The Accreditation Council for Graduate Medical Education implemented rules limiting work hours for residents in 2003 and 2011, decreasing the availability of residents as providers at teaching hospitals.[1] These restrictions have increased reliance on advance practice providers (APPs) including nurse practitioners (NPs) and physicians' assistants in providing inpatient care. The NP hospitalist role includes inpatient medical management, coordination of care, patient and staff education, and quality improvement activities.[2] The NP hospitalist role has expanded beyond a replacement for reduced resident work hours, adding value through resident teaching, development of clinical care guidelines (CCGs), continuity of care, and familiarity with inpatient management.[3] The NP hospitalist role has been shown to improve the quality, efficiency, and cost effectiveness of inpatient care.[4, 5]

Favorable quality and cost measure results have been documented for adult NP hospitalists compared to housestaff, including improved patient outcomes, increased patient and staff satisfaction, decreased length of stay (LOS) and cost of care, and improved access to care.[6] These findings are supported by NP inpatient program evaluations at several academic medical centers, which also show increased patient and family satisfaction and improved communication between physicians, nurses, and families.[6, 7, 8] One study demonstrated that collaborative care management of adult medical patients by a hospitalist physician and advanced practice nurse led to decreased LOS and improved hospital profit without changing patient readmission or mortality.[9] Although there is a growing body of evidence supporting the quality and cost effectiveness of the NP hospitalist role in adult inpatient care, there are little published data for pediatric programs.

METHODS

The pediatric nurse practitioner (PNP) hospitalist role at Children's Hospital Colorado (CHCO) was initiated in 2006 to meet the need for additional inpatient providers. Inpatient staffing challenges included decreased resident work hours as well as high inpatient volume during the winter respiratory season. The PNP hospitalist providers at CHCO independently manage care throughout hospitalization for patients within their scope of practice, and comanage more complex patients with the attending doctor of medicine (MD). The PNPs complete history and physical exams, order and interpret diagnostic tests, perform procedures, prescribe medications, and assist with discharge coordination. Patient populations within the PNP hospitalist scope of practice include uncomplicated bronchiolitis, pneumonia, and asthma.

The hospitalist section at CHCO's main campus includes 2 resident teams and 1 PNP team. The hospitalist section also provides inpatient care at several network of care (NOC) sites. These NOC sites are CHCO‐staffed facilities that are either freestanding or connected to a community hospital, with an emergency department and 6 to 8 inpatient beds. The PNP hospitalist role includes inpatient management at the CHCO main campus as well as in the NOC. The NOC sites are staffed with a PNP and MD team who work collaboratively to manage inpatient care. The Advanced Practice Hospitalist Program was implemented to improve staffing and maintain quality of patient care in a cost‐effective manner. We undertook a program evaluation with the goal of comparing quality and cost of care between the PNP team, PNP/MD team, and resident teams.

Administrative and electronic medical record data from July 1, 2009 through June 30, 2010 were reviewed retrospectively. Data were obtained from inpatient records at CHCO inpatient medical unit and inpatient satellite sites in the CHCO NOC. The 2008 versions 26 and 27 of the 3M All Patient Refined Diagnosis‐Related Groups (APR‐DRG) were used to categorize patients by diagnosis, severity of illness, and risk of mortality.[10, 11] The top 3 APR‐DRGs at CHCO, based on volume of inpatient admissions, were selected for this analysis, including bronchiolitis and RSV pneumonia (APR‐DRG 138), pneumonia NEC (APR‐DRG 139), and asthma (APR‐DRG 141) (N = 1664). These 3 diagnoses accounted for approximately 60% of all inpatient hospitalist encounters and comprised 78% of the PNP encounters, 52% of the resident encounters, and 76% of the PNP/MD encounters. APR‐DRG severity of illness categories include I, II, III, and IV (minor, moderate, major, and extreme, respectively).[12] Severity of illness levels I and II were used for this analysis. Severity III and IV levels were excluded due to lack of patients in these categories on the PNP team and in the NOC. We also included observation status patients. The PNP team accounted for approximately 20% of the inpatient encounters, with 45% on the resident teams and 35% on the PNP/MD team in the NOC (Table 1).

The PNP hospitalist program was evaluated by comparing patient records from the PNP team, the PNP/MD team, and the resident teams. Evaluation measures included compliance with specific components of the bronchiolitis and asthma CCGs, LOS, and cost of care.

RESULTS

PNP adherence to CCGs was comparable to resident teams for the specific measures used in this evaluation. Based on a hospital‐wide goal of ordering diagnostic tests for less than 25% of inpatients with bronchiolitis, there was no significant difference between the PNP team and resident teams. There was no significant difference in the rate of chest x‐ray ordering between the PNP team and the resident teams (15% vs 22%, P = 0.1079). Similarly, there was no significant difference in viral testing between the PNP and physician teams (24% vs 25%, P = 0.9813) (Table 2). Post hoc power analysis indicated that a larger sample size would be required to increase the power of detecting a statistically significant difference in chest x‐ray ordering between these groups. The PNP and resident teams were also compared using compliance with the asthma CCGs, specifically related to the goal of providing an accurate AAP to every patient admitted for asthma. The PNP and resident teams had a similar rate of compliance, with PNPs achieving 81% compliance and MDs 76% (P = 0.4351) (Table 2).

LOS and direct costs were compared for the 3 teams for the top 3 APR‐DRGs and controlling for acuity. Table 3 illustrates that there were no significant differences in LOS between the PNP and resident teams or between the PNP and PNP/MD teams for these 3 APR‐DRGs (P 0.017 considered statistically significant). There was a statistically significant difference in LOS between resident and PNP/MD teams for asthma and pneumonia (P 0.001). The direct cost of care per patient encounter provided by the PNP team was significantly less than the PNP/MD team for all 3 APR‐DRGs (P 0.001). The direct cost of care per patient encounter provided by the PNP team was significantly less than the resident teams for asthma (P = 0.0021) and pneumonia (P = 0.0001), although the difference was not statistically significant for bronchiolitis (P = 0.0228) for level of significance P 0.0017 (Table 3, 4).

Figure 1 illustrates the monthly patient census on the PNP and resident teams obtained from daily midnight census. There was a dramatic seasonal fluctuation in PNP team census, with a low census in July 2009 (22 patients) and high census in February 2010 (355 patients). The resident teams maintained a relatively stable census year round compared to the PNP team.

Figure 1

CONCLUSIONS/DISCUSSION

The results of this program evaluation suggest that the PNP team at CHCO provides inpatient care comparable to the resident teams at a lower cost per patient encounter for uncomplicated bronchiolitis, pneumonia, and asthma. The results of this program evaluation are consistent with previously published studies demonstrating that NPs improve outcomes such as decreased LOS and cost of care.[9]

In the setting of increasingly stringent restrictions in residency work hours, PNP hospitalists are a valuable resource for managing inpatient care. PNPs can provide additional benefits not explored in this program evaluation, such as increased access to care, increased patient and family satisfaction, improved documentation, and improved communication between nurses and physicians.[6] NP hospitalist providers can also decrease the patient care burden on housestaff, allowing teaching teams to focus on resident education.[6] This point could be made for the PNP team at CHCO, which contributed to care of inpatients during the peak respiratory season census. This strategy has allowed the resident teaching teams to maintain a more manageable patient census during the winter respiratory season, and presumably has allowed greater focus on resident education year round.[17]

Hospitals have been increasingly using evidence based CCGs as a strategy to improve patient outcomes and decrease LOS and cost.[18] CCGs provide an excellent tool for hospitalist physicians and APPs to deliver consistent inpatient care for common diagnoses such as bronchiolitis, asthma, and pneumonia. Increased reliance on CCGs has provided an opportunity to standardize evidence‐based practices and has allowed PNPs to expand their inpatient role at CHCO. The addition of a PNP inpatient team at CHCO also provided an effective strategy for management of seasonal fluctuations in inpatient census, particularly during the winter respiratory season.

The Accreditation Council for Graduate Medical Education implemented rules limiting work hours for residents in 2003 and 2011, decreasing the availability of residents as providers at teaching hospitals.[1] These restrictions have increased reliance on advance practice providers (APPs) including nurse practitioners (NPs) and physicians' assistants in providing inpatient care. The NP hospitalist role includes inpatient medical management, coordination of care, patient and staff education, and quality improvement activities.[2] The NP hospitalist role has expanded beyond a replacement for reduced resident work hours, adding value through resident teaching, development of clinical care guidelines (CCGs), continuity of care, and familiarity with inpatient management.[3] The NP hospitalist role has been shown to improve the quality, efficiency, and cost effectiveness of inpatient care.[4, 5]

Favorable quality and cost measure results have been documented for adult NP hospitalists compared to housestaff, including improved patient outcomes, increased patient and staff satisfaction, decreased length of stay (LOS) and cost of care, and improved access to care.[6] These findings are supported by NP inpatient program evaluations at several academic medical centers, which also show increased patient and family satisfaction and improved communication between physicians, nurses, and families.[6, 7, 8] One study demonstrated that collaborative care management of adult medical patients by a hospitalist physician and advanced practice nurse led to decreased LOS and improved hospital profit without changing patient readmission or mortality.[9] Although there is a growing body of evidence supporting the quality and cost effectiveness of the NP hospitalist role in adult inpatient care, there are little published data for pediatric programs.

METHODS

The pediatric nurse practitioner (PNP) hospitalist role at Children's Hospital Colorado (CHCO) was initiated in 2006 to meet the need for additional inpatient providers. Inpatient staffing challenges included decreased resident work hours as well as high inpatient volume during the winter respiratory season. The PNP hospitalist providers at CHCO independently manage care throughout hospitalization for patients within their scope of practice, and comanage more complex patients with the attending doctor of medicine (MD). The PNPs complete history and physical exams, order and interpret diagnostic tests, perform procedures, prescribe medications, and assist with discharge coordination. Patient populations within the PNP hospitalist scope of practice include uncomplicated bronchiolitis, pneumonia, and asthma.

The hospitalist section at CHCO's main campus includes 2 resident teams and 1 PNP team. The hospitalist section also provides inpatient care at several network of care (NOC) sites. These NOC sites are CHCO‐staffed facilities that are either freestanding or connected to a community hospital, with an emergency department and 6 to 8 inpatient beds. The PNP hospitalist role includes inpatient management at the CHCO main campus as well as in the NOC. The NOC sites are staffed with a PNP and MD team who work collaboratively to manage inpatient care. The Advanced Practice Hospitalist Program was implemented to improve staffing and maintain quality of patient care in a cost‐effective manner. We undertook a program evaluation with the goal of comparing quality and cost of care between the PNP team, PNP/MD team, and resident teams.

Administrative and electronic medical record data from July 1, 2009 through June 30, 2010 were reviewed retrospectively. Data were obtained from inpatient records at CHCO inpatient medical unit and inpatient satellite sites in the CHCO NOC. The 2008 versions 26 and 27 of the 3M All Patient Refined Diagnosis‐Related Groups (APR‐DRG) were used to categorize patients by diagnosis, severity of illness, and risk of mortality.[10, 11] The top 3 APR‐DRGs at CHCO, based on volume of inpatient admissions, were selected for this analysis, including bronchiolitis and RSV pneumonia (APR‐DRG 138), pneumonia NEC (APR‐DRG 139), and asthma (APR‐DRG 141) (N = 1664). These 3 diagnoses accounted for approximately 60% of all inpatient hospitalist encounters and comprised 78% of the PNP encounters, 52% of the resident encounters, and 76% of the PNP/MD encounters. APR‐DRG severity of illness categories include I, II, III, and IV (minor, moderate, major, and extreme, respectively).[12] Severity of illness levels I and II were used for this analysis. Severity III and IV levels were excluded due to lack of patients in these categories on the PNP team and in the NOC. We also included observation status patients. The PNP team accounted for approximately 20% of the inpatient encounters, with 45% on the resident teams and 35% on the PNP/MD team in the NOC (Table 1).

The PNP hospitalist program was evaluated by comparing patient records from the PNP team, the PNP/MD team, and the resident teams. Evaluation measures included compliance with specific components of the bronchiolitis and asthma CCGs, LOS, and cost of care.

RESULTS

PNP adherence to CCGs was comparable to resident teams for the specific measures used in this evaluation. Based on a hospital‐wide goal of ordering diagnostic tests for less than 25% of inpatients with bronchiolitis, there was no significant difference between the PNP team and resident teams. There was no significant difference in the rate of chest x‐ray ordering between the PNP team and the resident teams (15% vs 22%, P = 0.1079). Similarly, there was no significant difference in viral testing between the PNP and physician teams (24% vs 25%, P = 0.9813) (Table 2). Post hoc power analysis indicated that a larger sample size would be required to increase the power of detecting a statistically significant difference in chest x‐ray ordering between these groups. The PNP and resident teams were also compared using compliance with the asthma CCGs, specifically related to the goal of providing an accurate AAP to every patient admitted for asthma. The PNP and resident teams had a similar rate of compliance, with PNPs achieving 81% compliance and MDs 76% (P = 0.4351) (Table 2).

LOS and direct costs were compared for the 3 teams for the top 3 APR‐DRGs and controlling for acuity. Table 3 illustrates that there were no significant differences in LOS between the PNP and resident teams or between the PNP and PNP/MD teams for these 3 APR‐DRGs (P 0.017 considered statistically significant). There was a statistically significant difference in LOS between resident and PNP/MD teams for asthma and pneumonia (P 0.001). The direct cost of care per patient encounter provided by the PNP team was significantly less than the PNP/MD team for all 3 APR‐DRGs (P 0.001). The direct cost of care per patient encounter provided by the PNP team was significantly less than the resident teams for asthma (P = 0.0021) and pneumonia (P = 0.0001), although the difference was not statistically significant for bronchiolitis (P = 0.0228) for level of significance P 0.0017 (Table 3, 4).

Figure 1 illustrates the monthly patient census on the PNP and resident teams obtained from daily midnight census. There was a dramatic seasonal fluctuation in PNP team census, with a low census in July 2009 (22 patients) and high census in February 2010 (355 patients). The resident teams maintained a relatively stable census year round compared to the PNP team.

Figure 1

CONCLUSIONS/DISCUSSION

The results of this program evaluation suggest that the PNP team at CHCO provides inpatient care comparable to the resident teams at a lower cost per patient encounter for uncomplicated bronchiolitis, pneumonia, and asthma. The results of this program evaluation are consistent with previously published studies demonstrating that NPs improve outcomes such as decreased LOS and cost of care.[9]

In the setting of increasingly stringent restrictions in residency work hours, PNP hospitalists are a valuable resource for managing inpatient care. PNPs can provide additional benefits not explored in this program evaluation, such as increased access to care, increased patient and family satisfaction, improved documentation, and improved communication between nurses and physicians.[6] NP hospitalist providers can also decrease the patient care burden on housestaff, allowing teaching teams to focus on resident education.[6] This point could be made for the PNP team at CHCO, which contributed to care of inpatients during the peak respiratory season census. This strategy has allowed the resident teaching teams to maintain a more manageable patient census during the winter respiratory season, and presumably has allowed greater focus on resident education year round.[17]

Hospitals have been increasingly using evidence based CCGs as a strategy to improve patient outcomes and decrease LOS and cost.[18] CCGs provide an excellent tool for hospitalist physicians and APPs to deliver consistent inpatient care for common diagnoses such as bronchiolitis, asthma, and pneumonia. Increased reliance on CCGs has provided an opportunity to standardize evidence‐based practices and has allowed PNPs to expand their inpatient role at CHCO. The addition of a PNP inpatient team at CHCO also provided an effective strategy for management of seasonal fluctuations in inpatient census, particularly during the winter respiratory season.

The Accreditation Council for Graduate Medical Education implemented rules limiting work hours for residents in 2003 and 2011, decreasing the availability of residents as providers at teaching hospitals.[1] These restrictions have increased reliance on advance practice providers (APPs) including nurse practitioners (NPs) and physicians' assistants in providing inpatient care. The NP hospitalist role includes inpatient medical management, coordination of care, patient and staff education, and quality improvement activities.[2] The NP hospitalist role has expanded beyond a replacement for reduced resident work hours, adding value through resident teaching, development of clinical care guidelines (CCGs), continuity of care, and familiarity with inpatient management.[3] The NP hospitalist role has been shown to improve the quality, efficiency, and cost effectiveness of inpatient care.[4, 5]

Favorable quality and cost measure results have been documented for adult NP hospitalists compared to housestaff, including improved patient outcomes, increased patient and staff satisfaction, decreased length of stay (LOS) and cost of care, and improved access to care.[6] These findings are supported by NP inpatient program evaluations at several academic medical centers, which also show increased patient and family satisfaction and improved communication between physicians, nurses, and families.[6, 7, 8] One study demonstrated that collaborative care management of adult medical patients by a hospitalist physician and advanced practice nurse led to decreased LOS and improved hospital profit without changing patient readmission or mortality.[9] Although there is a growing body of evidence supporting the quality and cost effectiveness of the NP hospitalist role in adult inpatient care, there are little published data for pediatric programs.

METHODS

The pediatric nurse practitioner (PNP) hospitalist role at Children's Hospital Colorado (CHCO) was initiated in 2006 to meet the need for additional inpatient providers. Inpatient staffing challenges included decreased resident work hours as well as high inpatient volume during the winter respiratory season. The PNP hospitalist providers at CHCO independently manage care throughout hospitalization for patients within their scope of practice, and comanage more complex patients with the attending doctor of medicine (MD). The PNPs complete history and physical exams, order and interpret diagnostic tests, perform procedures, prescribe medications, and assist with discharge coordination. Patient populations within the PNP hospitalist scope of practice include uncomplicated bronchiolitis, pneumonia, and asthma.

The hospitalist section at CHCO's main campus includes 2 resident teams and 1 PNP team. The hospitalist section also provides inpatient care at several network of care (NOC) sites. These NOC sites are CHCO‐staffed facilities that are either freestanding or connected to a community hospital, with an emergency department and 6 to 8 inpatient beds. The PNP hospitalist role includes inpatient management at the CHCO main campus as well as in the NOC. The NOC sites are staffed with a PNP and MD team who work collaboratively to manage inpatient care. The Advanced Practice Hospitalist Program was implemented to improve staffing and maintain quality of patient care in a cost‐effective manner. We undertook a program evaluation with the goal of comparing quality and cost of care between the PNP team, PNP/MD team, and resident teams.

Administrative and electronic medical record data from July 1, 2009 through June 30, 2010 were reviewed retrospectively. Data were obtained from inpatient records at CHCO inpatient medical unit and inpatient satellite sites in the CHCO NOC. The 2008 versions 26 and 27 of the 3M All Patient Refined Diagnosis‐Related Groups (APR‐DRG) were used to categorize patients by diagnosis, severity of illness, and risk of mortality.[10, 11] The top 3 APR‐DRGs at CHCO, based on volume of inpatient admissions, were selected for this analysis, including bronchiolitis and RSV pneumonia (APR‐DRG 138), pneumonia NEC (APR‐DRG 139), and asthma (APR‐DRG 141) (N = 1664). These 3 diagnoses accounted for approximately 60% of all inpatient hospitalist encounters and comprised 78% of the PNP encounters, 52% of the resident encounters, and 76% of the PNP/MD encounters. APR‐DRG severity of illness categories include I, II, III, and IV (minor, moderate, major, and extreme, respectively).[12] Severity of illness levels I and II were used for this analysis. Severity III and IV levels were excluded due to lack of patients in these categories on the PNP team and in the NOC. We also included observation status patients. The PNP team accounted for approximately 20% of the inpatient encounters, with 45% on the resident teams and 35% on the PNP/MD team in the NOC (Table 1).

The PNP hospitalist program was evaluated by comparing patient records from the PNP team, the PNP/MD team, and the resident teams. Evaluation measures included compliance with specific components of the bronchiolitis and asthma CCGs, LOS, and cost of care.

RESULTS

PNP adherence to CCGs was comparable to resident teams for the specific measures used in this evaluation. Based on a hospital‐wide goal of ordering diagnostic tests for less than 25% of inpatients with bronchiolitis, there was no significant difference between the PNP team and resident teams. There was no significant difference in the rate of chest x‐ray ordering between the PNP team and the resident teams (15% vs 22%, P = 0.1079). Similarly, there was no significant difference in viral testing between the PNP and physician teams (24% vs 25%, P = 0.9813) (Table 2). Post hoc power analysis indicated that a larger sample size would be required to increase the power of detecting a statistically significant difference in chest x‐ray ordering between these groups. The PNP and resident teams were also compared using compliance with the asthma CCGs, specifically related to the goal of providing an accurate AAP to every patient admitted for asthma. The PNP and resident teams had a similar rate of compliance, with PNPs achieving 81% compliance and MDs 76% (P = 0.4351) (Table 2).

LOS and direct costs were compared for the 3 teams for the top 3 APR‐DRGs and controlling for acuity. Table 3 illustrates that there were no significant differences in LOS between the PNP and resident teams or between the PNP and PNP/MD teams for these 3 APR‐DRGs (P 0.017 considered statistically significant). There was a statistically significant difference in LOS between resident and PNP/MD teams for asthma and pneumonia (P 0.001). The direct cost of care per patient encounter provided by the PNP team was significantly less than the PNP/MD team for all 3 APR‐DRGs (P 0.001). The direct cost of care per patient encounter provided by the PNP team was significantly less than the resident teams for asthma (P = 0.0021) and pneumonia (P = 0.0001), although the difference was not statistically significant for bronchiolitis (P = 0.0228) for level of significance P 0.0017 (Table 3, 4).

Figure 1 illustrates the monthly patient census on the PNP and resident teams obtained from daily midnight census. There was a dramatic seasonal fluctuation in PNP team census, with a low census in July 2009 (22 patients) and high census in February 2010 (355 patients). The resident teams maintained a relatively stable census year round compared to the PNP team.

Figure 1

CONCLUSIONS/DISCUSSION

The results of this program evaluation suggest that the PNP team at CHCO provides inpatient care comparable to the resident teams at a lower cost per patient encounter for uncomplicated bronchiolitis, pneumonia, and asthma. The results of this program evaluation are consistent with previously published studies demonstrating that NPs improve outcomes such as decreased LOS and cost of care.[9]

In the setting of increasingly stringent restrictions in residency work hours, PNP hospitalists are a valuable resource for managing inpatient care. PNPs can provide additional benefits not explored in this program evaluation, such as increased access to care, increased patient and family satisfaction, improved documentation, and improved communication between nurses and physicians.[6] NP hospitalist providers can also decrease the patient care burden on housestaff, allowing teaching teams to focus on resident education.[6] This point could be made for the PNP team at CHCO, which contributed to care of inpatients during the peak respiratory season census. This strategy has allowed the resident teaching teams to maintain a more manageable patient census during the winter respiratory season, and presumably has allowed greater focus on resident education year round.[17]

Hospitals have been increasingly using evidence based CCGs as a strategy to improve patient outcomes and decrease LOS and cost.[18] CCGs provide an excellent tool for hospitalist physicians and APPs to deliver consistent inpatient care for common diagnoses such as bronchiolitis, asthma, and pneumonia. Increased reliance on CCGs has provided an opportunity to standardize evidence‐based practices and has allowed PNPs to expand their inpatient role at CHCO. The addition of a PNP inpatient team at CHCO also provided an effective strategy for management of seasonal fluctuations in inpatient census, particularly during the winter respiratory season.

There is consensus that the hospital is an appropriate place to start chronic medications for conditions that caused the hospitalization (e.g., aspirin for a patient admitted with acute myocardial infarction). However, little is known about physician attitudes toward starting chronic medications for conditions unrelated to the reason for hospitalization (e.g., aspirin in a patient with a history of myocardial infarction admitted for cellulitis). Although hospitalists can identify and remedy potential gaps in the management of chronic conditions, changes in such medications during the hospital stay can create a number of problems. Contextual factors, such as prior medication trials, patient preferences, and longstanding patterns of disease management, may be unknown to the inpatient clinician, and medication confusion, nonadherence, and adverse effects can result from multiple medication changes.[1, 2] The lack of consensus about changing chronic medications for conditions unrelated to the reason for admission reflects a lack of clarity regarding the risk‐benefit equation in this area.

The study by Breu and colleagues[3] in this issue provides one of the first studies of hospitalist and primary care physician (PCP) attitudes about changing chronic medications during hospitalization for conditions unrelated to the reason for admission. The authors had hospitalists and PCPs consider six cases, half involving a medication change related to the reason for admission and half involving a medication change unrelated to the reason for admission. They found that PCPs were more likely than hospitalists to feel that inpatient interventions were appropriate when unrelated to the reason for admission. However, the majority of both hospitalists and PCPs did not feel interventions in these cases were appropriate.

Although this study provides useful insight into the attitudes of physicians toward these issues, it is likely that even more physicians would be skeptical of initiating chronic medications in the hospital if the scenarios reflected the messy reality that often faces clinicians when patients are hospitalized. The study asked physician respondents to assume full outpatient electronic medical record (EMR) access and communication at discharge. However, in practice, inpatient physicians often do not have full outpatient EMR access. If they do have full access to records, they typically do not have the time to thoroughly review the chart, leading to over half of internal medicine patients having at least one medication discrepancy at admission.[4] In addition, communication between hospitalists and PCPs occurs infrequently, and discharge summaries are often not available by the time of the first postdischarge clinic visit and lack important information, such as diagnostic test results and discharge medications.[2]

We believe that in most clinical settings, the serious problems that accompany changing medications in hospitalized patients argue for a judicious approach to modifying medications for chronic conditions not related to the reason for hospitalization. However, the more important question is how the prescribing process in hospitalized patients can be re‐envisioned in a manner that allows individualization of these decisions to serve both the short‐ and long‐term needs of patients. Because the success and appropriateness of long‐term treatment decisions often depends on contextual factors, PCP follow‐up, and patient medication compliance, in most cases decisions about initiating long‐term therapy for conditions not central to the hospital admission should involve each of these circumstances. Shared decision making models involve clinicians and patients sharing information, expressing treatment preferences, deliberating the options, and coming to an agreement on a treatment plan,[5] and these models have been associated with improved adherence and disease‐specific outcomes.[6] Shared decision making in many cases could be done quickly and efficiently through a quick check‐in with the PCP and a brief discussion with the patient. When consensus cannot be reached with these methods, then raising the issue with the PCP and patient but deferring the final decision until after discharge would be appropriate.

In hospitalized patients, less is often more, and minimizing the number of nonessential medication changes may ultimately yield better outcomes. Although inpatient clinicians can identify important gaps in care, the best solutions come from discussions that can bridge the inpatient‐outpatient divide and ultimately serve the long‐term needs of patients.

There is consensus that the hospital is an appropriate place to start chronic medications for conditions that caused the hospitalization (e.g., aspirin for a patient admitted with acute myocardial infarction). However, little is known about physician attitudes toward starting chronic medications for conditions unrelated to the reason for hospitalization (e.g., aspirin in a patient with a history of myocardial infarction admitted for cellulitis). Although hospitalists can identify and remedy potential gaps in the management of chronic conditions, changes in such medications during the hospital stay can create a number of problems. Contextual factors, such as prior medication trials, patient preferences, and longstanding patterns of disease management, may be unknown to the inpatient clinician, and medication confusion, nonadherence, and adverse effects can result from multiple medication changes.[1, 2] The lack of consensus about changing chronic medications for conditions unrelated to the reason for admission reflects a lack of clarity regarding the risk‐benefit equation in this area.

The study by Breu and colleagues[3] in this issue provides one of the first studies of hospitalist and primary care physician (PCP) attitudes about changing chronic medications during hospitalization for conditions unrelated to the reason for admission. The authors had hospitalists and PCPs consider six cases, half involving a medication change related to the reason for admission and half involving a medication change unrelated to the reason for admission. They found that PCPs were more likely than hospitalists to feel that inpatient interventions were appropriate when unrelated to the reason for admission. However, the majority of both hospitalists and PCPs did not feel interventions in these cases were appropriate.

Although this study provides useful insight into the attitudes of physicians toward these issues, it is likely that even more physicians would be skeptical of initiating chronic medications in the hospital if the scenarios reflected the messy reality that often faces clinicians when patients are hospitalized. The study asked physician respondents to assume full outpatient electronic medical record (EMR) access and communication at discharge. However, in practice, inpatient physicians often do not have full outpatient EMR access. If they do have full access to records, they typically do not have the time to thoroughly review the chart, leading to over half of internal medicine patients having at least one medication discrepancy at admission.[4] In addition, communication between hospitalists and PCPs occurs infrequently, and discharge summaries are often not available by the time of the first postdischarge clinic visit and lack important information, such as diagnostic test results and discharge medications.[2]

We believe that in most clinical settings, the serious problems that accompany changing medications in hospitalized patients argue for a judicious approach to modifying medications for chronic conditions not related to the reason for hospitalization. However, the more important question is how the prescribing process in hospitalized patients can be re‐envisioned in a manner that allows individualization of these decisions to serve both the short‐ and long‐term needs of patients. Because the success and appropriateness of long‐term treatment decisions often depends on contextual factors, PCP follow‐up, and patient medication compliance, in most cases decisions about initiating long‐term therapy for conditions not central to the hospital admission should involve each of these circumstances. Shared decision making models involve clinicians and patients sharing information, expressing treatment preferences, deliberating the options, and coming to an agreement on a treatment plan,[5] and these models have been associated with improved adherence and disease‐specific outcomes.[6] Shared decision making in many cases could be done quickly and efficiently through a quick check‐in with the PCP and a brief discussion with the patient. When consensus cannot be reached with these methods, then raising the issue with the PCP and patient but deferring the final decision until after discharge would be appropriate.

In hospitalized patients, less is often more, and minimizing the number of nonessential medication changes may ultimately yield better outcomes. Although inpatient clinicians can identify important gaps in care, the best solutions come from discussions that can bridge the inpatient‐outpatient divide and ultimately serve the long‐term needs of patients.

There is consensus that the hospital is an appropriate place to start chronic medications for conditions that caused the hospitalization (e.g., aspirin for a patient admitted with acute myocardial infarction). However, little is known about physician attitudes toward starting chronic medications for conditions unrelated to the reason for hospitalization (e.g., aspirin in a patient with a history of myocardial infarction admitted for cellulitis). Although hospitalists can identify and remedy potential gaps in the management of chronic conditions, changes in such medications during the hospital stay can create a number of problems. Contextual factors, such as prior medication trials, patient preferences, and longstanding patterns of disease management, may be unknown to the inpatient clinician, and medication confusion, nonadherence, and adverse effects can result from multiple medication changes.[1, 2] The lack of consensus about changing chronic medications for conditions unrelated to the reason for admission reflects a lack of clarity regarding the risk‐benefit equation in this area.

The study by Breu and colleagues[3] in this issue provides one of the first studies of hospitalist and primary care physician (PCP) attitudes about changing chronic medications during hospitalization for conditions unrelated to the reason for admission. The authors had hospitalists and PCPs consider six cases, half involving a medication change related to the reason for admission and half involving a medication change unrelated to the reason for admission. They found that PCPs were more likely than hospitalists to feel that inpatient interventions were appropriate when unrelated to the reason for admission. However, the majority of both hospitalists and PCPs did not feel interventions in these cases were appropriate.

Although this study provides useful insight into the attitudes of physicians toward these issues, it is likely that even more physicians would be skeptical of initiating chronic medications in the hospital if the scenarios reflected the messy reality that often faces clinicians when patients are hospitalized. The study asked physician respondents to assume full outpatient electronic medical record (EMR) access and communication at discharge. However, in practice, inpatient physicians often do not have full outpatient EMR access. If they do have full access to records, they typically do not have the time to thoroughly review the chart, leading to over half of internal medicine patients having at least one medication discrepancy at admission.[4] In addition, communication between hospitalists and PCPs occurs infrequently, and discharge summaries are often not available by the time of the first postdischarge clinic visit and lack important information, such as diagnostic test results and discharge medications.[2]

We believe that in most clinical settings, the serious problems that accompany changing medications in hospitalized patients argue for a judicious approach to modifying medications for chronic conditions not related to the reason for hospitalization. However, the more important question is how the prescribing process in hospitalized patients can be re‐envisioned in a manner that allows individualization of these decisions to serve both the short‐ and long‐term needs of patients. Because the success and appropriateness of long‐term treatment decisions often depends on contextual factors, PCP follow‐up, and patient medication compliance, in most cases decisions about initiating long‐term therapy for conditions not central to the hospital admission should involve each of these circumstances. Shared decision making models involve clinicians and patients sharing information, expressing treatment preferences, deliberating the options, and coming to an agreement on a treatment plan,[5] and these models have been associated with improved adherence and disease‐specific outcomes.[6] Shared decision making in many cases could be done quickly and efficiently through a quick check‐in with the PCP and a brief discussion with the patient. When consensus cannot be reached with these methods, then raising the issue with the PCP and patient but deferring the final decision until after discharge would be appropriate.

In hospitalized patients, less is often more, and minimizing the number of nonessential medication changes may ultimately yield better outcomes. Although inpatient clinicians can identify important gaps in care, the best solutions come from discussions that can bridge the inpatient‐outpatient divide and ultimately serve the long‐term needs of patients.

Over the past 2 decades, the care of the hospitalized patient has changed dramatically. Hospitalists now account for the care of more than one‐third of general medicine inpatients, and this number is likely to grow.[1] The emergence of hospital medicine has resulted in a partnership between primary care physicians (PCPs) and hospitalists wherein hospitalists focus on acute medical issues requiring hospitalization, whereas more chronic issues unrelated to the reason for hospitalization remain largely the domain of the PCP.[2, 3]

However, several evolving financial and quality incentives have already begun to blur the distinction between inpatient and outpatient care. First, as private and public payers increasingly scrutinize readmission rates, it has become clear that the responsibility for patient outcomes extends beyond the day of discharge.[4] The birth of Accountable Care Organizations and patient‐centered medical homes may further blur distinctions between what has traditionally constituted inpatient and outpatient care.[5] Bundled payments may force providers to ensure that each visit, whether hospital‐ or clinic‐based, is taken as an opportunity to enact meaningful change.[6] The Centers for Medicare and Medicaid Services (CMS) are already tracking hospital performance on institution of medical therapy for certain conditions regardless of their relatedness to the reason for hospitalization.[7]

No published literature has yet examined the attitudes of inpatient and outpatient providers regarding this issue. Through a case‐based survey conducted at 3 large urban academic medical centers, we aimed to assess opinions among hospitalists and PCPs regarding the role of hospitalists in the management of conditions unrelated to the reason for admission. Our study had 2 main objectives: (1) to determine whether surveyed physicians were more likely to rate an inpatient intervention as appropriate when it related to the reason for admission as compared to interventions unrelated to the reason for admission; and (2) to determine whether these attitudes differed between PCPs and hospitalists.

METHODS

Survey Administration

Between October 23, 2012 and November 10, 2012, 3 emails containing a link to the online survey were sent to all hospitalist and hospital‐based PCPs at the 3 study institutions. The BIDMC Committee on Clinical Investigations, to whom authority was ceded by the remaining 2 study institutions, certified this research protocol as exempt.

RESULTS

DISCUSSION

In this survey‐based study of PCPs and hospitalists across 3 Boston‐area academic medical centers, we found that: (1) physicians were more likely to see inpatient interventions as appropriate when those interventions dealt with the reason for admission as compared to interventions unrelated to the reason for admission; and (2) PCPs were more likely than hospitalists to feel that inpatient interventions were appropriate, even when they targeted chronic conditions unrelated to the reason for admission. To our knowledge, this study represents the first investigation into the attitudes of PCPs and hospitalists regarding the inpatient management of conditions unrelated to the reason for admission.

That surveyed physicians, regardless of role, were less likely to report an intervention unrelated to the reason for hospitalization as appropriateeven those with likely mortality benefitsuggests that opportunities to affect meaningful change may be missed in a healthcare system that adheres to strict inpatient and outpatient roles. For several of the cases, a change in therapy could lead to benefit soon after implementation. For example, aldosterone antagonists reduce mortality as early as 1 month after initiation in select patients.[8] If a major goal of inpatient care is to reduce 30‐day mortality, it could be argued that hospitalists should more actively adjust congestive heart failure therapy in appropriate inpatients, even when this is not their admitting diagnosis.

For some conditions, CMS is already tracking hospital performance. Since 2003, hospitals have been required to document whether a patient with congestive heart failure (either acute or chronic and regardless of the relationship to admission) was prescribed an angiotensin‐converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) at the time of discharge.[7] CMS has determined that the proven benefits of ACE inhibitors and ARBs confer hospital accountability for their inclusion in appropriate patients, independent of the acuity of heart failure. There are many potential therapeutic maneuvers on which health systems (and their physicians) may be graded, and accepting the view that a hospitalization provides a window of opportunity for medical optimization may allow for more fruitful interventions and more patient‐centered care.

Despite the potential benefits of addressing chronic medical issues during hospitalization, there are important limitations on what can and/or should be done in the hospital setting. Hospitalizations are a time of fluctuating clinical status, which continues beyond discharge and is often accompanied by several medication changes.[9] In our study, more than 20% of those who believed that a medication intervention was inappropriate selected I do not believe hospitalization is the right time to start this new medication as one of their explanations. Although some medication interventions have been shown in randomized controlled trials to reduce short‐term mortality, the ability to generalize these findings to the average hospitalized patient with multiple comorbidities, concurrent medication changes, and rapidly fluctuating clinical status is limited. Furthermore, there are interventions most would agree should not be dealt with in the hospital (eg, screening colonoscopy) and encounters that may be too short to allow for change (eg, 24‐hour observation). These issues notwithstanding, the average 4‐day hospitalization likely provides an opportunity for monitored change that may currently be underutilized.

Our study suggests several additional explanations for physicians' current practice and opinions. Only 6.5% of respondents who answered that an intervention was inappropriate indicated as a justification that I do not believe this is an appropriate pharmacologic intervention for this particular medical problem. This suggests that the hesitancy has little to do with a lack of benefit but instead relates to systems issues (eg, access to all pertinent records and concerns regarding follow‐up testing) and perceived limitations to what a hospitalist should and should not do without actively involving the PCP. There are likely additional concerns that the medical record and/or patient histories do not fully outline the rationale for exclusion or inclusion of particular medications. Advances in information technology that enhance information exchange and enable streamlined communication may help to address these perceived barriers. However, an additional barrier may be trust, as PCPs appear more concerned that hospitalists will not review all the pertinent records or discuss risks and benefits before enacting important medication changes. Increased attempts at communication between hospitalists and outpatient providers may help to build trust and alleviate concerns regarding the loss of information that often occurs both on admission and at discharge.

We also noted that PCPs were more likely than hospitalists to feel that inpatient interventions were appropriate, even when targeting chronic conditions unrelated to the reason for admission. It may be that PCPs, with an increasing number of problems to address per outpatient visit,[10, 11] are more open to hospitalists managing any medical problems during their patients' admissions. At the same time, with increased acuity[12, 13, 14] and shortened length of stays,[15, 16] hospitalists have only a finite amount of time to ensure acute issues are managed, leaving potentially modifiable chronic conditions to the outpatient setting. These differences aside, a minority of both PCPs and hospitalists in our study were ready to embrace the idea of hospitalists playing a larger role in the management of conditions unrelated to the reason for hospitalization.

Even though our study benefits from its multisite design, there are a number of limitations. First, although we crafted our survey with input from general medicine focus groups, our survey instrument has not been validated. In addition, the cases are necessarily contrived and do not take into account the complexities of inpatient medicine. Furthermore, though our goal was to create paired cases that isolate a management decision as being simply based on whether it was related or unrelated to the reason for admission, it is possible that other factors, not captured by our survey, influenced the responses. For example, the benefits of aspirin as part of secondary prevention are not equal to the benefits in an acute MI.[17]

In an attempt to isolate the hospitalists' role in these management decisions, respondents were instructed to assume that the decisions were being made without discussing it with the primary care physician, but that the hospitalist would communicate the details of any hospitalization at the time of discharge. They were also instructed to assume that the hospitalist has access to the patient's outpatient electronic medical record. These assumptions were made to address concerns regarding the flow of information and communication, and to simulate the ideal system from a communication and information accessibility standpoint. Had these assumptions not been placed, the responses may have differed. It is likely that PCPs and hospitalists practicing in systems without shared, accessible inpatient/outpatient medical records would be even more reluctant to enact medication changes unrelated to the reason for admission.

Along the same lines, our physician cohort consisted of several metropolitan academic physician groups, in which hospitalists have had a presence for almost 20 years. As a result, our findings may not be generalizable to other academic hospitals, community‐based hospitalist programs, or nonhospital‐based PCP practices. Finally, we do not know whether survey nonresponders differed from responders in ways that could have meaningfully affected our results.

In conclusion, our findings suggest that both PCPs and hospitalists see the management of conditions unrelated to the reason for admission as less appropriate than the management of conditions related to the reason for admission. Our findings also suggest that PCPs may be more open to this practice when compared to hospitalists. Failure to capitalize on opportunities for meaningful medical interventions, independent of patient location, suggests a possible lack of patient centeredness in the current partnership between PCPs and hospitalists. Further studies should examine existing barriers and investigate interventions designed to address those barriers, in an effort to improve both quality of care and the degree of patient‐centeredness in our current healthcare system.

Disclosures: Dr. Herzig is supported by a grant from the National Institute on Aging (K23 AG042459). Dr. Herzig had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Author contributions: study concept and design, Breu, Allen‐Dicker, Mueller, Herzig; acquisition of data, Breu, Allen‐Dicker, Mueller, Palamara, Herzig; analysis and interpretation of data, Breu, Allen‐Dicker, Hinami, Herzig; drafting of the manuscript, Breu; critical revision of the manuscript for important intellectual content, Breu, Allen‐Dicker, Mueller, Palamara, Hinami, Herzig; statistical analysis, Allen‐Dicker, Hinami, Herzig; study supervision, Breu, Herzig. This study was presented as a poster at the Society of Hospital Medicine National Meeting, Washington, DC, May 17, 2013.

Over the past 2 decades, the care of the hospitalized patient has changed dramatically. Hospitalists now account for the care of more than one‐third of general medicine inpatients, and this number is likely to grow.[1] The emergence of hospital medicine has resulted in a partnership between primary care physicians (PCPs) and hospitalists wherein hospitalists focus on acute medical issues requiring hospitalization, whereas more chronic issues unrelated to the reason for hospitalization remain largely the domain of the PCP.[2, 3]

However, several evolving financial and quality incentives have already begun to blur the distinction between inpatient and outpatient care. First, as private and public payers increasingly scrutinize readmission rates, it has become clear that the responsibility for patient outcomes extends beyond the day of discharge.[4] The birth of Accountable Care Organizations and patient‐centered medical homes may further blur distinctions between what has traditionally constituted inpatient and outpatient care.[5] Bundled payments may force providers to ensure that each visit, whether hospital‐ or clinic‐based, is taken as an opportunity to enact meaningful change.[6] The Centers for Medicare and Medicaid Services (CMS) are already tracking hospital performance on institution of medical therapy for certain conditions regardless of their relatedness to the reason for hospitalization.[7]

No published literature has yet examined the attitudes of inpatient and outpatient providers regarding this issue. Through a case‐based survey conducted at 3 large urban academic medical centers, we aimed to assess opinions among hospitalists and PCPs regarding the role of hospitalists in the management of conditions unrelated to the reason for admission. Our study had 2 main objectives: (1) to determine whether surveyed physicians were more likely to rate an inpatient intervention as appropriate when it related to the reason for admission as compared to interventions unrelated to the reason for admission; and (2) to determine whether these attitudes differed between PCPs and hospitalists.

METHODS

Survey Administration

Between October 23, 2012 and November 10, 2012, 3 emails containing a link to the online survey were sent to all hospitalist and hospital‐based PCPs at the 3 study institutions. The BIDMC Committee on Clinical Investigations, to whom authority was ceded by the remaining 2 study institutions, certified this research protocol as exempt.

RESULTS

DISCUSSION

In this survey‐based study of PCPs and hospitalists across 3 Boston‐area academic medical centers, we found that: (1) physicians were more likely to see inpatient interventions as appropriate when those interventions dealt with the reason for admission as compared to interventions unrelated to the reason for admission; and (2) PCPs were more likely than hospitalists to feel that inpatient interventions were appropriate, even when they targeted chronic conditions unrelated to the reason for admission. To our knowledge, this study represents the first investigation into the attitudes of PCPs and hospitalists regarding the inpatient management of conditions unrelated to the reason for admission.

That surveyed physicians, regardless of role, were less likely to report an intervention unrelated to the reason for hospitalization as appropriateeven those with likely mortality benefitsuggests that opportunities to affect meaningful change may be missed in a healthcare system that adheres to strict inpatient and outpatient roles. For several of the cases, a change in therapy could lead to benefit soon after implementation. For example, aldosterone antagonists reduce mortality as early as 1 month after initiation in select patients.[8] If a major goal of inpatient care is to reduce 30‐day mortality, it could be argued that hospitalists should more actively adjust congestive heart failure therapy in appropriate inpatients, even when this is not their admitting diagnosis.

For some conditions, CMS is already tracking hospital performance. Since 2003, hospitals have been required to document whether a patient with congestive heart failure (either acute or chronic and regardless of the relationship to admission) was prescribed an angiotensin‐converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) at the time of discharge.[7] CMS has determined that the proven benefits of ACE inhibitors and ARBs confer hospital accountability for their inclusion in appropriate patients, independent of the acuity of heart failure. There are many potential therapeutic maneuvers on which health systems (and their physicians) may be graded, and accepting the view that a hospitalization provides a window of opportunity for medical optimization may allow for more fruitful interventions and more patient‐centered care.

Despite the potential benefits of addressing chronic medical issues during hospitalization, there are important limitations on what can and/or should be done in the hospital setting. Hospitalizations are a time of fluctuating clinical status, which continues beyond discharge and is often accompanied by several medication changes.[9] In our study, more than 20% of those who believed that a medication intervention was inappropriate selected I do not believe hospitalization is the right time to start this new medication as one of their explanations. Although some medication interventions have been shown in randomized controlled trials to reduce short‐term mortality, the ability to generalize these findings to the average hospitalized patient with multiple comorbidities, concurrent medication changes, and rapidly fluctuating clinical status is limited. Furthermore, there are interventions most would agree should not be dealt with in the hospital (eg, screening colonoscopy) and encounters that may be too short to allow for change (eg, 24‐hour observation). These issues notwithstanding, the average 4‐day hospitalization likely provides an opportunity for monitored change that may currently be underutilized.

Our study suggests several additional explanations for physicians' current practice and opinions. Only 6.5% of respondents who answered that an intervention was inappropriate indicated as a justification that I do not believe this is an appropriate pharmacologic intervention for this particular medical problem. This suggests that the hesitancy has little to do with a lack of benefit but instead relates to systems issues (eg, access to all pertinent records and concerns regarding follow‐up testing) and perceived limitations to what a hospitalist should and should not do without actively involving the PCP. There are likely additional concerns that the medical record and/or patient histories do not fully outline the rationale for exclusion or inclusion of particular medications. Advances in information technology that enhance information exchange and enable streamlined communication may help to address these perceived barriers. However, an additional barrier may be trust, as PCPs appear more concerned that hospitalists will not review all the pertinent records or discuss risks and benefits before enacting important medication changes. Increased attempts at communication between hospitalists and outpatient providers may help to build trust and alleviate concerns regarding the loss of information that often occurs both on admission and at discharge.

We also noted that PCPs were more likely than hospitalists to feel that inpatient interventions were appropriate, even when targeting chronic conditions unrelated to the reason for admission. It may be that PCPs, with an increasing number of problems to address per outpatient visit,[10, 11] are more open to hospitalists managing any medical problems during their patients' admissions. At the same time, with increased acuity[12, 13, 14] and shortened length of stays,[15, 16] hospitalists have only a finite amount of time to ensure acute issues are managed, leaving potentially modifiable chronic conditions to the outpatient setting. These differences aside, a minority of both PCPs and hospitalists in our study were ready to embrace the idea of hospitalists playing a larger role in the management of conditions unrelated to the reason for hospitalization.

Even though our study benefits from its multisite design, there are a number of limitations. First, although we crafted our survey with input from general medicine focus groups, our survey instrument has not been validated. In addition, the cases are necessarily contrived and do not take into account the complexities of inpatient medicine. Furthermore, though our goal was to create paired cases that isolate a management decision as being simply based on whether it was related or unrelated to the reason for admission, it is possible that other factors, not captured by our survey, influenced the responses. For example, the benefits of aspirin as part of secondary prevention are not equal to the benefits in an acute MI.[17]

In an attempt to isolate the hospitalists' role in these management decisions, respondents were instructed to assume that the decisions were being made without discussing it with the primary care physician, but that the hospitalist would communicate the details of any hospitalization at the time of discharge. They were also instructed to assume that the hospitalist has access to the patient's outpatient electronic medical record. These assumptions were made to address concerns regarding the flow of information and communication, and to simulate the ideal system from a communication and information accessibility standpoint. Had these assumptions not been placed, the responses may have differed. It is likely that PCPs and hospitalists practicing in systems without shared, accessible inpatient/outpatient medical records would be even more reluctant to enact medication changes unrelated to the reason for admission.

Along the same lines, our physician cohort consisted of several metropolitan academic physician groups, in which hospitalists have had a presence for almost 20 years. As a result, our findings may not be generalizable to other academic hospitals, community‐based hospitalist programs, or nonhospital‐based PCP practices. Finally, we do not know whether survey nonresponders differed from responders in ways that could have meaningfully affected our results.

In conclusion, our findings suggest that both PCPs and hospitalists see the management of conditions unrelated to the reason for admission as less appropriate than the management of conditions related to the reason for admission. Our findings also suggest that PCPs may be more open to this practice when compared to hospitalists. Failure to capitalize on opportunities for meaningful medical interventions, independent of patient location, suggests a possible lack of patient centeredness in the current partnership between PCPs and hospitalists. Further studies should examine existing barriers and investigate interventions designed to address those barriers, in an effort to improve both quality of care and the degree of patient‐centeredness in our current healthcare system.

Disclosures: Dr. Herzig is supported by a grant from the National Institute on Aging (K23 AG042459). Dr. Herzig had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Author contributions: study concept and design, Breu, Allen‐Dicker, Mueller, Herzig; acquisition of data, Breu, Allen‐Dicker, Mueller, Palamara, Herzig; analysis and interpretation of data, Breu, Allen‐Dicker, Hinami, Herzig; drafting of the manuscript, Breu; critical revision of the manuscript for important intellectual content, Breu, Allen‐Dicker, Mueller, Palamara, Hinami, Herzig; statistical analysis, Allen‐Dicker, Hinami, Herzig; study supervision, Breu, Herzig. This study was presented as a poster at the Society of Hospital Medicine National Meeting, Washington, DC, May 17, 2013.

Over the past 2 decades, the care of the hospitalized patient has changed dramatically. Hospitalists now account for the care of more than one‐third of general medicine inpatients, and this number is likely to grow.[1] The emergence of hospital medicine has resulted in a partnership between primary care physicians (PCPs) and hospitalists wherein hospitalists focus on acute medical issues requiring hospitalization, whereas more chronic issues unrelated to the reason for hospitalization remain largely the domain of the PCP.[2, 3]

However, several evolving financial and quality incentives have already begun to blur the distinction between inpatient and outpatient care. First, as private and public payers increasingly scrutinize readmission rates, it has become clear that the responsibility for patient outcomes extends beyond the day of discharge.[4] The birth of Accountable Care Organizations and patient‐centered medical homes may further blur distinctions between what has traditionally constituted inpatient and outpatient care.[5] Bundled payments may force providers to ensure that each visit, whether hospital‐ or clinic‐based, is taken as an opportunity to enact meaningful change.[6] The Centers for Medicare and Medicaid Services (CMS) are already tracking hospital performance on institution of medical therapy for certain conditions regardless of their relatedness to the reason for hospitalization.[7]

No published literature has yet examined the attitudes of inpatient and outpatient providers regarding this issue. Through a case‐based survey conducted at 3 large urban academic medical centers, we aimed to assess opinions among hospitalists and PCPs regarding the role of hospitalists in the management of conditions unrelated to the reason for admission. Our study had 2 main objectives: (1) to determine whether surveyed physicians were more likely to rate an inpatient intervention as appropriate when it related to the reason for admission as compared to interventions unrelated to the reason for admission; and (2) to determine whether these attitudes differed between PCPs and hospitalists.

METHODS

Survey Administration

Between October 23, 2012 and November 10, 2012, 3 emails containing a link to the online survey were sent to all hospitalist and hospital‐based PCPs at the 3 study institutions. The BIDMC Committee on Clinical Investigations, to whom authority was ceded by the remaining 2 study institutions, certified this research protocol as exempt.

RESULTS

DISCUSSION

In this survey‐based study of PCPs and hospitalists across 3 Boston‐area academic medical centers, we found that: (1) physicians were more likely to see inpatient interventions as appropriate when those interventions dealt with the reason for admission as compared to interventions unrelated to the reason for admission; and (2) PCPs were more likely than hospitalists to feel that inpatient interventions were appropriate, even when they targeted chronic conditions unrelated to the reason for admission. To our knowledge, this study represents the first investigation into the attitudes of PCPs and hospitalists regarding the inpatient management of conditions unrelated to the reason for admission.

That surveyed physicians, regardless of role, were less likely to report an intervention unrelated to the reason for hospitalization as appropriateeven those with likely mortality benefitsuggests that opportunities to affect meaningful change may be missed in a healthcare system that adheres to strict inpatient and outpatient roles. For several of the cases, a change in therapy could lead to benefit soon after implementation. For example, aldosterone antagonists reduce mortality as early as 1 month after initiation in select patients.[8] If a major goal of inpatient care is to reduce 30‐day mortality, it could be argued that hospitalists should more actively adjust congestive heart failure therapy in appropriate inpatients, even when this is not their admitting diagnosis.

For some conditions, CMS is already tracking hospital performance. Since 2003, hospitals have been required to document whether a patient with congestive heart failure (either acute or chronic and regardless of the relationship to admission) was prescribed an angiotensin‐converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) at the time of discharge.[7] CMS has determined that the proven benefits of ACE inhibitors and ARBs confer hospital accountability for their inclusion in appropriate patients, independent of the acuity of heart failure. There are many potential therapeutic maneuvers on which health systems (and their physicians) may be graded, and accepting the view that a hospitalization provides a window of opportunity for medical optimization may allow for more fruitful interventions and more patient‐centered care.

Despite the potential benefits of addressing chronic medical issues during hospitalization, there are important limitations on what can and/or should be done in the hospital setting. Hospitalizations are a time of fluctuating clinical status, which continues beyond discharge and is often accompanied by several medication changes.[9] In our study, more than 20% of those who believed that a medication intervention was inappropriate selected I do not believe hospitalization is the right time to start this new medication as one of their explanations. Although some medication interventions have been shown in randomized controlled trials to reduce short‐term mortality, the ability to generalize these findings to the average hospitalized patient with multiple comorbidities, concurrent medication changes, and rapidly fluctuating clinical status is limited. Furthermore, there are interventions most would agree should not be dealt with in the hospital (eg, screening colonoscopy) and encounters that may be too short to allow for change (eg, 24‐hour observation). These issues notwithstanding, the average 4‐day hospitalization likely provides an opportunity for monitored change that may currently be underutilized.

Our study suggests several additional explanations for physicians' current practice and opinions. Only 6.5% of respondents who answered that an intervention was inappropriate indicated as a justification that I do not believe this is an appropriate pharmacologic intervention for this particular medical problem. This suggests that the hesitancy has little to do with a lack of benefit but instead relates to systems issues (eg, access to all pertinent records and concerns regarding follow‐up testing) and perceived limitations to what a hospitalist should and should not do without actively involving the PCP. There are likely additional concerns that the medical record and/or patient histories do not fully outline the rationale for exclusion or inclusion of particular medications. Advances in information technology that enhance information exchange and enable streamlined communication may help to address these perceived barriers. However, an additional barrier may be trust, as PCPs appear more concerned that hospitalists will not review all the pertinent records or discuss risks and benefits before enacting important medication changes. Increased attempts at communication between hospitalists and outpatient providers may help to build trust and alleviate concerns regarding the loss of information that often occurs both on admission and at discharge.

We also noted that PCPs were more likely than hospitalists to feel that inpatient interventions were appropriate, even when targeting chronic conditions unrelated to the reason for admission. It may be that PCPs, with an increasing number of problems to address per outpatient visit,[10, 11] are more open to hospitalists managing any medical problems during their patients' admissions. At the same time, with increased acuity[12, 13, 14] and shortened length of stays,[15, 16] hospitalists have only a finite amount of time to ensure acute issues are managed, leaving potentially modifiable chronic conditions to the outpatient setting. These differences aside, a minority of both PCPs and hospitalists in our study were ready to embrace the idea of hospitalists playing a larger role in the management of conditions unrelated to the reason for hospitalization.

Even though our study benefits from its multisite design, there are a number of limitations. First, although we crafted our survey with input from general medicine focus groups, our survey instrument has not been validated. In addition, the cases are necessarily contrived and do not take into account the complexities of inpatient medicine. Furthermore, though our goal was to create paired cases that isolate a management decision as being simply based on whether it was related or unrelated to the reason for admission, it is possible that other factors, not captured by our survey, influenced the responses. For example, the benefits of aspirin as part of secondary prevention are not equal to the benefits in an acute MI.[17]

In an attempt to isolate the hospitalists' role in these management decisions, respondents were instructed to assume that the decisions were being made without discussing it with the primary care physician, but that the hospitalist would communicate the details of any hospitalization at the time of discharge. They were also instructed to assume that the hospitalist has access to the patient's outpatient electronic medical record. These assumptions were made to address concerns regarding the flow of information and communication, and to simulate the ideal system from a communication and information accessibility standpoint. Had these assumptions not been placed, the responses may have differed. It is likely that PCPs and hospitalists practicing in systems without shared, accessible inpatient/outpatient medical records would be even more reluctant to enact medication changes unrelated to the reason for admission.

Along the same lines, our physician cohort consisted of several metropolitan academic physician groups, in which hospitalists have had a presence for almost 20 years. As a result, our findings may not be generalizable to other academic hospitals, community‐based hospitalist programs, or nonhospital‐based PCP practices. Finally, we do not know whether survey nonresponders differed from responders in ways that could have meaningfully affected our results.

In conclusion, our findings suggest that both PCPs and hospitalists see the management of conditions unrelated to the reason for admission as less appropriate than the management of conditions related to the reason for admission. Our findings also suggest that PCPs may be more open to this practice when compared to hospitalists. Failure to capitalize on opportunities for meaningful medical interventions, independent of patient location, suggests a possible lack of patient centeredness in the current partnership between PCPs and hospitalists. Further studies should examine existing barriers and investigate interventions designed to address those barriers, in an effort to improve both quality of care and the degree of patient‐centeredness in our current healthcare system.

Disclosures: Dr. Herzig is supported by a grant from the National Institute on Aging (K23 AG042459). Dr. Herzig had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Author contributions: study concept and design, Breu, Allen‐Dicker, Mueller, Herzig; acquisition of data, Breu, Allen‐Dicker, Mueller, Palamara, Herzig; analysis and interpretation of data, Breu, Allen‐Dicker, Hinami, Herzig; drafting of the manuscript, Breu; critical revision of the manuscript for important intellectual content, Breu, Allen‐Dicker, Mueller, Palamara, Hinami, Herzig; statistical analysis, Allen‐Dicker, Hinami, Herzig; study supervision, Breu, Herzig. This study was presented as a poster at the Society of Hospital Medicine National Meeting, Washington, DC, May 17, 2013.

The Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements implemented in July 2011 increased supervision requirements and limited continuous work hours for first‐year residents.[1] Similar to the 2003 mandates, these requirements were introduced to improve patient safety and education at academic medical centers.[2] Work‐hour reforms have been associated with decreased resident burnout and improved sleep.[3, 4, 5] However, national observational studies and systematic reviews of the impact of the 2003 reforms on patient safety and quality of care have been varied in terms of outcome.[6, 7, 8, 9, 10] Small studies of the 2011 recommendations have shown increased sleep duration and decreased burnout, but also an increased number of handoffs and increased resident concerns about making a serious medical error.[11, 12, 13, 14] Although national surveys of residents and program directors have not indicated improvements in education or quality of life, 1 observational study did show improvement in clinical exposure and conference attendance.[15, 16, 17, 18] The impact of the 2011 reforms on patient safety remains unclear.[19, 20]

The objective of this study was to evaluate the association between implementation of the 2011 residency work‐hour mandates and patient safety outcomes at a large academic medical center.

METHODS

RESULTS

In the 3 years before the 2011 residency work‐hour reforms were implemented (prereform), there were a total of 15,688 discharges for 8983 patients to the resident services and 4622 discharges for 3649 patients to the hospitalist services. In the year following implementation of residency work‐hour changes (postreform), there were 5253 discharges for 3805 patients to the resident services and 1767 discharges for 1454 patients to the hospitalist service. Table 1 shows the characteristics of patients discharged from the resident and hospitalist services in the pre‐ and postreform periods. Patients discharged from the resident services were more likely to be older, male, African American, and have a higher CMI.

DISCUSSION

Using difference‐in‐differences estimation, we evaluated whether the implementation of the 2011 residency work‐hour mandate was associated with differences in patient safety outcomes including length of stay, 30‐day readmission, inpatient mortality, MHACs, and ICU admissions comparing resident and hospitalist services at a large academic medical center. Adjusting for patient age, race, gender, and clinical complexity, we found no significant changes in any of the patient safety outcomes indicators in the postreform period comparing resident to hospitalist services.

Our quasiexperimental study design allowed us to gauge differences in patient safety outcomes, while reducing bias due to unmeasured confounders that might impact patient safety indicators.[9] We were able to examine all discharges from the resident and hospitalist general medicine services during the academic years 2009 to 2012, while adjusting for age, race, gender, and clinical complexity. Though ICU admission was higher and readmission rates were lower on the resident services post‐2011, we did not observe a significant difference in ICU admission or 30‐day readmission rates in the postreform period comparing patients discharged from the resident and hospitalist services and all patients in the prereform period.

Our neutral findings differ from some other single‐institution evaluations of reduced resident work hours, several of which have shown improved quality of life, education, and patient safety indicators.[18, 21, 26, 27, 28] It is unclear why improvements in patient safety were not identified in the current study. The 2011 reforms were more broad‐based than some of the preliminary studies of reduced work hours, and therefore additional variables may be at play. For instance, challenges related to decreased work hours, including the increased number of handoffs in care and work compression, may require specific interventions to produce sustained improvements in patient safety.[3, 14, 29, 30]

Improving patient safety requires more than changing resident work hours. Blum et al. recommended enhanced funding to increase supervision, decrease resident caseload, and incentivize achievement of quality indicators to achieve the goal of improved patient safety within work‐hour reform.[31] Schumacher et al. proposed a focus on supervision, professionalism, safe transitions of care, and optimizing workloads as a means to improve patient safety and education within the new residency training paradigm.[29]

Limitations of this study include limited follow‐up time after implementation of the work‐hour reforms. It may take more time to optimize systems of care to see benefits in patient safety indicators. This was a single‐institution study of a limited number of outcomes in a single department, which limits generalizability and may reflect local experience rather than broader trends. The call schedule on the resident service in this study differs from programs that have adopted night float schedules. [27] This may have had an effect on patient care outcomes.[32] In an attempt to conduct a timely study of inpatient safety indicators following the 2011 changes, our study was not powered to detect small changes in low‐frequency outcomes such as mortality; longer‐term studies at multiple institutions will be needed to answer these key questions. We limited the prereform period where our test of controls indicated differential prereform trends, which reduced power.

As this was an observational study rather than an experiment, there may have been both measured and unmeasured differences in patient characteristics and comorbidity between the intervention and control group. For example, CMI was lower on the hospitalist service than the resident services. Demographics varied somewhat between services; male and African American patients were more likely to be discharged from resident services than hospitalist services for unknown reasons. Although we adjusted for demographics and CMI in our model, there may be residual confounding. Limitations in data collection did not allow us to separate patients initially admitted to the ICU from patients transferred to the ICU from the inpatient floors. We attempted to overcome this limitation through use of a difference‐in‐differences model to account for secular trends, but factors other than residency work hours may have impacted the resident and hospitalist services differentially. For example, hospital quality‐improvement programs or provider‐level factors may have differentially impacted the resident versus hospitalist services during the study period.

Work‐hour limitations for residents were established to improve residency education and patient safety. As noted by the Institute of Medicine, improving patient safety will require significant investment by program directors, hospitals, and the public to keep resident caseloads manageable, ensure adequate supervision of first‐year residents, train residents on safe handoffs in care, and conduct ongoing evaluations of patient safety and any unintended consequences of the regulations.[33] In the first year after implementation of the 2011 work‐hour reforms, we found no change in ICU admission, inpatient mortality, 30‐day readmission rates, length of stay, or MHACs compared with patients treated by hospitalists. Studies of the long‐term impact of residency work‐hour reform are necessary to determine whether changes in work hours have been associated with improvement in resident education and patient safety.

Disclosure: Nothing to report.

The Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements implemented in July 2011 increased supervision requirements and limited continuous work hours for first‐year residents.[1] Similar to the 2003 mandates, these requirements were introduced to improve patient safety and education at academic medical centers.[2] Work‐hour reforms have been associated with decreased resident burnout and improved sleep.[3, 4, 5] However, national observational studies and systematic reviews of the impact of the 2003 reforms on patient safety and quality of care have been varied in terms of outcome.[6, 7, 8, 9, 10] Small studies of the 2011 recommendations have shown increased sleep duration and decreased burnout, but also an increased number of handoffs and increased resident concerns about making a serious medical error.[11, 12, 13, 14] Although national surveys of residents and program directors have not indicated improvements in education or quality of life, 1 observational study did show improvement in clinical exposure and conference attendance.[15, 16, 17, 18] The impact of the 2011 reforms on patient safety remains unclear.[19, 20]

The objective of this study was to evaluate the association between implementation of the 2011 residency work‐hour mandates and patient safety outcomes at a large academic medical center.

METHODS

RESULTS

In the 3 years before the 2011 residency work‐hour reforms were implemented (prereform), there were a total of 15,688 discharges for 8983 patients to the resident services and 4622 discharges for 3649 patients to the hospitalist services. In the year following implementation of residency work‐hour changes (postreform), there were 5253 discharges for 3805 patients to the resident services and 1767 discharges for 1454 patients to the hospitalist service. Table 1 shows the characteristics of patients discharged from the resident and hospitalist services in the pre‐ and postreform periods. Patients discharged from the resident services were more likely to be older, male, African American, and have a higher CMI.

DISCUSSION

Using difference‐in‐differences estimation, we evaluated whether the implementation of the 2011 residency work‐hour mandate was associated with differences in patient safety outcomes including length of stay, 30‐day readmission, inpatient mortality, MHACs, and ICU admissions comparing resident and hospitalist services at a large academic medical center. Adjusting for patient age, race, gender, and clinical complexity, we found no significant changes in any of the patient safety outcomes indicators in the postreform period comparing resident to hospitalist services.

Our quasiexperimental study design allowed us to gauge differences in patient safety outcomes, while reducing bias due to unmeasured confounders that might impact patient safety indicators.[9] We were able to examine all discharges from the resident and hospitalist general medicine services during the academic years 2009 to 2012, while adjusting for age, race, gender, and clinical complexity. Though ICU admission was higher and readmission rates were lower on the resident services post‐2011, we did not observe a significant difference in ICU admission or 30‐day readmission rates in the postreform period comparing patients discharged from the resident and hospitalist services and all patients in the prereform period.

Our neutral findings differ from some other single‐institution evaluations of reduced resident work hours, several of which have shown improved quality of life, education, and patient safety indicators.[18, 21, 26, 27, 28] It is unclear why improvements in patient safety were not identified in the current study. The 2011 reforms were more broad‐based than some of the preliminary studies of reduced work hours, and therefore additional variables may be at play. For instance, challenges related to decreased work hours, including the increased number of handoffs in care and work compression, may require specific interventions to produce sustained improvements in patient safety.[3, 14, 29, 30]

Improving patient safety requires more than changing resident work hours. Blum et al. recommended enhanced funding to increase supervision, decrease resident caseload, and incentivize achievement of quality indicators to achieve the goal of improved patient safety within work‐hour reform.[31] Schumacher et al. proposed a focus on supervision, professionalism, safe transitions of care, and optimizing workloads as a means to improve patient safety and education within the new residency training paradigm.[29]

Limitations of this study include limited follow‐up time after implementation of the work‐hour reforms. It may take more time to optimize systems of care to see benefits in patient safety indicators. This was a single‐institution study of a limited number of outcomes in a single department, which limits generalizability and may reflect local experience rather than broader trends. The call schedule on the resident service in this study differs from programs that have adopted night float schedules. [27] This may have had an effect on patient care outcomes.[32] In an attempt to conduct a timely study of inpatient safety indicators following the 2011 changes, our study was not powered to detect small changes in low‐frequency outcomes such as mortality; longer‐term studies at multiple institutions will be needed to answer these key questions. We limited the prereform period where our test of controls indicated differential prereform trends, which reduced power.

As this was an observational study rather than an experiment, there may have been both measured and unmeasured differences in patient characteristics and comorbidity between the intervention and control group. For example, CMI was lower on the hospitalist service than the resident services. Demographics varied somewhat between services; male and African American patients were more likely to be discharged from resident services than hospitalist services for unknown reasons. Although we adjusted for demographics and CMI in our model, there may be residual confounding. Limitations in data collection did not allow us to separate patients initially admitted to the ICU from patients transferred to the ICU from the inpatient floors. We attempted to overcome this limitation through use of a difference‐in‐differences model to account for secular trends, but factors other than residency work hours may have impacted the resident and hospitalist services differentially. For example, hospital quality‐improvement programs or provider‐level factors may have differentially impacted the resident versus hospitalist services during the study period.

Work‐hour limitations for residents were established to improve residency education and patient safety. As noted by the Institute of Medicine, improving patient safety will require significant investment by program directors, hospitals, and the public to keep resident caseloads manageable, ensure adequate supervision of first‐year residents, train residents on safe handoffs in care, and conduct ongoing evaluations of patient safety and any unintended consequences of the regulations.[33] In the first year after implementation of the 2011 work‐hour reforms, we found no change in ICU admission, inpatient mortality, 30‐day readmission rates, length of stay, or MHACs compared with patients treated by hospitalists. Studies of the long‐term impact of residency work‐hour reform are necessary to determine whether changes in work hours have been associated with improvement in resident education and patient safety.

Disclosure: Nothing to report.

The Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements implemented in July 2011 increased supervision requirements and limited continuous work hours for first‐year residents.[1] Similar to the 2003 mandates, these requirements were introduced to improve patient safety and education at academic medical centers.[2] Work‐hour reforms have been associated with decreased resident burnout and improved sleep.[3, 4, 5] However, national observational studies and systematic reviews of the impact of the 2003 reforms on patient safety and quality of care have been varied in terms of outcome.[6, 7, 8, 9, 10] Small studies of the 2011 recommendations have shown increased sleep duration and decreased burnout, but also an increased number of handoffs and increased resident concerns about making a serious medical error.[11, 12, 13, 14] Although national surveys of residents and program directors have not indicated improvements in education or quality of life, 1 observational study did show improvement in clinical exposure and conference attendance.[15, 16, 17, 18] The impact of the 2011 reforms on patient safety remains unclear.[19, 20]

The objective of this study was to evaluate the association between implementation of the 2011 residency work‐hour mandates and patient safety outcomes at a large academic medical center.

METHODS

RESULTS

In the 3 years before the 2011 residency work‐hour reforms were implemented (prereform), there were a total of 15,688 discharges for 8983 patients to the resident services and 4622 discharges for 3649 patients to the hospitalist services. In the year following implementation of residency work‐hour changes (postreform), there were 5253 discharges for 3805 patients to the resident services and 1767 discharges for 1454 patients to the hospitalist service. Table 1 shows the characteristics of patients discharged from the resident and hospitalist services in the pre‐ and postreform periods. Patients discharged from the resident services were more likely to be older, male, African American, and have a higher CMI.

DISCUSSION

Using difference‐in‐differences estimation, we evaluated whether the implementation of the 2011 residency work‐hour mandate was associated with differences in patient safety outcomes including length of stay, 30‐day readmission, inpatient mortality, MHACs, and ICU admissions comparing resident and hospitalist services at a large academic medical center. Adjusting for patient age, race, gender, and clinical complexity, we found no significant changes in any of the patient safety outcomes indicators in the postreform period comparing resident to hospitalist services.

Our quasiexperimental study design allowed us to gauge differences in patient safety outcomes, while reducing bias due to unmeasured confounders that might impact patient safety indicators.[9] We were able to examine all discharges from the resident and hospitalist general medicine services during the academic years 2009 to 2012, while adjusting for age, race, gender, and clinical complexity. Though ICU admission was higher and readmission rates were lower on the resident services post‐2011, we did not observe a significant difference in ICU admission or 30‐day readmission rates in the postreform period comparing patients discharged from the resident and hospitalist services and all patients in the prereform period.

Our neutral findings differ from some other single‐institution evaluations of reduced resident work hours, several of which have shown improved quality of life, education, and patient safety indicators.[18, 21, 26, 27, 28] It is unclear why improvements in patient safety were not identified in the current study. The 2011 reforms were more broad‐based than some of the preliminary studies of reduced work hours, and therefore additional variables may be at play. For instance, challenges related to decreased work hours, including the increased number of handoffs in care and work compression, may require specific interventions to produce sustained improvements in patient safety.[3, 14, 29, 30]

Improving patient safety requires more than changing resident work hours. Blum et al. recommended enhanced funding to increase supervision, decrease resident caseload, and incentivize achievement of quality indicators to achieve the goal of improved patient safety within work‐hour reform.[31] Schumacher et al. proposed a focus on supervision, professionalism, safe transitions of care, and optimizing workloads as a means to improve patient safety and education within the new residency training paradigm.[29]

Limitations of this study include limited follow‐up time after implementation of the work‐hour reforms. It may take more time to optimize systems of care to see benefits in patient safety indicators. This was a single‐institution study of a limited number of outcomes in a single department, which limits generalizability and may reflect local experience rather than broader trends. The call schedule on the resident service in this study differs from programs that have adopted night float schedules. [27] This may have had an effect on patient care outcomes.[32] In an attempt to conduct a timely study of inpatient safety indicators following the 2011 changes, our study was not powered to detect small changes in low‐frequency outcomes such as mortality; longer‐term studies at multiple institutions will be needed to answer these key questions. We limited the prereform period where our test of controls indicated differential prereform trends, which reduced power.

As this was an observational study rather than an experiment, there may have been both measured and unmeasured differences in patient characteristics and comorbidity between the intervention and control group. For example, CMI was lower on the hospitalist service than the resident services. Demographics varied somewhat between services; male and African American patients were more likely to be discharged from resident services than hospitalist services for unknown reasons. Although we adjusted for demographics and CMI in our model, there may be residual confounding. Limitations in data collection did not allow us to separate patients initially admitted to the ICU from patients transferred to the ICU from the inpatient floors. We attempted to overcome this limitation through use of a difference‐in‐differences model to account for secular trends, but factors other than residency work hours may have impacted the resident and hospitalist services differentially. For example, hospital quality‐improvement programs or provider‐level factors may have differentially impacted the resident versus hospitalist services during the study period.

Work‐hour limitations for residents were established to improve residency education and patient safety. As noted by the Institute of Medicine, improving patient safety will require significant investment by program directors, hospitals, and the public to keep resident caseloads manageable, ensure adequate supervision of first‐year residents, train residents on safe handoffs in care, and conduct ongoing evaluations of patient safety and any unintended consequences of the regulations.[33] In the first year after implementation of the 2011 work‐hour reforms, we found no change in ICU admission, inpatient mortality, 30‐day readmission rates, length of stay, or MHACs compared with patients treated by hospitalists. Studies of the long‐term impact of residency work‐hour reform are necessary to determine whether changes in work hours have been associated with improvement in resident education and patient safety.

Disclosure: Nothing to report.