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Abstract

Background

The optimal structure of an internal medicine ward team at a teaching hospital is unknown. We hypothesized that increasing the ratio of attendings to housestaff would result in an enhanced perceived educational experience for residents.

Methods

Harbor-UCLA Medical Center (HUMC) is a tertiary care, public hospital in Los Angeles County. Standard ward teams at HUMC, with a housestaff∶attending ratio of 5∶1, were split by adding one attending and then dividing the teams into two experimental teams containing ratios of 3∶1 and 2∶1. Web-based Likert satisfaction surveys were completed by housestaff and attending physicians on the experimental and control teams at the end of their rotations, and objective healthcare outcomes (e.g., length of stay, hospital readmission, mortality) were compared.

Results

Nine hundred and ninety patients were admitted to the standard control teams and 184 were admitted to the experimental teams (81 to the one-intern team and 103 to the two-intern team). Patients admitted to the experimental and control teams had similar age and disease severity. Residents and attending physicians consistently indicated that the quality of the educational experience, time spent teaching, time devoted to patient care, and quality of life were superior on the experimental teams. Objective healthcare outcomes did not differ between experimental and control teams.

Conclusions

Altering internal medicine ward team structure to reduce the ratio of housestaff to attending physicians improved the perceived educational experience without altering objective healthcare outcomes.

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Most cited references 18

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Effects of a hospitalist model on elderly patients with hip fracture.

Erik Larson, Kirsten Hall Long, L. Joseph Melton … (2005)

Hospitalists' increased role in perioperative medicine allows for examination of their effects on surgical patients. This study examined the effects of a hospitalist service created to medically manage elderly patients with hip fracture. During a 2-year historical cohort study of 466 patients 65 years or older admitted for surgical repair of hip fracture, we examined outcomes 1 year prior to and subsequent to the change from the standard to the hospitalist model. The mean (SD) time to surgery (38 [47] vs 25 [53] hours; P<.001), time from surgery to dismissal (9 [8] vs 7 [5] days; P = .04), and length of stay (10.6 [9] vs 8.4 [6] days; P<.001) were shorter in the hospitalist group. Predictors of shorter time to surgery were care by the hospitalist group (P = .002), older age (P = .01), and fall as the mechanism of fracture (P<.001), while American Society of Anesthesia scores of 3 and 4 were associated with increased time to surgery (P<.001). Receiving care by the hospitalist group (P<.001) and diagnosis of delirium (P<.001) were associated with increased chance of earlier dismissal, while admission to the intensive care unit decreased this chance (P<.001). Diagnosis of delirium was more frequent in the hospitalist group (74 [32.2%] of 230 vs 42 [17.8%] of 236; P<.001). There were no differences in inpatient deaths or 30-day readmission rates. In elderly patients with hip fracture, a hospitalist model decreased time to surgery, time from surgery to dismissal, and length of stay without adversely affecting inpatient deaths or 30-day readmission rates.

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Outcomes of care by hospitalists, general internists, and family physicians.

John Benjamin, Michael Rothberg, P S Pekow … (2007)

The hospitalist model is rapidly altering the landscape for inpatient care in the United States, yet evidence about the clinical and economic outcomes of care by hospitalists is derived from a small number of single-hospital studies examining the practices of a few physicians. We conducted a retrospective cohort study of 76,926 patients 18 years of age or older who were hospitalized between September 2002 and June 2005 for pneumonia, heart failure, chest pain, ischemic stroke, urinary tract infection, acute exacerbation of chronic obstructive pulmonary disease, or acute myocardial infarction at 45 hospitals throughout the United States. We used multivariable models to compare the outcomes of care by 284 hospitalists, 993 general internists, and 971 family physicians. As compared with patients cared for by general internists, patients cared for by hospitalists had a modestly shorter hospital stay (adjusted difference, 0.4 day; P<0.001) and lower costs (adjusted difference, $268; P=0.02) but a similar inpatient rate of death (odds ratio, 0.95; 95% confidence interval [CI], 0.85 to 1.05) and 14-day readmission rate (odds ratio, 0.98; 95% CI, 0.91 to 1.05). As compared with patients cared for by family physicians, patients cared for by hospitalists had a shorter length of stay (adjusted difference, 0.4 day; P<0.001), and the costs (adjusted difference, $125; P=0.33), rate of death (odds ratio, 0.95; 95% CI, 0.83 to 1.07), and 14-day readmission rate (odds ratio, 0.95; 95% CI, 0.87 to 1.04) were similar. For common inpatient diagnoses, the hospitalist model is associated with a small reduction in the length of stay without an adverse effect on rates of death or readmission. Hospitalist care appears to be modestly less expensive than that provided by general internists, but it offers no significant savings as compared with the care provided by family physicians. Copyright 2007 Massachusetts Medical Society.

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Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes.

Jonathan Showstack, Alfred Baron, Robert M. Wachter … (2002)

Previous investigations of the effect of the hospitalist model on resource use and patient outcomes have focused on academic medical centers or have used short follow-up periods. To determine the effects of hospitalist care on resource use and patient outcomes and whether these effects change over time. Retrospective cohort study. Community-based, urban teaching hospital. 5308 patients cared for by community or hospitalist physicians in the 2 years after implementation of a voluntary hospitalist service. Length of stay, costs, 10-day readmission rates, use of consultative services, in-hospital mortality rate, and mortality rate at 30 and 60 days. Patients of hospitalists were younger than those of community physicians (65 years vs. 74 years; P < 0.001) and were more likely to be of black than of white ethnicity (33.3% vs. 17.9%; P < 0.001), have Medicaid insurance (25.1% vs. 10.2%; P < 0.001), and receive intensive care (19.9% vs. 15.8%; P < 0.001). After adjustment in multivariable models, length of stay and costs were not different in the first year of the study. In year 2, patients of hospitalists had shorter stays (0.61 day shorter; P = 0.002) and lower costs ($822 lower; P = 0.002). Over the 2 years of this study, patients of hospitalists had lower risk for death in the hospital (adjusted relative hazard, 0.71 [95% CI, 0.54 to 0.93]) and at 30 and 60 days of follow-up. A voluntary hospitalist service at a community-based teaching hospital produced reductions in length of stay and costs that became statistically significant in the second year of use. A mortality benefit extending beyond hospitalization was noted in both years. Future investigations are needed to understand the ways in which hospitalists increase clinical efficiency and appear to improve the quality of care.

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Author and article information

Contributors

: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, USA )

ISSN (Electronic): 1932-6203

Publication date Collection: 2012

Publication date (Electronic): 19 April 2012

Volume: 7

Issue: 4

Electronic Location Identifier: e35576

Affiliations

[1 ]Division of General Internal Medicine, Los Angeles Biomedical Research Institute at Harbor-University of California Los Angeles (UCLA) Medical Center, Torrance, California, United States of America

[2 ]David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, California, United States of America

[3 ]Department of Emergency Medicine, Los Angeles Biomedical Research Institute at Harbor-University of California Los Angeles (UCLA) Medical Center, Torrance, California, United States of America

[4 ]Division of Pulmonary and Critical Care Medicine, Los Angeles Biomedical Research Institute at Harbor-University of California Los Angeles (UCLA) Medical Center, Torrance, California, United States of America

[5 ]Department of Medicine, Los Angeles Biomedical Research Institute at Harbor-University of California Los Angeles (UCLA) Medical Center, Torrance, California, United States of America

[6 ]Division of HIV Medicine, Los Angeles Biomedical Research Institute at Harbor-University of California Los Angeles (UCLA) Medical Center, Torrance, California, United States of America

Yale University School of Medicine, United States of America

Author notes

* E-mail: bspellberg@ 123456labiomed.org

Conceived and designed the experiments: BS RL DS BC MW WS DH. Performed the experiments: BS RL DS BC JV MM CK CL. Analyzed the data: BS RL MW WS DH. Contributed reagents/materials/analysis tools: BS RL. Wrote the paper: BS RL DS BC MW WS DH.

Article

Publisher ID: PONE-D-12-04725

DOI: 10.1371/journal.pone.0035576

PMC ID: 3330818

PubMed ID: 22532860

SO-VID: 433be057-d991-4e01-a45b-024b77df9753

Copyright © Spellberg et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 10 February 2012

Date accepted : 20 March 2012

Page count

Pages: 6

A Controlled Investigation of Optimal Internal Medicine Ward Team Structure at a Teaching Hospital

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Most cited references 18

Effects of a hospitalist model on elderly patients with hip fracture.

Outcomes of care by hospitalists, general internists, and family physicians.

Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes.

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