Policy Matters: Hospitalists in Community Hospitals

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February 1, 2014 Volume 78, Number 2
Policy Matters: Hospitalists in Community Hospitals Thomas R. Miller, Ph.D., M.B.A.


The name “hospitalist” was officially coined in 1996 by Wachter and Goldman.1 The emergence of hospitalists was theorized to be an appropriate response to efficiency incentives and pressures resulting from growth in managed care in the early 1990s. Most anesthesiologists are familiar with the traditional roles of hospitalists and their focus on medical patients. However, anesthesi-ologists may not be aware of the expanding role of hospitalists in perioperative care and their prevalence in community hospitals.


The movement of hospitalists into the care of surgical patients was first described by Merli in 2004.2 The Society of Hospital Medicine subsequently published a special supplement to The Hospitalist titled “Perioperative Care,” in which perioperative medicine was declared “A fundamental facet of (the hospitalist’s) identity” as “perioperative expert.”3 Many peer-reviewed studies concerning the co-management of surgical patients by hospitalists focus on complex orthopedic patients, but more recent articles explore the expansion of the hospitalist model into other surgical specialties such as neurosurgery, urology, otolaryngology, gynecology and cancer surgery.


Clearly, as anesthesiologists seek to expand their role as perioperative physicians and lead initiatives such as the Perioperative Surgical Home,4-5 they will need to work with hospitalists in myriad settings. In a 2007 article, Adesanya and Joshi envision complementary roles of hospitalists and anesthesiologists as perioperative physicians. The authors began an important dialogue about the potential contributions of and collaboration between these specialties.6 In a 2013 article, Vetter et al. compare the anesthesiologist-led Perioperative SurgicalHome with the hospitalist model of peri-operative surgical care.


The primary purpose of this month’s “Policy Matters” is to examine recent hospital-reported data related to the number of hospitalists in community hospitals.


Prevalence of Hospitalists in Community Hospitals

The information presented here is based on the 2012 American Hospital Association (AHA) Annual Survey Database retrieved November 22, 2013 from the Healthcare Data Viewer, a Web-based application from Health Forum, LLC, an affiliate of the AHA. Data represent fiscal year 2012 for reporting community hospitals in the 50 U.S. states and the District of Columbia. Data include community hospitals designated as general medical and surgical, children’s, heart, obstetrics and gynecology, and surgical. The data exclude acute long-term care, cancer, psychiatric, rehabilitation and other specialty hospitals. The resulting analytic sample included 4,691 community hospitals. This author carefully reviewed the raw data and, for certain hospitals, revised the total number of hospitalists to adjust for inconsistencies and possible reporting errors.


In 2012, there were an estimated 33,163 hospitalists with privileges in the analytic sample of community hospitals. The hospitalists represented more than 21,000 full-time equivalent physicians (FTEs). Overall, 71.5 percent of the community hospitals in the sample had hospitalists on staff, an average of 10 per hospital. For the 272 major teaching hospitals reporting, 81.6 percent had hospitalists, averaging 20.5 per facility and 1.32 hospitalists with privileges per FTE hospitalist.


Table 1 presents the percentage of community hospitals with hospitalists, the average number of hospitalists with privileges and the number of community hospitals in the analytic sample. All of Iowa’s 117 community hospitals and the eight community hospitals in D.C. reported hospitalists. Six states (Missouri, Texas, Kansas, Maine, New Jersey and West Virginia) each had 90 percent or more of their community hospitals reporting hospitalists. Only four states (Louisiana, Arizona, Utah and Mississippi) had less than half of the community hospitals reporting the use of hospitalists.


Table 1: Prevalence (%) of Community Hospitals with Hospitalists and Average Number of Hospitalists with Privileges by State in Descending Order of Prevalence, FY 2012

State

% of Hospitals with Hospitalists 

Average # of Hospitalists 

# of Hospitals 

District of Columbia 

100.0

25.1

8

Iowa

100.0

2.9

117

Missouri

99.1

7.3

117

Texas

94.6

6.9

407

Kansas

92.5

1.8

133

Maine

91.7

7.6

36

New Jersey

90.6

15.3

64

West Virginia

90.0

4.3

50

Maryland

88.9

19.0

45

New Hampshire

88.5

10.5

26

Oklahoma

87.1

4.9

116

Vermont

85.7

8.2

14

North Carolina

83.6

13.8

110

Delaware

83.3

24.2

6

Pennsylvania

83.3

12.2

162

Oregon

82.8

16.3

58

Wisconsin

80.8

7.7

130

Connecticut

79.3

23.7

29

South Carolina

78.3

13.4

60

Virginia

77.8

15.3

81

Wyoming

77.8

10.0

27

Michigan

77.3

9.4

128

Indiana

76.2

5.6

122

Illinois

76.0

12.7

179

New York

74.7

18.0

170

Ohio

73.5

12.0

166

Massachusetts

71.4

25.2

63

Montana

68.6

2.9

51

Idaho

68.3

2.0

41

Arkansas

67.1

4.7

76

Minnesota

65.6

9.3

131

South Dakota

65.5

2.5

55

Hawaii

63.6

10.8

22

Rhode Island

63.6

20.9

11

Kentucky

61.4

9.2

101

North Dakota

59.5

5.8

42

Colorado

56.8

14.7

74

Georgia

55.1

8.8

136

Nevada

54.5

25.7

33

Tennessee

54.3

6.6

116

California

54.3

13.1

337

New Mexico

54.3

14.5

35

Alabama

53.3

7.7

92

Florida

52.1

15.3

190

Washington

51.7

16.6

87

Alaska

50.0

6.7

22

Nebraska

50.0

2.2

88

Louisiana

46.7

7.3

120

Arizona

44.8

19.2

67

Utah

43.5

15.7

46

Mississippi

37.2

7.7

94

TOTAL U.S.

71.5

10.0

4,691


Source: AHA Annual Survey of Hospitals, FY 2012 data. See full description in the article text.

Table 2 uses the same information as Table 1 but sorted by range of inpatient surgeries. Almost 1,400 community hospitals had between one and 400 inpatient surgeries in FY 2012; these community hospitals represent almost 30 percent of the sample, but only 2.2 percent of total inpatient surgeries. The 540 hospitals with the highest volume of inpatient surgeries represent almost half of the total inpatient surgeries in the analytic sample, but only 11.5 percent of the hospitals. Not surprisingly, the average number of hospitalists per hospital was greater in these high-volume hospitals. The percentage of high-volume hospitals with hospitalists (approximately 75 percent), however, was similar to that of hospitals in the analytic sample that reported no inpatient surgeries. This, in part, reflects the focus of hospitalists on non-surgical patients.



Table 2: Prevalence (%) of Community Hospitals with Hospitalists and Average Number of Hospitalists with Privileges by Range of Inpatient Surgeries, FY 2012

# of Reported Surgeries

% of Hospitals with Hospitalists

Average # of Hospitalists

# of Hospitals

No Surgeries

75.2

6.1

210

Outpatient Only

75.0

6.5

136

# of Inpatient Surgeries:

1-399

71.4

6.9

1,392

400-999

70.0

9.1

737

1,000-1,999

72.6

10.1

731

2,000-2,999

68.8

10.8

433

3,000-4,999

67.4

14.6

512

5,000-9,999

76.8

14.9

406

10,000 +

73.9

22.4

134

TOTAL U.S.

71.5

10.0

4,691

Source: AHA Annual Survey of Hospitals, FY 2012 data. See full description in the article text.



Conclusion


Despite the rapid growth in the number of hospitalists, it is likely that only a subset of the specialty will have the capacity, interest and qualifications to provide comprehensive care for the surgical patient. The role of anesthesiologists in caring for the surgical patient will continue to evolve, and many anesthesiologists will take the lead and expand their roles throughout the continuum of perioperative care while others may continue to focus on intraoperative care. In many community hospitals, it is likely that the anesthesiologist will work jointly with the surgeon and the hospitalist in the care of the surgical patient.


Based on the 2012 AHA survey data, about 70 percent of the hospitalists were employed (versus contracted) by the community hospitals in the study sample. Clearly, in the majority of community hospitals, anesthesiologists must demonstrate their unique value to both hospital administration and hospitalists in caring for the surgical patient beyond the intraoperative period, as envisioned by the Perioperative Surgical Home. Understanding the role of hospitalists and developing strong collegial relationships with these providers should serve to strengthen the anesthesiologist’s position as a leader in perioperative care.



Thomas R. Miller, Ph.D., M.B.A.is ASA Director of Health Policy Research.

References:

1. Society of Hospital Medicine. Perioperative Care: A Special Supplement to The Hospitalist. [Philadelphia, PA: Society of Hospital Medicine; 2005]. http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDisplay.cfm&ContentID=14891. Accessed December 10, 2013.

2. Merli GJ. The hospitalist joins the surgical team. Ann Intern Med. 2004;141(1):67-69.

3. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335(7):514-517.

4. Schweitzer M, Fahy B, Leib M, Rosenquist R, Merrick S. The Perioperative Surgical Home Model. ASA Newsl. 2013;77(6):58-59.

5. Vetter TR, Goeddel LA, Boudreaux AM, Hunt TR III, Jones KA, Pittet JF. The Perioperative Surgical Home: how can it make the case so everyone wins? BMC Anesthesiol. 2013;13:6. doi: 10.1186/1471-2253-13-6.

6. Adesanya AO, Joshi GP. Hospitalists and anesthesiologists as perioperative physicians: are their roles complementary? Proc (Bayl Univ Med Cent). 2007;20(2):140-142.