Hospital readmissions, which account for a substantial proportion of healthcare expenditures, have increasingly become a focus for hospitals and health systems. Hospitals now assume greater responsibility for population health, and face financial penalties by federal and state agencies that consider readmissions a key measure of the quality of care provided during hospitalization. Consequently, there is broad interest in identifying approaches to reduce hospital reutilization, including emergency department (ED) revisits and hospital readmissions. In this issue of the Journal of Hospital Medicine, Auger et al.[1] report the results of a systematic review, which evaluates the effect of discharge interventions on hospital reutilization among children.

As Auger et al. note, the transition from hospital to home is a vulnerable time for children and their families, with 1 in 5 parents reporting major challenges with such transitions.[2] Auger and colleagues identified 14 studies spanning 3 pediatric disease processes that addressed this issue. The authors concluded that several interventions were potentially effective, but individual studies frequently used multifactorial interventions, precluding determination of discrete elements essential to success. The larger body of care transitions literature in adult populations provides insights for interventions that may benefit pediatric patients, as well as informs future research and quality improvement priorities.

The authors identified some distinct interventions that may successfully decrease hospital reutilization, which share common themes from the adult literature. The first is the use of a dedicated transition coordinator (eg, nurse) or coordinating center to assist with the patient's transition home after discharge. In adult studies, this bridging strategy[3, 4] (ie, use of a dedicated transition coordinator or provider) is initiated during the hospitalization and continues postdischarge in the form of phone calls or home visits. The second theme illustrated in both this pediatric review[1] and adult reviews[3, 4, 5] focuses on enhanced or individualized patient education. Most studies have used a combination of these strategies. For example, the Care Transitions Intervention (one of the best validated adult discharge approaches) uses a transition coach to aid the patient in medication self‐management, creation of a patient‐centered record, scheduling follow‐up appointments, and understanding signs and symptoms of a worsening condition.[6] In a randomized study, this intervention demonstrated a reduction in readmissions within 90 days to 16.7% in the intervention group, compared with 22.5% in the control group.[6] One of the pediatric studies highlighted in the review by Auger et al. achieved a decrease in 14‐day ED revisits from 8% prior to implementation of the program to 2.7% following implementation of the program.[7] This program was for patients discharged from the neonatal intensive care unit and involved a nurse coordinator (similar to a transition coach) who worked closely with families and ensured adequate resources prior to discharge as well as a home visitation program.[7]

Although Auger et al. identify some effective approaches to reducing hospital reutilization after discharge in children, their review and the complementary adult literature bring to light 4 main unresolved questions for hospitalists seeking to improve care transitions: (1) how to dissect diverse and heterogeneous interventions to determine the key driver of success, (2) how to interpret and generally apply interventions from single centers where they may have been tailored to a specific healthcare environment, (3) how to generalize the findings of many disease‐specific interventions to other populations, and (4) how to evaluate the cost and assess the costbenefit of implementing many of the more resource intensive interventions. An example of a heterogeneous intervention addressed in this pediatric systematic review was described by Ng et al.,[8] in which the intervention group received a combination of an enhanced discharge education session, disease‐specific nurse evaluation, an animated education booklet, and postdischarge telephone follow‐up, whereas the control group received a shorter discharge education session, a disease‐specific nurse evaluation only if referred by a physician, a written education booklet, and no telephone follow‐up. Investigators found that intervention patients were less likely to be readmitted or revisit the ED as compared with controls. A similarly multifaceted intervention introduced by Taggart et al.[9] was unable to detect a difference in readmissions or ED revisits. It is unclear whether or not the differences in outcomes were related to differences in the intervention bundle itself or institutional or local contextual factors, thus limiting application to other hospitals. Generalizability of interventions is similarly complicated in adults.

The studies presented in this pediatric review article are specific to 3 disease processes: cancer, asthma, and neonatal intensive care (ie, premature) populations. Beyond these populations, there were no other pediatric conditions that met inclusion criteria, thus limiting the generalizability of the findings. As described by Rennke et al.,[3] adult systematic reviews that have focused only on disease‐specific interventions to reduce hospital reutilization are also difficult to generalize to broader populations. Two of the 3 recent adult transition intervention systematic reviews excluded disease‐specific interventions in an attempt to find more broadly applicable interventions but struggled with the same heterogeneity discussed in this review by Auger et al.[3, 4] Although disease‐specific interventions were included in the third adult systematic review and the evaluation was restricted to randomized controlled trials, the authors still grappled with finding 1 or 2 common, successful intervention components.[5] The fourth unresolved question involves understanding the financial burden of implementing more resource‐intensive interventions such as postdischarge home nurse visits. For example, it may be difficult to justify the business case for hiring a transition coach or initiating home nurse visits when the cost and financial implications are unclear. Neither the pediatric nor adult literature describes this well.

Some of the challenges in identifying effective interventions differ between adult and pediatric populations. Adults tend to have multiple comorbid conditions, making them more medically complex and at greater risk for adverse outcomes, medication errors, and hospital utilization.[10] Although a small subset of the pediatric population with complex chronic medical conditions accounts for a majority of hospital reutilization and cost,[11] most hospitalized pediatric patients are otherwise healthy with acute illnesses.[12] Additionally, pediatric patients have lower overall hospital reutilization rates when compared with adults. Adult 30‐day readmission rates are approximately 20%[13] compared with pediatric patients whose mean 30‐day readmission rate is 6.5%.[14] With readmission being an outcome upon which studies are basing intervention success or failure, the relatively low readmission rates in the pediatric population make shifting that outcome more challenging.

There is also controversy about whether policymakers should be focusing on decreasing 30‐day readmission rates as a measure of success. We believe that efforts should focus on identifying more meaningful outcomes, especially outcomes important to patients and their families. No single metric is likely to be an adequate measure of the quality of care transitions, but a combination of outcome measures could potentially be more informative both for patients and clinicians. Patient satisfaction with the discharge process is measured as part of standard patient experience surveys, and the 3‐question Care Transitions Measure[15] has been validated and endorsed as a measure of patient perception of discharge safety in adult populations. There is a growing consensus that 30‐day readmission rates are lacking as a measure of discharge quality, and therefore, measuring shorter‐term7‐ or 14‐dayreadmission rates along with short‐term ED utilization after discharge would likely be more helpful for identifying care transitions problems. Attention should also be paid to measuring rates of specific adverse events in the postdischarge period, such as adverse drug events or failure to follow up on pending test results, as these failures are often implicated in reutilization.

In reflecting upon the published data on adult and pediatric transitions of care interventions and the lingering unanswered questions, we propose a few considerations for future direction of the field. First, engagement of the primary care provider may be beneficial. In many interventions describing a care transition coordinator, nursing fulfilled this role; however, there are opportunities for the primary care provider to play a greater role in this arena. Second, the use of factorial design in future studies may help elucidate which specific parts of each intervention may be the most crucial.[16] Finally, readmission rates are a controversial quality measure in adults. Pediatric readmissions are relatively uncommon, making it difficult to track measurements and show improvement. Clinicians, patients, and policymakers should prioritize outcome measures that are most meaningful to patients and their families that occur at a much higher rate than that of readmissions.

Hospital readmissions, which account for a substantial proportion of healthcare expenditures, have increasingly become a focus for hospitals and health systems. Hospitals now assume greater responsibility for population health, and face financial penalties by federal and state agencies that consider readmissions a key measure of the quality of care provided during hospitalization. Consequently, there is broad interest in identifying approaches to reduce hospital reutilization, including emergency department (ED) revisits and hospital readmissions. In this issue of the Journal of Hospital Medicine, Auger et al.[1] report the results of a systematic review, which evaluates the effect of discharge interventions on hospital reutilization among children.

As Auger et al. note, the transition from hospital to home is a vulnerable time for children and their families, with 1 in 5 parents reporting major challenges with such transitions.[2] Auger and colleagues identified 14 studies spanning 3 pediatric disease processes that addressed this issue. The authors concluded that several interventions were potentially effective, but individual studies frequently used multifactorial interventions, precluding determination of discrete elements essential to success. The larger body of care transitions literature in adult populations provides insights for interventions that may benefit pediatric patients, as well as informs future research and quality improvement priorities.

The authors identified some distinct interventions that may successfully decrease hospital reutilization, which share common themes from the adult literature. The first is the use of a dedicated transition coordinator (eg, nurse) or coordinating center to assist with the patient's transition home after discharge. In adult studies, this bridging strategy[3, 4] (ie, use of a dedicated transition coordinator or provider) is initiated during the hospitalization and continues postdischarge in the form of phone calls or home visits. The second theme illustrated in both this pediatric review[1] and adult reviews[3, 4, 5] focuses on enhanced or individualized patient education. Most studies have used a combination of these strategies. For example, the Care Transitions Intervention (one of the best validated adult discharge approaches) uses a transition coach to aid the patient in medication self‐management, creation of a patient‐centered record, scheduling follow‐up appointments, and understanding signs and symptoms of a worsening condition.[6] In a randomized study, this intervention demonstrated a reduction in readmissions within 90 days to 16.7% in the intervention group, compared with 22.5% in the control group.[6] One of the pediatric studies highlighted in the review by Auger et al. achieved a decrease in 14‐day ED revisits from 8% prior to implementation of the program to 2.7% following implementation of the program.[7] This program was for patients discharged from the neonatal intensive care unit and involved a nurse coordinator (similar to a transition coach) who worked closely with families and ensured adequate resources prior to discharge as well as a home visitation program.[7]

Although Auger et al. identify some effective approaches to reducing hospital reutilization after discharge in children, their review and the complementary adult literature bring to light 4 main unresolved questions for hospitalists seeking to improve care transitions: (1) how to dissect diverse and heterogeneous interventions to determine the key driver of success, (2) how to interpret and generally apply interventions from single centers where they may have been tailored to a specific healthcare environment, (3) how to generalize the findings of many disease‐specific interventions to other populations, and (4) how to evaluate the cost and assess the costbenefit of implementing many of the more resource intensive interventions. An example of a heterogeneous intervention addressed in this pediatric systematic review was described by Ng et al.,[8] in which the intervention group received a combination of an enhanced discharge education session, disease‐specific nurse evaluation, an animated education booklet, and postdischarge telephone follow‐up, whereas the control group received a shorter discharge education session, a disease‐specific nurse evaluation only if referred by a physician, a written education booklet, and no telephone follow‐up. Investigators found that intervention patients were less likely to be readmitted or revisit the ED as compared with controls. A similarly multifaceted intervention introduced by Taggart et al.[9] was unable to detect a difference in readmissions or ED revisits. It is unclear whether or not the differences in outcomes were related to differences in the intervention bundle itself or institutional or local contextual factors, thus limiting application to other hospitals. Generalizability of interventions is similarly complicated in adults.

The studies presented in this pediatric review article are specific to 3 disease processes: cancer, asthma, and neonatal intensive care (ie, premature) populations. Beyond these populations, there were no other pediatric conditions that met inclusion criteria, thus limiting the generalizability of the findings. As described by Rennke et al.,[3] adult systematic reviews that have focused only on disease‐specific interventions to reduce hospital reutilization are also difficult to generalize to broader populations. Two of the 3 recent adult transition intervention systematic reviews excluded disease‐specific interventions in an attempt to find more broadly applicable interventions but struggled with the same heterogeneity discussed in this review by Auger et al.[3, 4] Although disease‐specific interventions were included in the third adult systematic review and the evaluation was restricted to randomized controlled trials, the authors still grappled with finding 1 or 2 common, successful intervention components.[5] The fourth unresolved question involves understanding the financial burden of implementing more resource‐intensive interventions such as postdischarge home nurse visits. For example, it may be difficult to justify the business case for hiring a transition coach or initiating home nurse visits when the cost and financial implications are unclear. Neither the pediatric nor adult literature describes this well.

Some of the challenges in identifying effective interventions differ between adult and pediatric populations. Adults tend to have multiple comorbid conditions, making them more medically complex and at greater risk for adverse outcomes, medication errors, and hospital utilization.[10] Although a small subset of the pediatric population with complex chronic medical conditions accounts for a majority of hospital reutilization and cost,[11] most hospitalized pediatric patients are otherwise healthy with acute illnesses.[12] Additionally, pediatric patients have lower overall hospital reutilization rates when compared with adults. Adult 30‐day readmission rates are approximately 20%[13] compared with pediatric patients whose mean 30‐day readmission rate is 6.5%.[14] With readmission being an outcome upon which studies are basing intervention success or failure, the relatively low readmission rates in the pediatric population make shifting that outcome more challenging.

There is also controversy about whether policymakers should be focusing on decreasing 30‐day readmission rates as a measure of success. We believe that efforts should focus on identifying more meaningful outcomes, especially outcomes important to patients and their families. No single metric is likely to be an adequate measure of the quality of care transitions, but a combination of outcome measures could potentially be more informative both for patients and clinicians. Patient satisfaction with the discharge process is measured as part of standard patient experience surveys, and the 3‐question Care Transitions Measure[15] has been validated and endorsed as a measure of patient perception of discharge safety in adult populations. There is a growing consensus that 30‐day readmission rates are lacking as a measure of discharge quality, and therefore, measuring shorter‐term7‐ or 14‐dayreadmission rates along with short‐term ED utilization after discharge would likely be more helpful for identifying care transitions problems. Attention should also be paid to measuring rates of specific adverse events in the postdischarge period, such as adverse drug events or failure to follow up on pending test results, as these failures are often implicated in reutilization.

In reflecting upon the published data on adult and pediatric transitions of care interventions and the lingering unanswered questions, we propose a few considerations for future direction of the field. First, engagement of the primary care provider may be beneficial. In many interventions describing a care transition coordinator, nursing fulfilled this role; however, there are opportunities for the primary care provider to play a greater role in this arena. Second, the use of factorial design in future studies may help elucidate which specific parts of each intervention may be the most crucial.[16] Finally, readmission rates are a controversial quality measure in adults. Pediatric readmissions are relatively uncommon, making it difficult to track measurements and show improvement. Clinicians, patients, and policymakers should prioritize outcome measures that are most meaningful to patients and their families that occur at a much higher rate than that of readmissions.

Hospital readmissions, which account for a substantial proportion of healthcare expenditures, have increasingly become a focus for hospitals and health systems. Hospitals now assume greater responsibility for population health, and face financial penalties by federal and state agencies that consider readmissions a key measure of the quality of care provided during hospitalization. Consequently, there is broad interest in identifying approaches to reduce hospital reutilization, including emergency department (ED) revisits and hospital readmissions. In this issue of the Journal of Hospital Medicine, Auger et al.[1] report the results of a systematic review, which evaluates the effect of discharge interventions on hospital reutilization among children.

As Auger et al. note, the transition from hospital to home is a vulnerable time for children and their families, with 1 in 5 parents reporting major challenges with such transitions.[2] Auger and colleagues identified 14 studies spanning 3 pediatric disease processes that addressed this issue. The authors concluded that several interventions were potentially effective, but individual studies frequently used multifactorial interventions, precluding determination of discrete elements essential to success. The larger body of care transitions literature in adult populations provides insights for interventions that may benefit pediatric patients, as well as informs future research and quality improvement priorities.

The authors identified some distinct interventions that may successfully decrease hospital reutilization, which share common themes from the adult literature. The first is the use of a dedicated transition coordinator (eg, nurse) or coordinating center to assist with the patient's transition home after discharge. In adult studies, this bridging strategy[3, 4] (ie, use of a dedicated transition coordinator or provider) is initiated during the hospitalization and continues postdischarge in the form of phone calls or home visits. The second theme illustrated in both this pediatric review[1] and adult reviews[3, 4, 5] focuses on enhanced or individualized patient education. Most studies have used a combination of these strategies. For example, the Care Transitions Intervention (one of the best validated adult discharge approaches) uses a transition coach to aid the patient in medication self‐management, creation of a patient‐centered record, scheduling follow‐up appointments, and understanding signs and symptoms of a worsening condition.[6] In a randomized study, this intervention demonstrated a reduction in readmissions within 90 days to 16.7% in the intervention group, compared with 22.5% in the control group.[6] One of the pediatric studies highlighted in the review by Auger et al. achieved a decrease in 14‐day ED revisits from 8% prior to implementation of the program to 2.7% following implementation of the program.[7] This program was for patients discharged from the neonatal intensive care unit and involved a nurse coordinator (similar to a transition coach) who worked closely with families and ensured adequate resources prior to discharge as well as a home visitation program.[7]

Although Auger et al. identify some effective approaches to reducing hospital reutilization after discharge in children, their review and the complementary adult literature bring to light 4 main unresolved questions for hospitalists seeking to improve care transitions: (1) how to dissect diverse and heterogeneous interventions to determine the key driver of success, (2) how to interpret and generally apply interventions from single centers where they may have been tailored to a specific healthcare environment, (3) how to generalize the findings of many disease‐specific interventions to other populations, and (4) how to evaluate the cost and assess the costbenefit of implementing many of the more resource intensive interventions. An example of a heterogeneous intervention addressed in this pediatric systematic review was described by Ng et al.,[8] in which the intervention group received a combination of an enhanced discharge education session, disease‐specific nurse evaluation, an animated education booklet, and postdischarge telephone follow‐up, whereas the control group received a shorter discharge education session, a disease‐specific nurse evaluation only if referred by a physician, a written education booklet, and no telephone follow‐up. Investigators found that intervention patients were less likely to be readmitted or revisit the ED as compared with controls. A similarly multifaceted intervention introduced by Taggart et al.[9] was unable to detect a difference in readmissions or ED revisits. It is unclear whether or not the differences in outcomes were related to differences in the intervention bundle itself or institutional or local contextual factors, thus limiting application to other hospitals. Generalizability of interventions is similarly complicated in adults.

The studies presented in this pediatric review article are specific to 3 disease processes: cancer, asthma, and neonatal intensive care (ie, premature) populations. Beyond these populations, there were no other pediatric conditions that met inclusion criteria, thus limiting the generalizability of the findings. As described by Rennke et al.,[3] adult systematic reviews that have focused only on disease‐specific interventions to reduce hospital reutilization are also difficult to generalize to broader populations. Two of the 3 recent adult transition intervention systematic reviews excluded disease‐specific interventions in an attempt to find more broadly applicable interventions but struggled with the same heterogeneity discussed in this review by Auger et al.[3, 4] Although disease‐specific interventions were included in the third adult systematic review and the evaluation was restricted to randomized controlled trials, the authors still grappled with finding 1 or 2 common, successful intervention components.[5] The fourth unresolved question involves understanding the financial burden of implementing more resource‐intensive interventions such as postdischarge home nurse visits. For example, it may be difficult to justify the business case for hiring a transition coach or initiating home nurse visits when the cost and financial implications are unclear. Neither the pediatric nor adult literature describes this well.

Some of the challenges in identifying effective interventions differ between adult and pediatric populations. Adults tend to have multiple comorbid conditions, making them more medically complex and at greater risk for adverse outcomes, medication errors, and hospital utilization.[10] Although a small subset of the pediatric population with complex chronic medical conditions accounts for a majority of hospital reutilization and cost,[11] most hospitalized pediatric patients are otherwise healthy with acute illnesses.[12] Additionally, pediatric patients have lower overall hospital reutilization rates when compared with adults. Adult 30‐day readmission rates are approximately 20%[13] compared with pediatric patients whose mean 30‐day readmission rate is 6.5%.[14] With readmission being an outcome upon which studies are basing intervention success or failure, the relatively low readmission rates in the pediatric population make shifting that outcome more challenging.

There is also controversy about whether policymakers should be focusing on decreasing 30‐day readmission rates as a measure of success. We believe that efforts should focus on identifying more meaningful outcomes, especially outcomes important to patients and their families. No single metric is likely to be an adequate measure of the quality of care transitions, but a combination of outcome measures could potentially be more informative both for patients and clinicians. Patient satisfaction with the discharge process is measured as part of standard patient experience surveys, and the 3‐question Care Transitions Measure[15] has been validated and endorsed as a measure of patient perception of discharge safety in adult populations. There is a growing consensus that 30‐day readmission rates are lacking as a measure of discharge quality, and therefore, measuring shorter‐term7‐ or 14‐dayreadmission rates along with short‐term ED utilization after discharge would likely be more helpful for identifying care transitions problems. Attention should also be paid to measuring rates of specific adverse events in the postdischarge period, such as adverse drug events or failure to follow up on pending test results, as these failures are often implicated in reutilization.

In reflecting upon the published data on adult and pediatric transitions of care interventions and the lingering unanswered questions, we propose a few considerations for future direction of the field. First, engagement of the primary care provider may be beneficial. In many interventions describing a care transition coordinator, nursing fulfilled this role; however, there are opportunities for the primary care provider to play a greater role in this arena. Second, the use of factorial design in future studies may help elucidate which specific parts of each intervention may be the most crucial.[16] Finally, readmission rates are a controversial quality measure in adults. Pediatric readmissions are relatively uncommon, making it difficult to track measurements and show improvement. Clinicians, patients, and policymakers should prioritize outcome measures that are most meaningful to patients and their families that occur at a much higher rate than that of readmissions.

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.