Michael Ehresman, MBA

Over the past decade, hospital medicine has been the nation's fastest‐growing medical specialty. According to the American Hospital Association's (AHA) 2009 survey, 58% of United States (US) hospitals now have hospital medicine programs, and for hospitals with 200 or more beds, this figure is 89%.1 In 2009, the AHA estimated that the number of US hospitalists would increase to over 34,000 by 2011, over double that of the 16,000 present in 2005.1 Studies demonstrate that, compared to a system where primary care physicians provide inpatient care, the hospitalist model improves efficiency while maintaining at least equal patient outcomes.211 However, scant data exist as to the effects of hospitalists on patient satisfaction.12 Understanding how care models affect patient experience is vital in the current environment of healthcare reform and performance reporting, especially in light of the Centers for Medicare and Medicaid Services' (CMS) efforts to link the patient experience to reimbursement through value‐based purchasing.13 Value‐based purchasing is a strategy to encourage and reward excellence in healthcare delivery through differential reimbursement based on defined performance measures. As one part of value‐based purchasing, hospital reimbursement will be linked to patient‐experience measures, including patient ratings of their doctor's ability to communicate with them and other questions assessing patient satisfaction with their hospital stay.14

In the outpatient setting, trust is the variable most strongly associated with patient satisfaction.1518 In contrast to PCPs, who may develop relationships with patients over years, hospitalists often first meet a patient in the hospital and must engender trust quickly. In addition, hospitalists work in shifts and may not be responsible for the same patients each day. Since continuity is positively related to trust,19, 20 there is reason to believe satisfaction with hospitalist care might be lower than satisfaction with care provided by PCPs. We report on 8295 patients and 6 years experience with hospitalist programs at 3 hospitals. Based on the known link between continuity and patient satisfaction, we hypothesized that patient satisfaction would be lower with hospitalists than with primary care internists.

METHODS

RESULTS

Of patients who were reached by telephone, 87% agreed to participate in the hospital survey. However, most patients could not be reached by phone; thus our estimated response rate, including those who could not be reached, was 27%. For the subset of patients interviewed using the HCAHPS protocol, the response rate was 40%. Our final sample included 8295 patients (3597 cared for by 59 hospitalists and 4698 by 288 PCPs) interviewed between 2003 and 2009. Three‐quarters of the patients were from the tertiary care center, whereas 17% and 8% were from each of the community hospitals (see Supporting Appendix B in the online version of this article). Patient characteristics appear in Table 1. Patients cared for by hospitalists were similar to those cared for by PCPs in terms of age, sex, marital status, education, and language, but hospitalist patients were more likely to have been admitted through the emergency department (93% vs 84%, P < 0.001) and less likely to be white (83% vs 85%, P = 0.01). Patients cared for by hospitalists also had higher average illness severity score (2.2 0.8 vs 2.0 0.8, P < 0.001), longer average LOS (4.3 4.3 vs 4.0 3.6, P < 0.001), and lower mean perceived health score (2.8 1.2 vs 3.0 1.2, P = 0.01).

Unadjusted patient reported satisfaction with physician care quality was slightly greater for PCPs than hospitalists (4.25 vs 4.19, P = 0.009). After multivariable adjustment, the difference was attenuated but persisted (4.24 vs 4.20, P = 0.04). We found no statistical difference among the hospitals or the specific hospitalist groups in terms of satisfaction with overall physician care quality (Figure 1). There were no statistical differences in patient satisfaction ratings of hospitalist and PCPs for the subdomains of behavior, pain, and communication (Table 2). There were also no differences in the proportion of patients cared for by hospitalists or PCPs who rated their physicians in the highest satisfaction category (79% vs 81%, P = 0.17) or the lowest (5% vs 5%, P = 0.19). Among patients cared for by academic hospitalists, there was no difference in satisfaction rating between those patients who had a designated primary care physician in the outpatient setting and those who did not (4.22 0.94 vs 4.19 0.94, P = 0.97). Finally, satisfaction with both hospitalists and PCPs showed equivalent rates of improvement over time (Figure 2).

Figure 1

Figure 2

DISCUSSION

In this observational study of over 8200 patients cared for over 6 years by 347 physicians at 3 hospitals, we found that patient satisfaction with inpatient care provided by hospitalists and primary care doctors was almost identical. As we hypothesized, overall satisfaction with physician care quality, our primary outcome, was slightly greater with primary care doctors; however, the observed difference, 0.04 on a scale of 1 to 5, cannot be considered clinically significant. All patients were generally satisfied (4.2‐4.3 rating on 5‐point scale) with their inpatient care, and satisfaction scores increased over time. We also found no differences among the specific domains of satisfaction, including communication skills, pain control, and physician behavior. Finally, we found no significant difference in patient satisfaction with physician care quality among the different hospitalist services.

Previous studies of patient satisfaction conducted in the outpatient setting found that continuity of care was an important determinant of trust and, consequently, overall satisfaction.15, 16, 19, 20, 22 Because hospitalist models introduce discontinuity, they might be expected to undermine satisfaction. Surprisingly, few studies have addressed this issue. In a review of the hospitalist studies through 2002, Wachter and Goldman found 19 studies, 5 of which measured patient satisfaction.23 Three of these were conducted on teaching services and compared designated faculty hospitalists to traditional ward attendings, who rotated onto the inpatient services 1 to 2 months per year. Primary care doctors were excluded.2426 A fourth study provided a descriptive narrative of the development of the first hospitalist program in Minneapolis, Minnesota, and anecdotally noted no difference in patient satisfaction between the hospitalist and traditional model, but presented no data because the satisfaction surveys were not designed with publication in mind.27 The only study to actually assess whether patient satisfaction was greater with hospitalists or PCPs was an observational study by Davis et al., conducted in 1 rural hospital during the first year of its hospitalist program. In that study, 2 hospitalists were compared to 17 PCPs, and patient satisfaction surveys were available for approximately 44 patients managed by hospitalists and 168 patients managed by PCPs. Specific data were not reported, but it was noted that there was no statistical difference in satisfaction between those cared for by hospitalists versus PCPs.28 On the basis of these studies, Wachter and Goldman concluded that surveys of patients who were cared for by hospitalists show high levels of satisfaction, no lower than that of similar patients cared for by their own primary physicians.23 Wachter and Goldman's review has been highly cited, and we could find no subsequent studies addressing this issue. Our study provides the first real evidence to support this conclusion, including data from 59 hospitalists practicing in 5 separate hospitalist programs at 3 different hospitals.

Our finding that hospitalists maintain satisfaction despite a lack of continuity suggests that other aspects of care may be more important to patient satisfaction. Larson et al. found that physician ability to meet patient's information needs was positively associated with patient satisfaction.29 Similarly, Tarrant et al. found that patient's trust in a physician improved with increasing communication, interpersonal care, and knowledge of the patient. Interestingly, continuity, ie. the proportion of visits to the usual general practitioner (GP) or duration with the practice, did not correlate with trust.30 Finally, a systematic review of determinants of outpatient satisfaction found that continuity has a variable effect on satisfaction. Subjective continuity measures, such as whether patients saw their regular physician on the day they were surveyed, were consistently associated with patient satisfaction, however, quantitative measures including relationship duration were not.31

It is also possible that patients believe they value continuity more than they actually do. In 1 survey of inpatients with an established PCP yet cared for by a hospitalist, most agreed that patients receive better care and have more trust in physicians with whom they have long‐term relationships. Yet most also had positive opinions of their hospital care.32 Similarly, in a survey of over 2500 outpatients, 92% rated continuity as very important or important, but the majority was unwilling to expend substantial personal time (88%), defined as driving greater than 60 minutes, or money (82%), defined as spending an additional $20 to $40 a month, to maintain continuity with their PCP.33 Our study appears to confirm the lack of connection between continuity and satisfaction. Even those patients who valued continuity, as evidenced by having an established PCP, were as satisfied with hospitalist physician care as patients who had no established PCP.

Our study has several limitations. First, we report on outcomes of 3 institutions within a single healthcare system, within a limited geographic area. Although our sample included a wide range of patient demographics, hundreds of physicians, and multiple hospitalist models, it is possible that some hospitalist models may provide greater or lesser satisfaction than those we observed. Second, our study was observational, and thus subject to selection bias and confounding. Patients cared for by the hospitalists differed in a number of ways from those cared for by PCPs. We controlled for identifiable confounders such as illness severity, self‐perceived health, and admission through the emergency department, but the possibility exists that additional unidentified factors could have affected our results. It is possible other drivers of patient satisfaction, such as amenities, nursing, or food, could have influenced our findings. However, this is unlikely because all patient groups shared these components of hospital experience equally. Third, only a minority of patients could be reached for interview. This is typical for post‐hospitalization surveys, and our response rate of 40% for HCAHPS patients compared favorably to the 2010 HCAHPS national average of 33%.34 Still, the responses of those who could not be reached may have differed from those who were interviewed. Fourth, we identified hospitalists and PCPs by the attending of record, but we were unable to tell who provided care to the patient on any given day. Thus, we could not determine to what extent patients cared for by PCPs were actually seen by their own doctor, as opposed to an associated physician within the practice. Nevertheless, our results are representative of the care model provided by PCPs in the hospital. Similarly, we could not know or compare the number of different attending physicians each patient experienced during their hospitalization. Higher turnover of inpatient physicians may have affected patient satisfaction scores independent of attending physician designation. These are potentially important measures of relationship duration, yet whether duration affects patient satisfaction remains undecided.1618, 20, 28, 30, 32, 33 We assessed satisfaction using HCAHPS questions, in order to provide objective and meaningful comparisons across hospitals. The HCAHPS instrument, however, is intended to assess patient satisfaction with doctors in general, not with subgroups or individuals, and responses in our study were uniformly high. A more sensitive survey instrument may have yielded different results. Finally, it is possible that individual physicians may possess lower satisfaction scores than others, making the results not representative of hospitalist models as much as specific doctors' care quality. We think this is unlikely since surveys reached over 8000 patients, over 6 years, representing the care of 347 individual physicians. However, hospital medicine is a rapidly evolving field with many divergent organizational structures, and patient satisfaction is bound to fluctuate while there exists high variability in how care is provided.

Over the past decade, the hospitalist model has become one of the dominant models for care of medical inpatients. Compared to the traditional model in which PCPs provide inpatient care, the hospitalist model has a number of advantages, including continuous on‐site coverage for increasingly acute patients, specialization, and incentives aligned with the hospital to provide efficient, high‐quality care. One concern that remains, however, is that patients may not trust doctors they first meet in the hospital or may be dissatisfied with the lack of continuity from day to day. Our findings are reassuring in this regard. Although patients cared for by hospitalists were slightly less satisfied, the differences could not be considered clinically meaningful and should be outweighed by gains in quality and efficiency. Furthermore, hospitalists can expect to fare well under value‐based purchasing. Given the rapid ascension of hospital medicine programs, prospective comparisons of hospitalists and PCPs may no longer be feasible. Future research might employ survey instruments designed specifically to measure patient experience under hospitalist care in order to identify methods to maximize patient satisfaction within the hospitalist model.

Over the past decade, hospital medicine has been the nation's fastest‐growing medical specialty. According to the American Hospital Association's (AHA) 2009 survey, 58% of United States (US) hospitals now have hospital medicine programs, and for hospitals with 200 or more beds, this figure is 89%.1 In 2009, the AHA estimated that the number of US hospitalists would increase to over 34,000 by 2011, over double that of the 16,000 present in 2005.1 Studies demonstrate that, compared to a system where primary care physicians provide inpatient care, the hospitalist model improves efficiency while maintaining at least equal patient outcomes.211 However, scant data exist as to the effects of hospitalists on patient satisfaction.12 Understanding how care models affect patient experience is vital in the current environment of healthcare reform and performance reporting, especially in light of the Centers for Medicare and Medicaid Services' (CMS) efforts to link the patient experience to reimbursement through value‐based purchasing.13 Value‐based purchasing is a strategy to encourage and reward excellence in healthcare delivery through differential reimbursement based on defined performance measures. As one part of value‐based purchasing, hospital reimbursement will be linked to patient‐experience measures, including patient ratings of their doctor's ability to communicate with them and other questions assessing patient satisfaction with their hospital stay.14

In the outpatient setting, trust is the variable most strongly associated with patient satisfaction.1518 In contrast to PCPs, who may develop relationships with patients over years, hospitalists often first meet a patient in the hospital and must engender trust quickly. In addition, hospitalists work in shifts and may not be responsible for the same patients each day. Since continuity is positively related to trust,19, 20 there is reason to believe satisfaction with hospitalist care might be lower than satisfaction with care provided by PCPs. We report on 8295 patients and 6 years experience with hospitalist programs at 3 hospitals. Based on the known link between continuity and patient satisfaction, we hypothesized that patient satisfaction would be lower with hospitalists than with primary care internists.

METHODS

RESULTS

Of patients who were reached by telephone, 87% agreed to participate in the hospital survey. However, most patients could not be reached by phone; thus our estimated response rate, including those who could not be reached, was 27%. For the subset of patients interviewed using the HCAHPS protocol, the response rate was 40%. Our final sample included 8295 patients (3597 cared for by 59 hospitalists and 4698 by 288 PCPs) interviewed between 2003 and 2009. Three‐quarters of the patients were from the tertiary care center, whereas 17% and 8% were from each of the community hospitals (see Supporting Appendix B in the online version of this article). Patient characteristics appear in Table 1. Patients cared for by hospitalists were similar to those cared for by PCPs in terms of age, sex, marital status, education, and language, but hospitalist patients were more likely to have been admitted through the emergency department (93% vs 84%, P < 0.001) and less likely to be white (83% vs 85%, P = 0.01). Patients cared for by hospitalists also had higher average illness severity score (2.2 0.8 vs 2.0 0.8, P < 0.001), longer average LOS (4.3 4.3 vs 4.0 3.6, P < 0.001), and lower mean perceived health score (2.8 1.2 vs 3.0 1.2, P = 0.01).

Unadjusted patient reported satisfaction with physician care quality was slightly greater for PCPs than hospitalists (4.25 vs 4.19, P = 0.009). After multivariable adjustment, the difference was attenuated but persisted (4.24 vs 4.20, P = 0.04). We found no statistical difference among the hospitals or the specific hospitalist groups in terms of satisfaction with overall physician care quality (Figure 1). There were no statistical differences in patient satisfaction ratings of hospitalist and PCPs for the subdomains of behavior, pain, and communication (Table 2). There were also no differences in the proportion of patients cared for by hospitalists or PCPs who rated their physicians in the highest satisfaction category (79% vs 81%, P = 0.17) or the lowest (5% vs 5%, P = 0.19). Among patients cared for by academic hospitalists, there was no difference in satisfaction rating between those patients who had a designated primary care physician in the outpatient setting and those who did not (4.22 0.94 vs 4.19 0.94, P = 0.97). Finally, satisfaction with both hospitalists and PCPs showed equivalent rates of improvement over time (Figure 2).

Figure 1

Figure 2

DISCUSSION

In this observational study of over 8200 patients cared for over 6 years by 347 physicians at 3 hospitals, we found that patient satisfaction with inpatient care provided by hospitalists and primary care doctors was almost identical. As we hypothesized, overall satisfaction with physician care quality, our primary outcome, was slightly greater with primary care doctors; however, the observed difference, 0.04 on a scale of 1 to 5, cannot be considered clinically significant. All patients were generally satisfied (4.2‐4.3 rating on 5‐point scale) with their inpatient care, and satisfaction scores increased over time. We also found no differences among the specific domains of satisfaction, including communication skills, pain control, and physician behavior. Finally, we found no significant difference in patient satisfaction with physician care quality among the different hospitalist services.

Previous studies of patient satisfaction conducted in the outpatient setting found that continuity of care was an important determinant of trust and, consequently, overall satisfaction.15, 16, 19, 20, 22 Because hospitalist models introduce discontinuity, they might be expected to undermine satisfaction. Surprisingly, few studies have addressed this issue. In a review of the hospitalist studies through 2002, Wachter and Goldman found 19 studies, 5 of which measured patient satisfaction.23 Three of these were conducted on teaching services and compared designated faculty hospitalists to traditional ward attendings, who rotated onto the inpatient services 1 to 2 months per year. Primary care doctors were excluded.2426 A fourth study provided a descriptive narrative of the development of the first hospitalist program in Minneapolis, Minnesota, and anecdotally noted no difference in patient satisfaction between the hospitalist and traditional model, but presented no data because the satisfaction surveys were not designed with publication in mind.27 The only study to actually assess whether patient satisfaction was greater with hospitalists or PCPs was an observational study by Davis et al., conducted in 1 rural hospital during the first year of its hospitalist program. In that study, 2 hospitalists were compared to 17 PCPs, and patient satisfaction surveys were available for approximately 44 patients managed by hospitalists and 168 patients managed by PCPs. Specific data were not reported, but it was noted that there was no statistical difference in satisfaction between those cared for by hospitalists versus PCPs.28 On the basis of these studies, Wachter and Goldman concluded that surveys of patients who were cared for by hospitalists show high levels of satisfaction, no lower than that of similar patients cared for by their own primary physicians.23 Wachter and Goldman's review has been highly cited, and we could find no subsequent studies addressing this issue. Our study provides the first real evidence to support this conclusion, including data from 59 hospitalists practicing in 5 separate hospitalist programs at 3 different hospitals.

Our finding that hospitalists maintain satisfaction despite a lack of continuity suggests that other aspects of care may be more important to patient satisfaction. Larson et al. found that physician ability to meet patient's information needs was positively associated with patient satisfaction.29 Similarly, Tarrant et al. found that patient's trust in a physician improved with increasing communication, interpersonal care, and knowledge of the patient. Interestingly, continuity, ie. the proportion of visits to the usual general practitioner (GP) or duration with the practice, did not correlate with trust.30 Finally, a systematic review of determinants of outpatient satisfaction found that continuity has a variable effect on satisfaction. Subjective continuity measures, such as whether patients saw their regular physician on the day they were surveyed, were consistently associated with patient satisfaction, however, quantitative measures including relationship duration were not.31

It is also possible that patients believe they value continuity more than they actually do. In 1 survey of inpatients with an established PCP yet cared for by a hospitalist, most agreed that patients receive better care and have more trust in physicians with whom they have long‐term relationships. Yet most also had positive opinions of their hospital care.32 Similarly, in a survey of over 2500 outpatients, 92% rated continuity as very important or important, but the majority was unwilling to expend substantial personal time (88%), defined as driving greater than 60 minutes, or money (82%), defined as spending an additional $20 to $40 a month, to maintain continuity with their PCP.33 Our study appears to confirm the lack of connection between continuity and satisfaction. Even those patients who valued continuity, as evidenced by having an established PCP, were as satisfied with hospitalist physician care as patients who had no established PCP.

Our study has several limitations. First, we report on outcomes of 3 institutions within a single healthcare system, within a limited geographic area. Although our sample included a wide range of patient demographics, hundreds of physicians, and multiple hospitalist models, it is possible that some hospitalist models may provide greater or lesser satisfaction than those we observed. Second, our study was observational, and thus subject to selection bias and confounding. Patients cared for by the hospitalists differed in a number of ways from those cared for by PCPs. We controlled for identifiable confounders such as illness severity, self‐perceived health, and admission through the emergency department, but the possibility exists that additional unidentified factors could have affected our results. It is possible other drivers of patient satisfaction, such as amenities, nursing, or food, could have influenced our findings. However, this is unlikely because all patient groups shared these components of hospital experience equally. Third, only a minority of patients could be reached for interview. This is typical for post‐hospitalization surveys, and our response rate of 40% for HCAHPS patients compared favorably to the 2010 HCAHPS national average of 33%.34 Still, the responses of those who could not be reached may have differed from those who were interviewed. Fourth, we identified hospitalists and PCPs by the attending of record, but we were unable to tell who provided care to the patient on any given day. Thus, we could not determine to what extent patients cared for by PCPs were actually seen by their own doctor, as opposed to an associated physician within the practice. Nevertheless, our results are representative of the care model provided by PCPs in the hospital. Similarly, we could not know or compare the number of different attending physicians each patient experienced during their hospitalization. Higher turnover of inpatient physicians may have affected patient satisfaction scores independent of attending physician designation. These are potentially important measures of relationship duration, yet whether duration affects patient satisfaction remains undecided.1618, 20, 28, 30, 32, 33 We assessed satisfaction using HCAHPS questions, in order to provide objective and meaningful comparisons across hospitals. The HCAHPS instrument, however, is intended to assess patient satisfaction with doctors in general, not with subgroups or individuals, and responses in our study were uniformly high. A more sensitive survey instrument may have yielded different results. Finally, it is possible that individual physicians may possess lower satisfaction scores than others, making the results not representative of hospitalist models as much as specific doctors' care quality. We think this is unlikely since surveys reached over 8000 patients, over 6 years, representing the care of 347 individual physicians. However, hospital medicine is a rapidly evolving field with many divergent organizational structures, and patient satisfaction is bound to fluctuate while there exists high variability in how care is provided.

Over the past decade, the hospitalist model has become one of the dominant models for care of medical inpatients. Compared to the traditional model in which PCPs provide inpatient care, the hospitalist model has a number of advantages, including continuous on‐site coverage for increasingly acute patients, specialization, and incentives aligned with the hospital to provide efficient, high‐quality care. One concern that remains, however, is that patients may not trust doctors they first meet in the hospital or may be dissatisfied with the lack of continuity from day to day. Our findings are reassuring in this regard. Although patients cared for by hospitalists were slightly less satisfied, the differences could not be considered clinically meaningful and should be outweighed by gains in quality and efficiency. Furthermore, hospitalists can expect to fare well under value‐based purchasing. Given the rapid ascension of hospital medicine programs, prospective comparisons of hospitalists and PCPs may no longer be feasible. Future research might employ survey instruments designed specifically to measure patient experience under hospitalist care in order to identify methods to maximize patient satisfaction within the hospitalist model.

Over the past decade, hospital medicine has been the nation's fastest‐growing medical specialty. According to the American Hospital Association's (AHA) 2009 survey, 58% of United States (US) hospitals now have hospital medicine programs, and for hospitals with 200 or more beds, this figure is 89%.1 In 2009, the AHA estimated that the number of US hospitalists would increase to over 34,000 by 2011, over double that of the 16,000 present in 2005.1 Studies demonstrate that, compared to a system where primary care physicians provide inpatient care, the hospitalist model improves efficiency while maintaining at least equal patient outcomes.211 However, scant data exist as to the effects of hospitalists on patient satisfaction.12 Understanding how care models affect patient experience is vital in the current environment of healthcare reform and performance reporting, especially in light of the Centers for Medicare and Medicaid Services' (CMS) efforts to link the patient experience to reimbursement through value‐based purchasing.13 Value‐based purchasing is a strategy to encourage and reward excellence in healthcare delivery through differential reimbursement based on defined performance measures. As one part of value‐based purchasing, hospital reimbursement will be linked to patient‐experience measures, including patient ratings of their doctor's ability to communicate with them and other questions assessing patient satisfaction with their hospital stay.14

In the outpatient setting, trust is the variable most strongly associated with patient satisfaction.1518 In contrast to PCPs, who may develop relationships with patients over years, hospitalists often first meet a patient in the hospital and must engender trust quickly. In addition, hospitalists work in shifts and may not be responsible for the same patients each day. Since continuity is positively related to trust,19, 20 there is reason to believe satisfaction with hospitalist care might be lower than satisfaction with care provided by PCPs. We report on 8295 patients and 6 years experience with hospitalist programs at 3 hospitals. Based on the known link between continuity and patient satisfaction, we hypothesized that patient satisfaction would be lower with hospitalists than with primary care internists.

METHODS

RESULTS

Of patients who were reached by telephone, 87% agreed to participate in the hospital survey. However, most patients could not be reached by phone; thus our estimated response rate, including those who could not be reached, was 27%. For the subset of patients interviewed using the HCAHPS protocol, the response rate was 40%. Our final sample included 8295 patients (3597 cared for by 59 hospitalists and 4698 by 288 PCPs) interviewed between 2003 and 2009. Three‐quarters of the patients were from the tertiary care center, whereas 17% and 8% were from each of the community hospitals (see Supporting Appendix B in the online version of this article). Patient characteristics appear in Table 1. Patients cared for by hospitalists were similar to those cared for by PCPs in terms of age, sex, marital status, education, and language, but hospitalist patients were more likely to have been admitted through the emergency department (93% vs 84%, P < 0.001) and less likely to be white (83% vs 85%, P = 0.01). Patients cared for by hospitalists also had higher average illness severity score (2.2 0.8 vs 2.0 0.8, P < 0.001), longer average LOS (4.3 4.3 vs 4.0 3.6, P < 0.001), and lower mean perceived health score (2.8 1.2 vs 3.0 1.2, P = 0.01).

Unadjusted patient reported satisfaction with physician care quality was slightly greater for PCPs than hospitalists (4.25 vs 4.19, P = 0.009). After multivariable adjustment, the difference was attenuated but persisted (4.24 vs 4.20, P = 0.04). We found no statistical difference among the hospitals or the specific hospitalist groups in terms of satisfaction with overall physician care quality (Figure 1). There were no statistical differences in patient satisfaction ratings of hospitalist and PCPs for the subdomains of behavior, pain, and communication (Table 2). There were also no differences in the proportion of patients cared for by hospitalists or PCPs who rated their physicians in the highest satisfaction category (79% vs 81%, P = 0.17) or the lowest (5% vs 5%, P = 0.19). Among patients cared for by academic hospitalists, there was no difference in satisfaction rating between those patients who had a designated primary care physician in the outpatient setting and those who did not (4.22 0.94 vs 4.19 0.94, P = 0.97). Finally, satisfaction with both hospitalists and PCPs showed equivalent rates of improvement over time (Figure 2).

Figure 1

Figure 2

DISCUSSION

In this observational study of over 8200 patients cared for over 6 years by 347 physicians at 3 hospitals, we found that patient satisfaction with inpatient care provided by hospitalists and primary care doctors was almost identical. As we hypothesized, overall satisfaction with physician care quality, our primary outcome, was slightly greater with primary care doctors; however, the observed difference, 0.04 on a scale of 1 to 5, cannot be considered clinically significant. All patients were generally satisfied (4.2‐4.3 rating on 5‐point scale) with their inpatient care, and satisfaction scores increased over time. We also found no differences among the specific domains of satisfaction, including communication skills, pain control, and physician behavior. Finally, we found no significant difference in patient satisfaction with physician care quality among the different hospitalist services.

Previous studies of patient satisfaction conducted in the outpatient setting found that continuity of care was an important determinant of trust and, consequently, overall satisfaction.15, 16, 19, 20, 22 Because hospitalist models introduce discontinuity, they might be expected to undermine satisfaction. Surprisingly, few studies have addressed this issue. In a review of the hospitalist studies through 2002, Wachter and Goldman found 19 studies, 5 of which measured patient satisfaction.23 Three of these were conducted on teaching services and compared designated faculty hospitalists to traditional ward attendings, who rotated onto the inpatient services 1 to 2 months per year. Primary care doctors were excluded.2426 A fourth study provided a descriptive narrative of the development of the first hospitalist program in Minneapolis, Minnesota, and anecdotally noted no difference in patient satisfaction between the hospitalist and traditional model, but presented no data because the satisfaction surveys were not designed with publication in mind.27 The only study to actually assess whether patient satisfaction was greater with hospitalists or PCPs was an observational study by Davis et al., conducted in 1 rural hospital during the first year of its hospitalist program. In that study, 2 hospitalists were compared to 17 PCPs, and patient satisfaction surveys were available for approximately 44 patients managed by hospitalists and 168 patients managed by PCPs. Specific data were not reported, but it was noted that there was no statistical difference in satisfaction between those cared for by hospitalists versus PCPs.28 On the basis of these studies, Wachter and Goldman concluded that surveys of patients who were cared for by hospitalists show high levels of satisfaction, no lower than that of similar patients cared for by their own primary physicians.23 Wachter and Goldman's review has been highly cited, and we could find no subsequent studies addressing this issue. Our study provides the first real evidence to support this conclusion, including data from 59 hospitalists practicing in 5 separate hospitalist programs at 3 different hospitals.

Our finding that hospitalists maintain satisfaction despite a lack of continuity suggests that other aspects of care may be more important to patient satisfaction. Larson et al. found that physician ability to meet patient's information needs was positively associated with patient satisfaction.29 Similarly, Tarrant et al. found that patient's trust in a physician improved with increasing communication, interpersonal care, and knowledge of the patient. Interestingly, continuity, ie. the proportion of visits to the usual general practitioner (GP) or duration with the practice, did not correlate with trust.30 Finally, a systematic review of determinants of outpatient satisfaction found that continuity has a variable effect on satisfaction. Subjective continuity measures, such as whether patients saw their regular physician on the day they were surveyed, were consistently associated with patient satisfaction, however, quantitative measures including relationship duration were not.31

It is also possible that patients believe they value continuity more than they actually do. In 1 survey of inpatients with an established PCP yet cared for by a hospitalist, most agreed that patients receive better care and have more trust in physicians with whom they have long‐term relationships. Yet most also had positive opinions of their hospital care.32 Similarly, in a survey of over 2500 outpatients, 92% rated continuity as very important or important, but the majority was unwilling to expend substantial personal time (88%), defined as driving greater than 60 minutes, or money (82%), defined as spending an additional $20 to $40 a month, to maintain continuity with their PCP.33 Our study appears to confirm the lack of connection between continuity and satisfaction. Even those patients who valued continuity, as evidenced by having an established PCP, were as satisfied with hospitalist physician care as patients who had no established PCP.

Our study has several limitations. First, we report on outcomes of 3 institutions within a single healthcare system, within a limited geographic area. Although our sample included a wide range of patient demographics, hundreds of physicians, and multiple hospitalist models, it is possible that some hospitalist models may provide greater or lesser satisfaction than those we observed. Second, our study was observational, and thus subject to selection bias and confounding. Patients cared for by the hospitalists differed in a number of ways from those cared for by PCPs. We controlled for identifiable confounders such as illness severity, self‐perceived health, and admission through the emergency department, but the possibility exists that additional unidentified factors could have affected our results. It is possible other drivers of patient satisfaction, such as amenities, nursing, or food, could have influenced our findings. However, this is unlikely because all patient groups shared these components of hospital experience equally. Third, only a minority of patients could be reached for interview. This is typical for post‐hospitalization surveys, and our response rate of 40% for HCAHPS patients compared favorably to the 2010 HCAHPS national average of 33%.34 Still, the responses of those who could not be reached may have differed from those who were interviewed. Fourth, we identified hospitalists and PCPs by the attending of record, but we were unable to tell who provided care to the patient on any given day. Thus, we could not determine to what extent patients cared for by PCPs were actually seen by their own doctor, as opposed to an associated physician within the practice. Nevertheless, our results are representative of the care model provided by PCPs in the hospital. Similarly, we could not know or compare the number of different attending physicians each patient experienced during their hospitalization. Higher turnover of inpatient physicians may have affected patient satisfaction scores independent of attending physician designation. These are potentially important measures of relationship duration, yet whether duration affects patient satisfaction remains undecided.1618, 20, 28, 30, 32, 33 We assessed satisfaction using HCAHPS questions, in order to provide objective and meaningful comparisons across hospitals. The HCAHPS instrument, however, is intended to assess patient satisfaction with doctors in general, not with subgroups or individuals, and responses in our study were uniformly high. A more sensitive survey instrument may have yielded different results. Finally, it is possible that individual physicians may possess lower satisfaction scores than others, making the results not representative of hospitalist models as much as specific doctors' care quality. We think this is unlikely since surveys reached over 8000 patients, over 6 years, representing the care of 347 individual physicians. However, hospital medicine is a rapidly evolving field with many divergent organizational structures, and patient satisfaction is bound to fluctuate while there exists high variability in how care is provided.

Over the past decade, the hospitalist model has become one of the dominant models for care of medical inpatients. Compared to the traditional model in which PCPs provide inpatient care, the hospitalist model has a number of advantages, including continuous on‐site coverage for increasingly acute patients, specialization, and incentives aligned with the hospital to provide efficient, high‐quality care. One concern that remains, however, is that patients may not trust doctors they first meet in the hospital or may be dissatisfied with the lack of continuity from day to day. Our findings are reassuring in this regard. Although patients cared for by hospitalists were slightly less satisfied, the differences could not be considered clinically meaningful and should be outweighed by gains in quality and efficiency. Furthermore, hospitalists can expect to fare well under value‐based purchasing. Given the rapid ascension of hospital medicine programs, prospective comparisons of hospitalists and PCPs may no longer be feasible. Future research might employ survey instruments designed specifically to measure patient experience under hospitalist care in order to identify methods to maximize patient satisfaction within the hospitalist model.