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Payers are increasingly holding hospitals accountable for patients’ experiences with their care. This may conflict with another trend among U.S. hospitals -- greater hospitalist care – as hospitalists may have less familiarity with the history and preferences of their patients compared to primary care physicians.
To better understand the relationship between greater hospitalist care and patients’ experiences with their care.
Retrospective cohort study.
2,843 U.S. acute care hospitals (bottom tertile or “non-hospitalist” hospitals: median of 0% of general medicine patients cared for by hospitalists; middle tertile or “mixed” hospitals: median of 39.5%; top tertile or “hospitalist” hospitals: median of 76.5%).
132,814 hospitalized fee-for-service Medicare beneficiaries cared for by a general medicine physician in 2009.
Hospitalist use, based on claims data from the Medicare Provider Analysis and Review File. Patient satisfaction as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey..
We found that “hospitalist” hospitals had better performance on global measures of patient satisfaction than “mixed” or “non-hospitalist hospitals (overall satisfaction: 65.6% vs. 63.9% vs. 63.9% respectively, p-value for difference <0.001). Hospitalist hospitals performed better in six specific domains of care, with the largest difference in satisfaction with discharge compared to mixed or non-hospitalist hospitals (80.3% vs. 79.1% vs. 78.1%; p-value<0.001). Hospitalist care was not associated with patient satisfaction in two domains of care: cleanliness of room, and communication with physician.
For most measures of patient satisfaction, greater hospitalist care was associated with modestly better patient-centered care.
Payers and policymakers are increasingly holding hospitals accountable for patients’ experiences with their care. Since 2006, the Centers for Medicare and Medicaid Services (CMS) have collected data on patients’ experience with inpatient care using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a well-validated and widely used tool. In 2008, these data on patient experience began to be publicly reported, and CMS now plans to base part of its payments to hospitals on HCAHPS performance scores. In this context, hospitals are looking for ways to improve patient satisfaction.
The effort to hold hospitals accountable for patient experience may conflict with another major trend in U.S. hospitals: the increasing use of hospitalists.1 While hospitalists may have greater expertise in the day-to-day care of the hospitalized patient, they generally do not know the patient and cannot cater to patients’ preferences in ways that the primary care provider might. Therefore, given that patients may prefer to be seen by their primary care provider,2 greater use of hospitalists may actually lead to a decrease in patient satisfaction. Unfortunately, we are unaware of any national examination of the relationship between hospitalist use in an institution and that entity’s performance on patient experience scores.
To better understand the relationship between greater hospitalist staffing and patient-centered care, we examined the association between hospitalist staffing and patient satisfaction with both overall care and specific domains of patient-centered care. We hypothesized that hospitals that used a high proportion of hospitalists would generally have lower patient experience scores. Further, we expected that the relationship would be monotonic (greater use of hospitalists associated with lower scores) and particularly pronounced in two domains: patient experience with discharge planning and patient experience with physician communication.
We sought to identify acute care hospitals with elderly medical patients cared for by hospitalists, non-hospitalists, or some combination of the two. To construct this cohort, we used three 2009 Medicare files. The Beneficiary Summary File contains demographic information on Medicare beneficiaries and data on enrollment in managed care plans. To identify medical hospitalizations, we used the Medicare Provider Analysis and Review (MedPAR) 100% Files, which contain the clinical diagnoses and payments for all fee-for-service Medicare beneficiaries discharged from acute care hospitals. To identify hospitalists and non-hospitalists, we used the 5% Carrier File, which contains physician billing data for a 5% random sample of fee-for-service Medicare beneficiaries. We also obtained information on hospital characteristics from the American Hospital Association Annual Survey. We supplemented this with hospital-level data on patient satisfaction from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey conducted in 2009. The HCAHPS is a standard survey developed by the Agency for Healthcare Research and Quality (AHRQ) and administered by hospitals to a random sample of adult patients 48 hours to six weeks after discharge. HCAHPS results are adjusted for patient mix and have been tested for non-response bias.3 Details about the development and design of HCAHPS have been described previously.4
We started with 48,861,000 Medicare beneficiaries in the Beneficiary Summary File, and excluded 38% because they were less than age 65 or members of an HMO. At the same time, from the 1,850,000 patients in the 5% Carrier File, we excluded 55% who had not been cared for by a general internist. Finally, we used the MedPAR File to identify 17,387,000 hospital admissions by fee-for-service Medicare beneficiaries. From MedPAR, we excluded admissions to a facility other than an acute care hospital (24%), surgical admissions identified by diagnosis-related group (DRG) (29%), and admissions to hospitals with fewer than 5 medicine admissions in 2009 (<0.1%). After merging these three files (Beneficiary Summary, MedPAR, and 5% Carrier), we were left with 229,496 admissions among 180,399 patients at 3,365 hospitals. We subsequently excluded readmissions and were left with 156,333 admissions at 3,244 hospitals. Finally, we excluded those patients cared for by both hospitalists and non-hospitalists during the same hospitalization, and those hospitals missing AHA or HCAHPS data, leaving us with 132,814 patients at 2,843 hospitals.
We used the claims-based definition developed and validated by Kuo and Goodwin in earlier work.1 Hospitalists are defined as those general internists (providers in general practice or internal medicine) who had at least five E&M billings (in a 5% sample of Medicare beneficiaries) in 2009, and generated more than 90% of their claims from the care of hospitalized patients in 2009.
There are two HCAHPS questions about overall satisfaction, one that asks patients to rate their experience on a scale of 0 to 10 and another that asks whether they would recommend the hospital. Not surprisingly, hospitals’ performance on these two questions is highly correlated.5 We measured overall patient experience using commonly-used approaches: the proportion of patients who gave the hospital a 9 or 10 (on the 10-point scale) or the proportion of patients who reported that they definitely recommend the hospital. The HCAHPS also contains 24 questions, which are reported by CMS in 8 domains: communication with nurse, communication with physician, responsiveness of the staff, pain control, communication about medications, adequacy of discharge planning, cleanliness of the room, and quietness of the room. The patient satisfaction score for each of these domains represents the proportion of patients who answered always to each of the questions, or who answered “yes” to the question about asked if needed help at discharge.
Because we were worried that hospitals with hospitalists would be different than hospitals without hospitalists, we identified a series of covariates for adjustment in a multivariable model. We extracted data from the American Hospital Association on hospitals’ structural characteristics that we assumed might be associated both with having a hospitalist and with patient experience. These variables included: size (number of beds), teaching status (membership in the Council of Teaching Hospitals versus not), location (urban versus rural), region (the four census regions), ownership (for profit, private non-profit, or public), and presence of advanced clinical capabilities (as measured by having a medical, surgical, and/or cardiac intensive care unit). We also used information about the patient population (proportion of patients with Medicare or with Medicaid) as well as nurse-staffing level (ratio of full-time equivalent registered nurses to total hospital beds).
We first quantified hospital variation in the proportion of general medicine patients cared for by hospitalists, using basic descriptive statistics. Based on these analyses, we categorized hospitals into three groups: non-hospitalist, mixed, and hospitalist (corresponding to lowest, middle, and highest tertile of hospitalist use respectively). We used bivariate techniques to describe the patient and hospital characteristics of hospitals in each group. Patient characteristics included number of co-morbidities, which were calculated using software from the Healthcare Cost and Utilization Project (HCUP),6 based on methods developed by Elixhauser et al.7 We used the chi-squared test to assess whether or not hospital or patient characteristics differed between hospitalist, mixed, and non-hospitalist hospitals.
To examine the association between hospitalist care and patient satisfaction, we first constructed bivariate models for each measure of patient satisfaction. In these models, hospital type (hospitalist, mixed, and non-hospitalist) was our predictor. We next constructed multivariable models, which adjusted for each of the hospital characteristics described above in order to assess the independent relationship between hospitalist care and HCAHPS performance.
In sensitivity analyses, we first examined hospitalist use as a continuous variable and had qualitatively very similar results. Those data are not presented. Additionally, we conducted a propensity score analysis, with results presented in the Appendix. In our first-stage logistic regression model, being a hospitalist hospital (defined as being in the top tertile of hospitalist use vs. bottom two tertiles) was the outcome. Hospital structural factors were co-variates. Based on this first-stage model, each hospital was assigned a propensity of being a hospitalist hospital. We divided the hospitals into three groups (i.e., highest propensity tertile, middle propensity, lowest propensity tertile). In a second-stage linear regression model, patient satisfaction score was the outcome. The predictors were hospital type (dichotomized, and defined as being in the top tertile of hospitalist use vs. bottom two tertiles), and propensity of being a hospitalist hospital (three categories, with low propensity as the reference).
All analyses were performed using SAS 9.2. The project was reviewed by the Institutional Review Board at the University of Michigan, and determined to be “not regulated” given our use of publicly available datasets.
Among all hospitals, the median proportion of general medicine admissions cared for by hospitalists was 41.2% (IQR: 11.5% to 67.4%). However, U.S. hospitals varied widely in the proportion of general medicine patients cared for by hospitalists (Figure 1). While 3.5% of hospitals had all of their general medicine patients cared for by hospitalists, 16.6% had none of their general medicine patients seen by hospitalists. For hospitals with at least some hospitalist care, the proportion of patients cared for by hospitalists was distributed fairly evenly across the range of possibilities (Figure 1).
Because hospitalist care varied widely among hospitals, we categorized hospitals into three groups (non-hospitalist, mixed, and hospitalist). The median proportion of patients cared for by hospitalists in the three groups was 0%, 39.5%, and 76.5% respectively (Table 1A). The non-hospitalist hospitals, when compared to mixed and hospitalist hospitals, were more likely to be small, non-teaching, for-profit institutions located in the Midwestern United States. They were also less likely to have an intensive care unit and had lower nurse-to-bed ratios.
The types of patients cared for at all three hospital types (non-hospitalist, mixed, and hospitalist) were similar in age and day of admission (Table 1B). Patients cared for at non-hospitalist hospitals were slightly more likely to be female and non-White, and less likely to be admitted from the emergency department or another hospital or health care facility.
When we examined unadjusted relationships between type of hospital and patient experience, we found that patients at hospitalist vs. non-hospitalist hospitals were more likely to recommend the hospital (69.4% vs. 65.1%; p-value<0.001), and report higher overall satisfaction (65.9% vs. 63.6%; p-value<0.001) (see Appendix Table A1). Care at hospitalist hospitals was associated with higher satisfaction with discharge, but lower satisfaction with room cleanliness and communication with doctors. These differences were statistically significant at the p<0.05 level.
When we examined the relationship between having more hospitalists and patient experience using multivariable models that accounted for differences in hospital characteristics, we found largely similar results: the proportion of patients who were satisfied with their overall care was still higher at hospitalist compared to non-hospitalist hospitals (65.6% vs. 63.9%, p<0.001) (Figure 2). Similarly, patients were more likely to definitely recommend their hospital if they had been cared for at a hospitalist vs. non-hospitalist hospital (66.0% vs. 63.4%; p<0.001).
To better understand which domains of care might be contributing to greater overall satisfaction, we also examined patient satisfaction with specific domains of care at hospitalist vs. non-hospitalist hospitals (Table 2) in our adjusted analyses. Among eight domains, the largest difference in satisfaction between patients cared for at hospitalist vs. non-hospitalist hospitals occurred with discharge. At hospitalist hospitals, 80.3% of patients said they were satisfied with the quality of the discharge planning compared to 78.1% at non-hospitalist hospitals (p<0.001). Patients at hospitalist hospitals were more satisfied with most other domains of care as well. Patients cared for at hospitalist hospitals were slightly less likely to be satisfied with communication with doctors, but this difference was not statistically significant (p=0.45). Results were qualitatively similar in propensity score analyses (see Appendix Table A2).
We found that in 2009, U.S. hospitals varied widely in the proportion of general medicine patients cared for by hospitalists. Hospitals with higher levels of hospitalist care did better on most measures of patient satisfaction. Differences were largest in overall satisfaction and for discharge planning. In five other domains of care, differences were smaller, but hospitals with more hospitalist care consistently performed better than non-hospitalist hospitals. Hospitalist care was not associated with patient satisfaction in two domains: communication with doctors and cleanliness of room.
Our findings of modestly higher patient satisfaction at hospitalist hospitals along most dimensions of care are surprising and reassuring. Indeed, when hospitalists first began caring for inpatients, some expressed concerns that hospitalist care would decrease patient satisfaction.8, 9 While this has been an ongoing concern, we found no evidence to support this contention. It may be that as a response to the concern, hospitals with hospitalists have paid particular attention to issues such as effective handoffs to primary care providers.10–13 Whether due to these efforts or other factors such as the 24/7 inpatient presence of hospitalists, we found that patients at hospitalist hospitals were more likely to be satisfied with their inpatient care, including their experience at discharge. In contrast, one area that may offer room for improvement for hospitalist hospitals, is communication with physicians. It may be that any benefit of having an ever-present hospitalist is offset by the fact that patients do not know their physicians as well as those whose care is being orchestrated by their primary care provider.
The magnitude of the associations that we found should also be placed in the context of existing research on patient satisfaction. Prior work has described baseline hospital performance, changes over time, and factors associated with greater inpatient satisfaction.5, 14, 15 The associations that we found between hospitalist care and satisfaction with care at discharge were larger than those found for teaching (vs. non-teaching) hospitals.5 However, compared to other hospital characteristics such as nurse staffing of profit status, hospitalist care was associated with smaller differences in patient satisfaction. In one study, hospitals in the highest quartile of nurse staffing had HCAHPS scores (i.e., willingness to recommend measure) that were 6.7 points higher than those in the lowest quartile of nurse staffing, and similar differences existed between not-for-profit, public hospitals vs. for-profit hospitals.5
Taken together, our findings address an important gap in knowledge about hospitalist care. Prior research has documented growth in the use of hospitalist care,1 and described the association of hospitalist care with outcomes such as mortality and resource use, and receipt of recommended care.16–19 However, we are unaware of any national study that has examined the association of hospitalist care with patient satisfaction. One study surveyed patients in a single health system, and found that patients were similarly satisfied with care provided by hospitalists and primary care physicians.20 Our findings should be reassuring to clinical leaders and policymakers who have advocated greater use of hospitalists: the results suggest that there need be no trade-off between greater use of hospitalist services and patient satisfaction. Indeed, patients appear to be even more satisfied in hospitals that have greater use of hospitalist physicians.
Our study has several limitations. First, it was a cross-sectional study, and thus we cannot make any conclusions about causality. Although we adjusted for several potential confounders (e.g., teaching status, advanced care capabilities, nurse staffing), it is possible that hospitalist care is a surrogate marker for features of hospitals that we could not measure, but that directly influence patient experience. In addition, it is possible that patients cared for at hospitalist hospitals differ in unmeasured ways from those patients cared for at other types of hospitals. . Second, we constructed our primary predictor and outcome from different cohorts. Our primary predictor was derived from the proportion of general medicine patients cared for by hospitalists in Medicare claims data. In contrast, our primary outcome was based on HCAHPS responses from a random sampling of all hospital admissions. This misclassification likely would have biased us towards finding small or no associations. Therefore, we are likely underestimating the true association between hospitalist use and patient experience. Third, our findings may not be generalizable to hospitals that serve younger patients, or have a large number of specialist hospitalists (who were not included in our definition of hospitalists). For example, compared to older patients with multiple co-morbidities, those relatively healthy patients under 65 years of age may derive less benefit from an ever-present hospitalist who can explain discharge plans or an attentive nurse.
In summary, we found that U.S. hospitals varied widely in their use of hospitalist physicians and those where a greater proportion of care was delivered by hospitalists generally had better scores on patient experience, especially on the global assessment of satisfaction and in discharge care. Our findings suggest that adoption of the hospitalist model -- one of the strategies employed by U.S. hospitals in the past two decades to provide efficient care – should not detract from achieving the goal of more patient-centered care.
Author Funding Support:
Dr. Chen’s work is supported in part by the NIH-NIA (AG024824, University of Michigan Claude Pepper Older Americans Independence Center), and the NIH-NCRR (UL1-RR024986, Michigan Institute for Clinical & Health Research). Dr. Chen is also supported by a Career Development Grant Award (K08HS020671) from the Agency for Healthcare Research and Quality.