The Journal of Pediatrics
Volume 148, Issue 3 , Pages 296-299, March 2006

Hospitalists in children’s hospitals: What we know now and what we need to know

  • Gary L. Freed, MD, MPH

      Affiliations

    • Corresponding Author InformationReprint requests: Gary L. Freed, MD, MPH, University of Michigan, Division of General Pediatrics, 300 N Ingalls, Room 6C27, Ann Arbor, MI 48109-0456
    • ,
  • Rebecca L. Uren, MHSA

Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan

Received 28 November 2005; received in revised form 19 December 2005; accepted 20 December 2005.

Article Outline

Abbreviations:  AAP, American Academy of Pediatrics , LOS, Length of stay , PCP, Primary care provider , SHM, Society of Hospital Medicine

 

The concept of hospitalists was made popular in 1996 by Robert Wachter, who defined them as physicians who spend at least 25% of their time serving as the physician of record for inpatients, during which time they accept handoffs of hospitalized patients from primary care providers (PCPs), returning the patients to their PCPs at the time of hospital discharge.1 More recently, the hospitalists’ professional association, the Society of Hospital Medicine (SHM), defined the hospitalist as a physician whose primary focus is the general medical care of hospitalized patients and whose responsibilities also include teaching, research, and leadership related to hospital care.2

We have conducted a review to synthesize the existing knowledge surrounding the topic of hospitalists, especially as it relates to pediatric providers. Most of the literature available focuses on research that examines the potential benefit of using a hospitalist program. This report provides an overview of over 100 articles pertaining to hospitalists published since the year 2000. The articles were classified as research—data studies, research—opinion surveys, literature reviews, case studies, and commentaries. A link is provided to a comprehensive review matrix for details on each of the individual articles (http://www.abp.org/jpeds/hospitalist/hospitalist2006.pdf).

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Background/overview 

In the past 10 years, the use of hospitalists has grown in both the adult and pediatric setting as a response to pressure to deliver cost-effective, high-quality care.3 There were approximately 8000 hospitalists (adult and pediatric) in the United States in 2004.4 The hypothesized advantages of using hospitalists include that patients may receive better care because hospitalists specialize in handling acute or chronic illness and have become proficient in navigating the hospitals’ administrative procedures and are available “real time” to monitor patients.5, 6, 7 Additionally, PCPs may experience less interruption in office hours, more profitability, and improved lifestyle once relieved of hospital duties.5, 8

The hypothesized disadvantages of using hospitalists include concerns about discontinuity of care and patient satisfaction, the possibility that there are other effects such as cost shifting from the inpatient to outpatient setting, that PCPs may feel threatened by being limited to outpatient practice, incentives paid to hospitalists to reduce lengths of stay (LOS), and concerns about resident autonomy when using hospitalists as educators.8, 9, 10, 11

Hospitalist Core Competencies/Training 

A number of articles discuss the potential need for hospitalist-specific training in core competencies because these skills are not traditionally taught in residency programs.12, 13, 14, 15, 16 A survey of hospitalists about residency training found that training programs may need to be modified to address gaps in medical consultation, communication skills, continuum-of-care competency and end-of-life issues.15 Flanders and Wachter note that hospitalist residency tracks, fellowships, and continuing education programs are beginning to address these issues.12

Less than 30% of pediatric academic department chairs surveyed believed that hospitalists require training not currently provided in residency.16 Narang found that “most pediatric residency programs are designed to provide inpatient exposure, but some are developing pediatric hospitalist tracks or fellowships that would focus on skills in health economics, quality assurance/improvement, palliative care, communication skills, as well as augmenting clinical skills in acute/subacute care of children in an inpatient setting.”14

Pediatric Hospitalists 

More than 30 of the articles reviewed related specifically to pediatrics. Although there are fewer rigorous research studies in the pediatric setting, the available studies reflect findings common to the internal medicine studies. Authors posit that more pediatric-specific studies must be performed because children’s diseases are different, LOS are shorter, the cost of hospitalization is lower, and the structure and finance of pediatric primary care is different.5, 17

In 2002, there were approximately 600 pediatric hospitalists.14 The pediatric hospitalist primarily works in the pediatric ward, the newborn nursery or the neonatal intensive care unit, pediatric intensive care unit, and special care nurseries.18 Carlson et al suggest that the newborn nursery is particularly good for hospitalists because “although there may be an ongoing relationship between the PCP and family, no relationship has developed between the newborn infant and PCP.”18 Furthermore, “unlike pediatric residents who rotate monthly, hospitalists become familiar with protocols, procedures, newborn medicine literature, and the infants with extended stays as well as their families. Pediatric hospitalists can also fill the need for 24 hour coverage and frequently attend several deliveries in a shift (making them more experienced than a typical PCP).”18

In 1999, the American Academy of Pediatrics (AAP) recognized pediatric hospitalists by creating a Provisional Section on Hospital Care—a forum for pediatricians who have chosen to concentrate on inpatient care.5 In 2005, the AAP also issued a policy statement providing 6 guiding principles for the development of pediatric hospitalist programs:2

1.Pediatric hospitalist programs should be voluntary, and physicians should retain the option to admit/manage their own patients;

2.Pediatric hospitalist programs should be designed to meet the unique needs of the community;

3.Hospitalists should be board certified in pediatrics or have equivalent qualifications;

4.Pediatric hospitalist programs should include appropriate outpatient follow-up;

5.Pediatric hospitalist programs should provide for timely/complete communication between the hospitalist and the outpatient physician; and

6.Pediatric hospitalist programs should include data collection and outcome assessment to monitor performance.

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Research—data studies 

There is a growing body of literature supporting the use of hospitalists, with most studies touting improved efficiency (reductions in LOS and total cost of care) without adversely impacting outcomes, quality of care, or satisfaction.3, 8, 17, 19

Impact on Costs and LOS 

The hospitalist model has been shown to be effective in a variety of settings, with most studies demonstrating that patients treated by hospitalists have lower total costs and reduced LOS.3, 8 Wachter and Goldman found that 15 of the 19 studies reviewed reported an average 13.4% decrease in hospital costs and a 16.6% decrease in LOS with the use of hospitalists.3 Studies by Auerbach et al 9 and Meltzer et al 20 found that hospitalist care was associated with LOS and cost reductions that only became statistically significant in the second year of the hospitalist’s experience, which suggests a “practice makes perfect” relationship.21 Most studies only evaluate periods <2 years, so caution should be used when interpreting the long-term impact of the hospitalist model.8

Only 1 recently published study failed to support the economic benefit of hospitalists. Smith et al found the mean charge by PCPs was significantly lower than that of critical care hospitalists and family physician hospitalists.22 However, the study focused only on pneumonia, and the critical care hospitalists were all members of a health maintenance organization-mandated team.

Kaboli et al compared outcomes of patients on a general medicine hospitalist service with those of patients on a traditional inpatient service.23 They found patients treated by hospitalists had shorter LOS and lower overall costs than patients treated by non-hospitalists, but had higher costs per day. This suggests hospitalists may increase the intensity of care in a shorter period.

Published studies about the clinical impact of pediatric hospitalists also report mixed results. For example, Landrigan et al report that a study at Southern California Children’s Hospital found no difference in costs, LOS, or outcomes in patients with pediatric asthma/bronchiolitis who were cared for by hospitalists compared with those treated by community pediatricians.17 Conversely, in a study at Cincinnati Children’s Hospital, LOS decreased by 0.3 days (11%), hospitalization charges decreased by $282 (9%), and the readmission rates increased (2%) after the introduction of hospitalists.24 Landrigan et al found that the implementation of a pediatric hospitalist program within a staff model health maintenance organization significantly decreased LOS (12%; 0.3 days), reduced costs (16%; $217), and improved parental ratings of care without affecting outcomes.17

Impact on Quality and Clinical Outcomes 

Published studies related to clinical outcomes also report mixed results and typically only examine mortality and readmission rates. Most only examine single hospitals, small numbers of hospitalists, and the initial years of the programs.4 In most studies, hospitalists appear to have less of an impact on quality and outcomes than on cost and LOS.8 Further, most studies fail to find any statistically significant differences in readmission or mortality rates.3, 8 However, both Meltzer and Auerbach found improvements in outcomes increased with time, suggesting that experience is a factor in the quality improvement.9, 20

Baudendistel and Wachter also report that the impact of hospitalists on readmission rates is mixed, with 7 studies finding no change, 2 studies finding a reduction, and 1 study showing an increase.25 Tenner et al studied pediatric hospitalists in a pediatric intensive care unit.26 They found improved survival rates and shorter LOS when pediatric hospitalists, rather than residents, were providing after-hours care. Wells et al evaluated the inpatient care of 182 patients with pediatric asthma, half of whom were cared for by hospitalists and half by their PCP, and found hospitalists delivered care more efficiently with no significant differences in the rates of readmission to the emergency department or rehospitalization.27

Common Study Limitations 

There are many limitations associated with these studies. One key limitation is that many are not generalizable and may only be accurate assessments of the study population itself. Other common limitations include focusing on academic centers rather than community hospitals, the nonrandom assignment of patients to hospitalists or non-hospitalists, not controlling for severity of illness, short observational periods, and the use of rudimentary outcomes measures. Coffman and Rundall provide a comprehensive assessment of common methodological limitations in their literature review.8

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Research—opinion surveys 

In addition to data studies, much of the available literature focuses on surveys of patients and physicians to ascertain their attitudes toward hospitalists.

Impact on Patient Satisfaction 

A common concern noted by hospitalist critics is that patients will be less satisfied and the doctor-patient relationship may be impaired. However, most patient surveys show either no change in satisfaction or improved levels of satisfaction with hospitalists.3 Coffman and Rundall’s review found that “none of the 4 studies that evaluated patient satisfaction found statistically significant differences in satisfaction with inpatient care. However, 2 of the 3 evaluations that did assess parents’ satisfaction with care provided to their children found that parents were more satisfied with some aspects of care provided by hospitalists.”8

Impact on Provider Satisfaction 

Another area of interest has been the impact on non-hospitalist providers. Although concerns exist, most surveys seem to show that non-hospitalists generally approve of hospitalists. In a national survey of 2829 internists, 79% who used hospitalists were “very satisfied” or “satisfied” with them.21 Another survey of 236 internists about their attitudes toward hospitalists before and after program implementation found that physician attitudes about career satisfaction and relationship with patients improved after implementation.28

However, a survey of 313 physicians found attitudes about hospitalists vary among physician groups (eg, community- or hospital-based practice) and are influenced by practice characteristics.29 This study reported that “community physicians more often characterized inpatient care as an inefficient use of time, but were less likely to think hospitalists would improve quality of care, increase patient satisfaction, or provide more effective teaching.” Additionally, community physicians who were younger (eg, <40 years old) or practicing a great distance from the hospital (eg, >13 miles) were found to have more positive attitudes toward hospitalists.

Impact on Medical Education 

A positive effect of hospitalists, including pediatric hospitalists, on medical education has been documented in a number of survey-based studies in both community and academic settings.18, 30 In most of the studies, hospitalists are rated higher as educators than traditional attending physicians.13, 21, 30, 31, 32 Kripalani found that hospitalists were considered more enthusiastic, conveyed greater enjoyment of teaching, and related well to trainees.32 Similarly, hospitalists have been rated higher in the areas of communication of rotation goals, establishing a favorable learning climate, knowledge of relevant subject matter, use of educational time, teaching style, and providing feedback.31, 33

Carlson et al note that “most studies on the impact of the hospitalist on pediatric medical education have been positive.”18 However, 1 study did report decreased ratings in resident autonomy and supervisory skills after the introduction of a hospitalist system.13

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Literature reviews 

There were 15 literature reviews identified in our search that focused primarily on the impact of the hospitalist movement. Coffman and Rundall examined 21 articles about the impact of hospitalists (4 of the 21 were conducted in a pediatric setting).8 They report that “most of the evaluations found patients managed by hospitalists had lower total costs or charges primarily due to reduced LOS and most of the evaluations found no statistically significant differences in quality of care or satisfaction.”

Similarly, Wachter and Goldman reviewed 19 studies and found that most show that hospitalist programs are associated with significant reductions in resource use.3 They also found results related to clinical outcomes to be inconsistent, that patient satisfaction typically remained unchanged, and that there was limited data to determine the impact on teaching.

Landrigan et al reviewed literature related to adult and pediatric hospitalists and found that pediatric hospitalist data show mixed results.19 This variability, the authors suggest, “is due to the lack of external regulation or accreditation for the practice of pediatric hospitalist medicine.”

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Case studies 

These articles provide examples of the broader findings from previous sections. For example, Ogershok et al describe the restructuring of an inpatient pediatric ward using the hospitalist model and report that hospital costs per patient fell 13%.34 In another study, hospitalists managing inpatient care reduced commercial LOS to 3.8 days from 6.2 days and Medicare length of stay to 4.2 days from 7.1.35

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Commentaries 

These articles provide overviews of the hospitalist “movement” and offer comments on the various limitations of the existing studies. Because the focus of this review is on research that quantifies the impact of hospitalists, we have not included a detailed discussion of commentaries and recommend the accompanying literature review matrix for details.

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Areas for further research 

Because the literature surrounding the specific impact of pediatric hospitalists is still fairly limited, larger and more rigorous pediatric-focused studies must be performed to identify how pediatric hospitalists affect outcomes, costs, and satisfaction.3, 16 There is also a need for further research about the educational impact of hospitalists. A 2001 literature review by Landrigan et al specifies a detailed research agenda to further evaluate pediatric hospitalist systems.19

Other areas requiring further research include: comparison of different hospitalist models (eg, rotation versus dedicated, faculty-led versus non-faculty); comparison of hospitalist model to other strategies for controlling costs or improving quality; comparison of hospitalist model with less costly interventions (eg, clinical practice guidelines, non-physician case managers); evaluation of characteristics of hospitalists to determine the mechanisms by which hospitalists improve quality and reduce costs; and more studies of non-teaching and community hospitalists to improve the generalizability of findings.8, 13, 35

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References 

  1. Wachter RM . The evolution of the hospitalist model in the United States . Med Clin North Am . 2002;86:687–706
  2. Percelay JM , Strong GB . Guiding principles for pediatric hospitalist programs . Pediatrics . 2005;115:1101–1102
  3. Wachter RM , Goldman L . The hospitalist movement 5 years later . JAMA . 2002;287:487–494
  4. Wachter RM . Hospitalists in the United States—mission accomplished or work in progress? . N Engl J Med . 2004;350:1935–1936
  5. Rogers JC . Pediatric hospitalist programs offer chance to improve quality and cost . Health Care Strateg Manage . 2003;21:12–15
  6. Melzer SM , Molteni RA , Marcuse EK , Rivara FP . Characteristics and financial performance of a pediatric faculty inpatient attending service (a resource-based relative value scale analysis) . Pediatrics . 2001;108:79–84
  7. Hauer KE , Wachter RM . Implications of the hospitalist model for medical students’ education . Acad Med . 2001;76:324–330
  8. Coffman J , Rundall TG . The impact of hospitalists on the cost and quality of inpatient care in the United States (a research synthesis) . Med Care Res Rev . 2005;62:379–406
  9. Auerbach AD , Wachter RM , Katz P , Showstack J , Baron RB , Goldman L . Implementation of a voluntary hospitalist service at a community teaching hospital (improved clinical efficiency and patient outcomes) . Ann Intern Med . 2002;137:859–865
  10. Fernandez A , Grumbach K , Goitein L , Vranizan K , Osmond DH , Bindman AB . Friend or foe? How primary care physicians perceive hospitalists . Arch Intern Med . 2000;160:2902–2908
  11. Roy CL , Poon EG , Karson AS , Ladak-Merchant Z , Johnson RE , Maviglia SM , et al.   Patient safety concerns arising from test results that return after hospital discharge . Ann Intern Med . 2005;143:121–128
  12. Flanders SA , Wachter RM . Hospitalists (the new model of inpatient medical care in the United States) . Eur J Intern Med . 2003;14:65–70
  13. Landrigan CP , Muret-Wagstaff S , Chiang VW , Nigrin DJ , Goldmann DA , Finkelstein JA . Effect of a pediatric hospitalist system on housestaff education and experience . Arch Pediatr Adolesc Med . 2002;156:877–883
  14. Narang AS , Ey J . The emerging role of pediatric hospitalists . Clin Pediatr (Phila) . 2003;42:295–297
  15. Plauth WH , Pantilat SZ , Wachter RM , Fenton CL . Hospitalists’ perceptions of their residency training needs (results of a national survey) . 3rd ?? Am J Med . 2001;111:247–254
  16. Srivastava R , Landrigan C , Gidwani P , Harary OH , Muret-Wagstaff S , Homer CJ . Pediatric hospitalists in Canada and the United States (a survey of pediatric academic department chairs) . Ambul Pediatr . 2001;1:338–339
  17. Landrigan CP , Srivastava R , Muret-Wagstaff S , Soumerai SB , Ross-Degnan D , Graef JW , et al.   Impact of a health maintenance organization hospitalist system in academic pediatrics . Pediatrics . 2002;110:720–728
  18. Carlson DW , Fentzke KM , Dawson JG . Pediatric hospitalists fill varied roles in the care of newborns . Pediatr Ann . 2003;32:802–810
  19. Landrigan C , Srivastava R , Muret-Wagstaff S , Dyck IJ , Homer CJ , Goldmann DA . Pediatric hospitalists (what do we know, and where do we go from here?) . Ambul Pediatr . 2001;1:340–345
  20. Meltzer D , Manning WG , Morrison J , Shah MN , Jin L , Guth T , 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
  21. Freed DH . Hospitalists (evolution, evidence, and eventualities) . Health Care Manage (Frederick) . 2004;23:238–256
  22. Smith PC , Westfall JM , Nichols RA . Primary care family physicians and 2 hospitalist models (comparison of outcomes, processes, and costs) . J Fam Pract . 2002;51:1021–1027
  23. Kaboli PJ , Barnett MJ , Rosenthal GE . Associations with reduced length of stay and costs on an academic hospitalist service . Am J Manag Care . 2004;10:561–568
  24. Bellet PS , Whitaker RC . Evaluation of a pediatric hospitalist service (impact on length of stay and hospital charges) . Pediatrics . 2000;105:478–484
  25. Baudendistel TE , Wachter RM . The evolution of the hospitalist movement in the USA . Clin Med . 2002;2:327–330
  26. Tenner PA , Dibrell H , Taylor RP . Improved survival with hospitalists in a pediatric intensive care unit . Crit Care Med . 2003;31:847–852
  27. Wells RD , Dahl B , Wilson SD . Pediatric hospitalists (quality care for the underserved?) . Am J Med Qual . 2001;16:174–180
  28. Auerbach AD , Aronson MD , Davis RB , Phillips RS . How physicians perceive hospitalist services after implementation (anticipation versus reality) . Arch Intern Med . 2003;163:2330–2336
  29. Srivastava R , Norlin C , James BC , Muret-Wagstaff S , Young PC , Auerbach A . Community and hospital-based physicians’ attitudes regarding pediatric hospitalist systems . Pediatrics . 2005;115:34–38
  30. Saint S , Flanders SA . Hospitalists in teaching hospitals (opportunities but not without danger) . J Gen Intern Med . 2004;19:392–393
  31. Hunter AJ , Desai SS , Harrison RA , Chan BK . Medical student evaluation of the quality of hospitalist and nonhospitalist teaching faculty on inpatient medicine rotations . Acad Med . 2004;79:78–82
  32. Kripalani S , Pope AC , Rask K , Hunt K , Dressler DD , Branch WT , et al.   Hospitalists as teachers . J Gen Intern Med . 2004;19:8–15
  33. Hauer KE , Wachter RM , McCulloch CE , Woo GA , Auerbach AD . Effects of hospitalist attending physicians on trainee satisfaction with teaching and with internal medicine rotations . Arch Intern Med . 2004;164:1866–1871
  34. Ogershok PR , Li X , Palmer HC , Moore RS , Weisse ME , Ferrari ND . Restructuring an academic pediatric inpatient service using concepts developed by hospitalists . Clin Pediatr (Phila) . 2001;40:653–662
  35. Alta Bates uses hospitalists to reduce inpatient days, improve capitation performance . Capitation Manag Rep . 2004;11:106–108 97

 Supported by a grant from the American Board of Pediatrics Foundation.

PII: S0022-3476(05)01234-5

doi:10.1016/j.jpeds.2005.12.048

The Journal of Pediatrics
Volume 148, Issue 3 , Pages 296-299, March 2006

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