Jonathan Zenilman, MD

Inappropriate antibiotic use is a major public health concern and demonstrates the need for quality improvement initiatives in the delivery of health care.16 Each year nearly 2 million patients in the United States acquire an infection in the hospital, and about 90,000 of them die from these infections.7 More than 70% of the bacteria that cause hospital‐acquired infections are resistant to at least one commonly used drug.7 Persons infected with drug‐resistant organisms have longer hospital stays and higher mortality rates.7

Inappropriate antibiotic use in the inpatient hospital setting can be classified into 5 categories. First, antibiotics may be given for illnesses for which they are not indicated (eg, viral infections). Second, broad‐spectrum antibiotics (such as piperacillin‐tazobactam and quinolones) may be overused in the empiric treatment of common infections.8 Overuse of broad‐spectrum drugs increases selective pressure for antimicrobial resistance and exposes patients to the side effects of some of these drugs, such as Clostridium difficile colitis.8 Third, clinicians occasionally prescribe intravenous (IV) antibiotics when the efficacy of oral agents would be similar. Inappropriate intravenous therapy increases the cost of care and also exposes the patient to the risk of intravenous catheters.8 Fourth, when the correct antibiotic choice is made, inappropriate antibiotic dosage, schedule, and/or duration of treatment can threaten patient safety.8 Fifth, bug‐drug mismatch occurs when susceptibility studies indicate that the drug being used is ineffective or only marginally effective.8 Beyond antimicrobial resistance and safety, these practices also usually increase costs to both the patient and the hospital.7, 910

Influencing providers' prescribing patterns is difficult.11 In this project we assessed the prescribing patterns of hospitalists in an active inpatient environment and then developed an intervention to improve the providers' use of antibiotics. The intervention utilized public health methodologyprior to implementation, we defined the problem, determined its magnitude, identified a behavior change model, and constructed a conceptual framework that identifyied the key determinants. A pilot academic detailing project addressing many determinants was developed, implemented, and evaluated.

Conceptual Model

To change prescribing behaviors is to change learned behaviors. Changing behavior is a complex process affected by several factors including beliefs, expectations, motivations, and the psychosocial environments of the target groups.12 Each of these factors must be considered when attempting to bring about behavior changes. In doing so, a theory that can be depicted in a model often emerges.13 This approach is widely used in understanding and developing public health interventions.

Formulating the Model

In any public health intervention, recognizing and engaging key stakeholders is a critical step. We identified the following stakeholders: (1) hospitalist practitioners and other prescribing providers including residents and infectious disease specialists; (2) nurses; (3) administrators who are focused on cost effectiveness; (4) patients and their families, who want to get well affordably, without side effects; (5) pharmacists; (6) risk management; and (7) society, which is fearful of the propagation of resistant microbes. In consulting with some of the stakeholders, 4 factors that influence hospitalists' prescribing patterns became apparent. These are practitioner factors, environmental factors, perceived rewards, and perceived threats (Fig. 1).

Figure 1

The practitioner factors shaping prescribing are: (1) knowledge of current best care; (2) self‐efficacy, which determines whether a provider is confident in his or her knowledge to adequately treat a specific infection; (3) habit, which causes providers to pick from a narrow repertoire of antibiotics when treating an infection; and (4) fear of liability, which forces some providers to be cautious. Four environmental factors affecting antibiotic prescriptions are: (1) published guidelines regarding organisms' sensitivity to antibiotics; (2) patient‐driven factors such as affordability, compliance with dosing regimens, side effects, and interactions between the antibiotics and other medications; (3) peer influence, in that providers are reluctant to change a prescription started by another provider (eg, emergency room physician); and (4) the formulary of the hospital, as it forces providers to prescribe within specific parameters. The perceived rewards of specific prescribing practices may include improving patient safety and reducing antibiotic resistance and costs, whereas the perceived threats are increasing antimicrobial resistance, having adverse patient outcomes, and increasing costs and hospital length of stay. We selected a high‐yield, low‐effort intervention in order to have an impact on some of the factors underlying hospitalists' prescribing patterns.

METHODS

Data Collection

We collected and assessed prescription patterns over 3 periods: preintervention, interim, and postintervention.

Detailing Procedures

After the review, a profile was assembled for each of the CIMS providers. The study team detailers (a physician and a pharmacist) met with the individual providers for 30 to 45 minutes. Each hospitalist participant completed a short survey that collected demographic information and was asked about the rationale for his or her antibiotic prescribing pattern. Next, the appraisal of the provider's prescribing pattern was reviewed. This review included looking at the costs of the prescribed antibiotics compared with those of the appropriate alternatives and a reexamination of the guidelines for the selected target drugspiperacillin‐tazobactam, vancomycin, and extended‐spectrum quinolones. These 3 antibiotics were picked because our providers had been particularly vulnerable to inappropriately prescribing them. The hospitalists were provided an antibiotic guide developed specifically for this project and based on the Johns Hopkins Antibiotic Guide14 that summarizes the consensus guidelines.

Data Analysis

The primary outcome variable was the aggregate proportion of inappropriate antibiotic prescribed (as defined earlier) before the intervention, during the interim between obtaining informed consent and intervening on all study subjects, and after the intervention. The percentage of appropriate prescriptions versus total not appropriate prescriptions (combining of the effective but inappropriate and inappropriate categories) were compared across the 3 periods. Ninety‐five percent confidence intervals for comparisons of the proportions were determined using Stata 9.0 (College Station, TX). The difference between the proportions of total not appropriate prescriptions before and after academic detailing was computed in Stata using Fisher's exact test to assess significance.

RESULTS

Demographic information and professional characteristics of the 17 providers are shown in Table 1. Their mean age was 36 years, and 76% were female. The top 4 reasons the providers gave for their prescribing practices were: (1) published guidelines, (2) easier dosing schedule for patient when discharged, (3) continuing an antibiotic course initiated in the emergency room, and (4) broad‐spectrum antibiotics cover all possible microbes.

DISCUSSION

We have demonstrated that academic detailing had a positive impact on the prescribing patterns of hospitalists. The aggregated improvement in antibiotic prescribing patterns can be attributed to improvement in the prescribing patterns of almost every hospitalist practitioner (Table 2). This study focused on aggregate prescriptions as the primary outcome measure because the hospitalists at JHBMC, like at many other institutions, function as a team, with a patient routinely having multiple providers over the course of the hospital stay. The improved prescribing patterns noted during the interim period suggest that the mere knowledge of a project can have an impact on providers. Providers informed the investigators that they were more thoughtful about their choice of antibiotics when they knew that they were being studied. The further statistically significant improvement in prescribing patterns with the intervention shows that the academic detailing itself was successful.

The greatest absolute change in practice was seen in effective but inappropriate prescribing (from 30.4% to 6%), whereas inappropriate prescribing only decreased from 26.6% to 20.6%. Although we aimed to have an impact on all inappropriate antibiotic prescribing patterns, we specifically reviewed the prescribing guidelines for piperacillin‐tazobactam, extended‐spectrum quinolones, and vancomycin. These 3 antibiotics were targeted because our providers had been particularly susceptible to inappropriately prescribing them. The focus on these antibiotics may have resulted in the larger absolute change noted in effective but inappropriate prescribing. We did not collect any data to determine if having an impact on effective but inappropriate prescribing changed the clinical course of the patients, such as shortening their hospital stays. Anecdotal evidence, however, suggests that it does. At our institution it is not uncommon for patients to be kept in the hospital for an extra day to ensure they are stable when transitioned from extended‐spectrum to narrower‐spectrum antibiotics prior to discharge. The effect of reducing effective but inappropriate prescriptions on the clinical course of patients could be an outcome measure assessed by a future, larger study.

Our one‐on‐one appraisal of each provider's prescribing patterns included a review of the cost of the prescribed antibiotics compared with that of the appropriate alternatives. Although decisions on antibiotic choice should be driven by clinical guidelines and appropriateness rather than price, we believed it was relevant to include education about costs and pricing so that providers would be reminded to ascertain whether patients would be able to afford their antibiotics. Antibiotic resistance is influenced by a patient's failure to complete the course of treatment, and noncompliance may be caused by an inability to afford the medication. Often, there are affordable, appropriate alternatives to the newest and most expensive drugs.

A hospitalist‐based academic detailing approach to improving antibiotic prescribing may have far‐reaching benefits and influence. First, it has the potential to affect other practitioners by setting an example and role modeling. In addition to that with their immediate peer group, hospitalists have close and repeated contact with house officers and emergency room physicians and often act as consultants to physicians in other departments such as surgery and psychiatry. Furthermore, some community hospitals have no infectious disease specialists readily available. So this represents an opportunity for hospitalists to promote quality in antibiotic prescribing. Practice‐based learning was very effective because it brought the practitioners face to face with their prescribing patterns. Although intellectually everyone agreed that antibiotics are often misused, this approach forced the providers to stop and reflect on their individual practices. This peer‐delivered intervention allowed for a collaborative approach to solving the problem; the peer (detailer) was approachable, nonjudgmental, and available for further discussion and guidance.

The public health quality improvement approach that we used for our intervention helped us to realize and appreciate the factors underlying prescribing patterns. Only by understanding the motivations for prescribing patterns can we hope to make sustainable changes. This coincides with our previous assertion that hospitalists are engaging in some public health practice.16 In pubic health, the programs, services, and institutions involved emphasize the prevention of disease and the health needs of the population as a whole.17 Hospitalist teams aim to make sure that the high‐quality services needed for protecting the health of their community (hospitalized patients) are available and that this population receives proper consideration in the allocation of resources. Antibiotic optimization is a key role that could fall within the mantra of public health practice for the hospitalist.

Several limitations of this pilot should be considered. First, the intervention is labor intensive. However, it is essential to use the problem‐solving paradigm and incorporate behavior change theories in order to identify interventions that can lead to sustainable change. Second, this was not a randomized controlled trial, and it is possible that there might have been some contamination by external forces. However, in reviewing the educational events at our institution, the press, and articles published during the study period, we could not identify any external factors that would have influenced antibiotic prescribing patterns. It would not have been possible to conduct a randomized trial at our institution because the hospitalists work so closely together that we could not ensure complete separation if the subjects were randomized. There would have been contamination from the intervention group to the control group. A trial with randomization at the institution level is the next step. Third, the number of months retrospectively reviewed in order to identify 20 prescriptions of a provider varied. This study assumed there were no other differences during those months that could have affected provider prescribing behavior; this may have introduced some bias. Fourth, the sustainability of this intervention's positive impact is unknown. We assessed outcome soon after the intervention, and it is unknown whether continual booster sessions are required to maintain the positive impact on prescribing patterns.

This pilot was a good starting place to show that behavior change can be realized with a well‐conceived and methodically executed intervention, even among the busiest of physicians. Audit and feedback, or practice‐based learning, appears to be a powerful educational intervention among professionals who take great pride in their work.

Inappropriate antibiotic use is a major public health concern and demonstrates the need for quality improvement initiatives in the delivery of health care.16 Each year nearly 2 million patients in the United States acquire an infection in the hospital, and about 90,000 of them die from these infections.7 More than 70% of the bacteria that cause hospital‐acquired infections are resistant to at least one commonly used drug.7 Persons infected with drug‐resistant organisms have longer hospital stays and higher mortality rates.7

Inappropriate antibiotic use in the inpatient hospital setting can be classified into 5 categories. First, antibiotics may be given for illnesses for which they are not indicated (eg, viral infections). Second, broad‐spectrum antibiotics (such as piperacillin‐tazobactam and quinolones) may be overused in the empiric treatment of common infections.8 Overuse of broad‐spectrum drugs increases selective pressure for antimicrobial resistance and exposes patients to the side effects of some of these drugs, such as Clostridium difficile colitis.8 Third, clinicians occasionally prescribe intravenous (IV) antibiotics when the efficacy of oral agents would be similar. Inappropriate intravenous therapy increases the cost of care and also exposes the patient to the risk of intravenous catheters.8 Fourth, when the correct antibiotic choice is made, inappropriate antibiotic dosage, schedule, and/or duration of treatment can threaten patient safety.8 Fifth, bug‐drug mismatch occurs when susceptibility studies indicate that the drug being used is ineffective or only marginally effective.8 Beyond antimicrobial resistance and safety, these practices also usually increase costs to both the patient and the hospital.7, 910

Influencing providers' prescribing patterns is difficult.11 In this project we assessed the prescribing patterns of hospitalists in an active inpatient environment and then developed an intervention to improve the providers' use of antibiotics. The intervention utilized public health methodologyprior to implementation, we defined the problem, determined its magnitude, identified a behavior change model, and constructed a conceptual framework that identifyied the key determinants. A pilot academic detailing project addressing many determinants was developed, implemented, and evaluated.

Conceptual Model

To change prescribing behaviors is to change learned behaviors. Changing behavior is a complex process affected by several factors including beliefs, expectations, motivations, and the psychosocial environments of the target groups.12 Each of these factors must be considered when attempting to bring about behavior changes. In doing so, a theory that can be depicted in a model often emerges.13 This approach is widely used in understanding and developing public health interventions.

Formulating the Model

In any public health intervention, recognizing and engaging key stakeholders is a critical step. We identified the following stakeholders: (1) hospitalist practitioners and other prescribing providers including residents and infectious disease specialists; (2) nurses; (3) administrators who are focused on cost effectiveness; (4) patients and their families, who want to get well affordably, without side effects; (5) pharmacists; (6) risk management; and (7) society, which is fearful of the propagation of resistant microbes. In consulting with some of the stakeholders, 4 factors that influence hospitalists' prescribing patterns became apparent. These are practitioner factors, environmental factors, perceived rewards, and perceived threats (Fig. 1).

Figure 1

The practitioner factors shaping prescribing are: (1) knowledge of current best care; (2) self‐efficacy, which determines whether a provider is confident in his or her knowledge to adequately treat a specific infection; (3) habit, which causes providers to pick from a narrow repertoire of antibiotics when treating an infection; and (4) fear of liability, which forces some providers to be cautious. Four environmental factors affecting antibiotic prescriptions are: (1) published guidelines regarding organisms' sensitivity to antibiotics; (2) patient‐driven factors such as affordability, compliance with dosing regimens, side effects, and interactions between the antibiotics and other medications; (3) peer influence, in that providers are reluctant to change a prescription started by another provider (eg, emergency room physician); and (4) the formulary of the hospital, as it forces providers to prescribe within specific parameters. The perceived rewards of specific prescribing practices may include improving patient safety and reducing antibiotic resistance and costs, whereas the perceived threats are increasing antimicrobial resistance, having adverse patient outcomes, and increasing costs and hospital length of stay. We selected a high‐yield, low‐effort intervention in order to have an impact on some of the factors underlying hospitalists' prescribing patterns.

METHODS

Data Collection

We collected and assessed prescription patterns over 3 periods: preintervention, interim, and postintervention.

Detailing Procedures

After the review, a profile was assembled for each of the CIMS providers. The study team detailers (a physician and a pharmacist) met with the individual providers for 30 to 45 minutes. Each hospitalist participant completed a short survey that collected demographic information and was asked about the rationale for his or her antibiotic prescribing pattern. Next, the appraisal of the provider's prescribing pattern was reviewed. This review included looking at the costs of the prescribed antibiotics compared with those of the appropriate alternatives and a reexamination of the guidelines for the selected target drugspiperacillin‐tazobactam, vancomycin, and extended‐spectrum quinolones. These 3 antibiotics were picked because our providers had been particularly vulnerable to inappropriately prescribing them. The hospitalists were provided an antibiotic guide developed specifically for this project and based on the Johns Hopkins Antibiotic Guide14 that summarizes the consensus guidelines.

Data Analysis

The primary outcome variable was the aggregate proportion of inappropriate antibiotic prescribed (as defined earlier) before the intervention, during the interim between obtaining informed consent and intervening on all study subjects, and after the intervention. The percentage of appropriate prescriptions versus total not appropriate prescriptions (combining of the effective but inappropriate and inappropriate categories) were compared across the 3 periods. Ninety‐five percent confidence intervals for comparisons of the proportions were determined using Stata 9.0 (College Station, TX). The difference between the proportions of total not appropriate prescriptions before and after academic detailing was computed in Stata using Fisher's exact test to assess significance.

RESULTS

Demographic information and professional characteristics of the 17 providers are shown in Table 1. Their mean age was 36 years, and 76% were female. The top 4 reasons the providers gave for their prescribing practices were: (1) published guidelines, (2) easier dosing schedule for patient when discharged, (3) continuing an antibiotic course initiated in the emergency room, and (4) broad‐spectrum antibiotics cover all possible microbes.

DISCUSSION

We have demonstrated that academic detailing had a positive impact on the prescribing patterns of hospitalists. The aggregated improvement in antibiotic prescribing patterns can be attributed to improvement in the prescribing patterns of almost every hospitalist practitioner (Table 2). This study focused on aggregate prescriptions as the primary outcome measure because the hospitalists at JHBMC, like at many other institutions, function as a team, with a patient routinely having multiple providers over the course of the hospital stay. The improved prescribing patterns noted during the interim period suggest that the mere knowledge of a project can have an impact on providers. Providers informed the investigators that they were more thoughtful about their choice of antibiotics when they knew that they were being studied. The further statistically significant improvement in prescribing patterns with the intervention shows that the academic detailing itself was successful.

The greatest absolute change in practice was seen in effective but inappropriate prescribing (from 30.4% to 6%), whereas inappropriate prescribing only decreased from 26.6% to 20.6%. Although we aimed to have an impact on all inappropriate antibiotic prescribing patterns, we specifically reviewed the prescribing guidelines for piperacillin‐tazobactam, extended‐spectrum quinolones, and vancomycin. These 3 antibiotics were targeted because our providers had been particularly susceptible to inappropriately prescribing them. The focus on these antibiotics may have resulted in the larger absolute change noted in effective but inappropriate prescribing. We did not collect any data to determine if having an impact on effective but inappropriate prescribing changed the clinical course of the patients, such as shortening their hospital stays. Anecdotal evidence, however, suggests that it does. At our institution it is not uncommon for patients to be kept in the hospital for an extra day to ensure they are stable when transitioned from extended‐spectrum to narrower‐spectrum antibiotics prior to discharge. The effect of reducing effective but inappropriate prescriptions on the clinical course of patients could be an outcome measure assessed by a future, larger study.

Our one‐on‐one appraisal of each provider's prescribing patterns included a review of the cost of the prescribed antibiotics compared with that of the appropriate alternatives. Although decisions on antibiotic choice should be driven by clinical guidelines and appropriateness rather than price, we believed it was relevant to include education about costs and pricing so that providers would be reminded to ascertain whether patients would be able to afford their antibiotics. Antibiotic resistance is influenced by a patient's failure to complete the course of treatment, and noncompliance may be caused by an inability to afford the medication. Often, there are affordable, appropriate alternatives to the newest and most expensive drugs.

A hospitalist‐based academic detailing approach to improving antibiotic prescribing may have far‐reaching benefits and influence. First, it has the potential to affect other practitioners by setting an example and role modeling. In addition to that with their immediate peer group, hospitalists have close and repeated contact with house officers and emergency room physicians and often act as consultants to physicians in other departments such as surgery and psychiatry. Furthermore, some community hospitals have no infectious disease specialists readily available. So this represents an opportunity for hospitalists to promote quality in antibiotic prescribing. Practice‐based learning was very effective because it brought the practitioners face to face with their prescribing patterns. Although intellectually everyone agreed that antibiotics are often misused, this approach forced the providers to stop and reflect on their individual practices. This peer‐delivered intervention allowed for a collaborative approach to solving the problem; the peer (detailer) was approachable, nonjudgmental, and available for further discussion and guidance.

The public health quality improvement approach that we used for our intervention helped us to realize and appreciate the factors underlying prescribing patterns. Only by understanding the motivations for prescribing patterns can we hope to make sustainable changes. This coincides with our previous assertion that hospitalists are engaging in some public health practice.16 In pubic health, the programs, services, and institutions involved emphasize the prevention of disease and the health needs of the population as a whole.17 Hospitalist teams aim to make sure that the high‐quality services needed for protecting the health of their community (hospitalized patients) are available and that this population receives proper consideration in the allocation of resources. Antibiotic optimization is a key role that could fall within the mantra of public health practice for the hospitalist.

Several limitations of this pilot should be considered. First, the intervention is labor intensive. However, it is essential to use the problem‐solving paradigm and incorporate behavior change theories in order to identify interventions that can lead to sustainable change. Second, this was not a randomized controlled trial, and it is possible that there might have been some contamination by external forces. However, in reviewing the educational events at our institution, the press, and articles published during the study period, we could not identify any external factors that would have influenced antibiotic prescribing patterns. It would not have been possible to conduct a randomized trial at our institution because the hospitalists work so closely together that we could not ensure complete separation if the subjects were randomized. There would have been contamination from the intervention group to the control group. A trial with randomization at the institution level is the next step. Third, the number of months retrospectively reviewed in order to identify 20 prescriptions of a provider varied. This study assumed there were no other differences during those months that could have affected provider prescribing behavior; this may have introduced some bias. Fourth, the sustainability of this intervention's positive impact is unknown. We assessed outcome soon after the intervention, and it is unknown whether continual booster sessions are required to maintain the positive impact on prescribing patterns.

This pilot was a good starting place to show that behavior change can be realized with a well‐conceived and methodically executed intervention, even among the busiest of physicians. Audit and feedback, or practice‐based learning, appears to be a powerful educational intervention among professionals who take great pride in their work.

Inappropriate antibiotic use is a major public health concern and demonstrates the need for quality improvement initiatives in the delivery of health care.16 Each year nearly 2 million patients in the United States acquire an infection in the hospital, and about 90,000 of them die from these infections.7 More than 70% of the bacteria that cause hospital‐acquired infections are resistant to at least one commonly used drug.7 Persons infected with drug‐resistant organisms have longer hospital stays and higher mortality rates.7

Inappropriate antibiotic use in the inpatient hospital setting can be classified into 5 categories. First, antibiotics may be given for illnesses for which they are not indicated (eg, viral infections). Second, broad‐spectrum antibiotics (such as piperacillin‐tazobactam and quinolones) may be overused in the empiric treatment of common infections.8 Overuse of broad‐spectrum drugs increases selective pressure for antimicrobial resistance and exposes patients to the side effects of some of these drugs, such as Clostridium difficile colitis.8 Third, clinicians occasionally prescribe intravenous (IV) antibiotics when the efficacy of oral agents would be similar. Inappropriate intravenous therapy increases the cost of care and also exposes the patient to the risk of intravenous catheters.8 Fourth, when the correct antibiotic choice is made, inappropriate antibiotic dosage, schedule, and/or duration of treatment can threaten patient safety.8 Fifth, bug‐drug mismatch occurs when susceptibility studies indicate that the drug being used is ineffective or only marginally effective.8 Beyond antimicrobial resistance and safety, these practices also usually increase costs to both the patient and the hospital.7, 910

Influencing providers' prescribing patterns is difficult.11 In this project we assessed the prescribing patterns of hospitalists in an active inpatient environment and then developed an intervention to improve the providers' use of antibiotics. The intervention utilized public health methodologyprior to implementation, we defined the problem, determined its magnitude, identified a behavior change model, and constructed a conceptual framework that identifyied the key determinants. A pilot academic detailing project addressing many determinants was developed, implemented, and evaluated.

Conceptual Model

To change prescribing behaviors is to change learned behaviors. Changing behavior is a complex process affected by several factors including beliefs, expectations, motivations, and the psychosocial environments of the target groups.12 Each of these factors must be considered when attempting to bring about behavior changes. In doing so, a theory that can be depicted in a model often emerges.13 This approach is widely used in understanding and developing public health interventions.

Formulating the Model

In any public health intervention, recognizing and engaging key stakeholders is a critical step. We identified the following stakeholders: (1) hospitalist practitioners and other prescribing providers including residents and infectious disease specialists; (2) nurses; (3) administrators who are focused on cost effectiveness; (4) patients and their families, who want to get well affordably, without side effects; (5) pharmacists; (6) risk management; and (7) society, which is fearful of the propagation of resistant microbes. In consulting with some of the stakeholders, 4 factors that influence hospitalists' prescribing patterns became apparent. These are practitioner factors, environmental factors, perceived rewards, and perceived threats (Fig. 1).

Figure 1

The practitioner factors shaping prescribing are: (1) knowledge of current best care; (2) self‐efficacy, which determines whether a provider is confident in his or her knowledge to adequately treat a specific infection; (3) habit, which causes providers to pick from a narrow repertoire of antibiotics when treating an infection; and (4) fear of liability, which forces some providers to be cautious. Four environmental factors affecting antibiotic prescriptions are: (1) published guidelines regarding organisms' sensitivity to antibiotics; (2) patient‐driven factors such as affordability, compliance with dosing regimens, side effects, and interactions between the antibiotics and other medications; (3) peer influence, in that providers are reluctant to change a prescription started by another provider (eg, emergency room physician); and (4) the formulary of the hospital, as it forces providers to prescribe within specific parameters. The perceived rewards of specific prescribing practices may include improving patient safety and reducing antibiotic resistance and costs, whereas the perceived threats are increasing antimicrobial resistance, having adverse patient outcomes, and increasing costs and hospital length of stay. We selected a high‐yield, low‐effort intervention in order to have an impact on some of the factors underlying hospitalists' prescribing patterns.

METHODS

Data Collection

We collected and assessed prescription patterns over 3 periods: preintervention, interim, and postintervention.

Detailing Procedures

After the review, a profile was assembled for each of the CIMS providers. The study team detailers (a physician and a pharmacist) met with the individual providers for 30 to 45 minutes. Each hospitalist participant completed a short survey that collected demographic information and was asked about the rationale for his or her antibiotic prescribing pattern. Next, the appraisal of the provider's prescribing pattern was reviewed. This review included looking at the costs of the prescribed antibiotics compared with those of the appropriate alternatives and a reexamination of the guidelines for the selected target drugspiperacillin‐tazobactam, vancomycin, and extended‐spectrum quinolones. These 3 antibiotics were picked because our providers had been particularly vulnerable to inappropriately prescribing them. The hospitalists were provided an antibiotic guide developed specifically for this project and based on the Johns Hopkins Antibiotic Guide14 that summarizes the consensus guidelines.

Data Analysis

The primary outcome variable was the aggregate proportion of inappropriate antibiotic prescribed (as defined earlier) before the intervention, during the interim between obtaining informed consent and intervening on all study subjects, and after the intervention. The percentage of appropriate prescriptions versus total not appropriate prescriptions (combining of the effective but inappropriate and inappropriate categories) were compared across the 3 periods. Ninety‐five percent confidence intervals for comparisons of the proportions were determined using Stata 9.0 (College Station, TX). The difference between the proportions of total not appropriate prescriptions before and after academic detailing was computed in Stata using Fisher's exact test to assess significance.

RESULTS

Demographic information and professional characteristics of the 17 providers are shown in Table 1. Their mean age was 36 years, and 76% were female. The top 4 reasons the providers gave for their prescribing practices were: (1) published guidelines, (2) easier dosing schedule for patient when discharged, (3) continuing an antibiotic course initiated in the emergency room, and (4) broad‐spectrum antibiotics cover all possible microbes.

DISCUSSION

We have demonstrated that academic detailing had a positive impact on the prescribing patterns of hospitalists. The aggregated improvement in antibiotic prescribing patterns can be attributed to improvement in the prescribing patterns of almost every hospitalist practitioner (Table 2). This study focused on aggregate prescriptions as the primary outcome measure because the hospitalists at JHBMC, like at many other institutions, function as a team, with a patient routinely having multiple providers over the course of the hospital stay. The improved prescribing patterns noted during the interim period suggest that the mere knowledge of a project can have an impact on providers. Providers informed the investigators that they were more thoughtful about their choice of antibiotics when they knew that they were being studied. The further statistically significant improvement in prescribing patterns with the intervention shows that the academic detailing itself was successful.

The greatest absolute change in practice was seen in effective but inappropriate prescribing (from 30.4% to 6%), whereas inappropriate prescribing only decreased from 26.6% to 20.6%. Although we aimed to have an impact on all inappropriate antibiotic prescribing patterns, we specifically reviewed the prescribing guidelines for piperacillin‐tazobactam, extended‐spectrum quinolones, and vancomycin. These 3 antibiotics were targeted because our providers had been particularly susceptible to inappropriately prescribing them. The focus on these antibiotics may have resulted in the larger absolute change noted in effective but inappropriate prescribing. We did not collect any data to determine if having an impact on effective but inappropriate prescribing changed the clinical course of the patients, such as shortening their hospital stays. Anecdotal evidence, however, suggests that it does. At our institution it is not uncommon for patients to be kept in the hospital for an extra day to ensure they are stable when transitioned from extended‐spectrum to narrower‐spectrum antibiotics prior to discharge. The effect of reducing effective but inappropriate prescriptions on the clinical course of patients could be an outcome measure assessed by a future, larger study.

Our one‐on‐one appraisal of each provider's prescribing patterns included a review of the cost of the prescribed antibiotics compared with that of the appropriate alternatives. Although decisions on antibiotic choice should be driven by clinical guidelines and appropriateness rather than price, we believed it was relevant to include education about costs and pricing so that providers would be reminded to ascertain whether patients would be able to afford their antibiotics. Antibiotic resistance is influenced by a patient's failure to complete the course of treatment, and noncompliance may be caused by an inability to afford the medication. Often, there are affordable, appropriate alternatives to the newest and most expensive drugs.

A hospitalist‐based academic detailing approach to improving antibiotic prescribing may have far‐reaching benefits and influence. First, it has the potential to affect other practitioners by setting an example and role modeling. In addition to that with their immediate peer group, hospitalists have close and repeated contact with house officers and emergency room physicians and often act as consultants to physicians in other departments such as surgery and psychiatry. Furthermore, some community hospitals have no infectious disease specialists readily available. So this represents an opportunity for hospitalists to promote quality in antibiotic prescribing. Practice‐based learning was very effective because it brought the practitioners face to face with their prescribing patterns. Although intellectually everyone agreed that antibiotics are often misused, this approach forced the providers to stop and reflect on their individual practices. This peer‐delivered intervention allowed for a collaborative approach to solving the problem; the peer (detailer) was approachable, nonjudgmental, and available for further discussion and guidance.

The public health quality improvement approach that we used for our intervention helped us to realize and appreciate the factors underlying prescribing patterns. Only by understanding the motivations for prescribing patterns can we hope to make sustainable changes. This coincides with our previous assertion that hospitalists are engaging in some public health practice.16 In pubic health, the programs, services, and institutions involved emphasize the prevention of disease and the health needs of the population as a whole.17 Hospitalist teams aim to make sure that the high‐quality services needed for protecting the health of their community (hospitalized patients) are available and that this population receives proper consideration in the allocation of resources. Antibiotic optimization is a key role that could fall within the mantra of public health practice for the hospitalist.

Several limitations of this pilot should be considered. First, the intervention is labor intensive. However, it is essential to use the problem‐solving paradigm and incorporate behavior change theories in order to identify interventions that can lead to sustainable change. Second, this was not a randomized controlled trial, and it is possible that there might have been some contamination by external forces. However, in reviewing the educational events at our institution, the press, and articles published during the study period, we could not identify any external factors that would have influenced antibiotic prescribing patterns. It would not have been possible to conduct a randomized trial at our institution because the hospitalists work so closely together that we could not ensure complete separation if the subjects were randomized. There would have been contamination from the intervention group to the control group. A trial with randomization at the institution level is the next step. Third, the number of months retrospectively reviewed in order to identify 20 prescriptions of a provider varied. This study assumed there were no other differences during those months that could have affected provider prescribing behavior; this may have introduced some bias. Fourth, the sustainability of this intervention's positive impact is unknown. We assessed outcome soon after the intervention, and it is unknown whether continual booster sessions are required to maintain the positive impact on prescribing patterns.

This pilot was a good starting place to show that behavior change can be realized with a well‐conceived and methodically executed intervention, even among the busiest of physicians. Audit and feedback, or practice‐based learning, appears to be a powerful educational intervention among professionals who take great pride in their work.

The field of hospital medicine came into being in response to numerous factors involving physicians, patients, and hospitals themselves1 Now, years later, hospital medicine is a specialty that is growing, both in size and sophistication such that the role of the hospitalist is constantly evolving.2 A compelling function that has not yet been clearly articulated is the opportunity for hospitalists to serve as public health practitioners in their unique clinical environment. There is precedence for the power of collaboration between medicine and public health as has been seen with emergency medicine's willingness to embrace opportunities to advance public health.35

In public health, the programs, services, and institutions involved emphasize the prevention of disease and the health needs of the population as a whole. Public health activities vary with changing technology and social values, but the goals remain the same: to reduce the amount of disease, premature death, and disease‐associated discomfort and disability in the population.6 The authors of a leading textbook of public health, Scutchfield and Keck, contend that the most important skill for public health practice is the capacity to visualize the potential for health that exists in a community.6

Hospitalists care for a distinct subset of the general populationinpatients, only a small percentage of society in a given year. Yet over time hospitalists affect a substantial subset of the larger population that uses considerable health care resources.79 Furthermore, hospitalization can be a sentinel event with public health implications (eg, newly diagnosed HIV infection or acute myocardial infarction in a patient with an extended family of cigarette smokers). This presents an opportunity to educate and counsel both the patient and the patient's social network. One model of public health practice by hospitalists is to influence the patient, his or her family, and the community by touching and inspiring the hospitalized patient.

Hospitalists are already involved in many of the core functions of public health (assessment, assurance, and policy development; Fig. 1).10 Achieving ongoing success in this arena means developing hospitalists who are consciously in tune with their roles as public health practitioners.

Figure 1

In this article we define the specific public health contributions that hospitalists have made and describe the possibilities for further innovative advances. To this end, we outline specific public health roles under the broad categories of assessment, assurance, and policy. We point to advances in public health accomplished by hospitalists as well as those being performed by nonhospitalists in the hospital setting. We conclude by describing some of the barriers to and implications of hospitalists taking on public health roles.

ASSESSMENT

Assessment is the systematic collection, analysis, and dissemination of health status information.10 These activities include disease surveillance and investigation of acute outbreaks or changes in the epidemiology of chronic diseases. Assessment also involves understanding the health of a population and the key determinants of a population's health from a variety of perspectives: physical, biological, behavioral, social, cultural, and spiritual.6 Human health has been defined as a state characterized by anatomic integrity; ability to perform personally valued family work and community roles; ability to deal with physical, biologic, and social stress; a feeling of well‐being; and freedom from the risk of disease and untimely death.6 Hospitalists interact with individuals at times of stress and acute illness and thus have a unique opportunity to assess the strength, viability, and resources available to individuals. Key roles that may fall within the auspices of assessment in hospital medicine are infection control, epidemic recognition, disaster response, preventive care, substance abuse treatment, and chronic disease management.

ASSURANCE

Assurance is the provision of access to necessary health services. It entails efforts to solve problems that threaten the health of populations and empowers individuals to maintain their own health. This is accomplished by either encouraging action, delegating to other entities (private or public sector), mandating specific requirements through regulation, or providing services directly.10 Hospitalist teams aim to ensure that the high‐quality services needed to protect the health of their community (hospitalized patients) are available and that this population receives proper consideration in the allocation of resources. The few studies to date that have directly examined the quality of care that hospitalists provide38 have done so using evidence‐based measures believed to correlate with improved health care outcomes.38 The ambiguities in assessing quality may in part limit such studies.39 Specific hospitalist roles that fall under the assurance umbrella include antibiotic optimization, palliative care, patient safety, and medical error management.

POLICY

Policy development defines health control goals and objectives and develops implementation plans for those goals.10 By necessity, it operates at the intersection of legislative, political, and regulatory processes.10 At many institutions, hospitalists have been involved in the development of policies ensuring that the core functions of assessment and assurance are addressed and maintained. In fact, hospitalists report that development of quality assurance and practice guidelines accounts for most of their nonclinical time.56 This role of hospitalists is supported by anecdotal reports rather than published empiric evidence.57 For example, at Johns Hopkins Bayview Medical Center, hospitalist‐led teams have developed triage and patient handoff policies designed to improve patient safety. Parameters for admission to the general medicine ward have been elaborated and are periodically refined by the hospitalist team.

Another area that falls within the genre of policy is development of clinical practice guidelines. Guidelines for the treatment of pneumonia, congestive heart failure, deep‐vein thrombosis prophylaxis, alcohol and drug withdrawal, pain management, delirium, and chronic obstructive pulmonary disease have been developed by nonhospitalists.58, 59 These areas are considered core competencies in hospital medicine, and as such, hospitalists have an obligation to review and refine these guidelines to ensure the best provision of care to our patients.59

Hospitalists have been engaged in upholding guidelines that affect community practice. For example, in a study comparing treatment of patients admitted with congestive heart failure by hospitalists compared with that by nonhospitalists, hospitalists were found to be more likely to document left ventricular function, a core measure of quality as defined by JCAHO.39, 60 Knowledge about cardiac function can direct future care for patients when they return to the community and into the care of their primary care providers. In another example, Rifkin found that patients with community‐acquired pneumonia treated by hospitalists were more rapidly converted to oral antibiotics from intravenous antibiotics, facilitating a shorter length of stay,61 which reduced the opportunity for nosocomial infections to propagate. Because hospitalists are skilled at following guidelines,59 it follows that they should seize the opportunity to develop more of them.

As the hospitalist movement continues to grow, hospitalists will likely be engaged in implementing citywide, statewide, and even national policies that ensure optimal care of the hospitalized patient.

BARRIERS TO HOSPITALISTS FOCUSING ON PUBLIC HEALTH

Hospitalists are involved in public health activities even though they may not recognize the extent of this involvement. However, there may be some drawbacks to hospitalists viewing each patient encounter as an opportunity for a public health intervention. First, in viewing a patient as part of a cohort, the individual needs of the patient may be overlooked. There is inherent tension between population‐based and individual‐based care, which is a challenge. Second, hospitalists are busy clinicians who may be most highly valued because of their focus on efficiency and cost savings in the acute care setting. This factor alone may prevent substantive involvement by hospitalists in public health practice. Moving beyond the management of an acute illness may interfere with this efficiency and cost effectiveness from the hospital's perspective. However, interventions that promote health and prevent or reduce rehospitalizations may be cost effective to society in the long run. Third, current billing systems do not adequately reward or reimburse providers for the extra time that may be necessary to engage in public health practice. Fourth, hospitalists may not have the awareness, interest, training, or commitment to engage in public health practice. Finally, there may not be effective collaboration and communication systems between primary care providers and hospitalists. This barrier limits or hinders many possibilities for the effective execution of several public health initiatives.

CONCLUSIONS AND IMPLICATIONS

Hospitalists and the specialty of hospital medicine materialized because of myriad economic forces and the need to provide safe, high‐quality care to hospitalized patients. In this article we have described the ways in which hospitalists can be explicitly involved in public health practice. Traditionally, physicians caring for hospitalized patients have collected information through histories and physical examinations, interpreted laboratory data and tests, and formulated assessments and plans of care. To become public health practitioners, hospitalists have to go beyond these tasks and consider public health thought processes, such as problem‐solving paradigms and theories of behavior change. In adopting this public health perspective, hospitalists may begin to think of a patient in the context of the larger community in order to define the problems facing the community, not just the patient, determine the magnitude of such problems, identify key stakeholders, create intervention/prevention strategies, set priorities and recommend interventions, and implement and evaluate those interventions. This approach forces providers to move beyond the physicianpatient model and draw on public health models to invoke change. Hopefully, future research will further convince hospitalists of the benefits of this approach. Although it may be easier to defer care and management decisions to an outpatient physician, data suggest that intervening when patients are in the hospital may be most effective.62, 63 For example, is it possible that patients are more likely to quit smoking when they are sick in the hospital than when they are in their usual state of health on a routine visit at their primary care provider's office?64 Further, although deferring care to a primary care provider (PCP) may be easier, it is not always possible given these barriers: (1) some patients are routinely rehospitalized, precluding primary care visits, (2) some recommendations may not be received by PCPs, and (3) PCPpatient encounters are brief and the agendas full, and there are limited resources to address recommendations from the hospital.

As hospitalists become more involved in public health practice, their collaboration with physicians and researchers in other fields, nurses, policymakers, and administrators will expand. Succeeding in this arena requires integrity, motivation, capacity, understanding, knowledge, and experience.65 It is hoped that hospitalists will embrace the opportunity and master the requisite skill set necessary to practice in and advance this field. As hospitalist fellowship programs are developed, public health practice skills could be incorporated into the curriculum. Currently 6 of 16 fellowship programs offer either a master of public health degree or public health courses.66 Public health skills can also be taught at Society of Hospital Medicine meetings and other continuing medical education events.

With the evolution of hospital medicine, hospitalists have to be malleable in order to optimally meet the needs of the population they serve. The possibilities are endless.

The field of hospital medicine came into being in response to numerous factors involving physicians, patients, and hospitals themselves1 Now, years later, hospital medicine is a specialty that is growing, both in size and sophistication such that the role of the hospitalist is constantly evolving.2 A compelling function that has not yet been clearly articulated is the opportunity for hospitalists to serve as public health practitioners in their unique clinical environment. There is precedence for the power of collaboration between medicine and public health as has been seen with emergency medicine's willingness to embrace opportunities to advance public health.35

In public health, the programs, services, and institutions involved emphasize the prevention of disease and the health needs of the population as a whole. Public health activities vary with changing technology and social values, but the goals remain the same: to reduce the amount of disease, premature death, and disease‐associated discomfort and disability in the population.6 The authors of a leading textbook of public health, Scutchfield and Keck, contend that the most important skill for public health practice is the capacity to visualize the potential for health that exists in a community.6

Hospitalists care for a distinct subset of the general populationinpatients, only a small percentage of society in a given year. Yet over time hospitalists affect a substantial subset of the larger population that uses considerable health care resources.79 Furthermore, hospitalization can be a sentinel event with public health implications (eg, newly diagnosed HIV infection or acute myocardial infarction in a patient with an extended family of cigarette smokers). This presents an opportunity to educate and counsel both the patient and the patient's social network. One model of public health practice by hospitalists is to influence the patient, his or her family, and the community by touching and inspiring the hospitalized patient.

Hospitalists are already involved in many of the core functions of public health (assessment, assurance, and policy development; Fig. 1).10 Achieving ongoing success in this arena means developing hospitalists who are consciously in tune with their roles as public health practitioners.

Figure 1

In this article we define the specific public health contributions that hospitalists have made and describe the possibilities for further innovative advances. To this end, we outline specific public health roles under the broad categories of assessment, assurance, and policy. We point to advances in public health accomplished by hospitalists as well as those being performed by nonhospitalists in the hospital setting. We conclude by describing some of the barriers to and implications of hospitalists taking on public health roles.

ASSESSMENT

Assessment is the systematic collection, analysis, and dissemination of health status information.10 These activities include disease surveillance and investigation of acute outbreaks or changes in the epidemiology of chronic diseases. Assessment also involves understanding the health of a population and the key determinants of a population's health from a variety of perspectives: physical, biological, behavioral, social, cultural, and spiritual.6 Human health has been defined as a state characterized by anatomic integrity; ability to perform personally valued family work and community roles; ability to deal with physical, biologic, and social stress; a feeling of well‐being; and freedom from the risk of disease and untimely death.6 Hospitalists interact with individuals at times of stress and acute illness and thus have a unique opportunity to assess the strength, viability, and resources available to individuals. Key roles that may fall within the auspices of assessment in hospital medicine are infection control, epidemic recognition, disaster response, preventive care, substance abuse treatment, and chronic disease management.

ASSURANCE

Assurance is the provision of access to necessary health services. It entails efforts to solve problems that threaten the health of populations and empowers individuals to maintain their own health. This is accomplished by either encouraging action, delegating to other entities (private or public sector), mandating specific requirements through regulation, or providing services directly.10 Hospitalist teams aim to ensure that the high‐quality services needed to protect the health of their community (hospitalized patients) are available and that this population receives proper consideration in the allocation of resources. The few studies to date that have directly examined the quality of care that hospitalists provide38 have done so using evidence‐based measures believed to correlate with improved health care outcomes.38 The ambiguities in assessing quality may in part limit such studies.39 Specific hospitalist roles that fall under the assurance umbrella include antibiotic optimization, palliative care, patient safety, and medical error management.

POLICY

Policy development defines health control goals and objectives and develops implementation plans for those goals.10 By necessity, it operates at the intersection of legislative, political, and regulatory processes.10 At many institutions, hospitalists have been involved in the development of policies ensuring that the core functions of assessment and assurance are addressed and maintained. In fact, hospitalists report that development of quality assurance and practice guidelines accounts for most of their nonclinical time.56 This role of hospitalists is supported by anecdotal reports rather than published empiric evidence.57 For example, at Johns Hopkins Bayview Medical Center, hospitalist‐led teams have developed triage and patient handoff policies designed to improve patient safety. Parameters for admission to the general medicine ward have been elaborated and are periodically refined by the hospitalist team.

Another area that falls within the genre of policy is development of clinical practice guidelines. Guidelines for the treatment of pneumonia, congestive heart failure, deep‐vein thrombosis prophylaxis, alcohol and drug withdrawal, pain management, delirium, and chronic obstructive pulmonary disease have been developed by nonhospitalists.58, 59 These areas are considered core competencies in hospital medicine, and as such, hospitalists have an obligation to review and refine these guidelines to ensure the best provision of care to our patients.59

Hospitalists have been engaged in upholding guidelines that affect community practice. For example, in a study comparing treatment of patients admitted with congestive heart failure by hospitalists compared with that by nonhospitalists, hospitalists were found to be more likely to document left ventricular function, a core measure of quality as defined by JCAHO.39, 60 Knowledge about cardiac function can direct future care for patients when they return to the community and into the care of their primary care providers. In another example, Rifkin found that patients with community‐acquired pneumonia treated by hospitalists were more rapidly converted to oral antibiotics from intravenous antibiotics, facilitating a shorter length of stay,61 which reduced the opportunity for nosocomial infections to propagate. Because hospitalists are skilled at following guidelines,59 it follows that they should seize the opportunity to develop more of them.

As the hospitalist movement continues to grow, hospitalists will likely be engaged in implementing citywide, statewide, and even national policies that ensure optimal care of the hospitalized patient.

BARRIERS TO HOSPITALISTS FOCUSING ON PUBLIC HEALTH

Hospitalists are involved in public health activities even though they may not recognize the extent of this involvement. However, there may be some drawbacks to hospitalists viewing each patient encounter as an opportunity for a public health intervention. First, in viewing a patient as part of a cohort, the individual needs of the patient may be overlooked. There is inherent tension between population‐based and individual‐based care, which is a challenge. Second, hospitalists are busy clinicians who may be most highly valued because of their focus on efficiency and cost savings in the acute care setting. This factor alone may prevent substantive involvement by hospitalists in public health practice. Moving beyond the management of an acute illness may interfere with this efficiency and cost effectiveness from the hospital's perspective. However, interventions that promote health and prevent or reduce rehospitalizations may be cost effective to society in the long run. Third, current billing systems do not adequately reward or reimburse providers for the extra time that may be necessary to engage in public health practice. Fourth, hospitalists may not have the awareness, interest, training, or commitment to engage in public health practice. Finally, there may not be effective collaboration and communication systems between primary care providers and hospitalists. This barrier limits or hinders many possibilities for the effective execution of several public health initiatives.

CONCLUSIONS AND IMPLICATIONS

Hospitalists and the specialty of hospital medicine materialized because of myriad economic forces and the need to provide safe, high‐quality care to hospitalized patients. In this article we have described the ways in which hospitalists can be explicitly involved in public health practice. Traditionally, physicians caring for hospitalized patients have collected information through histories and physical examinations, interpreted laboratory data and tests, and formulated assessments and plans of care. To become public health practitioners, hospitalists have to go beyond these tasks and consider public health thought processes, such as problem‐solving paradigms and theories of behavior change. In adopting this public health perspective, hospitalists may begin to think of a patient in the context of the larger community in order to define the problems facing the community, not just the patient, determine the magnitude of such problems, identify key stakeholders, create intervention/prevention strategies, set priorities and recommend interventions, and implement and evaluate those interventions. This approach forces providers to move beyond the physicianpatient model and draw on public health models to invoke change. Hopefully, future research will further convince hospitalists of the benefits of this approach. Although it may be easier to defer care and management decisions to an outpatient physician, data suggest that intervening when patients are in the hospital may be most effective.62, 63 For example, is it possible that patients are more likely to quit smoking when they are sick in the hospital than when they are in their usual state of health on a routine visit at their primary care provider's office?64 Further, although deferring care to a primary care provider (PCP) may be easier, it is not always possible given these barriers: (1) some patients are routinely rehospitalized, precluding primary care visits, (2) some recommendations may not be received by PCPs, and (3) PCPpatient encounters are brief and the agendas full, and there are limited resources to address recommendations from the hospital.

As hospitalists become more involved in public health practice, their collaboration with physicians and researchers in other fields, nurses, policymakers, and administrators will expand. Succeeding in this arena requires integrity, motivation, capacity, understanding, knowledge, and experience.65 It is hoped that hospitalists will embrace the opportunity and master the requisite skill set necessary to practice in and advance this field. As hospitalist fellowship programs are developed, public health practice skills could be incorporated into the curriculum. Currently 6 of 16 fellowship programs offer either a master of public health degree or public health courses.66 Public health skills can also be taught at Society of Hospital Medicine meetings and other continuing medical education events.

With the evolution of hospital medicine, hospitalists have to be malleable in order to optimally meet the needs of the population they serve. The possibilities are endless.

The field of hospital medicine came into being in response to numerous factors involving physicians, patients, and hospitals themselves1 Now, years later, hospital medicine is a specialty that is growing, both in size and sophistication such that the role of the hospitalist is constantly evolving.2 A compelling function that has not yet been clearly articulated is the opportunity for hospitalists to serve as public health practitioners in their unique clinical environment. There is precedence for the power of collaboration between medicine and public health as has been seen with emergency medicine's willingness to embrace opportunities to advance public health.35

In public health, the programs, services, and institutions involved emphasize the prevention of disease and the health needs of the population as a whole. Public health activities vary with changing technology and social values, but the goals remain the same: to reduce the amount of disease, premature death, and disease‐associated discomfort and disability in the population.6 The authors of a leading textbook of public health, Scutchfield and Keck, contend that the most important skill for public health practice is the capacity to visualize the potential for health that exists in a community.6

Hospitalists care for a distinct subset of the general populationinpatients, only a small percentage of society in a given year. Yet over time hospitalists affect a substantial subset of the larger population that uses considerable health care resources.79 Furthermore, hospitalization can be a sentinel event with public health implications (eg, newly diagnosed HIV infection or acute myocardial infarction in a patient with an extended family of cigarette smokers). This presents an opportunity to educate and counsel both the patient and the patient's social network. One model of public health practice by hospitalists is to influence the patient, his or her family, and the community by touching and inspiring the hospitalized patient.

Hospitalists are already involved in many of the core functions of public health (assessment, assurance, and policy development; Fig. 1).10 Achieving ongoing success in this arena means developing hospitalists who are consciously in tune with their roles as public health practitioners.

Figure 1

In this article we define the specific public health contributions that hospitalists have made and describe the possibilities for further innovative advances. To this end, we outline specific public health roles under the broad categories of assessment, assurance, and policy. We point to advances in public health accomplished by hospitalists as well as those being performed by nonhospitalists in the hospital setting. We conclude by describing some of the barriers to and implications of hospitalists taking on public health roles.

ASSESSMENT

Assessment is the systematic collection, analysis, and dissemination of health status information.10 These activities include disease surveillance and investigation of acute outbreaks or changes in the epidemiology of chronic diseases. Assessment also involves understanding the health of a population and the key determinants of a population's health from a variety of perspectives: physical, biological, behavioral, social, cultural, and spiritual.6 Human health has been defined as a state characterized by anatomic integrity; ability to perform personally valued family work and community roles; ability to deal with physical, biologic, and social stress; a feeling of well‐being; and freedom from the risk of disease and untimely death.6 Hospitalists interact with individuals at times of stress and acute illness and thus have a unique opportunity to assess the strength, viability, and resources available to individuals. Key roles that may fall within the auspices of assessment in hospital medicine are infection control, epidemic recognition, disaster response, preventive care, substance abuse treatment, and chronic disease management.

ASSURANCE

Assurance is the provision of access to necessary health services. It entails efforts to solve problems that threaten the health of populations and empowers individuals to maintain their own health. This is accomplished by either encouraging action, delegating to other entities (private or public sector), mandating specific requirements through regulation, or providing services directly.10 Hospitalist teams aim to ensure that the high‐quality services needed to protect the health of their community (hospitalized patients) are available and that this population receives proper consideration in the allocation of resources. The few studies to date that have directly examined the quality of care that hospitalists provide38 have done so using evidence‐based measures believed to correlate with improved health care outcomes.38 The ambiguities in assessing quality may in part limit such studies.39 Specific hospitalist roles that fall under the assurance umbrella include antibiotic optimization, palliative care, patient safety, and medical error management.

POLICY

Policy development defines health control goals and objectives and develops implementation plans for those goals.10 By necessity, it operates at the intersection of legislative, political, and regulatory processes.10 At many institutions, hospitalists have been involved in the development of policies ensuring that the core functions of assessment and assurance are addressed and maintained. In fact, hospitalists report that development of quality assurance and practice guidelines accounts for most of their nonclinical time.56 This role of hospitalists is supported by anecdotal reports rather than published empiric evidence.57 For example, at Johns Hopkins Bayview Medical Center, hospitalist‐led teams have developed triage and patient handoff policies designed to improve patient safety. Parameters for admission to the general medicine ward have been elaborated and are periodically refined by the hospitalist team.

Another area that falls within the genre of policy is development of clinical practice guidelines. Guidelines for the treatment of pneumonia, congestive heart failure, deep‐vein thrombosis prophylaxis, alcohol and drug withdrawal, pain management, delirium, and chronic obstructive pulmonary disease have been developed by nonhospitalists.58, 59 These areas are considered core competencies in hospital medicine, and as such, hospitalists have an obligation to review and refine these guidelines to ensure the best provision of care to our patients.59

Hospitalists have been engaged in upholding guidelines that affect community practice. For example, in a study comparing treatment of patients admitted with congestive heart failure by hospitalists compared with that by nonhospitalists, hospitalists were found to be more likely to document left ventricular function, a core measure of quality as defined by JCAHO.39, 60 Knowledge about cardiac function can direct future care for patients when they return to the community and into the care of their primary care providers. In another example, Rifkin found that patients with community‐acquired pneumonia treated by hospitalists were more rapidly converted to oral antibiotics from intravenous antibiotics, facilitating a shorter length of stay,61 which reduced the opportunity for nosocomial infections to propagate. Because hospitalists are skilled at following guidelines,59 it follows that they should seize the opportunity to develop more of them.

As the hospitalist movement continues to grow, hospitalists will likely be engaged in implementing citywide, statewide, and even national policies that ensure optimal care of the hospitalized patient.

BARRIERS TO HOSPITALISTS FOCUSING ON PUBLIC HEALTH

Hospitalists are involved in public health activities even though they may not recognize the extent of this involvement. However, there may be some drawbacks to hospitalists viewing each patient encounter as an opportunity for a public health intervention. First, in viewing a patient as part of a cohort, the individual needs of the patient may be overlooked. There is inherent tension between population‐based and individual‐based care, which is a challenge. Second, hospitalists are busy clinicians who may be most highly valued because of their focus on efficiency and cost savings in the acute care setting. This factor alone may prevent substantive involvement by hospitalists in public health practice. Moving beyond the management of an acute illness may interfere with this efficiency and cost effectiveness from the hospital's perspective. However, interventions that promote health and prevent or reduce rehospitalizations may be cost effective to society in the long run. Third, current billing systems do not adequately reward or reimburse providers for the extra time that may be necessary to engage in public health practice. Fourth, hospitalists may not have the awareness, interest, training, or commitment to engage in public health practice. Finally, there may not be effective collaboration and communication systems between primary care providers and hospitalists. This barrier limits or hinders many possibilities for the effective execution of several public health initiatives.

CONCLUSIONS AND IMPLICATIONS

Hospitalists and the specialty of hospital medicine materialized because of myriad economic forces and the need to provide safe, high‐quality care to hospitalized patients. In this article we have described the ways in which hospitalists can be explicitly involved in public health practice. Traditionally, physicians caring for hospitalized patients have collected information through histories and physical examinations, interpreted laboratory data and tests, and formulated assessments and plans of care. To become public health practitioners, hospitalists have to go beyond these tasks and consider public health thought processes, such as problem‐solving paradigms and theories of behavior change. In adopting this public health perspective, hospitalists may begin to think of a patient in the context of the larger community in order to define the problems facing the community, not just the patient, determine the magnitude of such problems, identify key stakeholders, create intervention/prevention strategies, set priorities and recommend interventions, and implement and evaluate those interventions. This approach forces providers to move beyond the physicianpatient model and draw on public health models to invoke change. Hopefully, future research will further convince hospitalists of the benefits of this approach. Although it may be easier to defer care and management decisions to an outpatient physician, data suggest that intervening when patients are in the hospital may be most effective.62, 63 For example, is it possible that patients are more likely to quit smoking when they are sick in the hospital than when they are in their usual state of health on a routine visit at their primary care provider's office?64 Further, although deferring care to a primary care provider (PCP) may be easier, it is not always possible given these barriers: (1) some patients are routinely rehospitalized, precluding primary care visits, (2) some recommendations may not be received by PCPs, and (3) PCPpatient encounters are brief and the agendas full, and there are limited resources to address recommendations from the hospital.

As hospitalists become more involved in public health practice, their collaboration with physicians and researchers in other fields, nurses, policymakers, and administrators will expand. Succeeding in this arena requires integrity, motivation, capacity, understanding, knowledge, and experience.65 It is hoped that hospitalists will embrace the opportunity and master the requisite skill set necessary to practice in and advance this field. As hospitalist fellowship programs are developed, public health practice skills could be incorporated into the curriculum. Currently 6 of 16 fellowship programs offer either a master of public health degree or public health courses.66 Public health skills can also be taught at Society of Hospital Medicine meetings and other continuing medical education events.

With the evolution of hospital medicine, hospitalists have to be malleable in order to optimally meet the needs of the population they serve. The possibilities are endless.