%
Hospitalist only
19%
12%
12%
Insurance company
9%
10%
14%
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
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Distinct Body of Knowledge?
(Isn’t this what categorical Medicine residents have been learning
for decades?)
New skills:
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QA/QI
Operations
Systems improvement
Team-based medicine
Established skills:
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Medical consultation
Palliative / end of life
care
Medical ethics
Critical care
Rehabilitation / subacute care
Precedents
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Quasi-specialties:
 Geriatric Medicine
 GIM
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Site-specific specialties:
 Critical Care
 Emergency Medicine
Demonstrable Value?
Is medicine better due to the presence
of hospitalists?
Controversies and Problems
Moving target phenomenon
 Income
 Hospitalists in the ICU
 Longevity and Burnout
 Impact on General Internal Medicine
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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
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Hospitalists Can’t Generate
Their Own Incomes
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80-85% of all hospitalist practices receive
financial support
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Poor reimbursement for cognitive specialties
Adverse payer mixes
“Unbillable” time spent coordinating care
ROI for hospitals that support hospitalists
groups is 3-5:1
Hospitalists Don’t Belong in
the ICU
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When compared to generalists, intensivists
lower ICU mortality
Unfortunately, there aren’t enough of them:
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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.
Longevity and Burnout
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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
Longevity and Burnout
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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
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
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Can We (Should We?) Train
Internists to Become Expert in Both
Inpatient and Outpatient Medicine in
3 Years?
One Potential Model
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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
What Issues Have Hospitalists
Been Asked to Tackle at UW?
UWHC
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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
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Unattached patients!!!
24/7 & emergency
coverage
Referrals from outlying
areas
Improve quality
Support those PCPs
who no longer want to
do inpatient medicine
The Future of Hospitalists at
UW
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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