John D. Birkmeyer, MD

Payers, providers, and policymakers are testing several major approaches to reducing US healthcare spending without harming quality. One strategy is to bundle payments for a longitudinal episode of care, as in Medicare's popular Bundled Payments for Care Improvement initiative.[1] A second approach is to decrease rates of inappropriate care, through programs such as Choosing Wisely, that discourage use of low‐value services.[2] Finally, a third approach adopted by the Medicare Shared Savings Program strives to reduce both episode costs and rates of inappropriate care, by incorporating annual per capita Medicare spending into performance benchmarks.[3] Given these ongoing efforts, it would be important to compare the potential impact of reducing episode payments versus rates of care on total costs of care.

METHODS

For 3 common surgical procedures, we compared the relative influence of procedure rates versus episode payments (among those with procedures) on total Medicare expenditures.

We used complete Part A and B Medicare claims data for: coronary artery bypass grafting (CABG), prostatectomy, and hip replacement. We used International Classification of Diseases, Ninth Revision codes to identify the procedures (CABG: 361.0, 361.1, 361.2, 361.3, 361.4, 361.5, 361.6, 361.7, 361.9, 36.2; prostatectomy: 60.4, 60.5, 60.62 with a prostate cancer diagnosis code of 185 or 233.4; and hip replacement: 81.51, 81.52 excluding hip fracture codes 820.0, 820.1, 820.2, 820.3, 820.8, 820.9).

For each procedure, we estimated age‐ and sex‐adjusted episode rates for each hospital referral region (HRR). The numerator was the number of admissions to an acute care hospital for CABG (total n = 118,185), prostatectomy (total n = 18,328), or hip replacement (total n = 178,982) from January 2009 to June 2010. The denominator was fee‐for‐service Medicare beneficiaries age 65 years or older. We excluded those without continuous Part A and B enrollment (total denominator n = 23,403,051). Females were also excluded from the prostatectomy cohort.

For each of the 306 HRRs, we next calculated average HRR‐level episode payments. Using CABG as an example, we aggregated up the risk‐adjusted (age, sex, race, admission type, Elixhauser[4] comorbidities), price‐standardized[5] episode payments for all CABG patients residing in an HRR, and divided this by the number of CABG patients living in that HRR.

Finally, we obtained baseline per capita spending by multiplying the age‐ and sex‐adjusted CABG episode rate by the average CABG episode payment in that HRR. All payments were standardized to 2010 dollars using the Consumer Price Index.

We simulated changes in per capita Medicare spending for CABG across all HRRs under 2 scenarios: (1) reducing HRR‐level rates to the median versus (2) reducing HRR‐level episode payments to the median. We repeated this for prostatectomy and hip replacement.

RESULTS

Age‐ and sex‐adjusted rates of CABG varied more than risk‐adjusted, price‐standardized episode payments (90th:10th percentile of 2.0 for rates vs 1.2 for payments) (see Supporting Information, Appendix, in the online version of this article). Reducing rates of CABG to the 50th percentile decreased per capita episode payments by 11.1%. In contrast, reducing CABG episode payments to the 50th percentile decreased per capita episode payments by 3.6%. The absolute difference between the 2 simulations was 7.5% (95% confidence interval [CI]: 5.6%‐9.4%) (Figure 1). Results were similar for prostatectomy and hip replacement. In sensitivity analyses, reducing hospital‐level episode payments (rather than HRR‐level episode payments) produced similar findings. Employing the 90th percentile as a cutoff (instead of the median) also produced qualitatively similar results.

Figure 1

DISCUSSION

For 3 common surgical procedures, reducing procedure rates lowers total Medicare spending substantially more than reducing episode payments. These findings are attributable to a much greater variation in procedure rates compared to episode‐based payments. Prior research has documented wide variation in rates of surgical procedures.[6] This may be due to a number of factors, including physician beliefs about indications for surgery, as well as the degree to which patient preferences are incorporated into decision making.[6]

Our findings suggest that it would be important to incorporate population‐based episode rates into efforts aimed at incentivizing higher value care. Incentives tied to population‐based episode rates are difficult to design well. They may need to be paired with appropriateness criteria to avoid stinting on care. Attribution of a population to a hospital (including those who are not admitted to a hospital) is also complex.[7] Finally, hospitals are not solely responsible for rates of care, because the decision to admit a patient is sometimes made in the emergency department (eg, for chronic medical conditions), but at other times is made in the outpatient arena (eg, for elective surgery). Nevertheless, a narrow focus on per episode spending limits the potential impact of efforts to control Medicare spending.

Payers, providers, and policymakers are testing several major approaches to reducing US healthcare spending without harming quality. One strategy is to bundle payments for a longitudinal episode of care, as in Medicare's popular Bundled Payments for Care Improvement initiative.[1] A second approach is to decrease rates of inappropriate care, through programs such as Choosing Wisely, that discourage use of low‐value services.[2] Finally, a third approach adopted by the Medicare Shared Savings Program strives to reduce both episode costs and rates of inappropriate care, by incorporating annual per capita Medicare spending into performance benchmarks.[3] Given these ongoing efforts, it would be important to compare the potential impact of reducing episode payments versus rates of care on total costs of care.

METHODS

For 3 common surgical procedures, we compared the relative influence of procedure rates versus episode payments (among those with procedures) on total Medicare expenditures.

We used complete Part A and B Medicare claims data for: coronary artery bypass grafting (CABG), prostatectomy, and hip replacement. We used International Classification of Diseases, Ninth Revision codes to identify the procedures (CABG: 361.0, 361.1, 361.2, 361.3, 361.4, 361.5, 361.6, 361.7, 361.9, 36.2; prostatectomy: 60.4, 60.5, 60.62 with a prostate cancer diagnosis code of 185 or 233.4; and hip replacement: 81.51, 81.52 excluding hip fracture codes 820.0, 820.1, 820.2, 820.3, 820.8, 820.9).

For each procedure, we estimated age‐ and sex‐adjusted episode rates for each hospital referral region (HRR). The numerator was the number of admissions to an acute care hospital for CABG (total n = 118,185), prostatectomy (total n = 18,328), or hip replacement (total n = 178,982) from January 2009 to June 2010. The denominator was fee‐for‐service Medicare beneficiaries age 65 years or older. We excluded those without continuous Part A and B enrollment (total denominator n = 23,403,051). Females were also excluded from the prostatectomy cohort.

For each of the 306 HRRs, we next calculated average HRR‐level episode payments. Using CABG as an example, we aggregated up the risk‐adjusted (age, sex, race, admission type, Elixhauser[4] comorbidities), price‐standardized[5] episode payments for all CABG patients residing in an HRR, and divided this by the number of CABG patients living in that HRR.

Finally, we obtained baseline per capita spending by multiplying the age‐ and sex‐adjusted CABG episode rate by the average CABG episode payment in that HRR. All payments were standardized to 2010 dollars using the Consumer Price Index.

We simulated changes in per capita Medicare spending for CABG across all HRRs under 2 scenarios: (1) reducing HRR‐level rates to the median versus (2) reducing HRR‐level episode payments to the median. We repeated this for prostatectomy and hip replacement.

RESULTS

Age‐ and sex‐adjusted rates of CABG varied more than risk‐adjusted, price‐standardized episode payments (90th:10th percentile of 2.0 for rates vs 1.2 for payments) (see Supporting Information, Appendix, in the online version of this article). Reducing rates of CABG to the 50th percentile decreased per capita episode payments by 11.1%. In contrast, reducing CABG episode payments to the 50th percentile decreased per capita episode payments by 3.6%. The absolute difference between the 2 simulations was 7.5% (95% confidence interval [CI]: 5.6%‐9.4%) (Figure 1). Results were similar for prostatectomy and hip replacement. In sensitivity analyses, reducing hospital‐level episode payments (rather than HRR‐level episode payments) produced similar findings. Employing the 90th percentile as a cutoff (instead of the median) also produced qualitatively similar results.

Figure 1

DISCUSSION

For 3 common surgical procedures, reducing procedure rates lowers total Medicare spending substantially more than reducing episode payments. These findings are attributable to a much greater variation in procedure rates compared to episode‐based payments. Prior research has documented wide variation in rates of surgical procedures.[6] This may be due to a number of factors, including physician beliefs about indications for surgery, as well as the degree to which patient preferences are incorporated into decision making.[6]

Our findings suggest that it would be important to incorporate population‐based episode rates into efforts aimed at incentivizing higher value care. Incentives tied to population‐based episode rates are difficult to design well. They may need to be paired with appropriateness criteria to avoid stinting on care. Attribution of a population to a hospital (including those who are not admitted to a hospital) is also complex.[7] Finally, hospitals are not solely responsible for rates of care, because the decision to admit a patient is sometimes made in the emergency department (eg, for chronic medical conditions), but at other times is made in the outpatient arena (eg, for elective surgery). Nevertheless, a narrow focus on per episode spending limits the potential impact of efforts to control Medicare spending.

Payers, providers, and policymakers are testing several major approaches to reducing US healthcare spending without harming quality. One strategy is to bundle payments for a longitudinal episode of care, as in Medicare's popular Bundled Payments for Care Improvement initiative.[1] A second approach is to decrease rates of inappropriate care, through programs such as Choosing Wisely, that discourage use of low‐value services.[2] Finally, a third approach adopted by the Medicare Shared Savings Program strives to reduce both episode costs and rates of inappropriate care, by incorporating annual per capita Medicare spending into performance benchmarks.[3] Given these ongoing efforts, it would be important to compare the potential impact of reducing episode payments versus rates of care on total costs of care.

METHODS

For 3 common surgical procedures, we compared the relative influence of procedure rates versus episode payments (among those with procedures) on total Medicare expenditures.

We used complete Part A and B Medicare claims data for: coronary artery bypass grafting (CABG), prostatectomy, and hip replacement. We used International Classification of Diseases, Ninth Revision codes to identify the procedures (CABG: 361.0, 361.1, 361.2, 361.3, 361.4, 361.5, 361.6, 361.7, 361.9, 36.2; prostatectomy: 60.4, 60.5, 60.62 with a prostate cancer diagnosis code of 185 or 233.4; and hip replacement: 81.51, 81.52 excluding hip fracture codes 820.0, 820.1, 820.2, 820.3, 820.8, 820.9).

For each procedure, we estimated age‐ and sex‐adjusted episode rates for each hospital referral region (HRR). The numerator was the number of admissions to an acute care hospital for CABG (total n = 118,185), prostatectomy (total n = 18,328), or hip replacement (total n = 178,982) from January 2009 to June 2010. The denominator was fee‐for‐service Medicare beneficiaries age 65 years or older. We excluded those without continuous Part A and B enrollment (total denominator n = 23,403,051). Females were also excluded from the prostatectomy cohort.

For each of the 306 HRRs, we next calculated average HRR‐level episode payments. Using CABG as an example, we aggregated up the risk‐adjusted (age, sex, race, admission type, Elixhauser[4] comorbidities), price‐standardized[5] episode payments for all CABG patients residing in an HRR, and divided this by the number of CABG patients living in that HRR.

Finally, we obtained baseline per capita spending by multiplying the age‐ and sex‐adjusted CABG episode rate by the average CABG episode payment in that HRR. All payments were standardized to 2010 dollars using the Consumer Price Index.

We simulated changes in per capita Medicare spending for CABG across all HRRs under 2 scenarios: (1) reducing HRR‐level rates to the median versus (2) reducing HRR‐level episode payments to the median. We repeated this for prostatectomy and hip replacement.

RESULTS

Age‐ and sex‐adjusted rates of CABG varied more than risk‐adjusted, price‐standardized episode payments (90th:10th percentile of 2.0 for rates vs 1.2 for payments) (see Supporting Information, Appendix, in the online version of this article). Reducing rates of CABG to the 50th percentile decreased per capita episode payments by 11.1%. In contrast, reducing CABG episode payments to the 50th percentile decreased per capita episode payments by 3.6%. The absolute difference between the 2 simulations was 7.5% (95% confidence interval [CI]: 5.6%‐9.4%) (Figure 1). Results were similar for prostatectomy and hip replacement. In sensitivity analyses, reducing hospital‐level episode payments (rather than HRR‐level episode payments) produced similar findings. Employing the 90th percentile as a cutoff (instead of the median) also produced qualitatively similar results.

Figure 1

DISCUSSION

For 3 common surgical procedures, reducing procedure rates lowers total Medicare spending substantially more than reducing episode payments. These findings are attributable to a much greater variation in procedure rates compared to episode‐based payments. Prior research has documented wide variation in rates of surgical procedures.[6] This may be due to a number of factors, including physician beliefs about indications for surgery, as well as the degree to which patient preferences are incorporated into decision making.[6]

Our findings suggest that it would be important to incorporate population‐based episode rates into efforts aimed at incentivizing higher value care. Incentives tied to population‐based episode rates are difficult to design well. They may need to be paired with appropriateness criteria to avoid stinting on care. Attribution of a population to a hospital (including those who are not admitted to a hospital) is also complex.[7] Finally, hospitals are not solely responsible for rates of care, because the decision to admit a patient is sometimes made in the emergency department (eg, for chronic medical conditions), but at other times is made in the outpatient arena (eg, for elective surgery). Nevertheless, a narrow focus on per episode spending limits the potential impact of efforts to control Medicare spending.

The use of inferior vena cava (IVC) filters has increased substantially in recent years. These medical devices, which are used to prevent pulmonary embolism in patients considered to be at high risk of venous thromboembolism, were placed in 167,000 patients in 2007.¹ In 2012, it is estimated that 259,000 patients will undergo placement of an IVC filter, an increase of 55%.[1] Increasing use of IVC filters is attributable to the development of retrievable versions of the devices, which have expanded indications for use such as in bariatric surgery.

Unfortunately, the increase in the use of IVC filters has been accompanied by an increase in reports of adverse events in patients receiving them. The United States Food and Drug Administration (FDA) has received more than 900 adverse event reports involving IVC filters, prompting the agency to issue a warning about their use.[2] A prior study by our group demonstrated a lack of benefit of IVC filter insertion for the prevention of pulmonary embolism among bariatric surgery patients but lacked statistical power to prove harms associated with this practice.[3]

In the current study, we analyzed data from the prospective, statewide, clinical registry of the Michigan Bariatric Surgery Collaborative. Our study population now includes 35,477 bariatric surgery patients from 32 hospitals whose procedures were performed between 2006 and 2012. Since the publication of our prior study, the use of IVC filters in bariatric surgery has decreased significantly in Michigan. For this reason, our study population now includes many more high‐risk patients who did not undergo IVC filter placement, allowing us to match IVC filter patients to similarly high‐risk patients who did not receive IVC filters. We used these data to compare outcomes within 30 days of surgery, including rates of venous thromboembolism, overall serious complications, and death among patients who did and not receive IVC filters.

METHODS

RESULTS

Matching resulted in cohorts of IVC filter and control patients who were well balanced on all baseline characteristics (Table 1). In contrast, there were large and significant differences between IVC filter patients and unmatched control patients. For example, mean body mass index was 58 and 57 in the matched cohorts and 47 in the unmatched control patients. Prior history of venous thromboembolism was present in 39%, 39%, and 2% of the IVC filter, matched control, and unmatched control patients, respectively. With regard to procedure mix, unmatched control patients were less likely to have open gastric bypass and more likely to have adjustable gastric band procedures than IVC filter or matched control patients.

With regard to outcomes (Table 2, Figures 1 and 2), IVC filter patients had significantly higher rates of venous thromboembolism (1.9% vs 0.74%; OR, 2.7; 95% CI, 1.1‐6.3; P=0.027) and deep vein thrombosis (1.2% vs 0.37%, OR, 3.3; 95% CI, 1.1‐10.1; P=0.039) than matched control patients. Rates of pulmonary embolism were higher among IVC filter patients, but the difference was not statistically significant (0.84% vs 0.46%; OR, 2.0; 95% CI, 0.6‐6.5; P=0.232). Rates of pulmonary embolism were similar for patients with a low baseline risk of venous thromboembolism (0.27% vs 0.27%; OR, 1.0; 95% CI, 0.1‐7.7; P=0.965) but were higher for medium‐risk patients (2.1% vs 0.87%; OR, 2.5; 95% CI, 0.5‐12.7; P=0.288) and high‐risk patients (2.1% vs 0.97%; OR, 2.2; 95% CI, 0.2‐24.3; P=0.530).

Figure 1

Figure 2

Rates of other complications were also higher among IVC filter than matched control patients (Table 2 and Figure 3). There were significantly higher rates of complications (15.2% vs 11.6%; OR, 1.3; 95% CI, 1.0‐1.7; P=0.048), serious complications (5.8% vs 3.8%; OR, 1.6; 95% CI, 1.0‐2.4; P=0.031), and permanently disabling complications (1.2% vs 0.4%; OR, 4.3; 95% CI, 1.2‐15.6; P=0.028) among IVC filter patients. Rates of death (0.7% vs 0.1%; OR, 7.0; 95% CI, 0.9‐57.3; P=0.068) were also higher among IVC filter patients than matched control patients, but this difference was not statistically significant.

Figure 3

Among the 7 IVC filter patients who died, 4 had fatal pulmonary embolism, and 2 had IVC filter thrombosis/occlusion. Other IVC filter‐specific complications included IVC filter migration requiring heart valve replacement surgery in 1 patient, contrast‐induced nephropathy in 1 patient, IVC filter incision site infection in 1 patient, and technical difficulties removing a temporary IVC filter requiring that the device stay in place in 1 patient.

DISCUSSION

In this propensity matched, observational cohort study, we assessed the safety and effectiveness of prophylactic IVC filters among bariatric surgery patients. We found that patients with IVC filters had significantly worse outcomes than comparably high‐risk patients without IVC filters. Rates of venous thromboembolism were higher in the IVC filter patients, and a large proportion of the other complications among IVC filter patients were device related.

Our current study of IVC filters was prompted by an FDA advisory report regarding complications in patients receiving IVC filters.[2] The FDA's report was in turn prompted by a study indicating a high prevalence of strut fracture and embolization among 80 patients who received a certain type of retrievable IVC filter.[4] The FDA conveyed receiving 921 adverse events reports involving IVC filters between 2005 and 2009. Thirty‐six percent of these reports involved migration of the device, 16% were related to breakage and embolization of parts of the device, and 8% involved perforation of the IVC.

Research on the safety and efficacy of IVC filters in bariatric surgery patients has largely been limited to small, single‐center, case series or cohort studies.[5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15] A systematic review of this literature concluded that the evidence was insufficient to recommend IVC filters for patients undergoing bariatric surgery.[16] A 2010 study by our group was the largest and only multicenter study of IVC filters in the bariatric surgery population. We found no benefit of IVC filters in a comparison of 542 gastric bypass patients with prophylactic IVC filters to 5,834 gastric bypass patients without prophylactic IVC filters.[3]

When interpreting the results of this study, a number of limitations should be considered. Our study was observational, so there is the potential for unmeasured confounding variables to have influenced our results. To minimize the risk of confounding, we used propensity scores to match IVC filter patients to comparably high‐risk control patients, resulting in study cohorts that were well balanced on all baseline variables. Although this method accounts for confounding on the variables for which there are data, there is still the possibility that an unknown confounder could affect our findings. For example, our clinical registry lacks data on hypercoagulable states, so it is possible that a higher proportion of IVC filter patients could have had this risk factor and therefore a higher baseline risk of venous thromboembolism. However, most patients with a hypercoagulable state would have had a prior history of venous thromboembolism, which is a variable included in our database that patients were matched on.

The effects of changes in clinical care occurring during the time frame of this study should be considered in interpreting our findings. For example, bariatric surgery has been getting safer in general over time. Rates of death have fallen both in Michigan and in the rest of the country as bariatric surgeons have gained experience with this procedure. In Michigan during this time period, our group has developed and implemented a risk‐stratified, standardized approach to venous thromboembolism prophylaxis for patients undergoing bariatric surgery. For these reasons, we included the year of the procedure and the type of medical venous thromboembolism prophylaxis (unfractionated or low molecular weight heparin) used perioperatively as a matching variable in our analysis.

Another limitation that should be considered in interpreting our findings is statistical power. Although our study is the largest in this study population to date, many of the outcomes of interest are relatively rare. Considering the entire bariatric surgery population, rates of venous thromboembolism and death within 30 days are each less than 1%. Even in the high‐risk patients included in this analysis, there were a total of just 28 (1.3%) venous thromboembolism events and 8 (0.37) deaths. Nonetheless, our study did find significantly greater risks of multiple types of complications among patients receiving IVC filters.

Finally, our study captures events occurring within 30 days of bariatric surgery. Complications, including venous thromboembolism and other complications directly related to IVC filters, frequently occur after 30 days of bariatric surgery. Therefore, our study may be a conservative estimate of the risks associated with the use of IVC filters in bariatric surgery patients. Furthermore, certain brands of filters have been shown to be associated with higher risks of complications. Our study lacks data on the brand of IVC filter used and so cannot assess the extent to which this would affect our results.

CONCLUSIONS

In conclusion, our study indicates that IVC filters do not reduce the risk of pulmonary embolism in high‐risk bariatric surgery patients. They are also associated with other complications attributable to malfunctions of the device itself. We believe that the use of IVC filters among bariatric surgery patients should be discouraged.

Disclosure

This study was supported by a grant from the Agency for Healthcare Research and Quality (HS018050) and was presented at the Annual Meeting of the American Society for Metabolic and Bariatric Surgery (ASMBS), San Diego, California, June 20, 2012.

The use of inferior vena cava (IVC) filters has increased substantially in recent years. These medical devices, which are used to prevent pulmonary embolism in patients considered to be at high risk of venous thromboembolism, were placed in 167,000 patients in 2007.¹ In 2012, it is estimated that 259,000 patients will undergo placement of an IVC filter, an increase of 55%.[1] Increasing use of IVC filters is attributable to the development of retrievable versions of the devices, which have expanded indications for use such as in bariatric surgery.

Unfortunately, the increase in the use of IVC filters has been accompanied by an increase in reports of adverse events in patients receiving them. The United States Food and Drug Administration (FDA) has received more than 900 adverse event reports involving IVC filters, prompting the agency to issue a warning about their use.[2] A prior study by our group demonstrated a lack of benefit of IVC filter insertion for the prevention of pulmonary embolism among bariatric surgery patients but lacked statistical power to prove harms associated with this practice.[3]

In the current study, we analyzed data from the prospective, statewide, clinical registry of the Michigan Bariatric Surgery Collaborative. Our study population now includes 35,477 bariatric surgery patients from 32 hospitals whose procedures were performed between 2006 and 2012. Since the publication of our prior study, the use of IVC filters in bariatric surgery has decreased significantly in Michigan. For this reason, our study population now includes many more high‐risk patients who did not undergo IVC filter placement, allowing us to match IVC filter patients to similarly high‐risk patients who did not receive IVC filters. We used these data to compare outcomes within 30 days of surgery, including rates of venous thromboembolism, overall serious complications, and death among patients who did and not receive IVC filters.

METHODS

RESULTS

Matching resulted in cohorts of IVC filter and control patients who were well balanced on all baseline characteristics (Table 1). In contrast, there were large and significant differences between IVC filter patients and unmatched control patients. For example, mean body mass index was 58 and 57 in the matched cohorts and 47 in the unmatched control patients. Prior history of venous thromboembolism was present in 39%, 39%, and 2% of the IVC filter, matched control, and unmatched control patients, respectively. With regard to procedure mix, unmatched control patients were less likely to have open gastric bypass and more likely to have adjustable gastric band procedures than IVC filter or matched control patients.

With regard to outcomes (Table 2, Figures 1 and 2), IVC filter patients had significantly higher rates of venous thromboembolism (1.9% vs 0.74%; OR, 2.7; 95% CI, 1.1‐6.3; P=0.027) and deep vein thrombosis (1.2% vs 0.37%, OR, 3.3; 95% CI, 1.1‐10.1; P=0.039) than matched control patients. Rates of pulmonary embolism were higher among IVC filter patients, but the difference was not statistically significant (0.84% vs 0.46%; OR, 2.0; 95% CI, 0.6‐6.5; P=0.232). Rates of pulmonary embolism were similar for patients with a low baseline risk of venous thromboembolism (0.27% vs 0.27%; OR, 1.0; 95% CI, 0.1‐7.7; P=0.965) but were higher for medium‐risk patients (2.1% vs 0.87%; OR, 2.5; 95% CI, 0.5‐12.7; P=0.288) and high‐risk patients (2.1% vs 0.97%; OR, 2.2; 95% CI, 0.2‐24.3; P=0.530).

Figure 1

Figure 2

Rates of other complications were also higher among IVC filter than matched control patients (Table 2 and Figure 3). There were significantly higher rates of complications (15.2% vs 11.6%; OR, 1.3; 95% CI, 1.0‐1.7; P=0.048), serious complications (5.8% vs 3.8%; OR, 1.6; 95% CI, 1.0‐2.4; P=0.031), and permanently disabling complications (1.2% vs 0.4%; OR, 4.3; 95% CI, 1.2‐15.6; P=0.028) among IVC filter patients. Rates of death (0.7% vs 0.1%; OR, 7.0; 95% CI, 0.9‐57.3; P=0.068) were also higher among IVC filter patients than matched control patients, but this difference was not statistically significant.

Figure 3

Among the 7 IVC filter patients who died, 4 had fatal pulmonary embolism, and 2 had IVC filter thrombosis/occlusion. Other IVC filter‐specific complications included IVC filter migration requiring heart valve replacement surgery in 1 patient, contrast‐induced nephropathy in 1 patient, IVC filter incision site infection in 1 patient, and technical difficulties removing a temporary IVC filter requiring that the device stay in place in 1 patient.

DISCUSSION

In this propensity matched, observational cohort study, we assessed the safety and effectiveness of prophylactic IVC filters among bariatric surgery patients. We found that patients with IVC filters had significantly worse outcomes than comparably high‐risk patients without IVC filters. Rates of venous thromboembolism were higher in the IVC filter patients, and a large proportion of the other complications among IVC filter patients were device related.

Our current study of IVC filters was prompted by an FDA advisory report regarding complications in patients receiving IVC filters.[2] The FDA's report was in turn prompted by a study indicating a high prevalence of strut fracture and embolization among 80 patients who received a certain type of retrievable IVC filter.[4] The FDA conveyed receiving 921 adverse events reports involving IVC filters between 2005 and 2009. Thirty‐six percent of these reports involved migration of the device, 16% were related to breakage and embolization of parts of the device, and 8% involved perforation of the IVC.

Research on the safety and efficacy of IVC filters in bariatric surgery patients has largely been limited to small, single‐center, case series or cohort studies.[5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15] A systematic review of this literature concluded that the evidence was insufficient to recommend IVC filters for patients undergoing bariatric surgery.[16] A 2010 study by our group was the largest and only multicenter study of IVC filters in the bariatric surgery population. We found no benefit of IVC filters in a comparison of 542 gastric bypass patients with prophylactic IVC filters to 5,834 gastric bypass patients without prophylactic IVC filters.[3]

When interpreting the results of this study, a number of limitations should be considered. Our study was observational, so there is the potential for unmeasured confounding variables to have influenced our results. To minimize the risk of confounding, we used propensity scores to match IVC filter patients to comparably high‐risk control patients, resulting in study cohorts that were well balanced on all baseline variables. Although this method accounts for confounding on the variables for which there are data, there is still the possibility that an unknown confounder could affect our findings. For example, our clinical registry lacks data on hypercoagulable states, so it is possible that a higher proportion of IVC filter patients could have had this risk factor and therefore a higher baseline risk of venous thromboembolism. However, most patients with a hypercoagulable state would have had a prior history of venous thromboembolism, which is a variable included in our database that patients were matched on.

The effects of changes in clinical care occurring during the time frame of this study should be considered in interpreting our findings. For example, bariatric surgery has been getting safer in general over time. Rates of death have fallen both in Michigan and in the rest of the country as bariatric surgeons have gained experience with this procedure. In Michigan during this time period, our group has developed and implemented a risk‐stratified, standardized approach to venous thromboembolism prophylaxis for patients undergoing bariatric surgery. For these reasons, we included the year of the procedure and the type of medical venous thromboembolism prophylaxis (unfractionated or low molecular weight heparin) used perioperatively as a matching variable in our analysis.

Another limitation that should be considered in interpreting our findings is statistical power. Although our study is the largest in this study population to date, many of the outcomes of interest are relatively rare. Considering the entire bariatric surgery population, rates of venous thromboembolism and death within 30 days are each less than 1%. Even in the high‐risk patients included in this analysis, there were a total of just 28 (1.3%) venous thromboembolism events and 8 (0.37) deaths. Nonetheless, our study did find significantly greater risks of multiple types of complications among patients receiving IVC filters.

Finally, our study captures events occurring within 30 days of bariatric surgery. Complications, including venous thromboembolism and other complications directly related to IVC filters, frequently occur after 30 days of bariatric surgery. Therefore, our study may be a conservative estimate of the risks associated with the use of IVC filters in bariatric surgery patients. Furthermore, certain brands of filters have been shown to be associated with higher risks of complications. Our study lacks data on the brand of IVC filter used and so cannot assess the extent to which this would affect our results.

CONCLUSIONS

In conclusion, our study indicates that IVC filters do not reduce the risk of pulmonary embolism in high‐risk bariatric surgery patients. They are also associated with other complications attributable to malfunctions of the device itself. We believe that the use of IVC filters among bariatric surgery patients should be discouraged.

Disclosure

This study was supported by a grant from the Agency for Healthcare Research and Quality (HS018050) and was presented at the Annual Meeting of the American Society for Metabolic and Bariatric Surgery (ASMBS), San Diego, California, June 20, 2012.

The use of inferior vena cava (IVC) filters has increased substantially in recent years. These medical devices, which are used to prevent pulmonary embolism in patients considered to be at high risk of venous thromboembolism, were placed in 167,000 patients in 2007.¹ In 2012, it is estimated that 259,000 patients will undergo placement of an IVC filter, an increase of 55%.[1] Increasing use of IVC filters is attributable to the development of retrievable versions of the devices, which have expanded indications for use such as in bariatric surgery.

Unfortunately, the increase in the use of IVC filters has been accompanied by an increase in reports of adverse events in patients receiving them. The United States Food and Drug Administration (FDA) has received more than 900 adverse event reports involving IVC filters, prompting the agency to issue a warning about their use.[2] A prior study by our group demonstrated a lack of benefit of IVC filter insertion for the prevention of pulmonary embolism among bariatric surgery patients but lacked statistical power to prove harms associated with this practice.[3]

In the current study, we analyzed data from the prospective, statewide, clinical registry of the Michigan Bariatric Surgery Collaborative. Our study population now includes 35,477 bariatric surgery patients from 32 hospitals whose procedures were performed between 2006 and 2012. Since the publication of our prior study, the use of IVC filters in bariatric surgery has decreased significantly in Michigan. For this reason, our study population now includes many more high‐risk patients who did not undergo IVC filter placement, allowing us to match IVC filter patients to similarly high‐risk patients who did not receive IVC filters. We used these data to compare outcomes within 30 days of surgery, including rates of venous thromboembolism, overall serious complications, and death among patients who did and not receive IVC filters.

METHODS

RESULTS

Matching resulted in cohorts of IVC filter and control patients who were well balanced on all baseline characteristics (Table 1). In contrast, there were large and significant differences between IVC filter patients and unmatched control patients. For example, mean body mass index was 58 and 57 in the matched cohorts and 47 in the unmatched control patients. Prior history of venous thromboembolism was present in 39%, 39%, and 2% of the IVC filter, matched control, and unmatched control patients, respectively. With regard to procedure mix, unmatched control patients were less likely to have open gastric bypass and more likely to have adjustable gastric band procedures than IVC filter or matched control patients.

With regard to outcomes (Table 2, Figures 1 and 2), IVC filter patients had significantly higher rates of venous thromboembolism (1.9% vs 0.74%; OR, 2.7; 95% CI, 1.1‐6.3; P=0.027) and deep vein thrombosis (1.2% vs 0.37%, OR, 3.3; 95% CI, 1.1‐10.1; P=0.039) than matched control patients. Rates of pulmonary embolism were higher among IVC filter patients, but the difference was not statistically significant (0.84% vs 0.46%; OR, 2.0; 95% CI, 0.6‐6.5; P=0.232). Rates of pulmonary embolism were similar for patients with a low baseline risk of venous thromboembolism (0.27% vs 0.27%; OR, 1.0; 95% CI, 0.1‐7.7; P=0.965) but were higher for medium‐risk patients (2.1% vs 0.87%; OR, 2.5; 95% CI, 0.5‐12.7; P=0.288) and high‐risk patients (2.1% vs 0.97%; OR, 2.2; 95% CI, 0.2‐24.3; P=0.530).

Figure 1

Figure 2

Rates of other complications were also higher among IVC filter than matched control patients (Table 2 and Figure 3). There were significantly higher rates of complications (15.2% vs 11.6%; OR, 1.3; 95% CI, 1.0‐1.7; P=0.048), serious complications (5.8% vs 3.8%; OR, 1.6; 95% CI, 1.0‐2.4; P=0.031), and permanently disabling complications (1.2% vs 0.4%; OR, 4.3; 95% CI, 1.2‐15.6; P=0.028) among IVC filter patients. Rates of death (0.7% vs 0.1%; OR, 7.0; 95% CI, 0.9‐57.3; P=0.068) were also higher among IVC filter patients than matched control patients, but this difference was not statistically significant.

Figure 3

Among the 7 IVC filter patients who died, 4 had fatal pulmonary embolism, and 2 had IVC filter thrombosis/occlusion. Other IVC filter‐specific complications included IVC filter migration requiring heart valve replacement surgery in 1 patient, contrast‐induced nephropathy in 1 patient, IVC filter incision site infection in 1 patient, and technical difficulties removing a temporary IVC filter requiring that the device stay in place in 1 patient.

DISCUSSION

In this propensity matched, observational cohort study, we assessed the safety and effectiveness of prophylactic IVC filters among bariatric surgery patients. We found that patients with IVC filters had significantly worse outcomes than comparably high‐risk patients without IVC filters. Rates of venous thromboembolism were higher in the IVC filter patients, and a large proportion of the other complications among IVC filter patients were device related.

Our current study of IVC filters was prompted by an FDA advisory report regarding complications in patients receiving IVC filters.[2] The FDA's report was in turn prompted by a study indicating a high prevalence of strut fracture and embolization among 80 patients who received a certain type of retrievable IVC filter.[4] The FDA conveyed receiving 921 adverse events reports involving IVC filters between 2005 and 2009. Thirty‐six percent of these reports involved migration of the device, 16% were related to breakage and embolization of parts of the device, and 8% involved perforation of the IVC.

Research on the safety and efficacy of IVC filters in bariatric surgery patients has largely been limited to small, single‐center, case series or cohort studies.[5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15] A systematic review of this literature concluded that the evidence was insufficient to recommend IVC filters for patients undergoing bariatric surgery.[16] A 2010 study by our group was the largest and only multicenter study of IVC filters in the bariatric surgery population. We found no benefit of IVC filters in a comparison of 542 gastric bypass patients with prophylactic IVC filters to 5,834 gastric bypass patients without prophylactic IVC filters.[3]

When interpreting the results of this study, a number of limitations should be considered. Our study was observational, so there is the potential for unmeasured confounding variables to have influenced our results. To minimize the risk of confounding, we used propensity scores to match IVC filter patients to comparably high‐risk control patients, resulting in study cohorts that were well balanced on all baseline variables. Although this method accounts for confounding on the variables for which there are data, there is still the possibility that an unknown confounder could affect our findings. For example, our clinical registry lacks data on hypercoagulable states, so it is possible that a higher proportion of IVC filter patients could have had this risk factor and therefore a higher baseline risk of venous thromboembolism. However, most patients with a hypercoagulable state would have had a prior history of venous thromboembolism, which is a variable included in our database that patients were matched on.

The effects of changes in clinical care occurring during the time frame of this study should be considered in interpreting our findings. For example, bariatric surgery has been getting safer in general over time. Rates of death have fallen both in Michigan and in the rest of the country as bariatric surgeons have gained experience with this procedure. In Michigan during this time period, our group has developed and implemented a risk‐stratified, standardized approach to venous thromboembolism prophylaxis for patients undergoing bariatric surgery. For these reasons, we included the year of the procedure and the type of medical venous thromboembolism prophylaxis (unfractionated or low molecular weight heparin) used perioperatively as a matching variable in our analysis.

Another limitation that should be considered in interpreting our findings is statistical power. Although our study is the largest in this study population to date, many of the outcomes of interest are relatively rare. Considering the entire bariatric surgery population, rates of venous thromboembolism and death within 30 days are each less than 1%. Even in the high‐risk patients included in this analysis, there were a total of just 28 (1.3%) venous thromboembolism events and 8 (0.37) deaths. Nonetheless, our study did find significantly greater risks of multiple types of complications among patients receiving IVC filters.

Finally, our study captures events occurring within 30 days of bariatric surgery. Complications, including venous thromboembolism and other complications directly related to IVC filters, frequently occur after 30 days of bariatric surgery. Therefore, our study may be a conservative estimate of the risks associated with the use of IVC filters in bariatric surgery patients. Furthermore, certain brands of filters have been shown to be associated with higher risks of complications. Our study lacks data on the brand of IVC filter used and so cannot assess the extent to which this would affect our results.

CONCLUSIONS

In conclusion, our study indicates that IVC filters do not reduce the risk of pulmonary embolism in high‐risk bariatric surgery patients. They are also associated with other complications attributable to malfunctions of the device itself. We believe that the use of IVC filters among bariatric surgery patients should be discouraged.

Disclosure

This study was supported by a grant from the Agency for Healthcare Research and Quality (HS018050) and was presented at the Annual Meeting of the American Society for Metabolic and Bariatric Surgery (ASMBS), San Diego, California, June 20, 2012.

Payers and policymakers are increasingly holding hospitals accountable for patients' experiences with their care. Since 2006, the Centers for Medicare and Medicaid Services (CMS) have collected data on patients' experiences with inpatient care using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a well‐validated and widely used tool. In 2008, these data on patient experience began to be publicly reported, and CMS now plans to base part of its payments to hospitals on HCAHPS performance scores. In this context, hospitals are looking for ways to improve patient satisfaction.

The effort to hold hospitals accountable for patient experience may conflict with another major trend in US hospitals: the increasing use of hospitalists.[1] Although hospitalists may have greater expertise in the day‐to‐day care of the hospitalized patient, they generally do not know the patient and cannot cater to patients' preferences in ways that the primary‐care provider might. Therefore, given that patients may prefer to be seen by their primary‐care provider,[2] greater use of hospitalists may actually lead to a decrease in patient satisfaction. Unfortunately, we are unaware of any national examination of the relationship between hospitalist use in an institution and that entity's performance on patient‐experience scores.

To better understand the relationship between greater hospitalist staffing and patient‐centered care, we examined the association between hospitalist staffing and patient satisfaction with both overall care and specific domains of patient‐centered care. We hypothesized that hospitals that used a high proportion of hospitalists would generally have lower patient‐experience scores. Further, we expected that the relationship would be monotonic (greater use of hospitalists associated with lower scores) and particularly pronounced in 2 domains: patient experience with discharge planning and patient experience with physician communication.

METHODS

RESULTS

Among all hospitals, the median proportion of general‐medicine admissions cared for by hospitalists was 41.2% (interquartile range [IQR], 11.5%67.4%). However, US hospitals varied widely in the proportion of general‐medicine patients cared for by hospitalists (Figure 1). Whereas 3.5% of hospitals had all of their general‐medicine patients cared for by hospitalists, 16.6% had none of their general‐medicine patients seen by hospitalists. For hospitals with at least some hospitalist care, the proportion of patients cared for by hospitalists was distributed fairly evenly across the range of possibilities (Figure 1).

Figure 1

Because hospitalist care varied widely among hospitals, we categorized hospitals into 3 groups (non‐hospitalist, mixed, and hospitalist). The median proportion of patients cared for by hospitalists in the 3 groups was 0%, 39.5%, and 76.5%, respectively (Table 1). The non‐hospitalist hospitals, when compared with mixed and hospitalist hospitals, were more likely to be small, nonteaching, for‐profit institutions located in the Midwestern United States. They also were less likely to have an ICU and had lower nurse‐to‐bed ratios.

The types of patients cared for at all 3 hospital types (non‐hospitalist, mixed, and hospitalist) were similar in age and day of admission (Table 2). Patients cared for at non‐hospitalist hospitals were slightly more likely to be female and non‐White, and less likely to be admitted from the emergency department or another hospital or healthcare facility.

When we examined unadjusted relationships between type of hospital and patient experience, we found that patients at hospitalist vs non‐hospitalist hospitals were more likely to recommend the hospital (69.4% vs 65.1%: P < 0.001), and report higher overall satisfaction (65.9% vs 63.6%: P < 0.001) ((see Supporting Information, Appendix, Table A1, in the online version of this article)). Care at hospitalist hospitals was associated with higher satisfaction with discharge, but lower satisfaction with room cleanliness and communication with doctors. These differences were statistically significant at the P < 0.05 level.

When we examined the relationship between having more hospitalists and patient experience using multivariable models that accounted for differences in hospital characteristics, we found largely similar results: The proportion of patients who were satisfied with their overall care was still higher at hospitalist compared with non‐hospitalist hospitals (65.6% vs 63.9%: P < 0.001) (Figure 2). Similarly, patients were more likely to definitely recommend their hospital if they had been cared for at a hospitalist vs non‐hospitalist hospital (66.0% vs 63.4%: P < 0.001).

Figure 2

To better understand which domains of care might be contributing to greater overall satisfaction, we also examined patient satisfaction with specific domains of care at hospitalist vs non‐hospitalist hospitals (Table 3) in our adjusted analyses. Among 8 domains, the largest difference in satisfaction between patients cared for at hospitalist vs non‐hospitalist hospitals occurred with discharge. At hospitalist hospitals, 80.3% of patients said they were satisfied with the quality of the discharge planning compared with 78.1% at non‐hospitalist hospitals (P < 0.001). Patients at hospitalist hospitals were more satisfied with most other domains of care as well. Patients cared for at hospitalist hospitals were slightly less likely to be satisfied with communication with doctors, but this difference was not statistically significant (P = 0.45). Results were qualitatively similar in propensity‐score analyses (see Supporting Information, Appendix, Table A2, in the online version of this article).

DISCUSSION

We found that in 2009, US hospitals varied widely in the proportion of general medicine patients cared for by hospitalists. Hospitals with higher levels of hospitalist care did better on most measures of patient satisfaction. Differences were largest in overall satisfaction and for discharge planning. In 5 other domains of care, differences were smaller, but hospitals with more hospitalist care consistently performed better than non‐hospitalist hospitals. Hospitalist care was not associated with patient satisfaction in 2 domains: communication with doctors and cleanliness of room.

Our findings of modestly higher patient satisfaction at hospitalist hospitals along most dimensions of care are surprising and reassuring. Indeed, when hospitalists first began caring for inpatients, some expressed concerns that hospitalist care would decrease patient satisfaction.[8, 9] Though this has been an ongoing concern, we found no evidence to support this contention. It may be that as a response to the concern, hospitals with hospitalists have paid particular attention to issues such as effective handoffs to primary‐care providers.[10, 11, 12, 13] Whether due to these efforts or other factors such as the 24/7 inpatient presence of hospitalists, we found that patients at hospitalist hospitals were more likely to be satisfied with their inpatient care, including their experience at discharge. In contrast, one area that may offer room for improvement for hospitalist hospitals is communication with physicians. It may be that patients cared for by hospitalists do not know their physicians as well as patients whose care is being orchestrated by their primary‐care provider, and thus the benefits of having an ever‐present hospitalist are diminished.

The magnitude of the associations that we found should also be placed in the context of existing research on patient satisfaction. Prior work has described baseline hospital performance, changes over time, and factors associated with greater inpatient satisfaction.[5, 14, 15] The associations that we found between hospitalist care and satisfaction with care at discharge were larger than those found for teaching (vs non‐teaching) hospitals.[5] However, compared with other hospital characteristics such as nurse staffing or profit status, hospitalist care was associated with smaller differences in patient satisfaction. In one study, hospitals in the highest quartile of nurse staffing had HCAHPS scores (ie, willingness to recommend measure) that were 6.7 points higher than those in the lowest quartile of nurse staffing, and similar differences existed between not‐for‐profit, public hospitals vs for‐profit hospitals.[5]

Taken together, our findings address an important gap in knowledge about hospitalist care. Prior research has documented growth in the use of hospitalist care[1] and described the association of hospitalist care with outcomes such as mortality and resource use, and receipt of recommended care.[16, 17, 18, 19] However, we are unaware of any national study that has examined the association of hospitalist care with patient satisfaction. One study surveyed patients in a single health system and found that patients were similarly satisfied with care provided by hospitalists and primary‐care physicians.[20] Our findings should be reassuring to clinical leaders and policymakers who have advocated greater use of hospitalists: the results suggest that there need be no tradeoff between greater use of hospitalist services and patient satisfaction. Indeed, patients appear to be even more satisfied in hospitals that have greater use of hospitalist physicians.

Our study has several limitations. First, it was a cross‐sectional study, and thus we cannot make any conclusions about causality. Although we adjusted for several potential confounders (eg, teaching status, advanced care capabilities, nurse staffing), it is possible that hospitalist care is a surrogate marker for features of hospitals that we could not measure but that directly influence patient experience. In addition, it is possible that patients cared for at hospitalist hospitals differ in unmeasured ways from patients cared for at other types of hospitals. Second, we constructed our primary predictor and outcome from different cohorts. Our primary predictor was derived from the proportion of general‐medicine patients cared for by hospitalists in Medicare claims data. In contrast, our primary outcome was based on HCAHPS responses from a random sampling of all hospital admissions. This misclassification likely would have biased us towards finding small or no associations. Therefore, we are likely underestimating the true association between hospitalist use and patient experience. Third, our findings may not be generalizable to hospitals that serve younger patients or have a large number of specialist hospitalists (who were not included in our definition of hospitalists). For example, compared with older patients with multiple comorbidities, relatively healthy younger patients may derive less benefit from an ever‐present hospitalist who can explain discharge plans or an attentive nurse.

In summary, we found that US hospitals varied widely in their use of hospitalist physicians, and those which a greater proportion of care was delivered by hospitalists generally had better scores on patient experience, especially on the global assessment of satisfaction and in discharge care. Our findings suggest that adoption of the hospitalist modelone of the strategies employed by US hospitals in the past 2 decades to provide efficient careshould not detract from achieving the goal of more patient‐centered care.

Disclosures

Dr. Chen's work is supported in part by the National Institutes of Health/National Institute on Aging (AG024824, University of Michigan Claude D. Pepper Older Americans Independence Center), and the National Institutes of Health/National Center for Research Resources (UL1‐RR024986, Michigan Institute for Clinical and Health Research). Dr. Chen is also supported by a Career Development Grant Award (K08HS020671) from the Agency for Healthcare Research and Quality.

Payers and policymakers are increasingly holding hospitals accountable for patients' experiences with their care. Since 2006, the Centers for Medicare and Medicaid Services (CMS) have collected data on patients' experiences with inpatient care using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a well‐validated and widely used tool. In 2008, these data on patient experience began to be publicly reported, and CMS now plans to base part of its payments to hospitals on HCAHPS performance scores. In this context, hospitals are looking for ways to improve patient satisfaction.

The effort to hold hospitals accountable for patient experience may conflict with another major trend in US hospitals: the increasing use of hospitalists.[1] Although hospitalists may have greater expertise in the day‐to‐day care of the hospitalized patient, they generally do not know the patient and cannot cater to patients' preferences in ways that the primary‐care provider might. Therefore, given that patients may prefer to be seen by their primary‐care provider,[2] greater use of hospitalists may actually lead to a decrease in patient satisfaction. Unfortunately, we are unaware of any national examination of the relationship between hospitalist use in an institution and that entity's performance on patient‐experience scores.

To better understand the relationship between greater hospitalist staffing and patient‐centered care, we examined the association between hospitalist staffing and patient satisfaction with both overall care and specific domains of patient‐centered care. We hypothesized that hospitals that used a high proportion of hospitalists would generally have lower patient‐experience scores. Further, we expected that the relationship would be monotonic (greater use of hospitalists associated with lower scores) and particularly pronounced in 2 domains: patient experience with discharge planning and patient experience with physician communication.

METHODS

RESULTS

Among all hospitals, the median proportion of general‐medicine admissions cared for by hospitalists was 41.2% (interquartile range [IQR], 11.5%67.4%). However, US hospitals varied widely in the proportion of general‐medicine patients cared for by hospitalists (Figure 1). Whereas 3.5% of hospitals had all of their general‐medicine patients cared for by hospitalists, 16.6% had none of their general‐medicine patients seen by hospitalists. For hospitals with at least some hospitalist care, the proportion of patients cared for by hospitalists was distributed fairly evenly across the range of possibilities (Figure 1).

Figure 1

Because hospitalist care varied widely among hospitals, we categorized hospitals into 3 groups (non‐hospitalist, mixed, and hospitalist). The median proportion of patients cared for by hospitalists in the 3 groups was 0%, 39.5%, and 76.5%, respectively (Table 1). The non‐hospitalist hospitals, when compared with mixed and hospitalist hospitals, were more likely to be small, nonteaching, for‐profit institutions located in the Midwestern United States. They also were less likely to have an ICU and had lower nurse‐to‐bed ratios.

The types of patients cared for at all 3 hospital types (non‐hospitalist, mixed, and hospitalist) were similar in age and day of admission (Table 2). Patients cared for at non‐hospitalist hospitals were slightly more likely to be female and non‐White, and less likely to be admitted from the emergency department or another hospital or healthcare facility.

When we examined unadjusted relationships between type of hospital and patient experience, we found that patients at hospitalist vs non‐hospitalist hospitals were more likely to recommend the hospital (69.4% vs 65.1%: P < 0.001), and report higher overall satisfaction (65.9% vs 63.6%: P < 0.001) ((see Supporting Information, Appendix, Table A1, in the online version of this article)). Care at hospitalist hospitals was associated with higher satisfaction with discharge, but lower satisfaction with room cleanliness and communication with doctors. These differences were statistically significant at the P < 0.05 level.

When we examined the relationship between having more hospitalists and patient experience using multivariable models that accounted for differences in hospital characteristics, we found largely similar results: The proportion of patients who were satisfied with their overall care was still higher at hospitalist compared with non‐hospitalist hospitals (65.6% vs 63.9%: P < 0.001) (Figure 2). Similarly, patients were more likely to definitely recommend their hospital if they had been cared for at a hospitalist vs non‐hospitalist hospital (66.0% vs 63.4%: P < 0.001).

Figure 2

To better understand which domains of care might be contributing to greater overall satisfaction, we also examined patient satisfaction with specific domains of care at hospitalist vs non‐hospitalist hospitals (Table 3) in our adjusted analyses. Among 8 domains, the largest difference in satisfaction between patients cared for at hospitalist vs non‐hospitalist hospitals occurred with discharge. At hospitalist hospitals, 80.3% of patients said they were satisfied with the quality of the discharge planning compared with 78.1% at non‐hospitalist hospitals (P < 0.001). Patients at hospitalist hospitals were more satisfied with most other domains of care as well. Patients cared for at hospitalist hospitals were slightly less likely to be satisfied with communication with doctors, but this difference was not statistically significant (P = 0.45). Results were qualitatively similar in propensity‐score analyses (see Supporting Information, Appendix, Table A2, in the online version of this article).

DISCUSSION

We found that in 2009, US hospitals varied widely in the proportion of general medicine patients cared for by hospitalists. Hospitals with higher levels of hospitalist care did better on most measures of patient satisfaction. Differences were largest in overall satisfaction and for discharge planning. In 5 other domains of care, differences were smaller, but hospitals with more hospitalist care consistently performed better than non‐hospitalist hospitals. Hospitalist care was not associated with patient satisfaction in 2 domains: communication with doctors and cleanliness of room.

Our findings of modestly higher patient satisfaction at hospitalist hospitals along most dimensions of care are surprising and reassuring. Indeed, when hospitalists first began caring for inpatients, some expressed concerns that hospitalist care would decrease patient satisfaction.[8, 9] Though this has been an ongoing concern, we found no evidence to support this contention. It may be that as a response to the concern, hospitals with hospitalists have paid particular attention to issues such as effective handoffs to primary‐care providers.[10, 11, 12, 13] Whether due to these efforts or other factors such as the 24/7 inpatient presence of hospitalists, we found that patients at hospitalist hospitals were more likely to be satisfied with their inpatient care, including their experience at discharge. In contrast, one area that may offer room for improvement for hospitalist hospitals is communication with physicians. It may be that patients cared for by hospitalists do not know their physicians as well as patients whose care is being orchestrated by their primary‐care provider, and thus the benefits of having an ever‐present hospitalist are diminished.

The magnitude of the associations that we found should also be placed in the context of existing research on patient satisfaction. Prior work has described baseline hospital performance, changes over time, and factors associated with greater inpatient satisfaction.[5, 14, 15] The associations that we found between hospitalist care and satisfaction with care at discharge were larger than those found for teaching (vs non‐teaching) hospitals.[5] However, compared with other hospital characteristics such as nurse staffing or profit status, hospitalist care was associated with smaller differences in patient satisfaction. In one study, hospitals in the highest quartile of nurse staffing had HCAHPS scores (ie, willingness to recommend measure) that were 6.7 points higher than those in the lowest quartile of nurse staffing, and similar differences existed between not‐for‐profit, public hospitals vs for‐profit hospitals.[5]

Taken together, our findings address an important gap in knowledge about hospitalist care. Prior research has documented growth in the use of hospitalist care[1] and described the association of hospitalist care with outcomes such as mortality and resource use, and receipt of recommended care.[16, 17, 18, 19] However, we are unaware of any national study that has examined the association of hospitalist care with patient satisfaction. One study surveyed patients in a single health system and found that patients were similarly satisfied with care provided by hospitalists and primary‐care physicians.[20] Our findings should be reassuring to clinical leaders and policymakers who have advocated greater use of hospitalists: the results suggest that there need be no tradeoff between greater use of hospitalist services and patient satisfaction. Indeed, patients appear to be even more satisfied in hospitals that have greater use of hospitalist physicians.

Our study has several limitations. First, it was a cross‐sectional study, and thus we cannot make any conclusions about causality. Although we adjusted for several potential confounders (eg, teaching status, advanced care capabilities, nurse staffing), it is possible that hospitalist care is a surrogate marker for features of hospitals that we could not measure but that directly influence patient experience. In addition, it is possible that patients cared for at hospitalist hospitals differ in unmeasured ways from patients cared for at other types of hospitals. Second, we constructed our primary predictor and outcome from different cohorts. Our primary predictor was derived from the proportion of general‐medicine patients cared for by hospitalists in Medicare claims data. In contrast, our primary outcome was based on HCAHPS responses from a random sampling of all hospital admissions. This misclassification likely would have biased us towards finding small or no associations. Therefore, we are likely underestimating the true association between hospitalist use and patient experience. Third, our findings may not be generalizable to hospitals that serve younger patients or have a large number of specialist hospitalists (who were not included in our definition of hospitalists). For example, compared with older patients with multiple comorbidities, relatively healthy younger patients may derive less benefit from an ever‐present hospitalist who can explain discharge plans or an attentive nurse.

In summary, we found that US hospitals varied widely in their use of hospitalist physicians, and those which a greater proportion of care was delivered by hospitalists generally had better scores on patient experience, especially on the global assessment of satisfaction and in discharge care. Our findings suggest that adoption of the hospitalist modelone of the strategies employed by US hospitals in the past 2 decades to provide efficient careshould not detract from achieving the goal of more patient‐centered care.

Disclosures

Dr. Chen's work is supported in part by the National Institutes of Health/National Institute on Aging (AG024824, University of Michigan Claude D. Pepper Older Americans Independence Center), and the National Institutes of Health/National Center for Research Resources (UL1‐RR024986, Michigan Institute for Clinical and Health Research). Dr. Chen is also supported by a Career Development Grant Award (K08HS020671) from the Agency for Healthcare Research and Quality.

Payers and policymakers are increasingly holding hospitals accountable for patients' experiences with their care. Since 2006, the Centers for Medicare and Medicaid Services (CMS) have collected data on patients' experiences with inpatient care using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a well‐validated and widely used tool. In 2008, these data on patient experience began to be publicly reported, and CMS now plans to base part of its payments to hospitals on HCAHPS performance scores. In this context, hospitals are looking for ways to improve patient satisfaction.

The effort to hold hospitals accountable for patient experience may conflict with another major trend in US hospitals: the increasing use of hospitalists.[1] Although hospitalists may have greater expertise in the day‐to‐day care of the hospitalized patient, they generally do not know the patient and cannot cater to patients' preferences in ways that the primary‐care provider might. Therefore, given that patients may prefer to be seen by their primary‐care provider,[2] greater use of hospitalists may actually lead to a decrease in patient satisfaction. Unfortunately, we are unaware of any national examination of the relationship between hospitalist use in an institution and that entity's performance on patient‐experience scores.

To better understand the relationship between greater hospitalist staffing and patient‐centered care, we examined the association between hospitalist staffing and patient satisfaction with both overall care and specific domains of patient‐centered care. We hypothesized that hospitals that used a high proportion of hospitalists would generally have lower patient‐experience scores. Further, we expected that the relationship would be monotonic (greater use of hospitalists associated with lower scores) and particularly pronounced in 2 domains: patient experience with discharge planning and patient experience with physician communication.

METHODS

RESULTS

Among all hospitals, the median proportion of general‐medicine admissions cared for by hospitalists was 41.2% (interquartile range [IQR], 11.5%67.4%). However, US hospitals varied widely in the proportion of general‐medicine patients cared for by hospitalists (Figure 1). Whereas 3.5% of hospitals had all of their general‐medicine patients cared for by hospitalists, 16.6% had none of their general‐medicine patients seen by hospitalists. For hospitals with at least some hospitalist care, the proportion of patients cared for by hospitalists was distributed fairly evenly across the range of possibilities (Figure 1).

Figure 1

Because hospitalist care varied widely among hospitals, we categorized hospitals into 3 groups (non‐hospitalist, mixed, and hospitalist). The median proportion of patients cared for by hospitalists in the 3 groups was 0%, 39.5%, and 76.5%, respectively (Table 1). The non‐hospitalist hospitals, when compared with mixed and hospitalist hospitals, were more likely to be small, nonteaching, for‐profit institutions located in the Midwestern United States. They also were less likely to have an ICU and had lower nurse‐to‐bed ratios.

The types of patients cared for at all 3 hospital types (non‐hospitalist, mixed, and hospitalist) were similar in age and day of admission (Table 2). Patients cared for at non‐hospitalist hospitals were slightly more likely to be female and non‐White, and less likely to be admitted from the emergency department or another hospital or healthcare facility.

When we examined unadjusted relationships between type of hospital and patient experience, we found that patients at hospitalist vs non‐hospitalist hospitals were more likely to recommend the hospital (69.4% vs 65.1%: P < 0.001), and report higher overall satisfaction (65.9% vs 63.6%: P < 0.001) ((see Supporting Information, Appendix, Table A1, in the online version of this article)). Care at hospitalist hospitals was associated with higher satisfaction with discharge, but lower satisfaction with room cleanliness and communication with doctors. These differences were statistically significant at the P < 0.05 level.

When we examined the relationship between having more hospitalists and patient experience using multivariable models that accounted for differences in hospital characteristics, we found largely similar results: The proportion of patients who were satisfied with their overall care was still higher at hospitalist compared with non‐hospitalist hospitals (65.6% vs 63.9%: P < 0.001) (Figure 2). Similarly, patients were more likely to definitely recommend their hospital if they had been cared for at a hospitalist vs non‐hospitalist hospital (66.0% vs 63.4%: P < 0.001).

Figure 2

To better understand which domains of care might be contributing to greater overall satisfaction, we also examined patient satisfaction with specific domains of care at hospitalist vs non‐hospitalist hospitals (Table 3) in our adjusted analyses. Among 8 domains, the largest difference in satisfaction between patients cared for at hospitalist vs non‐hospitalist hospitals occurred with discharge. At hospitalist hospitals, 80.3% of patients said they were satisfied with the quality of the discharge planning compared with 78.1% at non‐hospitalist hospitals (P < 0.001). Patients at hospitalist hospitals were more satisfied with most other domains of care as well. Patients cared for at hospitalist hospitals were slightly less likely to be satisfied with communication with doctors, but this difference was not statistically significant (P = 0.45). Results were qualitatively similar in propensity‐score analyses (see Supporting Information, Appendix, Table A2, in the online version of this article).

DISCUSSION

We found that in 2009, US hospitals varied widely in the proportion of general medicine patients cared for by hospitalists. Hospitals with higher levels of hospitalist care did better on most measures of patient satisfaction. Differences were largest in overall satisfaction and for discharge planning. In 5 other domains of care, differences were smaller, but hospitals with more hospitalist care consistently performed better than non‐hospitalist hospitals. Hospitalist care was not associated with patient satisfaction in 2 domains: communication with doctors and cleanliness of room.

Our findings of modestly higher patient satisfaction at hospitalist hospitals along most dimensions of care are surprising and reassuring. Indeed, when hospitalists first began caring for inpatients, some expressed concerns that hospitalist care would decrease patient satisfaction.[8, 9] Though this has been an ongoing concern, we found no evidence to support this contention. It may be that as a response to the concern, hospitals with hospitalists have paid particular attention to issues such as effective handoffs to primary‐care providers.[10, 11, 12, 13] Whether due to these efforts or other factors such as the 24/7 inpatient presence of hospitalists, we found that patients at hospitalist hospitals were more likely to be satisfied with their inpatient care, including their experience at discharge. In contrast, one area that may offer room for improvement for hospitalist hospitals is communication with physicians. It may be that patients cared for by hospitalists do not know their physicians as well as patients whose care is being orchestrated by their primary‐care provider, and thus the benefits of having an ever‐present hospitalist are diminished.

The magnitude of the associations that we found should also be placed in the context of existing research on patient satisfaction. Prior work has described baseline hospital performance, changes over time, and factors associated with greater inpatient satisfaction.[5, 14, 15] The associations that we found between hospitalist care and satisfaction with care at discharge were larger than those found for teaching (vs non‐teaching) hospitals.[5] However, compared with other hospital characteristics such as nurse staffing or profit status, hospitalist care was associated with smaller differences in patient satisfaction. In one study, hospitals in the highest quartile of nurse staffing had HCAHPS scores (ie, willingness to recommend measure) that were 6.7 points higher than those in the lowest quartile of nurse staffing, and similar differences existed between not‐for‐profit, public hospitals vs for‐profit hospitals.[5]

Taken together, our findings address an important gap in knowledge about hospitalist care. Prior research has documented growth in the use of hospitalist care[1] and described the association of hospitalist care with outcomes such as mortality and resource use, and receipt of recommended care.[16, 17, 18, 19] However, we are unaware of any national study that has examined the association of hospitalist care with patient satisfaction. One study surveyed patients in a single health system and found that patients were similarly satisfied with care provided by hospitalists and primary‐care physicians.[20] Our findings should be reassuring to clinical leaders and policymakers who have advocated greater use of hospitalists: the results suggest that there need be no tradeoff between greater use of hospitalist services and patient satisfaction. Indeed, patients appear to be even more satisfied in hospitals that have greater use of hospitalist physicians.

Our study has several limitations. First, it was a cross‐sectional study, and thus we cannot make any conclusions about causality. Although we adjusted for several potential confounders (eg, teaching status, advanced care capabilities, nurse staffing), it is possible that hospitalist care is a surrogate marker for features of hospitals that we could not measure but that directly influence patient experience. In addition, it is possible that patients cared for at hospitalist hospitals differ in unmeasured ways from patients cared for at other types of hospitals. Second, we constructed our primary predictor and outcome from different cohorts. Our primary predictor was derived from the proportion of general‐medicine patients cared for by hospitalists in Medicare claims data. In contrast, our primary outcome was based on HCAHPS responses from a random sampling of all hospital admissions. This misclassification likely would have biased us towards finding small or no associations. Therefore, we are likely underestimating the true association between hospitalist use and patient experience. Third, our findings may not be generalizable to hospitals that serve younger patients or have a large number of specialist hospitalists (who were not included in our definition of hospitalists). For example, compared with older patients with multiple comorbidities, relatively healthy younger patients may derive less benefit from an ever‐present hospitalist who can explain discharge plans or an attentive nurse.

In summary, we found that US hospitals varied widely in their use of hospitalist physicians, and those which a greater proportion of care was delivered by hospitalists generally had better scores on patient experience, especially on the global assessment of satisfaction and in discharge care. Our findings suggest that adoption of the hospitalist modelone of the strategies employed by US hospitals in the past 2 decades to provide efficient careshould not detract from achieving the goal of more patient‐centered care.

Disclosures

Dr. Chen's work is supported in part by the National Institutes of Health/National Institute on Aging (AG024824, University of Michigan Claude D. Pepper Older Americans Independence Center), and the National Institutes of Health/National Center for Research Resources (UL1‐RR024986, Michigan Institute for Clinical and Health Research). Dr. Chen is also supported by a Career Development Grant Award (K08HS020671) from the Agency for Healthcare Research and Quality.