Outline 1. Background/Context 2. Objective and Hypotheses 3. Who to - PowerPoint PPT Presentation

Hospitalist Workload and Its Impact on Quality of Care and Patient Safety Henry Michtalik, MD, MPH An Intensive Intro to Clinical Research July 22, 2011

Outline 1. Background/Context 2. Objective and Hypotheses 3. Who to study? 4. What to study? 5. How to study? 6. Why should you care?

Background  Physician workload is an integral part of many compensation systems ◦ Has implications for workstaff planning, comparing physicians, and public policy.  Patient safety is an integral part of quality healthcare ◦ Has implications for the delivery, benchmarking, and reimbursement of medical care.  These two areas of healthcare research are often explored independently, with limited focus on the interaction of one area upon the other.  Historically, nursing-patient ratios and resident-physician workhours have explored this interaction.

The Attending Perspective? http://nathanbond.wordpress.com/2008/12/28/the-elephant-in-the-room/

Context  Ratios and staffing plans have been studied and established for nurses; ACGME workhour rules are in effect.  Hospitalists now account for nearly 40%, and in some regions up to 70%, of inpatient claims for general internist services.  Hospitalists provide a unique venue to study the effect of physician workload on patient safety and quality of care measures. ◦ Breadth and integration of their services ◦ Focus on quality of care training ◦ Specialization in inpatient medicine  Johns Hopkins Clinical Research Network ◦ “The JHCRN is a unique research resource that increases patient access to innovative therapies and outcomes research in their own local communities. It also empowers physicians to design and conduct a broad array of research projects relevant to their communities.”

Johns Hopkins Clinical Research Network

Objectives / Hypotheses  To study Hospitalists from the seven hospitals within the Johns Hopkins Clinical Research Network to assess the typical patient:physician ratio and examine and describe its variability. ◦ There will be minimal variation in the patient:physician ratios within each hospital. The ratio between hospitals will vary based on the Hospitalist system structure.  To adjust this ratio for the significant patient, physician, and hospital level factors which affect the number of patients that a single attending physician may be responsible for and assess its impact on quality of care measures, including readmissions, healthcare acquired conditions and mortality. ◦ Higher patient:physician ratios will be associated with poorer quality of care and safety measures, even after adjustment for patient, physician, and hospital level factors.  Ultimately, we seek to identify factors in attending physician workload which can be improved upon to make inpatient care a safer, more efficient, and higher quality care experience.

Predictors Table 1: Summary of Factors Affecting Patient:Physician Ratio Variable Level Name Type Average Age (Years) Continuous Race Categorical Gender Dichotomous Patient Typical Insurance Status Categorical Average Acuity of Care Categorical Frequency of Readmissions Continuous Age (Years) Continuous Race Categorical Gender Dichotomous Average Workday (Hrs) Continuous Assistance by Midlevels or Housestaff (%) Continuous Physician Clinical Experience (Years) Continuous Annual Salary ($) Continuous Bonus ($) Continuous Physician Group Size Continuous Non-Direct Patient Care Responsibilities (%) Continuous Practice Area Categorical Practice Location Categorical Hospital Magnet Status Dichotomous System to Deal With Increased Patient Volumes Categorical

Outcome: Percent Compliance with JC Core Measures Table 2A: Selected Joint Commission Quality of Care Measures Applicable to Hospitalists Description a Category AMI-2 Aspirin prescribed at discharge AMI-3 ACEI for LVSD Acute MI AMI-4 Adult smoking cessation advice/counseling AMI-5 Beta blocker prescribed at discharge AMI-9 Inpatient mortality HF-1 Discharge instructions HF-2 LVF assessment Heart Failure HF-3 ACEI for LVSD HF-4 Adult smoking cessation advice/counseling CAP-1 Oxygenation assessment Community CAP-2 Pneumococcal screening and/or vaccination Acquired CAP-3 Blood cultures Pneumonia CAP-4a Adult smoking cessation advice/counseling CAP-5 Antibiotic timing a: Labels correspond to Joint Commission core measure

Outcome: Absolute Number of Events Table 2B: Selected Maryland Health Services Cost Review Commission Quality of Care Measures Applicable to Hospitalists Description b Category 1 Stroke & Intracranial Hemorrhage 2 Extreme CNS Complications Neurologic 36 Acute Mental Health Changes 47 Encephalopathy 3, 4 Acute Pulmonary Edema and Respiratory Failure 5 Pneumonia & Other Lung Infections 6 Aspiration Pneumonia Pulmonary 7 Pulmonary Embolism 8 Other Pulmonary Complications 49 Iatrogenic Pneumothorax 9 Shock 10 Congestive Heart Failure 11 Acute Myocardial Infarction Cardiac 12 Cardiac Arrhythmias & Conduction Disturbances 13 Other Cardiac Complications 14 Ventricular Fibrillation/Cardiac Arrest 17, 18 Major Gastrointestinal Complications Gastrointestinal 19 Major Liver Complications 20 Other Gastrointestinal Complications 21 Clostridium Difficile Colitis 22 Urinary Tract Infection 33 Cellulitis Infectious 34 Moderate Infectious 35 Septicemia & Severe Infections 54 Infections due to Central Venous Catheters 23 GU Complications Except UTI Genitourinary 24, 25 Renal Failure 15 Peripheral Vascular Complications Except Venous Thrombosis 16 Venous Thrombosis 26 Diabetic Ketoacidosis & Coma Other 28 In-Hospital Trauma and Fractures 48 Other Complications of Medical Care 50 Mechanical Complication of Device, Implant & Graft 53 Infection, Inflammation & Clotting Complications of Peripheral Vascular Catheters & Infusions b: Numbers correspond to MHSCRC Potentially Preventable Complication (PPC) indexing number

The Study  Who?  Hospitalists from the JHCRN Predictors  What to study?  The patient:physician ratio (as assessed by billing encounters)  Patient, physician, and hospital level factors  Percent Compliance with Joint Commission Core measures  Number of Highly Preventable Hospital Acquired Conditions  Percent In-Hospital mortality  Percent 30 day readmission Outcomes

The Study: The How?  Next, we will examine how quality  Determine the average of care varies with the patient:physician ratio. patient:physician ratio per weekday shift based on  Quality of care will be defined administrative billing data in using two main outcome measures. each of the sites. One outcome will be percent  We will also describe the compliance with JC core measures; the second will be absolute number variability in the ratio over of HPHAC. time (weekly) within and between sites.  We will examine the association  Using linear regression between the adjusted patient:physician ratio and our (within sites) and ANOVA quality of care measure using (between sites), we will Analysis of Variance for JC calculate the adjusted compliance and poisson regression patient:physician ratio for HPHAC events. adjusted for patient, physician, and hospital factors.  We will perform a similar analysis between the adjusted ratio and percent 30 day readmission and in- hospital mortality

Why should you care?  Improve our knowledge in the relationship between attending physician workload and quality of care.  Define the association and identify important patient-, physician-, and hospital-level factors that affect physician workload.  Control for differences seen between patient populations, physicians, and hospitals, allowing for standardization of workload.  Lead to a greater focus on patient:physician ratios, distribution of responsibilities, and staffing plans, similar to those implemented and required for nursing.  Hopefully translate into safer and higher quality care.  Necessary, especially in the setting of increased patient access, a greater focus on patient safety and hospital acquired conditions, and rising healthcare costs.  It affects you, your family, and your institution.

Acknowledgements  Daniel Brotman, MD, FACP; Director, Hospitalist Program, Johns Hopkins Hospital  Daniel E. Ford, MD, MPH; Professor of Medicine, Vice Dean for Clinical Research  Peter Pronovost, MD, PhD; Professor of Medicine, Medical Director for the Center for Innovation in Quality Patient Care  The Rockin’ Small Group Number 8 ◦ Steve Sozio, MD, MHS, FASN; Assistant Professor, Division of Nephrology ◦ Sherley Abraham, MD ◦ Monica Giles, MD ◦ Eleni Liapi, MD ◦ Purva Sharma, MD  The Instructors of this Course!

Questions?

Conceptual Model

Conclusion: Little Picture  Physicians reported that their patient load often ( ≥4/5) led to: ◦ incomplete patient/family discussions (24.6%) ◦ ordering potentially unnecessary tests or procedures (22%), ◦ delaying admitting or discharging patients until the next shift or day (21.5%) ◦ cross-covering (20.3%) or caring (16.5%) for too many patients, ◦ worsened patient satisfaction (19.3%) ◦ poorer handoffs (17.9%) ◦ increased 30 day readmission (14%) ◦ worsened overall quality of care (12.4%) ◦ failure to promptly act on critical findings (9.8%) ◦ treatment errors (6.5%)