CONTEXT: The use of hospitalists--physicians who spend a substantial portion of their time providing in-hospital care to the patients of primary care physicians--has been proposed as a way to decrease costs and increase the quality of inpatient care. COUNT: Number of full-time hospitalists. CALCULATIONS: Average daily census = annual admissions x length of stay divided by 365. Number of hospitalists = (average daily census divided by patients per hospitalist) + 1 extra hospitalist for night coverage. DATA SOURCES: The average number of patients per hospitalist was obtained from a National Association of Inpatient Physicians membership survey. A low estimate of 10 patients per hospitalist was used to account for the extra manpower needed for coverage during vacations and other time off. RESULTS: A hospital with 3000 admissions per year and an average length of stay of 5 days would have an average daily census of 41 patients and would need 5 full-time hospitalists. Hospitals with a lower patient volume would need fewer hospitalists and would probably need to find persons other than hospitalists to cover some nights and weekends. CONCLUSIONS: Simple calculations based on hospital admissions and length of stay can estimate the number of hospitalists required for adequate staffing. Requirements will vary with the hospitalists' workload; the patient case complexity; and the duties other than inpatient care that are required of hospitalists, such as consultations, skilled nursing facility coverage, quality improvement work, teaching, and research. (+info)
Is hospitalism new? An analysis of medicare data from Washington State in 1994.
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CONTEXT: Managed care, increased disease severity, and more complex treatment options may be reasons for the recent enthusiasm for "hospitalists"--physicians who specialize in the care of inpatients. It is not clear, however, whether hospitalism is a new model for caring for inpatients or merely a new description for previously existing practice patterns. PRACTICE PATTERNS EXAMINED: The proportion of physician visits occurring in the hospital before the introduction of the term hospitalists. Five specialties were examined: family/general practice, general internal medicine, cardiology, gastroenterology, and pulmonology. DATA SOURCE: 1994 Medicare Part B claims data for beneficiaries 65 years of age and older who received all of their care in Washington State. RESULTS: For the average family/general practitioner, 10% of all Medicare visits occurred in the hospital. Corresponding figures for the other specialties were 20% for general internists, 36% for cardiologists, 38% for gastroenterologists, and 45% for pulmonologists. A substantial number of physicians devoted most of their Medicare effort to inpatient care (i.e., hospital visits > 50% of total visits). If this definition were used as a proxy for hospitalism, 4% of family/general practitioners, 10% of general internists, 20% of gastroenterologists, 29% of cardiologists, and 37% of pulmonologists would have been considered hospitalists in Washington State during 1994. On the other hand, 35% of family/general practitioners, 18% of general internists, 7% of both gastroenterologists and pulmonologists, and 4% of cardiologists did not bill Medicare for any inpatient visits and could reasonably be categorized as "officists." CONCLUSION: Physicians vary considerably in the proportion of their workload that occurs in the hospital or outpatient setting. Even before the term was coined, a considerable number of physicians were de facto "hospitalists." (+info)
The impact of an inpatient physician program on quality, utilization, and satisfaction.
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OBJECTIVE: To evaluate an inpatient physician system initiated in June 1996 for all patients of a health maintenance organization admitted to the general medicine service of an urban teaching hospital. In the new program, attending physician duties were transferred from the patient's own general internist to another internist serving on a hospital-based rotation. STUDY DESIGN: Cohort with historical controls. PARTICIPANTS AND METHODS: We compared the following measures before and after the new inpatient physician program began: (1) hospital length of stay and total charges, (2) outcomes related to quality of care, (3) primary care physician satisfaction, and (4) housestaff satisfaction. Differences before and after initiation of the inpatient physician program were evaluated using multivariate analyses to adjust for patient differences and secular trends. RESULTS: There were 2265 patients discharged from the general medical service in the year following implementation of the inpatient physician program. Postintervention average length of stay decreased from 3.5 to 3.0 days (P < .001). In multivariate analyses, average length of stay was reduced by 0.3 days (P = .008), and total hospital charges were reduced an average of $426 per admission (P = .001). In-hospital mortality rates, percentage of patients discharged home directly, and 30-day readmission rates did not change significantly in the postintervention period. Satisfaction among primary care physicians was high, with 90% of those answering a survey responding that they would recommend a similar program to other primary care groups. Medical housestaff satisfaction with their educational experience also increased. CONCLUSIONS: Implementation of an inpatient physician program at this institution significantly decreased resource utilization while maintaining or improving quality of care. Satisfaction with the program was high among primary care internists and housestaff. (+info)
Potential reduction in mortality rates using an intensivist model to manage intensive care units.
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CONTEXT: Because of evidence suggesting that outcomes are better in "intensivist-model" intensive care units (ICUs), the Leapfrog Group's hospital safety standards propose that ICUs be managed by critical care physicians (intensivists) who work exclusively in the ICU. COUNT: Number of lives saved annually in the United States. CALCULATION: Lives saved = (number of ICU admissions x in-hospital mortality rate of ICU patients) x reduction in mortality rates associated with the intensivist model. DATA SOURCE: Reduction in mortality rate associated with intensivist-model ICUs was determined by performing a structured literature review from 1986 to the present using MEDLINE. Other variables were estimated from various data sources. RESULTS: In the nine studies that met our selection criteria, relative reductions in mortality rates associated with intensivist-model ICUs ranged from 15% to 60%. On the basis of the most conservative estimate of effectiveness (15% reduction), full implementation of intensivist-model ICUs would save approximately 53,850 lives each year in the United States. CAUTIONS: Given the large number of ICU patients and their high baseline risks, even modest reductions in mortality rates would save many lives. Because of potential constraints related to the workforce and other resources, the feasibility of fully implementing intensivist-model ICUs nationwide is uncertain. (+info)
Program description: a hospitalist-run, medical short-stay unit in a teaching hospital.
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A hospitalist-run medical short-stay unit (MSSU) was created at a university-affiliated teaching hospital in Montreal in 1989. Its primary aim was to provide efficient and high-quality care to patients requiring a brief stay in hospital for short-lived medical conditions. After evaluation in the emergency department (ED), patients judged to have acute conditions requiring a short hospital stay are admitted directly to the MSSU. Conversely, patients with more complex conditions requiring a longer stay in hospital are admitted to a clinical teaching unit (CTU). Care in the MSSU is provided by a rotating group of hospitalists. Ensuring the admission of appropriate patients during non-daytime hours was the main difficulty identified. Preliminary evaluation of the MSSU suggested that ED consultants were effective at selecting suitable patients for admission to the MSSU, because only 1 in 5 patients later required transfer to other hospital wards. The 5 most common MSSU discharge diagnoses were asthma and chronic obstructive lung disease, pneumonia, congestive heart failure, urinary tract infection and cellulitis. MSSU patients had a shorter length of stay, lower rates of in-hospital complications and lower rates of readmission within 30 days of discharge compared with CTU patients. Our hospitalist-run MSSU appears to offer a workable system of health care delivery for patients with acute, self-limited illness requiring a brief stay in hospital. The MSSU appeared to promote the efficient use of hospital beds without compromising patient outcomes, however, further research is required to compare the efficiency and outcomes of care directly with that provided by the traditional CTU system. (+info)
Physician views on caring for hospitalized patients and the hospitalist model of inpatient care.
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We surveyed 241 board-certified internists affiliated with a large teaching hospital (Boston, Mass) before implementing a hospitalist service to determine attitudes towards providing inpatient care and the hospitalist model. Of physicians surveyed, 66% responded. Most disagreed that inpatient care is "an inefficient use of my time," only 10% felt a hospitalist service would improve patient satisfaction, and 54% felt it would hurt patient-doctor relationships. Multivariable analyses suggest that physicians physically furthest from their inpatient site were had more favorable attitudes toward the hospitalist model; more experienced and busier physicians were more negative. Future investigations should determine strategies for implementing the hospitalist model which address physicians' concerns. (+info)
Trends in hospital medicine: hospitalist advantages revealed.
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Although research on hospitalists is in its infancy, this model appears to reduce health care costs while providing care of at least equal quality to that provided by primary care physicians. This paper reviews recent reports. (+info)
Effects of an HMO hospitalist program on inpatient utilization.
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OBJECTIVE: To assess the impact of a health maintenance organization (HMO) hospitalist program on inpatient utilization. PATIENTS: The study sample consisted of patients admitted to the hospital for a routine, uncomplicated acute surgical or medical diagnosis included under Milliman and Robertson's Optimal Recovery Guidelines (ORGs). Evaluation involved comparison of 2 physician management groups: inpatients managed by staff primary care physicians (PCPs) (study group) and inpatients managed by network PCPs (comparison group). STUDY DESIGN: Data before and after introduction of the hospitalist program were available. From the same period, data were available from patients of network PCPs who managed their own inpatient stays (nonhospitalist comparison sample). Three outcomes were used to represent inpatient utilization: (1) number of inpatient stays meeting ORG goals; (2) number of inpatient stays not meeting ORG goals that had > or =1 medically necessary days; and (3) number of inpatient stays not meeting ORG goals that had > or =1 medically unnecessary days. RESULTS: Multiple logistic regression results indicated that inpatient stays were more likely to be within ORG utilization goals when managed by hospitalists vs nonhospitalists (P < .05). Introduction of the hospitalist program reduced the number of stays with unnecessary days among staff inpatients. There was an increase in stays with unnecessary days in the comparison group, ie, inpatients managed by network physicians. CONCLUSIONS: Full-time hospitalists are efficient managers of HMO inpatients. The ORGs for acute, uncomplicated diagnoses provided useful hospital utilization measures that captured inpatient management by hospitalists and PCPs. (+info)