David O. Meltzer, MD, PhD

METHODS

RESULTS

DISCUSSION

METHODS

RESULTS

DISCUSSION

METHODS

RESULTS

DISCUSSION

Studies examining the importance of continuity of care have shown that patients who maintain a continuous relationship with a single physician have improved outcomes.[1, 2] However, most of these studies were performed in the outpatient, rather than the inpatient setting. With over 35 million patients admitted to hospitals in 2013, along with the significant increase in hospital discontinuity over recent years, the impact of inpatient continuity of care on quality outcomes and patient satisfaction is becoming increasingly relevant.[3, 4]

Service handoffs, when a physician hands over treatment responsibility for a panel of patients and is not expected to return, are a type of handoff that contributes to inpatient discontinuity. In particular, service handoffs between hospitalists are an especially common and inherently risky type of transition, as there is a severing of an established relationship during a patient's hospitalization. Unfortunately, due to the lack of evidence on the effects of service handoffs, current guidelines are limited in their recommendations.[5] Whereas several recent studies have begun to explore the effects of these handoffs, no prior study has examined this issue from a patient's perspective.[6, 7, 8]

Patients are uniquely positioned to inform us about their experiences in care transitions. Furthermore, with patient satisfaction now affecting Medicare reimbursement rates, patient experiences while in the hospital are becoming even more significant.[9] Despite this emphasis toward more patient‐centered care, no study has explored the hospitalized patient's experience with hospitalist service handoffs. Our goal was to qualitatively assess the hospitalized patients' experiences with transitions between hospitalists to develop a conceptual model to inform future work on improving inpatient transitions of care.

METHODS

RESULTS

In total, 43 eligible patients were recruited, and 40 (93%) agreed to participate. Interviewed patients were between 51 and 65 (39%) years old, had a mean age of 54.5 (15) years, were predominantly female (65%), African American (58%), had a median length of stay at the time of interview of 6.5 days (interquartile range [IQR]: 48), and had an average of 2.0 (IQR: 13) hospitalists oversee their care at the time of interview (Table 1). Interview times ranged from 10:25 to 25:48 minutes, with an average of 15:32 minutes.

We identified 6 major themes on patient perceptions of hospitalist service handoffs including (1) physician‐patient communication, (2) transparency in the hospitalist transition process, (3) indifference toward the hospitalist transition, (4) hospitalist‐subspecialist communication, (5) recognition of new opportunities due to a transition, and (6) hospitalists' bedside manner (Table 2).

Conceptual Model

Following the collection and analysis of all patient responses, all themes were utilized to construct the ideal patient‐centered service handoff. The ideal transition describes open lines of communication between all involved parties, is facilitated by multiple modalities, such as the EHRs and nursing staff, and recognizes the patient as the primary stakeholder (Figure 1).

Figure 1

DISCUSSION

To our knowledge, this is the first qualitative investigation of the hospitalized patient's experience with service handoffs between hospitalists. The patient perspective adds a personal and first‐hand description of how fragmented care may impact the hospitalized patient experience.

Of the 6 themes, communication was found to be the most pertinent to our respondents. Because much of patient care is an inherently communicative activity, it is not surprising that patients, as well as patient safety experts, have focused on communication as an area in need of improvement in transition processes.[17, 18] Moreover, multiple medical societies have directly called for improvements within this area, and have specifically recommended clear and direct communication of treatment plans between the patient and physician, timely exchange of information, and knowledge of who is primarily in charge of the patients care.[11] Not surprisingly, each of these recommendations appears to be echoed by our participants. This theme is especially important given that good physician‐patient communication has been noted to be a major goal in achieving patient‐centered care, and has been positively correlated to medication adherence, patient satisfaction, and physical health outcomes.[19, 20, 21, 22, 23]

Although not a substitute for face‐to‐face interactions, other communication interventions between physicians and patients should be considered. For example, get to know me posters placed in patient rooms have been shown to encourage communication between patients and physicians.[24] Additionally, physician face cards have been used to improve patients' abilities to identify and clarify physicians' roles in patient care.[25] As a patient put it, If they got a new one [hospitalist], just as if I got a new medicationprint out information on themlike where they went to med school, and stuff(patient 13). These modalities may represent highly implementable, cost‐effective adjuncts to current handoff methods that may improve lines of communication between physicians and patients.

In addition to the importance placed on physician‐patient communication, interprofessional communication between hospitalists and subspecialists was also highly regarded. Studies have shown that practice‐based interprofessional communication, such as daily interdisciplinary rounds and the use of external facilitators, can improve healthcare processes and outcomes.[26] However, these interventions must be weighed with the many conflicting factors that both hospitalists and subspecialists face on daily basis, including high patient volumes, time limitations, patient availability, and scheduling conflicts.[27] None the less, the strong emphasis patients placed on this line of communication highlights this domain as an area in which hospitalist and subspecialist can work together for systematic improvement.

Patients also recognized the complexity of the transfer process between hospitalists and called for improved transparency. For example, patients repeatedly requested to be informed prior to any changes in their hospitalists, a request that remains consistent with current guidelines.[11] There also existed a strong desire for a more formalized process of transitioning between hospitalists, which often described a handoff procedure that would occur at the patient's bedside. This desire seems to be mirrored in the data that show that patients prefer to interact with their care team at the bedside and report higher satisfaction when they are involved with their care.[28, 29] Unfortunately, this desire for more direct interaction with physicians runs counter to the current paradigm of patient care, where most activities on rounds do not take place at the bedside.[30]

In contrast to patient's calls for improved transparency, an equally large portion of patients expressed relative indifference to the transition. Whereas on the surface this may seem salutary, some studies suggest that a lack of patient activation and engagement may have adverse effects toward patients' overall care.[31] Furthermore, others have shown evidence of better healthcare experiences, improved health outcomes, and lower costs in patients who are more active in their care.[30, 31] Altogether, this suggests that despite some patients' indifference, physicians should continue to engage patients in their hospital care.[32]

Although prevailing sentiments among patient safety advocates are that patient handoffs are inherently dangerous and place patients at increased risk of adverse events, patients did not always share this concern. A frequently occurring theme was that the transition is an opportunity for medical reevaluation or the establishment of a new, possibly improved therapeutic alliance. Recognizing this viewpoint offers oncoming hospitalists the opportunity to focus on issues that the patient may have felt were not being properly addressed with their prior physician.

Finally, although our conceptual model is not a strict guideline, we believe that any future studies should consider this framework when constructing interventions to improve service‐level handoffs. Several interventions already exist. For instance, educational interventions, such as patient‐centered interviewing, have been shown to improve patient satisfaction, compliance with medications, lead to fewer lawsuits, and improve health outcomes.[33, 34, 35] Additional methods of keeping the patient more informed include physician face sheets and performance of the handoff at the patient's bedside. Although well known in nursing literature, the idea of physicians performing handoffs at the patient's bedside is a particularly patient‐centric process.[36] This type of intervention may have the ability to transform the handoff from the current state of a 2‐way street, in which information is passed between 2 hospitalists, to a 3‐way stop, in which both hospitalists and the patient are able to communicate at this critical junction of care.

Although our study does offer new insight into the effects of discontinuous care, its exploratory nature does have limitations. First, being performed at a single academic center limits our ability to generalize our findings. Second, perspectives of those who did not wish to participate, patients' family members or caregivers, and those who were not queried, could highly differ from those we interviewed. Additionally, we did not collect data on patients' diagnoses or reason for admission, thus limiting our ability to assess if certain diagnosis or subpopulations predispose patients to experiencing a service handoff. Third, although our study was restricted to English‐speaking patients only, we must consider that non‐English speakers would likely suffer from even greater communication barriers than those who took part in our study. Finally, our interviews and data analysis were conducted by hospitalists, which could have subconsciously influenced the interview process, and the interpretation of patient responses. However, we tried to mitigate these issues by having the same individual interview all participants, by using an interview guide to ensure cross‐cohort consistency, by using open‐ended questions, and by attempting to give patients every opportunity to express themselves.

CONCLUSIONS

From a patients' perspective, inpatient service handoffs are often opaque experiences that are highlighted by poor communication between physicians and patients. Although deficits in communication and transparency acted as barriers to a patient‐centered handoff, physicians should recognize that service handoffs may also represent opportunities for improvement, and should focus on these domains when they start on a new service.

Studies examining the importance of continuity of care have shown that patients who maintain a continuous relationship with a single physician have improved outcomes.[1, 2] However, most of these studies were performed in the outpatient, rather than the inpatient setting. With over 35 million patients admitted to hospitals in 2013, along with the significant increase in hospital discontinuity over recent years, the impact of inpatient continuity of care on quality outcomes and patient satisfaction is becoming increasingly relevant.[3, 4]

Service handoffs, when a physician hands over treatment responsibility for a panel of patients and is not expected to return, are a type of handoff that contributes to inpatient discontinuity. In particular, service handoffs between hospitalists are an especially common and inherently risky type of transition, as there is a severing of an established relationship during a patient's hospitalization. Unfortunately, due to the lack of evidence on the effects of service handoffs, current guidelines are limited in their recommendations.[5] Whereas several recent studies have begun to explore the effects of these handoffs, no prior study has examined this issue from a patient's perspective.[6, 7, 8]

Patients are uniquely positioned to inform us about their experiences in care transitions. Furthermore, with patient satisfaction now affecting Medicare reimbursement rates, patient experiences while in the hospital are becoming even more significant.[9] Despite this emphasis toward more patient‐centered care, no study has explored the hospitalized patient's experience with hospitalist service handoffs. Our goal was to qualitatively assess the hospitalized patients' experiences with transitions between hospitalists to develop a conceptual model to inform future work on improving inpatient transitions of care.

METHODS

RESULTS

In total, 43 eligible patients were recruited, and 40 (93%) agreed to participate. Interviewed patients were between 51 and 65 (39%) years old, had a mean age of 54.5 (15) years, were predominantly female (65%), African American (58%), had a median length of stay at the time of interview of 6.5 days (interquartile range [IQR]: 48), and had an average of 2.0 (IQR: 13) hospitalists oversee their care at the time of interview (Table 1). Interview times ranged from 10:25 to 25:48 minutes, with an average of 15:32 minutes.

We identified 6 major themes on patient perceptions of hospitalist service handoffs including (1) physician‐patient communication, (2) transparency in the hospitalist transition process, (3) indifference toward the hospitalist transition, (4) hospitalist‐subspecialist communication, (5) recognition of new opportunities due to a transition, and (6) hospitalists' bedside manner (Table 2).

Conceptual Model

Following the collection and analysis of all patient responses, all themes were utilized to construct the ideal patient‐centered service handoff. The ideal transition describes open lines of communication between all involved parties, is facilitated by multiple modalities, such as the EHRs and nursing staff, and recognizes the patient as the primary stakeholder (Figure 1).

Figure 1

DISCUSSION

To our knowledge, this is the first qualitative investigation of the hospitalized patient's experience with service handoffs between hospitalists. The patient perspective adds a personal and first‐hand description of how fragmented care may impact the hospitalized patient experience.

Of the 6 themes, communication was found to be the most pertinent to our respondents. Because much of patient care is an inherently communicative activity, it is not surprising that patients, as well as patient safety experts, have focused on communication as an area in need of improvement in transition processes.[17, 18] Moreover, multiple medical societies have directly called for improvements within this area, and have specifically recommended clear and direct communication of treatment plans between the patient and physician, timely exchange of information, and knowledge of who is primarily in charge of the patients care.[11] Not surprisingly, each of these recommendations appears to be echoed by our participants. This theme is especially important given that good physician‐patient communication has been noted to be a major goal in achieving patient‐centered care, and has been positively correlated to medication adherence, patient satisfaction, and physical health outcomes.[19, 20, 21, 22, 23]

Although not a substitute for face‐to‐face interactions, other communication interventions between physicians and patients should be considered. For example, get to know me posters placed in patient rooms have been shown to encourage communication between patients and physicians.[24] Additionally, physician face cards have been used to improve patients' abilities to identify and clarify physicians' roles in patient care.[25] As a patient put it, If they got a new one [hospitalist], just as if I got a new medicationprint out information on themlike where they went to med school, and stuff(patient 13). These modalities may represent highly implementable, cost‐effective adjuncts to current handoff methods that may improve lines of communication between physicians and patients.

In addition to the importance placed on physician‐patient communication, interprofessional communication between hospitalists and subspecialists was also highly regarded. Studies have shown that practice‐based interprofessional communication, such as daily interdisciplinary rounds and the use of external facilitators, can improve healthcare processes and outcomes.[26] However, these interventions must be weighed with the many conflicting factors that both hospitalists and subspecialists face on daily basis, including high patient volumes, time limitations, patient availability, and scheduling conflicts.[27] None the less, the strong emphasis patients placed on this line of communication highlights this domain as an area in which hospitalist and subspecialist can work together for systematic improvement.

Patients also recognized the complexity of the transfer process between hospitalists and called for improved transparency. For example, patients repeatedly requested to be informed prior to any changes in their hospitalists, a request that remains consistent with current guidelines.[11] There also existed a strong desire for a more formalized process of transitioning between hospitalists, which often described a handoff procedure that would occur at the patient's bedside. This desire seems to be mirrored in the data that show that patients prefer to interact with their care team at the bedside and report higher satisfaction when they are involved with their care.[28, 29] Unfortunately, this desire for more direct interaction with physicians runs counter to the current paradigm of patient care, where most activities on rounds do not take place at the bedside.[30]

In contrast to patient's calls for improved transparency, an equally large portion of patients expressed relative indifference to the transition. Whereas on the surface this may seem salutary, some studies suggest that a lack of patient activation and engagement may have adverse effects toward patients' overall care.[31] Furthermore, others have shown evidence of better healthcare experiences, improved health outcomes, and lower costs in patients who are more active in their care.[30, 31] Altogether, this suggests that despite some patients' indifference, physicians should continue to engage patients in their hospital care.[32]

Although prevailing sentiments among patient safety advocates are that patient handoffs are inherently dangerous and place patients at increased risk of adverse events, patients did not always share this concern. A frequently occurring theme was that the transition is an opportunity for medical reevaluation or the establishment of a new, possibly improved therapeutic alliance. Recognizing this viewpoint offers oncoming hospitalists the opportunity to focus on issues that the patient may have felt were not being properly addressed with their prior physician.

Finally, although our conceptual model is not a strict guideline, we believe that any future studies should consider this framework when constructing interventions to improve service‐level handoffs. Several interventions already exist. For instance, educational interventions, such as patient‐centered interviewing, have been shown to improve patient satisfaction, compliance with medications, lead to fewer lawsuits, and improve health outcomes.[33, 34, 35] Additional methods of keeping the patient more informed include physician face sheets and performance of the handoff at the patient's bedside. Although well known in nursing literature, the idea of physicians performing handoffs at the patient's bedside is a particularly patient‐centric process.[36] This type of intervention may have the ability to transform the handoff from the current state of a 2‐way street, in which information is passed between 2 hospitalists, to a 3‐way stop, in which both hospitalists and the patient are able to communicate at this critical junction of care.

Although our study does offer new insight into the effects of discontinuous care, its exploratory nature does have limitations. First, being performed at a single academic center limits our ability to generalize our findings. Second, perspectives of those who did not wish to participate, patients' family members or caregivers, and those who were not queried, could highly differ from those we interviewed. Additionally, we did not collect data on patients' diagnoses or reason for admission, thus limiting our ability to assess if certain diagnosis or subpopulations predispose patients to experiencing a service handoff. Third, although our study was restricted to English‐speaking patients only, we must consider that non‐English speakers would likely suffer from even greater communication barriers than those who took part in our study. Finally, our interviews and data analysis were conducted by hospitalists, which could have subconsciously influenced the interview process, and the interpretation of patient responses. However, we tried to mitigate these issues by having the same individual interview all participants, by using an interview guide to ensure cross‐cohort consistency, by using open‐ended questions, and by attempting to give patients every opportunity to express themselves.

CONCLUSIONS

From a patients' perspective, inpatient service handoffs are often opaque experiences that are highlighted by poor communication between physicians and patients. Although deficits in communication and transparency acted as barriers to a patient‐centered handoff, physicians should recognize that service handoffs may also represent opportunities for improvement, and should focus on these domains when they start on a new service.

Studies examining the importance of continuity of care have shown that patients who maintain a continuous relationship with a single physician have improved outcomes.[1, 2] However, most of these studies were performed in the outpatient, rather than the inpatient setting. With over 35 million patients admitted to hospitals in 2013, along with the significant increase in hospital discontinuity over recent years, the impact of inpatient continuity of care on quality outcomes and patient satisfaction is becoming increasingly relevant.[3, 4]

Service handoffs, when a physician hands over treatment responsibility for a panel of patients and is not expected to return, are a type of handoff that contributes to inpatient discontinuity. In particular, service handoffs between hospitalists are an especially common and inherently risky type of transition, as there is a severing of an established relationship during a patient's hospitalization. Unfortunately, due to the lack of evidence on the effects of service handoffs, current guidelines are limited in their recommendations.[5] Whereas several recent studies have begun to explore the effects of these handoffs, no prior study has examined this issue from a patient's perspective.[6, 7, 8]

Patients are uniquely positioned to inform us about their experiences in care transitions. Furthermore, with patient satisfaction now affecting Medicare reimbursement rates, patient experiences while in the hospital are becoming even more significant.[9] Despite this emphasis toward more patient‐centered care, no study has explored the hospitalized patient's experience with hospitalist service handoffs. Our goal was to qualitatively assess the hospitalized patients' experiences with transitions between hospitalists to develop a conceptual model to inform future work on improving inpatient transitions of care.

METHODS

RESULTS

In total, 43 eligible patients were recruited, and 40 (93%) agreed to participate. Interviewed patients were between 51 and 65 (39%) years old, had a mean age of 54.5 (15) years, were predominantly female (65%), African American (58%), had a median length of stay at the time of interview of 6.5 days (interquartile range [IQR]: 48), and had an average of 2.0 (IQR: 13) hospitalists oversee their care at the time of interview (Table 1). Interview times ranged from 10:25 to 25:48 minutes, with an average of 15:32 minutes.

We identified 6 major themes on patient perceptions of hospitalist service handoffs including (1) physician‐patient communication, (2) transparency in the hospitalist transition process, (3) indifference toward the hospitalist transition, (4) hospitalist‐subspecialist communication, (5) recognition of new opportunities due to a transition, and (6) hospitalists' bedside manner (Table 2).

Conceptual Model

Following the collection and analysis of all patient responses, all themes were utilized to construct the ideal patient‐centered service handoff. The ideal transition describes open lines of communication between all involved parties, is facilitated by multiple modalities, such as the EHRs and nursing staff, and recognizes the patient as the primary stakeholder (Figure 1).

Figure 1

DISCUSSION

To our knowledge, this is the first qualitative investigation of the hospitalized patient's experience with service handoffs between hospitalists. The patient perspective adds a personal and first‐hand description of how fragmented care may impact the hospitalized patient experience.

Of the 6 themes, communication was found to be the most pertinent to our respondents. Because much of patient care is an inherently communicative activity, it is not surprising that patients, as well as patient safety experts, have focused on communication as an area in need of improvement in transition processes.[17, 18] Moreover, multiple medical societies have directly called for improvements within this area, and have specifically recommended clear and direct communication of treatment plans between the patient and physician, timely exchange of information, and knowledge of who is primarily in charge of the patients care.[11] Not surprisingly, each of these recommendations appears to be echoed by our participants. This theme is especially important given that good physician‐patient communication has been noted to be a major goal in achieving patient‐centered care, and has been positively correlated to medication adherence, patient satisfaction, and physical health outcomes.[19, 20, 21, 22, 23]

Although not a substitute for face‐to‐face interactions, other communication interventions between physicians and patients should be considered. For example, get to know me posters placed in patient rooms have been shown to encourage communication between patients and physicians.[24] Additionally, physician face cards have been used to improve patients' abilities to identify and clarify physicians' roles in patient care.[25] As a patient put it, If they got a new one [hospitalist], just as if I got a new medicationprint out information on themlike where they went to med school, and stuff(patient 13). These modalities may represent highly implementable, cost‐effective adjuncts to current handoff methods that may improve lines of communication between physicians and patients.

In addition to the importance placed on physician‐patient communication, interprofessional communication between hospitalists and subspecialists was also highly regarded. Studies have shown that practice‐based interprofessional communication, such as daily interdisciplinary rounds and the use of external facilitators, can improve healthcare processes and outcomes.[26] However, these interventions must be weighed with the many conflicting factors that both hospitalists and subspecialists face on daily basis, including high patient volumes, time limitations, patient availability, and scheduling conflicts.[27] None the less, the strong emphasis patients placed on this line of communication highlights this domain as an area in which hospitalist and subspecialist can work together for systematic improvement.

Patients also recognized the complexity of the transfer process between hospitalists and called for improved transparency. For example, patients repeatedly requested to be informed prior to any changes in their hospitalists, a request that remains consistent with current guidelines.[11] There also existed a strong desire for a more formalized process of transitioning between hospitalists, which often described a handoff procedure that would occur at the patient's bedside. This desire seems to be mirrored in the data that show that patients prefer to interact with their care team at the bedside and report higher satisfaction when they are involved with their care.[28, 29] Unfortunately, this desire for more direct interaction with physicians runs counter to the current paradigm of patient care, where most activities on rounds do not take place at the bedside.[30]

In contrast to patient's calls for improved transparency, an equally large portion of patients expressed relative indifference to the transition. Whereas on the surface this may seem salutary, some studies suggest that a lack of patient activation and engagement may have adverse effects toward patients' overall care.[31] Furthermore, others have shown evidence of better healthcare experiences, improved health outcomes, and lower costs in patients who are more active in their care.[30, 31] Altogether, this suggests that despite some patients' indifference, physicians should continue to engage patients in their hospital care.[32]

Although prevailing sentiments among patient safety advocates are that patient handoffs are inherently dangerous and place patients at increased risk of adverse events, patients did not always share this concern. A frequently occurring theme was that the transition is an opportunity for medical reevaluation or the establishment of a new, possibly improved therapeutic alliance. Recognizing this viewpoint offers oncoming hospitalists the opportunity to focus on issues that the patient may have felt were not being properly addressed with their prior physician.

Finally, although our conceptual model is not a strict guideline, we believe that any future studies should consider this framework when constructing interventions to improve service‐level handoffs. Several interventions already exist. For instance, educational interventions, such as patient‐centered interviewing, have been shown to improve patient satisfaction, compliance with medications, lead to fewer lawsuits, and improve health outcomes.[33, 34, 35] Additional methods of keeping the patient more informed include physician face sheets and performance of the handoff at the patient's bedside. Although well known in nursing literature, the idea of physicians performing handoffs at the patient's bedside is a particularly patient‐centric process.[36] This type of intervention may have the ability to transform the handoff from the current state of a 2‐way street, in which information is passed between 2 hospitalists, to a 3‐way stop, in which both hospitalists and the patient are able to communicate at this critical junction of care.

Although our study does offer new insight into the effects of discontinuous care, its exploratory nature does have limitations. First, being performed at a single academic center limits our ability to generalize our findings. Second, perspectives of those who did not wish to participate, patients' family members or caregivers, and those who were not queried, could highly differ from those we interviewed. Additionally, we did not collect data on patients' diagnoses or reason for admission, thus limiting our ability to assess if certain diagnosis or subpopulations predispose patients to experiencing a service handoff. Third, although our study was restricted to English‐speaking patients only, we must consider that non‐English speakers would likely suffer from even greater communication barriers than those who took part in our study. Finally, our interviews and data analysis were conducted by hospitalists, which could have subconsciously influenced the interview process, and the interpretation of patient responses. However, we tried to mitigate these issues by having the same individual interview all participants, by using an interview guide to ensure cross‐cohort consistency, by using open‐ended questions, and by attempting to give patients every opportunity to express themselves.

CONCLUSIONS

From a patients' perspective, inpatient service handoffs are often opaque experiences that are highlighted by poor communication between physicians and patients. Although deficits in communication and transparency acted as barriers to a patient‐centered handoff, physicians should recognize that service handoffs may also represent opportunities for improvement, and should focus on these domains when they start on a new service.

The hospitalized patient experience has become an area of increased focus for hospitals given the recent coupling of patient satisfaction to reimbursement rates for Medicare patients.[1] Although patient experiences are multifactorial, 1 component is the relationship that hospitalized patients develop with their inpatient physicians. In recognition of the importance of this relationship, several organizations including the Society of Hospital Medicine, Society of General Internal Medicine, American College of Physicians, the American College of Emergency Physicians, and the Accreditation Council for Graduate Medical Education have recommended that patients know and understand who is guiding their care at all times during their hospitalization.[2, 3] Unfortunately, previous studies have shown that hospitalized patients often lack the ability to identify[4, 5] and understand their course of care.[6, 7] This may be due to numerous clinical factors including lack of a prior relationship, rapid pace of clinical care, and the frequent transitions of care found in both hospitalists and general medicine teaching services.[5, 8, 9] Regardless of the cause, one could hypothesize that patients who are unable to identify or understand the role of their physician may be less informed about their hospitalization, which may lead to further confusion, dissatisfaction, and ultimately a poor experience.

Given the proliferation of nonteaching hospitalist services in teaching hospitals, it is important to understand if patient experiences differ between general medicine teaching and hospitalist services. Several reasons could explain why patient experiences may vary on these services. For example, patients on a hospitalist service will likely interact with a single physician caretaker, which may give a feeling of more personalized care. In contrast, patients on general medicine teaching services are cared for by larger teams of residents under the supervision of an attending physician. Residents are also subjected to duty‐hour restrictions, clinic responsibilities, and other educational requirements that may impede the continuity of care for hospitalized patients.[10, 11, 12] Although 1 study has shown that hospitalist‐intensive hospitals perform better on patient satisfaction measures,[13] no study to date has compared patient‐reported experiences on general medicine teaching and nonteaching hospitalist services. This study aimed to evaluate the hospitalized patient experience on both teaching and nonteaching hospitalist services by assessing several patient‐reported measures of their experience, namely their confidence in their ability to identify their physician(s), understand their roles, and their rating of both the coordination and overall care.

METHODS

RESULTS

In total, 14,855 patients were enrolled during their hospitalization with 57% and 61% completing the 30‐day follow‐up survey on the hospitalist and general medicine teaching service, respectively. In total, 4131 (69%) and 4322 (48%) of the hospitalist and general medicine services, respectively, either did not answer all survey questions, or were missing basic demographic data, and thus were excluded. Data from 4591 patients on the general medicine teaching (52% of those enrolled at hospitalization) and 1811 on the hospitalist service (31% of those enrolled at hospitalization) were used for final analysis (Figure 1). Respondents were predominantly female (61% and 56%), African American (75% and 63%), with a mean age of 56.2 (19.4) and 57.1 (16.1) years, for the general medicine teaching and hospitalist services, respectively. A majority of patients (71% and 66%) had a CCI of 0 to 3 on both services. There were differences in self‐reported comorbidities between the 2 groups, with hospitalist services having a higher prevalence of cancer (20% vs 7%), renal disease (25% vs 18%), and liver disease (23% vs 7%). Patients on the hospitalist service had a longer mean LOS (5.5 vs 4.8 days), a greater percentage of a hospitalization within 1 year (58% vs 52%), and a larger proportion who were admitted in 2011 to 2013 compared to 2007 to 2010 (75% vs 39%), when compared to the general medicine teaching services. Median LOS and interquartile ranges were similar between both groups. Although most baseline demographics were statistically different between the 2 groups (Table 1), these differences were likely clinically insignificant. Compared to those who responded to the follow‐up survey, nonresponders were more likely to be African American (73% and 64%, P < 0.001) and female (60% and 56%, P < 0.01). The nonresponders were more likely to be hospitalized in the past 1 year (62% and 53%, P < 0.001) and have a lower CCI (CCI 03 [75% and 80%, P < 0.001]) compared to responders. Demographics between responders and nonresponders were also statistically different from one another.

Figure 1

Unadjusted results revealed that patients on the hospitalist service were more confident in their abilities to identify their physician(s) (50% vs 45%, P < 0.001), perceived greater ability in understanding the role of their physician(s) (54% vs 50%, P < 0.001), and reported greater satisfaction with coordination and teamwork (68% vs 64%, P = 0.006) and with overall care (73% vs 67%, P < 0.001) (Figure 2).

Figure 2

From the mixed‐effects regression models it was discovered that admission to the hospitalist service was associated with a higher odds ratio (OR) of reporting overall care as excellent or very good (OR: 1.33; 95% confidence interval [CI]: 1.15‐1.47). There was no difference between services in patients' ability to identify their physician(s) (OR: 0.89; 95% CI: 0.61‐1.11), in patients reporting a better understanding of the role of their physician(s) (OR: 1.09; 95% CI: 0.94‐1.23), or in their rating of overall coordination and teamwork (OR: 0.71; 95% CI: 0.42‐1.89).

A subgroup analysis was performed on the 25% of hospitalist attendings in the general medicine teaching service comparing this cohort to the hospitalist services, and it was found that patients perceived better overall care on the hospitalist service (OR: 1.17; 95% CI: 1.01‐ 1.31) than on the general medicine service (Table 2). All other domains in the subgroup analysis were not statistically significant. Finally, an ordinal logistic regression was performed for each of these outcomes, but it did not show any major differences compared to the logistic regression of dichotomous outcomes.

DISCUSSION

This study is the first to directly compare measures of patient experience on hospitalist and general medicine teaching services in a large, multiyear comparison across multiple domains. In adjusted analysis, we found that patients on nonteaching hospitalist services rated their overall care better than those on general medicine teaching services, whereas no differences in patients' ability to identify their physician(s), understand their role in their care, or rating of coordination of care were found. Although the magnitude of the differences in rating of overall care may appear small, it remains noteworthy because of the recent focus on patient experience at the reimbursement level, where small differences in performance can lead to large changes in payment. Because of the observational design of this study, it is important to consider mechanisms that could account for our findings.

The first are the structural differences between the 2 services. Our subgroup analysis comparing patients rating of overall care on a general medicine service with a hospitalist attending to a pure hospitalist cohort found a significant difference between the groups, indicating that the structural differences between the 2 groups may be a significant contributor to patient satisfaction ratings. Under the care of a hospitalist service, a patient would only interact with a single physician on a daily basis, possibly leading to a more meaningful relationship and improved communication between patient and provider. Alternatively, while on a general medicine teaching service, patients would likely interact with multiple physicians, as a result making their confidence in their ability to identify and perception at understanding physicians' roles more challenging.[18] This dilemma is further compounded by duty hour restrictions, which have subsequently led to increased fragmentation in housestaff scheduling. The patient experience on the general medicine teaching service may be further complicated by recent data that show residents spend a minority of time in direct patient care,[19, 20] which could additionally contribute to patients' inability to understand who their physicians are and to the decreased satisfaction with their care. This combination of structural complexity, duty hour reform, and reduced direct patient interaction would likely decrease the chance a patient will interact with the same resident on a consistent basis,[5, 21] thus making the ability to truly understand who their caretakers are, and the role they play, more difficult.

Another contributing factor could be the use of NPAs on our hospitalist service. Given that these providers often see the patient on a more continual basis, hospitalized patients' exposure to a single, continuous caretaker may be a factor in our findings.[22] Furthermore, with studies showing that hospitalists also spend a small fraction of their day in direct patient care,[23, 24, 25] the use of NPAs may allow our hospitalists to spend greater amounts of time with their patients, thus improving patients' rating of their overall care and influencing their perceived ability to understand their physician's role.

Although there was no difference between general medicine teaching and hospitalist services with respect to patient understanding of their roles, our data suggest that both groups would benefit from interventions to target this area. Focused attempts at improving patient's ability to identify and explain the roles of their inpatient physician(s) have been performed. For example, previous studies have attempted to improve a patient's ability to identify their physician through physician facecards[8, 9] or the use of other simple interventions (ie, bedside whiteboards).[4, 26] Results from such interventions are mixed, as they have demonstrated the capacity to improve patients' ability to identify who their physician is, whereas few have shown any appreciable improvement in patient satisfaction.[26]

Although our findings suggest that structural differences in team composition may be a possible explanation, it is also important to consider how the quality of care a patient receives affects their experience. For instance, hospitalists have been shown to produce moderate improvements in patient‐centered outcomes such as 30‐day readmission[27] and hospital length of stay[14, 28, 29, 30, 31] when compared to other care providers, which in turn could be reflected in the patient's perception of their overall care. In a large national study of acute care hospitals using the Hospital Consumer Assessment of Healthcare Providers and Systems survey, Chen and colleagues found that for most measures of patient satisfaction, hospitals with greater use of hospitalist care were associated with better patient‐centered care.[13] These outcomes were in part driven by patient‐centered domains such as discharge planning, pain control, and medication management. It is possible that patients are sensitive to the improved outcomes that are associated with hospitalist services, and reflect this in their measures of patient satisfaction.

Last, because this is an observational study and not a randomized trial, it is possible that the clinical differences in the patients cared for by these services could have led to our findings. Although the clinical significance of the differences in patient demographics were small, patients seen on the hospitalist service were more likely to be older white males, with a slightly longer LOS, greater comorbidities, and more hospitalizations in the previous year than those seen on the general medicine teaching service. Additionally, our hospitalist service frequently cares for highly specific subpopulations (ie, liver and renal transplant patients, and oncology patients), which could have influenced our results. For example, transplant patients who may be very grateful for their second chance, are preferentially admitted to the hospitalist service, which could have biased our results in favor of hospitalists.[32] Unfortunately, we were unable to control for all such factors.

Although we hope that multivariable analysis can adjust for many of these differences, we are not able to account for possible unmeasured confounders such as time of day of admission, health literacy, personality differences, physician turnover, or nursing and other ancillary care that could contribute to these findings. In addition to its observational study design, our study has several other limitations. First, our study was performed at a single institution, thus limiting its generalizability. Second, as a retrospective study based on observational data, no definitive conclusions regarding causality can be made. Third, although our response rate was low, it is comparable to other studies that have examined underserved populations.[33, 34] Fourth, because our survey was performed 30 days after hospitalization, this may impart imprecision on our outcomes measures. Finally, we were not able to mitigate selection bias through imputation for missing data .

All together, given the small absolute differences between the groups in patients' ratings of their overall care compared to large differences in possible confounders, these findings call for further exploration into the significance and possible mechanisms of these outcomes. Our study raises the potential possibility that the structural component of a care team may play a role in overall patient satisfaction. If this is the case, future studies of team structure could help inform how best to optimize this component for the patient experience. On the other hand, if process differences are to explain our findings, it is important to distill the types of processes hospitalists are using to improve the patient experience and potentially export this to resident services.

Finally, if similar results were found in other institutions, these findings could have implications on how hospitals respond to new payment models that are linked to patient‐experience measures. For example, the Hospital Value‐Based Purchasing Program currently links the Centers for Medicare and Medicaid Services payments to a set of quality measures that consist of (1) clinical processes of care (70%) and (2) the patient experience (30%).[1] Given this linkage, any small changes in the domain of patient satisfaction could have large payment implications on a national level.

CONCLUSION

In summary, in this large‐scale multiyear study, patients cared for by a nonteaching hospitalist service reported greater satisfaction with their overall care than patients cared for by a general medicine teaching service. This difference could be mediated by the structural differences between these 2 services. As hospitals seek to optimize patient experiences in an era where reimbursement models are now being linked to patient‐experience measures, future work should focus on further understanding the mechanisms for these findings.

The hospitalized patient experience has become an area of increased focus for hospitals given the recent coupling of patient satisfaction to reimbursement rates for Medicare patients.[1] Although patient experiences are multifactorial, 1 component is the relationship that hospitalized patients develop with their inpatient physicians. In recognition of the importance of this relationship, several organizations including the Society of Hospital Medicine, Society of General Internal Medicine, American College of Physicians, the American College of Emergency Physicians, and the Accreditation Council for Graduate Medical Education have recommended that patients know and understand who is guiding their care at all times during their hospitalization.[2, 3] Unfortunately, previous studies have shown that hospitalized patients often lack the ability to identify[4, 5] and understand their course of care.[6, 7] This may be due to numerous clinical factors including lack of a prior relationship, rapid pace of clinical care, and the frequent transitions of care found in both hospitalists and general medicine teaching services.[5, 8, 9] Regardless of the cause, one could hypothesize that patients who are unable to identify or understand the role of their physician may be less informed about their hospitalization, which may lead to further confusion, dissatisfaction, and ultimately a poor experience.

Given the proliferation of nonteaching hospitalist services in teaching hospitals, it is important to understand if patient experiences differ between general medicine teaching and hospitalist services. Several reasons could explain why patient experiences may vary on these services. For example, patients on a hospitalist service will likely interact with a single physician caretaker, which may give a feeling of more personalized care. In contrast, patients on general medicine teaching services are cared for by larger teams of residents under the supervision of an attending physician. Residents are also subjected to duty‐hour restrictions, clinic responsibilities, and other educational requirements that may impede the continuity of care for hospitalized patients.[10, 11, 12] Although 1 study has shown that hospitalist‐intensive hospitals perform better on patient satisfaction measures,[13] no study to date has compared patient‐reported experiences on general medicine teaching and nonteaching hospitalist services. This study aimed to evaluate the hospitalized patient experience on both teaching and nonteaching hospitalist services by assessing several patient‐reported measures of their experience, namely their confidence in their ability to identify their physician(s), understand their roles, and their rating of both the coordination and overall care.

METHODS

RESULTS

In total, 14,855 patients were enrolled during their hospitalization with 57% and 61% completing the 30‐day follow‐up survey on the hospitalist and general medicine teaching service, respectively. In total, 4131 (69%) and 4322 (48%) of the hospitalist and general medicine services, respectively, either did not answer all survey questions, or were missing basic demographic data, and thus were excluded. Data from 4591 patients on the general medicine teaching (52% of those enrolled at hospitalization) and 1811 on the hospitalist service (31% of those enrolled at hospitalization) were used for final analysis (Figure 1). Respondents were predominantly female (61% and 56%), African American (75% and 63%), with a mean age of 56.2 (19.4) and 57.1 (16.1) years, for the general medicine teaching and hospitalist services, respectively. A majority of patients (71% and 66%) had a CCI of 0 to 3 on both services. There were differences in self‐reported comorbidities between the 2 groups, with hospitalist services having a higher prevalence of cancer (20% vs 7%), renal disease (25% vs 18%), and liver disease (23% vs 7%). Patients on the hospitalist service had a longer mean LOS (5.5 vs 4.8 days), a greater percentage of a hospitalization within 1 year (58% vs 52%), and a larger proportion who were admitted in 2011 to 2013 compared to 2007 to 2010 (75% vs 39%), when compared to the general medicine teaching services. Median LOS and interquartile ranges were similar between both groups. Although most baseline demographics were statistically different between the 2 groups (Table 1), these differences were likely clinically insignificant. Compared to those who responded to the follow‐up survey, nonresponders were more likely to be African American (73% and 64%, P < 0.001) and female (60% and 56%, P < 0.01). The nonresponders were more likely to be hospitalized in the past 1 year (62% and 53%, P < 0.001) and have a lower CCI (CCI 03 [75% and 80%, P < 0.001]) compared to responders. Demographics between responders and nonresponders were also statistically different from one another.

Figure 1

Unadjusted results revealed that patients on the hospitalist service were more confident in their abilities to identify their physician(s) (50% vs 45%, P < 0.001), perceived greater ability in understanding the role of their physician(s) (54% vs 50%, P < 0.001), and reported greater satisfaction with coordination and teamwork (68% vs 64%, P = 0.006) and with overall care (73% vs 67%, P < 0.001) (Figure 2).

Figure 2

From the mixed‐effects regression models it was discovered that admission to the hospitalist service was associated with a higher odds ratio (OR) of reporting overall care as excellent or very good (OR: 1.33; 95% confidence interval [CI]: 1.15‐1.47). There was no difference between services in patients' ability to identify their physician(s) (OR: 0.89; 95% CI: 0.61‐1.11), in patients reporting a better understanding of the role of their physician(s) (OR: 1.09; 95% CI: 0.94‐1.23), or in their rating of overall coordination and teamwork (OR: 0.71; 95% CI: 0.42‐1.89).

A subgroup analysis was performed on the 25% of hospitalist attendings in the general medicine teaching service comparing this cohort to the hospitalist services, and it was found that patients perceived better overall care on the hospitalist service (OR: 1.17; 95% CI: 1.01‐ 1.31) than on the general medicine service (Table 2). All other domains in the subgroup analysis were not statistically significant. Finally, an ordinal logistic regression was performed for each of these outcomes, but it did not show any major differences compared to the logistic regression of dichotomous outcomes.

DISCUSSION

This study is the first to directly compare measures of patient experience on hospitalist and general medicine teaching services in a large, multiyear comparison across multiple domains. In adjusted analysis, we found that patients on nonteaching hospitalist services rated their overall care better than those on general medicine teaching services, whereas no differences in patients' ability to identify their physician(s), understand their role in their care, or rating of coordination of care were found. Although the magnitude of the differences in rating of overall care may appear small, it remains noteworthy because of the recent focus on patient experience at the reimbursement level, where small differences in performance can lead to large changes in payment. Because of the observational design of this study, it is important to consider mechanisms that could account for our findings.

The first are the structural differences between the 2 services. Our subgroup analysis comparing patients rating of overall care on a general medicine service with a hospitalist attending to a pure hospitalist cohort found a significant difference between the groups, indicating that the structural differences between the 2 groups may be a significant contributor to patient satisfaction ratings. Under the care of a hospitalist service, a patient would only interact with a single physician on a daily basis, possibly leading to a more meaningful relationship and improved communication between patient and provider. Alternatively, while on a general medicine teaching service, patients would likely interact with multiple physicians, as a result making their confidence in their ability to identify and perception at understanding physicians' roles more challenging.[18] This dilemma is further compounded by duty hour restrictions, which have subsequently led to increased fragmentation in housestaff scheduling. The patient experience on the general medicine teaching service may be further complicated by recent data that show residents spend a minority of time in direct patient care,[19, 20] which could additionally contribute to patients' inability to understand who their physicians are and to the decreased satisfaction with their care. This combination of structural complexity, duty hour reform, and reduced direct patient interaction would likely decrease the chance a patient will interact with the same resident on a consistent basis,[5, 21] thus making the ability to truly understand who their caretakers are, and the role they play, more difficult.

Another contributing factor could be the use of NPAs on our hospitalist service. Given that these providers often see the patient on a more continual basis, hospitalized patients' exposure to a single, continuous caretaker may be a factor in our findings.[22] Furthermore, with studies showing that hospitalists also spend a small fraction of their day in direct patient care,[23, 24, 25] the use of NPAs may allow our hospitalists to spend greater amounts of time with their patients, thus improving patients' rating of their overall care and influencing their perceived ability to understand their physician's role.

Although there was no difference between general medicine teaching and hospitalist services with respect to patient understanding of their roles, our data suggest that both groups would benefit from interventions to target this area. Focused attempts at improving patient's ability to identify and explain the roles of their inpatient physician(s) have been performed. For example, previous studies have attempted to improve a patient's ability to identify their physician through physician facecards[8, 9] or the use of other simple interventions (ie, bedside whiteboards).[4, 26] Results from such interventions are mixed, as they have demonstrated the capacity to improve patients' ability to identify who their physician is, whereas few have shown any appreciable improvement in patient satisfaction.[26]

Although our findings suggest that structural differences in team composition may be a possible explanation, it is also important to consider how the quality of care a patient receives affects their experience. For instance, hospitalists have been shown to produce moderate improvements in patient‐centered outcomes such as 30‐day readmission[27] and hospital length of stay[14, 28, 29, 30, 31] when compared to other care providers, which in turn could be reflected in the patient's perception of their overall care. In a large national study of acute care hospitals using the Hospital Consumer Assessment of Healthcare Providers and Systems survey, Chen and colleagues found that for most measures of patient satisfaction, hospitals with greater use of hospitalist care were associated with better patient‐centered care.[13] These outcomes were in part driven by patient‐centered domains such as discharge planning, pain control, and medication management. It is possible that patients are sensitive to the improved outcomes that are associated with hospitalist services, and reflect this in their measures of patient satisfaction.

Last, because this is an observational study and not a randomized trial, it is possible that the clinical differences in the patients cared for by these services could have led to our findings. Although the clinical significance of the differences in patient demographics were small, patients seen on the hospitalist service were more likely to be older white males, with a slightly longer LOS, greater comorbidities, and more hospitalizations in the previous year than those seen on the general medicine teaching service. Additionally, our hospitalist service frequently cares for highly specific subpopulations (ie, liver and renal transplant patients, and oncology patients), which could have influenced our results. For example, transplant patients who may be very grateful for their second chance, are preferentially admitted to the hospitalist service, which could have biased our results in favor of hospitalists.[32] Unfortunately, we were unable to control for all such factors.

Although we hope that multivariable analysis can adjust for many of these differences, we are not able to account for possible unmeasured confounders such as time of day of admission, health literacy, personality differences, physician turnover, or nursing and other ancillary care that could contribute to these findings. In addition to its observational study design, our study has several other limitations. First, our study was performed at a single institution, thus limiting its generalizability. Second, as a retrospective study based on observational data, no definitive conclusions regarding causality can be made. Third, although our response rate was low, it is comparable to other studies that have examined underserved populations.[33, 34] Fourth, because our survey was performed 30 days after hospitalization, this may impart imprecision on our outcomes measures. Finally, we were not able to mitigate selection bias through imputation for missing data .

All together, given the small absolute differences between the groups in patients' ratings of their overall care compared to large differences in possible confounders, these findings call for further exploration into the significance and possible mechanisms of these outcomes. Our study raises the potential possibility that the structural component of a care team may play a role in overall patient satisfaction. If this is the case, future studies of team structure could help inform how best to optimize this component for the patient experience. On the other hand, if process differences are to explain our findings, it is important to distill the types of processes hospitalists are using to improve the patient experience and potentially export this to resident services.

Finally, if similar results were found in other institutions, these findings could have implications on how hospitals respond to new payment models that are linked to patient‐experience measures. For example, the Hospital Value‐Based Purchasing Program currently links the Centers for Medicare and Medicaid Services payments to a set of quality measures that consist of (1) clinical processes of care (70%) and (2) the patient experience (30%).[1] Given this linkage, any small changes in the domain of patient satisfaction could have large payment implications on a national level.

CONCLUSION

In summary, in this large‐scale multiyear study, patients cared for by a nonteaching hospitalist service reported greater satisfaction with their overall care than patients cared for by a general medicine teaching service. This difference could be mediated by the structural differences between these 2 services. As hospitals seek to optimize patient experiences in an era where reimbursement models are now being linked to patient‐experience measures, future work should focus on further understanding the mechanisms for these findings.

The hospitalized patient experience has become an area of increased focus for hospitals given the recent coupling of patient satisfaction to reimbursement rates for Medicare patients.[1] Although patient experiences are multifactorial, 1 component is the relationship that hospitalized patients develop with their inpatient physicians. In recognition of the importance of this relationship, several organizations including the Society of Hospital Medicine, Society of General Internal Medicine, American College of Physicians, the American College of Emergency Physicians, and the Accreditation Council for Graduate Medical Education have recommended that patients know and understand who is guiding their care at all times during their hospitalization.[2, 3] Unfortunately, previous studies have shown that hospitalized patients often lack the ability to identify[4, 5] and understand their course of care.[6, 7] This may be due to numerous clinical factors including lack of a prior relationship, rapid pace of clinical care, and the frequent transitions of care found in both hospitalists and general medicine teaching services.[5, 8, 9] Regardless of the cause, one could hypothesize that patients who are unable to identify or understand the role of their physician may be less informed about their hospitalization, which may lead to further confusion, dissatisfaction, and ultimately a poor experience.

Given the proliferation of nonteaching hospitalist services in teaching hospitals, it is important to understand if patient experiences differ between general medicine teaching and hospitalist services. Several reasons could explain why patient experiences may vary on these services. For example, patients on a hospitalist service will likely interact with a single physician caretaker, which may give a feeling of more personalized care. In contrast, patients on general medicine teaching services are cared for by larger teams of residents under the supervision of an attending physician. Residents are also subjected to duty‐hour restrictions, clinic responsibilities, and other educational requirements that may impede the continuity of care for hospitalized patients.[10, 11, 12] Although 1 study has shown that hospitalist‐intensive hospitals perform better on patient satisfaction measures,[13] no study to date has compared patient‐reported experiences on general medicine teaching and nonteaching hospitalist services. This study aimed to evaluate the hospitalized patient experience on both teaching and nonteaching hospitalist services by assessing several patient‐reported measures of their experience, namely their confidence in their ability to identify their physician(s), understand their roles, and their rating of both the coordination and overall care.

METHODS

RESULTS

In total, 14,855 patients were enrolled during their hospitalization with 57% and 61% completing the 30‐day follow‐up survey on the hospitalist and general medicine teaching service, respectively. In total, 4131 (69%) and 4322 (48%) of the hospitalist and general medicine services, respectively, either did not answer all survey questions, or were missing basic demographic data, and thus were excluded. Data from 4591 patients on the general medicine teaching (52% of those enrolled at hospitalization) and 1811 on the hospitalist service (31% of those enrolled at hospitalization) were used for final analysis (Figure 1). Respondents were predominantly female (61% and 56%), African American (75% and 63%), with a mean age of 56.2 (19.4) and 57.1 (16.1) years, for the general medicine teaching and hospitalist services, respectively. A majority of patients (71% and 66%) had a CCI of 0 to 3 on both services. There were differences in self‐reported comorbidities between the 2 groups, with hospitalist services having a higher prevalence of cancer (20% vs 7%), renal disease (25% vs 18%), and liver disease (23% vs 7%). Patients on the hospitalist service had a longer mean LOS (5.5 vs 4.8 days), a greater percentage of a hospitalization within 1 year (58% vs 52%), and a larger proportion who were admitted in 2011 to 2013 compared to 2007 to 2010 (75% vs 39%), when compared to the general medicine teaching services. Median LOS and interquartile ranges were similar between both groups. Although most baseline demographics were statistically different between the 2 groups (Table 1), these differences were likely clinically insignificant. Compared to those who responded to the follow‐up survey, nonresponders were more likely to be African American (73% and 64%, P < 0.001) and female (60% and 56%, P < 0.01). The nonresponders were more likely to be hospitalized in the past 1 year (62% and 53%, P < 0.001) and have a lower CCI (CCI 03 [75% and 80%, P < 0.001]) compared to responders. Demographics between responders and nonresponders were also statistically different from one another.

Figure 1

Unadjusted results revealed that patients on the hospitalist service were more confident in their abilities to identify their physician(s) (50% vs 45%, P < 0.001), perceived greater ability in understanding the role of their physician(s) (54% vs 50%, P < 0.001), and reported greater satisfaction with coordination and teamwork (68% vs 64%, P = 0.006) and with overall care (73% vs 67%, P < 0.001) (Figure 2).

Figure 2

From the mixed‐effects regression models it was discovered that admission to the hospitalist service was associated with a higher odds ratio (OR) of reporting overall care as excellent or very good (OR: 1.33; 95% confidence interval [CI]: 1.15‐1.47). There was no difference between services in patients' ability to identify their physician(s) (OR: 0.89; 95% CI: 0.61‐1.11), in patients reporting a better understanding of the role of their physician(s) (OR: 1.09; 95% CI: 0.94‐1.23), or in their rating of overall coordination and teamwork (OR: 0.71; 95% CI: 0.42‐1.89).

A subgroup analysis was performed on the 25% of hospitalist attendings in the general medicine teaching service comparing this cohort to the hospitalist services, and it was found that patients perceived better overall care on the hospitalist service (OR: 1.17; 95% CI: 1.01‐ 1.31) than on the general medicine service (Table 2). All other domains in the subgroup analysis were not statistically significant. Finally, an ordinal logistic regression was performed for each of these outcomes, but it did not show any major differences compared to the logistic regression of dichotomous outcomes.

DISCUSSION

This study is the first to directly compare measures of patient experience on hospitalist and general medicine teaching services in a large, multiyear comparison across multiple domains. In adjusted analysis, we found that patients on nonteaching hospitalist services rated their overall care better than those on general medicine teaching services, whereas no differences in patients' ability to identify their physician(s), understand their role in their care, or rating of coordination of care were found. Although the magnitude of the differences in rating of overall care may appear small, it remains noteworthy because of the recent focus on patient experience at the reimbursement level, where small differences in performance can lead to large changes in payment. Because of the observational design of this study, it is important to consider mechanisms that could account for our findings.

The first are the structural differences between the 2 services. Our subgroup analysis comparing patients rating of overall care on a general medicine service with a hospitalist attending to a pure hospitalist cohort found a significant difference between the groups, indicating that the structural differences between the 2 groups may be a significant contributor to patient satisfaction ratings. Under the care of a hospitalist service, a patient would only interact with a single physician on a daily basis, possibly leading to a more meaningful relationship and improved communication between patient and provider. Alternatively, while on a general medicine teaching service, patients would likely interact with multiple physicians, as a result making their confidence in their ability to identify and perception at understanding physicians' roles more challenging.[18] This dilemma is further compounded by duty hour restrictions, which have subsequently led to increased fragmentation in housestaff scheduling. The patient experience on the general medicine teaching service may be further complicated by recent data that show residents spend a minority of time in direct patient care,[19, 20] which could additionally contribute to patients' inability to understand who their physicians are and to the decreased satisfaction with their care. This combination of structural complexity, duty hour reform, and reduced direct patient interaction would likely decrease the chance a patient will interact with the same resident on a consistent basis,[5, 21] thus making the ability to truly understand who their caretakers are, and the role they play, more difficult.

Another contributing factor could be the use of NPAs on our hospitalist service. Given that these providers often see the patient on a more continual basis, hospitalized patients' exposure to a single, continuous caretaker may be a factor in our findings.[22] Furthermore, with studies showing that hospitalists also spend a small fraction of their day in direct patient care,[23, 24, 25] the use of NPAs may allow our hospitalists to spend greater amounts of time with their patients, thus improving patients' rating of their overall care and influencing their perceived ability to understand their physician's role.

Although there was no difference between general medicine teaching and hospitalist services with respect to patient understanding of their roles, our data suggest that both groups would benefit from interventions to target this area. Focused attempts at improving patient's ability to identify and explain the roles of their inpatient physician(s) have been performed. For example, previous studies have attempted to improve a patient's ability to identify their physician through physician facecards[8, 9] or the use of other simple interventions (ie, bedside whiteboards).[4, 26] Results from such interventions are mixed, as they have demonstrated the capacity to improve patients' ability to identify who their physician is, whereas few have shown any appreciable improvement in patient satisfaction.[26]

Although our findings suggest that structural differences in team composition may be a possible explanation, it is also important to consider how the quality of care a patient receives affects their experience. For instance, hospitalists have been shown to produce moderate improvements in patient‐centered outcomes such as 30‐day readmission[27] and hospital length of stay[14, 28, 29, 30, 31] when compared to other care providers, which in turn could be reflected in the patient's perception of their overall care. In a large national study of acute care hospitals using the Hospital Consumer Assessment of Healthcare Providers and Systems survey, Chen and colleagues found that for most measures of patient satisfaction, hospitals with greater use of hospitalist care were associated with better patient‐centered care.[13] These outcomes were in part driven by patient‐centered domains such as discharge planning, pain control, and medication management. It is possible that patients are sensitive to the improved outcomes that are associated with hospitalist services, and reflect this in their measures of patient satisfaction.

Last, because this is an observational study and not a randomized trial, it is possible that the clinical differences in the patients cared for by these services could have led to our findings. Although the clinical significance of the differences in patient demographics were small, patients seen on the hospitalist service were more likely to be older white males, with a slightly longer LOS, greater comorbidities, and more hospitalizations in the previous year than those seen on the general medicine teaching service. Additionally, our hospitalist service frequently cares for highly specific subpopulations (ie, liver and renal transplant patients, and oncology patients), which could have influenced our results. For example, transplant patients who may be very grateful for their second chance, are preferentially admitted to the hospitalist service, which could have biased our results in favor of hospitalists.[32] Unfortunately, we were unable to control for all such factors.

Although we hope that multivariable analysis can adjust for many of these differences, we are not able to account for possible unmeasured confounders such as time of day of admission, health literacy, personality differences, physician turnover, or nursing and other ancillary care that could contribute to these findings. In addition to its observational study design, our study has several other limitations. First, our study was performed at a single institution, thus limiting its generalizability. Second, as a retrospective study based on observational data, no definitive conclusions regarding causality can be made. Third, although our response rate was low, it is comparable to other studies that have examined underserved populations.[33, 34] Fourth, because our survey was performed 30 days after hospitalization, this may impart imprecision on our outcomes measures. Finally, we were not able to mitigate selection bias through imputation for missing data .

All together, given the small absolute differences between the groups in patients' ratings of their overall care compared to large differences in possible confounders, these findings call for further exploration into the significance and possible mechanisms of these outcomes. Our study raises the potential possibility that the structural component of a care team may play a role in overall patient satisfaction. If this is the case, future studies of team structure could help inform how best to optimize this component for the patient experience. On the other hand, if process differences are to explain our findings, it is important to distill the types of processes hospitalists are using to improve the patient experience and potentially export this to resident services.

Finally, if similar results were found in other institutions, these findings could have implications on how hospitals respond to new payment models that are linked to patient‐experience measures. For example, the Hospital Value‐Based Purchasing Program currently links the Centers for Medicare and Medicaid Services payments to a set of quality measures that consist of (1) clinical processes of care (70%) and (2) the patient experience (30%).[1] Given this linkage, any small changes in the domain of patient satisfaction could have large payment implications on a national level.

CONCLUSION

In summary, in this large‐scale multiyear study, patients cared for by a nonteaching hospitalist service reported greater satisfaction with their overall care than patients cared for by a general medicine teaching service. This difference could be mediated by the structural differences between these 2 services. As hospitals seek to optimize patient experiences in an era where reimbursement models are now being linked to patient‐experience measures, future work should focus on further understanding the mechanisms for these findings.

Chronic kidney disease (CKD) affects over 13% of the US population and is associated with increased morbidity, mortality, and healthcare costs.[1] However, only 10% of individuals with CKD are aware of their diagnoses.[2] Even in those with stage 5 CKD, only 60% of individuals are aware of their CKD.[3] To our knowledge, no work has examined CKD awareness in a hospitalized patient population.

Patient awareness of their CKD diagnosis is important because progression of kidney disease can be slowed by patient self‐management of diabetes and hypertension.[4] Patient awareness of CKD may also increase acceptance of preend‐stage renal disease (ESRD) patient education and nephrology referral, which have been shown to delay CKD progression and improve clinical status at dialysis initiation.[5] However, only 60% of patients with advanced CKD have visited a nephrologist in the past year or have seen a nephrologist prior to dialysis initiation.[1]

The hospital is an important site for patient education and linkage to outpatient care for patients with CKD.[6] The hospital serves high‐risk patients who may not be well connected to outpatient care or who have lesswell‐controlled disease.[6, 7] Thus, hospitalization represents an opportunity to identify existing CKD and to use a multidisciplinary approach to preventative care, patient education, and patient‐provider planning for renal replacement therapy needs. In our cross‐sectional study in an urban, minority‐serving hospital, we sought to determine what patient factors were associated with hospitalized patients correctly self‐identifying as having CKD.

METHODS

RESULTS

DISCUSSION

Although prior work has examined CKD awareness in the general population and in high‐risk cohorts,[2, 3, 13] this is the first study examining CKD awareness in an urban, underserved hospitalized population. We found that overall patients' CKD awareness was low (32%), but increased as high as 63% for CKD stage 5, even after controlling for patient demographic, clinical characteristics, and healthcare use. Our overall rate of CKD awareness was higher than prior studies overall and at lower CKD stages.[2, 3, 13] Our work is consistent with prior literature that shows increasing CKD awareness with advancing CKD stage.[2, 3, 13]

Older patients (>80 years) had lower awareness of CKD. Older patients are more likely to have a near normal creatinine, despite a markedly reduced eGFR, so their CKD may go unnoticed.[14] Even with appropriate recognition, providers may also feel like their CKD is unlikely to progress to ESRD, given its stability and/or their competing risk of death.[15] Finally, older hospitalized patients may also be less likely to report a CKD diagnosis due to difficulty in recall due to denial, dementia, or delirium.

One limitation is that our case‐finding for CKD was physician ICD‐9 coding, which is highly specific but not sensitive.[9] The majority of patients with physician‐identified CKD were CKD unspecified, perhaps due to poor coding, physician underdocumentation, or physician under‐recognition of CKD stage. Although only 27% of the CKD unspecified group correctly self‐identified as having CKD, over 75% were found to be CKD stage 3 or higher, which should trigger additional monitoring or care based on guidelines.[10] In addition, despite statistical significance, we may not be able to make meaningful inferences about our small other group (nonwhite, non‐African American). Our sample was from 1 hospitalan urban, academic, tertiary care center with a large proportion of African American patientswhich may limit generalizability. The multivariable model will need to be tested in other populations for reproducibility.

Our study significantly contributes to the literature by examining patient awareness of CKD in a high‐risk, urban, hospitalized minority population. Other study strengths include use of basic demographic information, as well as survey and laboratory data for a richer examination of the associations between patient factors and CKD awareness.

CONCLUSION

Hospitalized patients with CKD have a low CKD awareness. Patient awareness of their CKD is increased with physician documentation of CKD severity. Patient awareness of their CKD must be coupled with provider awareness and CKD documentation to link patients to multidisciplinary CKD education and care to slow CKD progression and reduce associated cardiovascular and metabolic complications. Further work is needed across hospitals to determineand improveCKD awareness among both patients and providers.

Chronic kidney disease (CKD) affects over 13% of the US population and is associated with increased morbidity, mortality, and healthcare costs.[1] However, only 10% of individuals with CKD are aware of their diagnoses.[2] Even in those with stage 5 CKD, only 60% of individuals are aware of their CKD.[3] To our knowledge, no work has examined CKD awareness in a hospitalized patient population.

Patient awareness of their CKD diagnosis is important because progression of kidney disease can be slowed by patient self‐management of diabetes and hypertension.[4] Patient awareness of CKD may also increase acceptance of preend‐stage renal disease (ESRD) patient education and nephrology referral, which have been shown to delay CKD progression and improve clinical status at dialysis initiation.[5] However, only 60% of patients with advanced CKD have visited a nephrologist in the past year or have seen a nephrologist prior to dialysis initiation.[1]

The hospital is an important site for patient education and linkage to outpatient care for patients with CKD.[6] The hospital serves high‐risk patients who may not be well connected to outpatient care or who have lesswell‐controlled disease.[6, 7] Thus, hospitalization represents an opportunity to identify existing CKD and to use a multidisciplinary approach to preventative care, patient education, and patient‐provider planning for renal replacement therapy needs. In our cross‐sectional study in an urban, minority‐serving hospital, we sought to determine what patient factors were associated with hospitalized patients correctly self‐identifying as having CKD.

METHODS

RESULTS

DISCUSSION

Although prior work has examined CKD awareness in the general population and in high‐risk cohorts,[2, 3, 13] this is the first study examining CKD awareness in an urban, underserved hospitalized population. We found that overall patients' CKD awareness was low (32%), but increased as high as 63% for CKD stage 5, even after controlling for patient demographic, clinical characteristics, and healthcare use. Our overall rate of CKD awareness was higher than prior studies overall and at lower CKD stages.[2, 3, 13] Our work is consistent with prior literature that shows increasing CKD awareness with advancing CKD stage.[2, 3, 13]

Older patients (>80 years) had lower awareness of CKD. Older patients are more likely to have a near normal creatinine, despite a markedly reduced eGFR, so their CKD may go unnoticed.[14] Even with appropriate recognition, providers may also feel like their CKD is unlikely to progress to ESRD, given its stability and/or their competing risk of death.[15] Finally, older hospitalized patients may also be less likely to report a CKD diagnosis due to difficulty in recall due to denial, dementia, or delirium.

One limitation is that our case‐finding for CKD was physician ICD‐9 coding, which is highly specific but not sensitive.[9] The majority of patients with physician‐identified CKD were CKD unspecified, perhaps due to poor coding, physician underdocumentation, or physician under‐recognition of CKD stage. Although only 27% of the CKD unspecified group correctly self‐identified as having CKD, over 75% were found to be CKD stage 3 or higher, which should trigger additional monitoring or care based on guidelines.[10] In addition, despite statistical significance, we may not be able to make meaningful inferences about our small other group (nonwhite, non‐African American). Our sample was from 1 hospitalan urban, academic, tertiary care center with a large proportion of African American patientswhich may limit generalizability. The multivariable model will need to be tested in other populations for reproducibility.

Our study significantly contributes to the literature by examining patient awareness of CKD in a high‐risk, urban, hospitalized minority population. Other study strengths include use of basic demographic information, as well as survey and laboratory data for a richer examination of the associations between patient factors and CKD awareness.

CONCLUSION

Hospitalized patients with CKD have a low CKD awareness. Patient awareness of their CKD is increased with physician documentation of CKD severity. Patient awareness of their CKD must be coupled with provider awareness and CKD documentation to link patients to multidisciplinary CKD education and care to slow CKD progression and reduce associated cardiovascular and metabolic complications. Further work is needed across hospitals to determineand improveCKD awareness among both patients and providers.

Chronic kidney disease (CKD) affects over 13% of the US population and is associated with increased morbidity, mortality, and healthcare costs.[1] However, only 10% of individuals with CKD are aware of their diagnoses.[2] Even in those with stage 5 CKD, only 60% of individuals are aware of their CKD.[3] To our knowledge, no work has examined CKD awareness in a hospitalized patient population.

Patient awareness of their CKD diagnosis is important because progression of kidney disease can be slowed by patient self‐management of diabetes and hypertension.[4] Patient awareness of CKD may also increase acceptance of preend‐stage renal disease (ESRD) patient education and nephrology referral, which have been shown to delay CKD progression and improve clinical status at dialysis initiation.[5] However, only 60% of patients with advanced CKD have visited a nephrologist in the past year or have seen a nephrologist prior to dialysis initiation.[1]

The hospital is an important site for patient education and linkage to outpatient care for patients with CKD.[6] The hospital serves high‐risk patients who may not be well connected to outpatient care or who have lesswell‐controlled disease.[6, 7] Thus, hospitalization represents an opportunity to identify existing CKD and to use a multidisciplinary approach to preventative care, patient education, and patient‐provider planning for renal replacement therapy needs. In our cross‐sectional study in an urban, minority‐serving hospital, we sought to determine what patient factors were associated with hospitalized patients correctly self‐identifying as having CKD.

METHODS

RESULTS

DISCUSSION

Although prior work has examined CKD awareness in the general population and in high‐risk cohorts,[2, 3, 13] this is the first study examining CKD awareness in an urban, underserved hospitalized population. We found that overall patients' CKD awareness was low (32%), but increased as high as 63% for CKD stage 5, even after controlling for patient demographic, clinical characteristics, and healthcare use. Our overall rate of CKD awareness was higher than prior studies overall and at lower CKD stages.[2, 3, 13] Our work is consistent with prior literature that shows increasing CKD awareness with advancing CKD stage.[2, 3, 13]

Older patients (>80 years) had lower awareness of CKD. Older patients are more likely to have a near normal creatinine, despite a markedly reduced eGFR, so their CKD may go unnoticed.[14] Even with appropriate recognition, providers may also feel like their CKD is unlikely to progress to ESRD, given its stability and/or their competing risk of death.[15] Finally, older hospitalized patients may also be less likely to report a CKD diagnosis due to difficulty in recall due to denial, dementia, or delirium.

One limitation is that our case‐finding for CKD was physician ICD‐9 coding, which is highly specific but not sensitive.[9] The majority of patients with physician‐identified CKD were CKD unspecified, perhaps due to poor coding, physician underdocumentation, or physician under‐recognition of CKD stage. Although only 27% of the CKD unspecified group correctly self‐identified as having CKD, over 75% were found to be CKD stage 3 or higher, which should trigger additional monitoring or care based on guidelines.[10] In addition, despite statistical significance, we may not be able to make meaningful inferences about our small other group (nonwhite, non‐African American). Our sample was from 1 hospitalan urban, academic, tertiary care center with a large proportion of African American patientswhich may limit generalizability. The multivariable model will need to be tested in other populations for reproducibility.

Our study significantly contributes to the literature by examining patient awareness of CKD in a high‐risk, urban, hospitalized minority population. Other study strengths include use of basic demographic information, as well as survey and laboratory data for a richer examination of the associations between patient factors and CKD awareness.

CONCLUSION

Hospitalized patients with CKD have a low CKD awareness. Patient awareness of their CKD is increased with physician documentation of CKD severity. Patient awareness of their CKD must be coupled with provider awareness and CKD documentation to link patients to multidisciplinary CKD education and care to slow CKD progression and reduce associated cardiovascular and metabolic complications. Further work is needed across hospitals to determineand improveCKD awareness among both patients and providers.