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From the Fraser Health Authority, Surrey, British Columbia, Canada.
Abstract
- Objective: To study care outcomes associated with a network of hospitalist services compared to traditional providers.
- Design: Retrospective review of administrative data.
- Setting and participants: Patients from a large integrated health care system in British Columbia in western Canada admitted and cared for by 3 provider groups between April 1, 2012, and March 31, 2018: hospitalists, family physicians (FP), and internal medicine (IM) physicians:
- Measurements: Average total length of stay (LOS), 30-day readmission, in-hospital mortality, and hospital standardized mortality ratio (HSMR) were the study outcome measures. Multiple logistic regression or generalized regression were completed to determine the relationship between provider groups and outcomes.
- Results: A total of 248,412 hospitalizations were included. Compared to patients admitted to hospitalists, patients admitted to other providers had higher odds of mortality (odds ratio [OR] for FP, 1.29; 95% confidence interval [CI], 1.21-1.37; OR for IM, 1.24; 95% CI, 1.15-1.33). Compared to hospitalist care, FP care was associated with higher readmission (OR, 1.27; 95% CI, 1.22-1.33), while IM care showed lower odds of readmission (OR, 0.83; 95% CI, 0.79-0.87). Patients admitted to the IM group had significantly lower total LOS (mean, 5.13 days; 95% CI, 5.04-5.21) compared to patients admitted to hospitalists (mean, 7.37 days; CI, 7.26-7.49) and FPs (mean, 7.30 days; 95% CI, 7.19-7.41). In a subgroup analysis of patients presenting with congestive heart failure, chronic obstructive pulmonary disease, and pneumonia, these general tendencies broadly persisted for mortality and LOS comparisons between FPs and hospitalists, but results were mixed for hospital readmissions.
- Conclusion: Care provided by hospitalists was associated with lower mortality and readmission rates compared with care provided by FPs, despite similar LOS. These findings may reflect differences in volume of services delivered by individual physicians, on-site availability to address urgent medical issues, and evolving specialization of clinical and nonclinical care processes in the acute care setting.
Keywords: hospital medicine; length of stay; readmission; mortality.
The hospitalist model of care has undergone rapid growth globally in recent years.1 The first hospitalist programs in Canada began around the same time as those in the United States and share many similarities in design and operations with their counterparts.2-4 However, unlike in the United States, where the hospitalist model has successfully established itself as an emerging specialty, debates about the merits of the model and its value proposition continue among Canadian observers.5-9
Historically, the type of physicians who acted as the most responsible provider (MRP) in Canadian hospitals depended on setting and geography.10 In large urban areas, groups of general internists or specialists have historically looked after general medicine patients as part of university-affiliated teaching services.11,12 Patients admitted to community hospitals have traditionally been cared for by their own primary care providers, typically general practitioners or family physicians (FPs). In the mid-1990s, many primary care providers in urban centers began to withdraw from inpatient care and primarily focused their practices in the outpatient setting.13-15 Hospitalist programs emerged as health care administrators sought to fill the resulting gap in MRP coverage.2,10
To date, attempts to understand the impact of hospitalist programs in Canada have been limited. A number of early studies aimed to describe16 the role of hospitalists in Canada and suggested improvements in length of stay (LOS) and staff satisfaction.17 However, these studies relied on unadjusted before-after comparisons and lacked methodological rigor to draw robust conclusions. More recently, a few studies have evaluated care outcomes associated with hospitalists using administrative databases, which attempted to control for potential confounding factors.18-21
While these studies are beginning to shed some light on the impact of hospital medicine programs in Canada, there are a number of issues that limit their generalizability. For example, the majority of studies to date focus on hospital medicine programs in Canada’s largest province (Ontario), and most describe experiences from single institutions. Since each of the 13 provincial and territorial governments organizes its health care system differently,22 results from 1 province may not be generalizable to other parts of the country. Moreover, hospitalists in Ontario are more diverse in their training backgrounds, with a larger percentage having trained in general internal medicine (IM), as compared to other parts of Canada, where the majority of hospitalists are overwhelmingly trained as FPs.3
We aimed to study care outcomes associated with a network of hospitalist services compared to “traditional” providers (community-based FPs and IM specialists) in a large integrated health care system in the province of British Columbia in western Canada. The hospital medicine services in this network span a range of community and academic hospitals, and collectively constitute 1 of the largest regional programs in the country. This provides a unique opportunity to understand the impact of hospitalists on outcome measures across a range of acute care institutions.
Methods
Setting and Population
Fraser Health Authority is 1 of 5 regional health authorities in British Columbia that emerged in 2001.23,24 It operates a network of hospitalist programs in 10 of its 12 acute care hospitals. In addition to hospitalists, there are a variable number of “traditional” physician providers who continue to act as MRPs. These include community-based FPs who continue to see their own patients in the hospital, either as part of a solo-practice model or a clinic-based call group. There are also a number of general internists and other subspecialists who accept MRP roles for general medicine patients who may present with higher-acuity conditions. As a result, patients requiring hospitalization due to nonsurgical or noncritical care conditions at each Fraser Health hospital may be cared for by a physician belonging to 1 of 3 groups, depending on local circumstances: an FP, a hospitalist, or an internist.
Inclusion and Exclusion Criteria
In order to evaluate comparative outcomes associated with hospitalist care, we included all patients admitted to a physician in each of the 3 provider groups between April 1, 2012, and March 31, 2018. We chose this time period for 2 reasons: first, we wanted to ensure comparability over an extended period of time, given the methodological changes implemented in 2009 by the Canadian Institute for Health Information (CIHI), the federal organization in the country responsible for setting standards for health care measures.25 Second, previous internal reviews had suggested that data quality prior to this year was inconsistent. We only considered hospitalizations where patients were admitted to and discharged by the same service, and excluded 2 acute care facilities and 1 free-standing rehabilitation facility without a hospitalist service during this period. We also excluded patients who resided in a location beyond the geographic catchment area of Fraser Health. Further details about data collection are outlined in the Appendix.
Measures
We used the framework developed by White and Glazier26 to inform the selection of our outcome measures, as well as relevant variables that may impact them. This framework proposes that the design of the inpatient care model (structures and processes of care) directly affects care outcomes. The model also proposes that patient and provider attributes can modulate this relationship, and suggests that a comprehensive evaluation of hospitalist performance needs to take these factors into account. We identified average total LOS, 30-day readmission rate, in-hospital mortality, and hospital standardized mortality ratio (HSMR)27 as primary outcome measures. HSMR is defined as actual over expected mortality and is measured by CIHI through a formula that takes into account patient illness attributes (eg, the most responsible diagnosis, comorbidity levels) and baseline population mortality rates.27 We chose these measures because they are clinically relevant and easy to obtain and have been utilized in previous similar studies in Canada and the United States.18-21,26
Statistical Analysis
Baseline demographic and clinical differences in patient outcomes were examined using independent t-tests or chi-square tests. Furthermore, baseline differences based on provider groups were explored using analysis of variance or chi-square tests. Multiple logistic regression analyses were completed to determine the relationship between provider groups and readmission and mortality, while the relationship between provider groups and hospital LOS was determined with generalized linear regression (using gamma distribution and a log link). Gamma distribution with a log link analysis is appropriate with outcome measures that are positively skewed (eg, hospital LOS). It assumes that data are sampled from an exponential family of distributions, thus mimicking a log-normal distribution, and minimizes estimation bias and standard errors. These analyses were completed while controlling for the effects of age, gender, and other potential confounding factors.
We initially attempted to control for case mix by incorporating case-mix groups (CMGs) in our multivariate analysis. However, we identified 475 CMGs with at least 1 patient in our study population. We then explored the inclusion of major clinical categories (MCCs) that broadly group CMGs into various higher order/organ-system level categories (eg, diseases of the respiratory system); however, we could not aggregate them into sufficiently homogenous groups to be entered into regression models. Instead, we conducted subgroup analyses on patients in our study population who were hospitalized with 1 of the following 3 CMGs: chronic obstructive pulmonary disease (COPD, n = 11,404 patients), congestive heart failure without coronary angiography (CHF, n = 7680), and pneumonia (itself an aggregate of 3 separate CMGs: aspiration pneumonia, bacterial pneumonia, viral/unspecified pneumonia, n = 11,155). We chose these CMGs as they are among the top 8 presentations for all 3 provider groups.
For all outcome measures, we excluded atypical patients (defined by CIHI as those with atypically long stays) and patients who had been transferred between facilities. For the readmission analysis, we also excluded patients who died in the hospital (Appendix A). Data analyses were completed in IBM SPSS, version 21. For all analyses, significance was determined using 2-tailed test and alpha < 0.05.
Ethics
The Fraser Health Department of Research and Evaluation reviewed this project to determine need for formal Ethics Review Board review, and granted an exemption based on institutional guidelines for program evaluations.
Results
A total of 132,178 patients were admitted to and discharged by 1 of the 3 study provider groups during the study period, accounting for a total of 248,412 hospitalizations. After excluding patients cared for in Fraser Health facilities without a hospitalist service and those who resided in a geographic area beyond Fraser Health, a total of 224,214 admissions were included in the final analysis.
Patient Characteristics
The demographic and clinical characteristics of patients by provider group are summarized in Table 1. Patients admitted to IM providers were substantially younger than those admitted to either FPs or hospitalists (61.00 vs 70.86 and 71.22 years, respectively; P < 0.005). However, patients admitted to hospitalists had higher degrees of complexity (as measured by higher comorbidity levels, number of secondary diagnoses, and higher resource intensity weights [RIWs]; P < 000.1 for all comparisons). Overall, the most common CMGs seen by FPs and hospitalists were similar, while IM providers primarily saw patients with cardiac conditions (Table 2).
Trends Over Time
During the study period, the number of patients admitted to the hospitalist services increased by 24%, while admissions to FPs and IM providers declined steadily (Figure). During this time, LOS for hospitalists progressively declined, while LOS for FPs and IM providers increased. Similar trends were observed for measures of mortality, while readmission rates remained constant for FPs, despite a decline observed for other providers.
Mortality
Table 3 summarizes the relationship between provider groups and in-hospital mortality (n = 183,779). Controlling for other variables, patients admitted to FP and IM providers had higher odds of mortality when compared to hospitalists (odds ratio [OR] for FPs, 1.29; 95% confidence interval [CI], 1.21-1.37; OR for IM, 1.24; 95% CI, 1.15-1.33). Older age, higher comorbidity level, higher number of secondary diagnoses, higher use of hospital resources (as measured by RIWs), longer than expected hospital stay (as measured by conservable days), and male gender were also associated with higher mortality. Similarly, patients receiving palliative care and those who spent at least 1 day in a special care unit (critical care, observation, and monitored care units) also had higher odds of mortality. On the other hand, admission to nonteaching medium facilities and longer hospital stay were associated with lower mortality. Compared to the first year of this analysis, lower mortality rates were observed in subsequent fiscal years. Finally, there appear to be geographic variations in mortality within Fraser Health.
Our analysis of patients with COPD, CHF, and pneumonia showed mixed results (Table 4). Patients admitted to the FP provider group with CHF and pneumonia had higher mortality compared to hospitalists (OR for CHF, 1.77; 95% CI, 1.38-2.27; OR for pneumonia, 1.53; 95% CI, 1.25-1.88), with a similar but nonstatistically significant trend observed for patients with COPD (OR, 1.29; 95% CI, 0.99-1.70). On the other hand, the higher observed mortality associated with the IM provider group in the overall study population only persisted for patients with COPD (OR, 2.71; 95% CI, 1.94-3.80), with no statistically significant differences for patients with CHF (OR, 1.18; 95% CI, 0.84-1.65) and pneumonia (OR, 0.93; 95% CI, 0.69-1.25).
We also studied adjusted mortality as measured by HSMRs. Currently, our Health Information Management system calculates an HSMR value for each patient admitted to our acute care facilities using the methodology developed by CIHI. Prior internal audits demonstrated that our internal calculations closely approximate those reported nationally. Our analysis suggests that over time, HSMR rates for the 3 provider groups have diverged, with patients admitted to IM providers having a higher mortality rate than what would be expected based on the presenting clinical conditions and comorbidity levels (Figure, part D).
Readmission
The results of our multiple logistic regression for readmission are summarized in Table 5 (n = 166,042). The impact of provider group on 30-day readmission is mixed, with higher odds associated with FPs compared to hospitalists (OR, 1.27; 95% CI, 1.22-1.34) and lower odds associated with IM physicians (OR, 0.83; 95% CI, 0.79-0.87). Gender and RIW did not show any significant associations, but increasing age, higher number of secondary diagnoses, higher comorbidity levels, and longer than expected LOS (as measure by conservable days) were associated with higher odds of readmission. Conversely, longer hospitalization, admission to a large community hospital, palliative status, admission to a special care unit, geography, and fiscal year were associated with lower odds of readmission.
The above differences between provider groups were no longer consistently present when we analyzed patients presenting with COPD, CHF, and pneumonias (Table 6). Only patients admitted to the FP provider group with pneumonia had higher odds of readmission compared to hospitalists (OR, 1.27; 95% CI, 1.05-1.54). Conversely, only patients admitted to the IM provider group with CHF showed lower readmission (OR, 0.75; 95% CI, 0.62-0.92).
Total LOS
Results using generalized linear regressions for total LOS are presented in Table 7 (n = 183,779). Patients admitted to the IM provider group had significantly lower total LOS (mean, 5.13 days; 95% CI, 5.04-5.21) compared to the hospitalist (mean, 7.37 days; 95% CI, 7.26-7.49) and FP (mean, 7.30 days; 95% CI, 7.19-7.41) groups, with no significant differences between the latter 2 groups. Older patients, females, patients with higher comorbidity levels or number of secondary diagnoses, higher RIW, palliative patients, and discharge to a facility other than the patient’s home were associated with a significantly longer LOS. On the other hand, admission to nonteaching hospitals and admission to a special care unit was associated with lower LOS.
When we compared total LOS for patients admitted with COPD, CHF, and pneumonias, the same differences observed for the broader comparisons persisted: IM patients consistently showed shorter LOS compared to hospitalist patients, while LOS associated with FP patients was similar (Table 8).
Discussion
To our knowledge, our evaluation is the largest study to date designed to understand outcomes associated with hospitalist care in Canada. Our analyses suggest that patients admitted to our large network of hospitalist services present with clinical conditions that are very similar to those of general medicine patients in other Canadian provinces.28,29 They also show that patients cared for by hospitalists experience lower mortality rates compared to those cared for by FPs. Our findings are similar to previous studies, which have suggested a 12% to 75% reduction in odds of mortality associated with hospitalist care.18,19 These differences persisted even when we focused on patients presenting with specific clinical conditions (CHF, COPD, and pneumonias).
White and colleagues have previously demonstrated that generalist physicians who had higher volumes of inpatient care activity also had lower mortality rates compared to those who cared for hospitalized patients less frequently.19 An association between higher physician caseloads and better outcomes has been established for many surgical and medical conditions.30-32 Given that 85% of hospitalists in our program have post-graduate medical training in family medicine (internal department surveys, data not shown), it is less likely that training background can explain differences in outcomes. Instead, differences in patient volumes and the dedicated focus of hospitalists on acute care are likely more important contributors to lower mortality. In our program, a full-time hospitalist spends an average of 2000 hours annually providing services in the hospital setting. The continuous on-site presence of hospitalists enhances their clinical experience with regards to the management of common medical conditions, and increases their exposure to less common presentations of illnesses. The ability to respond to deteriorating patients in a timely manner may be another factor in explaining the differences in mortality rates between dedicated hospital-based generalist providers and similarly trained physicians with a primarily community-based focus.
In our study, hospitalist care was also broadly associated with lower mortality compared to the IM providers, although these differences were not consistently present when patients with specific diagnoses were compared. This may be partly explained by the relationship between caseload and outcomes, but other factors may also be important. For example, patients admitted by IM providers spend significantly more time in specialized units. They also predominantly present with cardiac conditions, and as such may have higher acuity levels and require more invasive interventions. While this may explain the higher observed mortality, a within-group comparison still suggests higher than expected mortality for IM patients. The HSMR methodology measures actual mortality rates compared to what would be expected based on clinical presentation and baseline population characteristics. Calculating HSMR is highly dependent on proper documentation and chart abstraction,33,34 and it is possible that some of the differences observed are due to incomplete physician documentation. However, a more in-depth analysis of care processes will be required to clarify the observed trends.
Compared to hospitalists, patients cared for by FPs also had higher odds of readmission within 30 days, which is consistent with prior studies.18,19 One of the criticisms of the hospitalist model has been the inherent discontinuity of care that is built into the model, which can contribute to suboptimal transitions of care between the acute and community settings.35 The expectation is that FPs who admit their own patients do not face this challenge, and as a result their patients should be readmitted less frequently after discharge. Our data and those from previous studies do not support this hypothesis. At the same time, when we studied patients with specific clinical diagnoses, only those hospitalized for pneumonias continued to demonstrate higher readmission odds. This suggests that hospital readmission rate is a complex measure that may be influenced by a multitude of hospital and community factors, and may be different for patients who present with different clinical diagnoses. Further research is required to better understand the relationship between provider type and experience with hospital readmission for patients with various clinical presentations.
Unlike the United States, where hospitalist care has been associated with reductions in LOS,26,36 studies in the Canadian health care setting have shown mixed results.17-21 In our evaluation, hospitalist care is not associated with reductions in total LOS compared to care provided by FPs or IM physicians. This could be due to a number of factors. First, unlike FPs, who know their patients, hospitalists may have a more conservative risk tolerance in discharging patients with whom they are not familiar. Similarly, physicians who have trained in IM may have a lower threshold for discharging patients than hospitalists, whose training background is mainly rooted in family medicine.3 Second, discontinuity of care has been associated with longer LOS for hospitalized patients.37,38 Hospitalists generally work for 7- to 10-day rotations. As a result, a patient may see a number of different hospitalists during the same hospital stay, which could nullify any gains in LOS that may be expected from better familiarity with hospital processes. Third, whereas a FP or an internist may only have a few inpatients under their care at any given time, each hospitalist typically cares for 17 to 22 patients every day. Increasing hospitalist workload has been shown to negatively impact LOS and may result in lower efficiency.39 Finally, many patients in our health system who require more time to recuperate or need complex discharge planning are usually transferred to the care of the hospitalist service from other services, or are preferentially admitted to hospitalists from the emergency department. As a result, hospitalists may look after a disproportionately higher number of long-stay patients. Despite all this, hospitalists in our population perform similarly to FPs, regardless of the clinical diagnoses of hospitalized patients.
Our study has a number of notable limitations. First, we used administrative data to conduct our evaluation and could only control for factors that are available in our data systems. As a result, some potential confounders may not have been taken into consideration. For example, our databases do not contain provider characteristics (eg, age, years of clinical experience) that have been deemed to be relevant by White and Glazier.26 Similarly, we did not have all the necessary information about the characteristics of the various MRP programs (eg, number of physicians involved in group practices, the schedule model of community FP call groups) and were not able to account for the potential impact of these on observed outcomes. Second, although our findings mirror prior studies from other parts of Canada, they may not be applicable to hospitalist programs in other jurisdictions or in health systems that are not regionalized or integrated. Third, our IM provider group is heterogeneous, with a number of different IM subspecialties (cardiologists, gastroenterologists, general internists) grouped under the IM category in our database. As a result, comparisons between the IM provider group and the other 2 provider groups, which are more homogenous, should be interpreted with caution.
Finally, we included only patients admitted to facilities in which a hospitalist service existed during the study period. As a result, a medium-size community hospital without a hospitalist service where patients are cared for exclusively by FPs and IM physicians was not included in the comparisons, and in 4 of the 10 facilities included, the number of FP patients was less than 10% of total hospitalized patients at the site (Appendix A). This may have resulted in an under-representation of FP patients.
Conclusion
Debates about the merits of the hospitalist model in Canada continue, and are in part fueled by a paucity of robust evidence about its impact on care outcomes compared to more traditional ways of providing inpatient care. In our evaluation, care provided by hospitalists is associated with lower mortality and readmission rates, despite similar LOS compared with FPs. Hospitalist care is also associated with lower mortality compared to IM providers. Hospitalists also demonstrated progressive improvement over time, with decreasing LOS and mortality rates and a stable readmission rate. Our results suggest that physicians with a focus on inpatient care can have positive contributions to quality and efficiency of care in Canada.
Corresponding author: Vandad Yousefi MD, CCFP, FHM, Fraser Health Authority, 400, 13450–102 Avenue, Surrey BC V3T 0H1, Canada.
Financial disclosures: None.
1. Kisuule F, Howell E. Hospital medicine beyond the United States. Int J Gen Med. 2018;11:65-71.
2. Yousefi V, Wilton D. Dedesigning hospital care: learning from the experience of hospital medicine in Canada. J Global Health Care Syst. 2011;1(3).
3. Soong C, Fan E, Howell E, et al. Characteristics of hospitalists and hospitalist programs in the United States and Canada. J Clin Outcomes Manag. 2009;16:69-76.
4. Yousefi V. How Canadian hospitalists spend their time - A work-sampling study within a hospital medicine program in Ontario. J Clin Outcomes Manag. 2011;18:159-166.
5. Wilson G. Are inpatients’ needs better served by hospitalists than by their family doctors? No. Can Fam Physician. 2008;54:1101-1103.
6. Samoil D. Are inpatients’ needs better served by hospitalists than by their family doctors: Yes? Can Fam Physician. 2008;54:1100-1101.
7. Nicolson B. Where’s Marcus Welby when you need him? BC Medical J. 2016;58:63-64.
8. Lemire F. Enhanced skills in family medicine: Update. Can Fam Physician. 2018;64:160.
9. Lerner J. Wanting family medicine without primary care. Can Fam Physician. 2018; 64:155.
10. Canadian Society of Hospital Medicine. Core Competencies in Hospital Medicine - Care of the Medical Inpatient. 2015.
11. Redelmeier DA. A Canadian perspective on the American hospitalist movement. Arch Intern Med. 1999;159:1665-1668.
12. Ghali WA, Greenberg PB, Mejia R, et al. International perspectives on general internal medicine and the case for “globalization” of a discipline. J Gen Intern Med. 2006;21:197-200.
13. Day A, MacMillan L. Neglect of the inpatient: The hospitalist movement in Canada responds. Hosp Q. 2001;4:36.
14. Sullivan P. Enter the hospitalist: New type of patient creating a new type of specialist. CMAJ. 2000;162:1345-1346.
15. Chan BTB. The declining comprehensiveness of primary care. CMAJ. 2002;166:429-434.
16. Abenhaim HA, Kahn SR, Raffoul J, Becker MR. Program description: A hospitalist-run, medical short-stay unit in a teaching hospital. CMAJ. 2000;163:1477-1480.
17. McGowan B, Nightingale M. The hospitalist program a new specialty on the horizon in acute care medicine a hospital case study. BC Med J. 2003;45:391-394.
18. Yousefi V, Chong C. Does implementation of a hospitalist program in a Canadian community hospital improve measures of quality of care and utilization? An observational comparative analysis of hospitalists vs. traditional care providers. BMC Health Serv Res. 2013;13:204.
19. White HL. Assessing the prevalence, penetration and performance of hospital physicians in Ontario: Implications for the quality and efficiency of inpatient care. ProQuest Dissertations Publishing; 2016.
20. Gutierrez CA, Norris M, Chail M. Impact of a newly established hospitalist training program on patient LOS and RIW. Poster presented at the 9th Annual Canadian Society of Hospital Medicine Conference, September 23-25, 2011; Banff, Alberta.
21. Seth P, Nicholson K, Habbous S, Menard J. Implementation of a hospitalist medicine model in a full-service community hospital: Examining impact two years post-implementation on health resource use andpatient satisfaction. Poster presented at the 13th Annual Canadian Society of Hospital Medicine Conference. 2015; Niagara Falls, Ontario.
22. Lewis S. A system in name only--access, variation, and reform in Canada’s provinces. N Engl J Med. 2015;372:497-500.
23. Lewis S, Kouri D. Regionalization: Making sense of the Canadian experience. Healthcare Papers. 2004;5:12-31.
24. Fraser Health Authority. About Fraser health. www.fraserhealth.ca/about-us/about-fraser-health#.XFJrl9JKiUk. Updated 2018. Accessed January 30, 2019.
25. Canadian Institute for Health Information. CMG+. https://www.cihi.ca/en/cmg. Accessed January 30, 2019.
26. White HL, Glazier RH. Do hospitalist physicians improve the quality of inpatient care delivery? A systematic review of process, efficiency and outcome measures. BMC Med. 2011;9:58.
27. Canadian Institute for Health Information. Hospital standardized mortality ratio technical notes. 2008. www.cihi.ca/sites/default/files/document/hsmr-tech-notes_en_0.pdf.
28. McAlister FA, Youngson E, Bakal JA, et al. Physician experience and outcomes among patients admitted to general internal medicine teaching wards. CMAJ. 2015;187:1041-1048.
29. Verma AA, Guo Y, Kwan JL, et al. Patient characteristics, resource use and outcomes associated with general internal medicine hospital care: The general medicine inpatient initiative (GEMINI) retrospective cohort study. CMAJ Open. 2017;5:E849.
30. Morche J, Mathes T, Pieper D. Relationship between surgeon volume and outcomes: A systematic review of systematic reviews. Syst Rev. 2016;5:204.
31. Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med. 2002;137:511-520.
32. Chen CH, Chen YH, Lin HC, Lin HC. Association between physician caseload and patient outcome for sepsis treatment. Infect Control Hosp Epidemiol. 2009;30:556-562.
33. van Gestel YR, Lemmens VE, Lingsma HF, et al. The hospital standardized mortality ratio fallacy: A narrative review. Med Care. 2012;50:662-667.
34. Scott IA, Brand CA, Phelps GE, et al. Using hospital standardised mortality ratios to assess quality of care—proceed with extreme caution. Med J Aust. 2011; 194:645-648.
35. Wachter RM. Hospitalists in the United States -- mission accomplished or work in progress? N Engl J Med. 2004;350:1935-1936.
36. Peterson MC. A systematic review of outcomes and quality measures in adult patients cared for by hospitalists vs nonhospitalists. Mayo Clin Proc. 2009;84:248-254.
37. Chandra S, Wright SM, Howell EE. The creating incentives and continuity leading to efficiency staffing model: A quality improvement initiative in hospital medicine. Mayo Clin Proc. 2012;87:364-371.
38. Epstein K, Juarez E, Epstein A, et al. The impact of fragmentation of hospitalist care on length of stay. J Hosp Med. 2010;5:335-338.
39. Elliott DJ, Young RS, Brice J, et al. Effect of hospitalist workload on the quality and efficiency of care. JAMA Intern Med. 2014;174:786-793.
From the Fraser Health Authority, Surrey, British Columbia, Canada.
Abstract
- Objective: To study care outcomes associated with a network of hospitalist services compared to traditional providers.
- Design: Retrospective review of administrative data.
- Setting and participants: Patients from a large integrated health care system in British Columbia in western Canada admitted and cared for by 3 provider groups between April 1, 2012, and March 31, 2018: hospitalists, family physicians (FP), and internal medicine (IM) physicians:
- Measurements: Average total length of stay (LOS), 30-day readmission, in-hospital mortality, and hospital standardized mortality ratio (HSMR) were the study outcome measures. Multiple logistic regression or generalized regression were completed to determine the relationship between provider groups and outcomes.
- Results: A total of 248,412 hospitalizations were included. Compared to patients admitted to hospitalists, patients admitted to other providers had higher odds of mortality (odds ratio [OR] for FP, 1.29; 95% confidence interval [CI], 1.21-1.37; OR for IM, 1.24; 95% CI, 1.15-1.33). Compared to hospitalist care, FP care was associated with higher readmission (OR, 1.27; 95% CI, 1.22-1.33), while IM care showed lower odds of readmission (OR, 0.83; 95% CI, 0.79-0.87). Patients admitted to the IM group had significantly lower total LOS (mean, 5.13 days; 95% CI, 5.04-5.21) compared to patients admitted to hospitalists (mean, 7.37 days; CI, 7.26-7.49) and FPs (mean, 7.30 days; 95% CI, 7.19-7.41). In a subgroup analysis of patients presenting with congestive heart failure, chronic obstructive pulmonary disease, and pneumonia, these general tendencies broadly persisted for mortality and LOS comparisons between FPs and hospitalists, but results were mixed for hospital readmissions.
- Conclusion: Care provided by hospitalists was associated with lower mortality and readmission rates compared with care provided by FPs, despite similar LOS. These findings may reflect differences in volume of services delivered by individual physicians, on-site availability to address urgent medical issues, and evolving specialization of clinical and nonclinical care processes in the acute care setting.
Keywords: hospital medicine; length of stay; readmission; mortality.
The hospitalist model of care has undergone rapid growth globally in recent years.1 The first hospitalist programs in Canada began around the same time as those in the United States and share many similarities in design and operations with their counterparts.2-4 However, unlike in the United States, where the hospitalist model has successfully established itself as an emerging specialty, debates about the merits of the model and its value proposition continue among Canadian observers.5-9
Historically, the type of physicians who acted as the most responsible provider (MRP) in Canadian hospitals depended on setting and geography.10 In large urban areas, groups of general internists or specialists have historically looked after general medicine patients as part of university-affiliated teaching services.11,12 Patients admitted to community hospitals have traditionally been cared for by their own primary care providers, typically general practitioners or family physicians (FPs). In the mid-1990s, many primary care providers in urban centers began to withdraw from inpatient care and primarily focused their practices in the outpatient setting.13-15 Hospitalist programs emerged as health care administrators sought to fill the resulting gap in MRP coverage.2,10
To date, attempts to understand the impact of hospitalist programs in Canada have been limited. A number of early studies aimed to describe16 the role of hospitalists in Canada and suggested improvements in length of stay (LOS) and staff satisfaction.17 However, these studies relied on unadjusted before-after comparisons and lacked methodological rigor to draw robust conclusions. More recently, a few studies have evaluated care outcomes associated with hospitalists using administrative databases, which attempted to control for potential confounding factors.18-21
While these studies are beginning to shed some light on the impact of hospital medicine programs in Canada, there are a number of issues that limit their generalizability. For example, the majority of studies to date focus on hospital medicine programs in Canada’s largest province (Ontario), and most describe experiences from single institutions. Since each of the 13 provincial and territorial governments organizes its health care system differently,22 results from 1 province may not be generalizable to other parts of the country. Moreover, hospitalists in Ontario are more diverse in their training backgrounds, with a larger percentage having trained in general internal medicine (IM), as compared to other parts of Canada, where the majority of hospitalists are overwhelmingly trained as FPs.3
We aimed to study care outcomes associated with a network of hospitalist services compared to “traditional” providers (community-based FPs and IM specialists) in a large integrated health care system in the province of British Columbia in western Canada. The hospital medicine services in this network span a range of community and academic hospitals, and collectively constitute 1 of the largest regional programs in the country. This provides a unique opportunity to understand the impact of hospitalists on outcome measures across a range of acute care institutions.
Methods
Setting and Population
Fraser Health Authority is 1 of 5 regional health authorities in British Columbia that emerged in 2001.23,24 It operates a network of hospitalist programs in 10 of its 12 acute care hospitals. In addition to hospitalists, there are a variable number of “traditional” physician providers who continue to act as MRPs. These include community-based FPs who continue to see their own patients in the hospital, either as part of a solo-practice model or a clinic-based call group. There are also a number of general internists and other subspecialists who accept MRP roles for general medicine patients who may present with higher-acuity conditions. As a result, patients requiring hospitalization due to nonsurgical or noncritical care conditions at each Fraser Health hospital may be cared for by a physician belonging to 1 of 3 groups, depending on local circumstances: an FP, a hospitalist, or an internist.
Inclusion and Exclusion Criteria
In order to evaluate comparative outcomes associated with hospitalist care, we included all patients admitted to a physician in each of the 3 provider groups between April 1, 2012, and March 31, 2018. We chose this time period for 2 reasons: first, we wanted to ensure comparability over an extended period of time, given the methodological changes implemented in 2009 by the Canadian Institute for Health Information (CIHI), the federal organization in the country responsible for setting standards for health care measures.25 Second, previous internal reviews had suggested that data quality prior to this year was inconsistent. We only considered hospitalizations where patients were admitted to and discharged by the same service, and excluded 2 acute care facilities and 1 free-standing rehabilitation facility without a hospitalist service during this period. We also excluded patients who resided in a location beyond the geographic catchment area of Fraser Health. Further details about data collection are outlined in the Appendix.
Measures
We used the framework developed by White and Glazier26 to inform the selection of our outcome measures, as well as relevant variables that may impact them. This framework proposes that the design of the inpatient care model (structures and processes of care) directly affects care outcomes. The model also proposes that patient and provider attributes can modulate this relationship, and suggests that a comprehensive evaluation of hospitalist performance needs to take these factors into account. We identified average total LOS, 30-day readmission rate, in-hospital mortality, and hospital standardized mortality ratio (HSMR)27 as primary outcome measures. HSMR is defined as actual over expected mortality and is measured by CIHI through a formula that takes into account patient illness attributes (eg, the most responsible diagnosis, comorbidity levels) and baseline population mortality rates.27 We chose these measures because they are clinically relevant and easy to obtain and have been utilized in previous similar studies in Canada and the United States.18-21,26
Statistical Analysis
Baseline demographic and clinical differences in patient outcomes were examined using independent t-tests or chi-square tests. Furthermore, baseline differences based on provider groups were explored using analysis of variance or chi-square tests. Multiple logistic regression analyses were completed to determine the relationship between provider groups and readmission and mortality, while the relationship between provider groups and hospital LOS was determined with generalized linear regression (using gamma distribution and a log link). Gamma distribution with a log link analysis is appropriate with outcome measures that are positively skewed (eg, hospital LOS). It assumes that data are sampled from an exponential family of distributions, thus mimicking a log-normal distribution, and minimizes estimation bias and standard errors. These analyses were completed while controlling for the effects of age, gender, and other potential confounding factors.
We initially attempted to control for case mix by incorporating case-mix groups (CMGs) in our multivariate analysis. However, we identified 475 CMGs with at least 1 patient in our study population. We then explored the inclusion of major clinical categories (MCCs) that broadly group CMGs into various higher order/organ-system level categories (eg, diseases of the respiratory system); however, we could not aggregate them into sufficiently homogenous groups to be entered into regression models. Instead, we conducted subgroup analyses on patients in our study population who were hospitalized with 1 of the following 3 CMGs: chronic obstructive pulmonary disease (COPD, n = 11,404 patients), congestive heart failure without coronary angiography (CHF, n = 7680), and pneumonia (itself an aggregate of 3 separate CMGs: aspiration pneumonia, bacterial pneumonia, viral/unspecified pneumonia, n = 11,155). We chose these CMGs as they are among the top 8 presentations for all 3 provider groups.
For all outcome measures, we excluded atypical patients (defined by CIHI as those with atypically long stays) and patients who had been transferred between facilities. For the readmission analysis, we also excluded patients who died in the hospital (Appendix A). Data analyses were completed in IBM SPSS, version 21. For all analyses, significance was determined using 2-tailed test and alpha < 0.05.
Ethics
The Fraser Health Department of Research and Evaluation reviewed this project to determine need for formal Ethics Review Board review, and granted an exemption based on institutional guidelines for program evaluations.
Results
A total of 132,178 patients were admitted to and discharged by 1 of the 3 study provider groups during the study period, accounting for a total of 248,412 hospitalizations. After excluding patients cared for in Fraser Health facilities without a hospitalist service and those who resided in a geographic area beyond Fraser Health, a total of 224,214 admissions were included in the final analysis.
Patient Characteristics
The demographic and clinical characteristics of patients by provider group are summarized in Table 1. Patients admitted to IM providers were substantially younger than those admitted to either FPs or hospitalists (61.00 vs 70.86 and 71.22 years, respectively; P < 0.005). However, patients admitted to hospitalists had higher degrees of complexity (as measured by higher comorbidity levels, number of secondary diagnoses, and higher resource intensity weights [RIWs]; P < 000.1 for all comparisons). Overall, the most common CMGs seen by FPs and hospitalists were similar, while IM providers primarily saw patients with cardiac conditions (Table 2).
Trends Over Time
During the study period, the number of patients admitted to the hospitalist services increased by 24%, while admissions to FPs and IM providers declined steadily (Figure). During this time, LOS for hospitalists progressively declined, while LOS for FPs and IM providers increased. Similar trends were observed for measures of mortality, while readmission rates remained constant for FPs, despite a decline observed for other providers.
Mortality
Table 3 summarizes the relationship between provider groups and in-hospital mortality (n = 183,779). Controlling for other variables, patients admitted to FP and IM providers had higher odds of mortality when compared to hospitalists (odds ratio [OR] for FPs, 1.29; 95% confidence interval [CI], 1.21-1.37; OR for IM, 1.24; 95% CI, 1.15-1.33). Older age, higher comorbidity level, higher number of secondary diagnoses, higher use of hospital resources (as measured by RIWs), longer than expected hospital stay (as measured by conservable days), and male gender were also associated with higher mortality. Similarly, patients receiving palliative care and those who spent at least 1 day in a special care unit (critical care, observation, and monitored care units) also had higher odds of mortality. On the other hand, admission to nonteaching medium facilities and longer hospital stay were associated with lower mortality. Compared to the first year of this analysis, lower mortality rates were observed in subsequent fiscal years. Finally, there appear to be geographic variations in mortality within Fraser Health.
Our analysis of patients with COPD, CHF, and pneumonia showed mixed results (Table 4). Patients admitted to the FP provider group with CHF and pneumonia had higher mortality compared to hospitalists (OR for CHF, 1.77; 95% CI, 1.38-2.27; OR for pneumonia, 1.53; 95% CI, 1.25-1.88), with a similar but nonstatistically significant trend observed for patients with COPD (OR, 1.29; 95% CI, 0.99-1.70). On the other hand, the higher observed mortality associated with the IM provider group in the overall study population only persisted for patients with COPD (OR, 2.71; 95% CI, 1.94-3.80), with no statistically significant differences for patients with CHF (OR, 1.18; 95% CI, 0.84-1.65) and pneumonia (OR, 0.93; 95% CI, 0.69-1.25).
We also studied adjusted mortality as measured by HSMRs. Currently, our Health Information Management system calculates an HSMR value for each patient admitted to our acute care facilities using the methodology developed by CIHI. Prior internal audits demonstrated that our internal calculations closely approximate those reported nationally. Our analysis suggests that over time, HSMR rates for the 3 provider groups have diverged, with patients admitted to IM providers having a higher mortality rate than what would be expected based on the presenting clinical conditions and comorbidity levels (Figure, part D).
Readmission
The results of our multiple logistic regression for readmission are summarized in Table 5 (n = 166,042). The impact of provider group on 30-day readmission is mixed, with higher odds associated with FPs compared to hospitalists (OR, 1.27; 95% CI, 1.22-1.34) and lower odds associated with IM physicians (OR, 0.83; 95% CI, 0.79-0.87). Gender and RIW did not show any significant associations, but increasing age, higher number of secondary diagnoses, higher comorbidity levels, and longer than expected LOS (as measure by conservable days) were associated with higher odds of readmission. Conversely, longer hospitalization, admission to a large community hospital, palliative status, admission to a special care unit, geography, and fiscal year were associated with lower odds of readmission.
The above differences between provider groups were no longer consistently present when we analyzed patients presenting with COPD, CHF, and pneumonias (Table 6). Only patients admitted to the FP provider group with pneumonia had higher odds of readmission compared to hospitalists (OR, 1.27; 95% CI, 1.05-1.54). Conversely, only patients admitted to the IM provider group with CHF showed lower readmission (OR, 0.75; 95% CI, 0.62-0.92).
Total LOS
Results using generalized linear regressions for total LOS are presented in Table 7 (n = 183,779). Patients admitted to the IM provider group had significantly lower total LOS (mean, 5.13 days; 95% CI, 5.04-5.21) compared to the hospitalist (mean, 7.37 days; 95% CI, 7.26-7.49) and FP (mean, 7.30 days; 95% CI, 7.19-7.41) groups, with no significant differences between the latter 2 groups. Older patients, females, patients with higher comorbidity levels or number of secondary diagnoses, higher RIW, palliative patients, and discharge to a facility other than the patient’s home were associated with a significantly longer LOS. On the other hand, admission to nonteaching hospitals and admission to a special care unit was associated with lower LOS.
When we compared total LOS for patients admitted with COPD, CHF, and pneumonias, the same differences observed for the broader comparisons persisted: IM patients consistently showed shorter LOS compared to hospitalist patients, while LOS associated with FP patients was similar (Table 8).
Discussion
To our knowledge, our evaluation is the largest study to date designed to understand outcomes associated with hospitalist care in Canada. Our analyses suggest that patients admitted to our large network of hospitalist services present with clinical conditions that are very similar to those of general medicine patients in other Canadian provinces.28,29 They also show that patients cared for by hospitalists experience lower mortality rates compared to those cared for by FPs. Our findings are similar to previous studies, which have suggested a 12% to 75% reduction in odds of mortality associated with hospitalist care.18,19 These differences persisted even when we focused on patients presenting with specific clinical conditions (CHF, COPD, and pneumonias).
White and colleagues have previously demonstrated that generalist physicians who had higher volumes of inpatient care activity also had lower mortality rates compared to those who cared for hospitalized patients less frequently.19 An association between higher physician caseloads and better outcomes has been established for many surgical and medical conditions.30-32 Given that 85% of hospitalists in our program have post-graduate medical training in family medicine (internal department surveys, data not shown), it is less likely that training background can explain differences in outcomes. Instead, differences in patient volumes and the dedicated focus of hospitalists on acute care are likely more important contributors to lower mortality. In our program, a full-time hospitalist spends an average of 2000 hours annually providing services in the hospital setting. The continuous on-site presence of hospitalists enhances their clinical experience with regards to the management of common medical conditions, and increases their exposure to less common presentations of illnesses. The ability to respond to deteriorating patients in a timely manner may be another factor in explaining the differences in mortality rates between dedicated hospital-based generalist providers and similarly trained physicians with a primarily community-based focus.
In our study, hospitalist care was also broadly associated with lower mortality compared to the IM providers, although these differences were not consistently present when patients with specific diagnoses were compared. This may be partly explained by the relationship between caseload and outcomes, but other factors may also be important. For example, patients admitted by IM providers spend significantly more time in specialized units. They also predominantly present with cardiac conditions, and as such may have higher acuity levels and require more invasive interventions. While this may explain the higher observed mortality, a within-group comparison still suggests higher than expected mortality for IM patients. The HSMR methodology measures actual mortality rates compared to what would be expected based on clinical presentation and baseline population characteristics. Calculating HSMR is highly dependent on proper documentation and chart abstraction,33,34 and it is possible that some of the differences observed are due to incomplete physician documentation. However, a more in-depth analysis of care processes will be required to clarify the observed trends.
Compared to hospitalists, patients cared for by FPs also had higher odds of readmission within 30 days, which is consistent with prior studies.18,19 One of the criticisms of the hospitalist model has been the inherent discontinuity of care that is built into the model, which can contribute to suboptimal transitions of care between the acute and community settings.35 The expectation is that FPs who admit their own patients do not face this challenge, and as a result their patients should be readmitted less frequently after discharge. Our data and those from previous studies do not support this hypothesis. At the same time, when we studied patients with specific clinical diagnoses, only those hospitalized for pneumonias continued to demonstrate higher readmission odds. This suggests that hospital readmission rate is a complex measure that may be influenced by a multitude of hospital and community factors, and may be different for patients who present with different clinical diagnoses. Further research is required to better understand the relationship between provider type and experience with hospital readmission for patients with various clinical presentations.
Unlike the United States, where hospitalist care has been associated with reductions in LOS,26,36 studies in the Canadian health care setting have shown mixed results.17-21 In our evaluation, hospitalist care is not associated with reductions in total LOS compared to care provided by FPs or IM physicians. This could be due to a number of factors. First, unlike FPs, who know their patients, hospitalists may have a more conservative risk tolerance in discharging patients with whom they are not familiar. Similarly, physicians who have trained in IM may have a lower threshold for discharging patients than hospitalists, whose training background is mainly rooted in family medicine.3 Second, discontinuity of care has been associated with longer LOS for hospitalized patients.37,38 Hospitalists generally work for 7- to 10-day rotations. As a result, a patient may see a number of different hospitalists during the same hospital stay, which could nullify any gains in LOS that may be expected from better familiarity with hospital processes. Third, whereas a FP or an internist may only have a few inpatients under their care at any given time, each hospitalist typically cares for 17 to 22 patients every day. Increasing hospitalist workload has been shown to negatively impact LOS and may result in lower efficiency.39 Finally, many patients in our health system who require more time to recuperate or need complex discharge planning are usually transferred to the care of the hospitalist service from other services, or are preferentially admitted to hospitalists from the emergency department. As a result, hospitalists may look after a disproportionately higher number of long-stay patients. Despite all this, hospitalists in our population perform similarly to FPs, regardless of the clinical diagnoses of hospitalized patients.
Our study has a number of notable limitations. First, we used administrative data to conduct our evaluation and could only control for factors that are available in our data systems. As a result, some potential confounders may not have been taken into consideration. For example, our databases do not contain provider characteristics (eg, age, years of clinical experience) that have been deemed to be relevant by White and Glazier.26 Similarly, we did not have all the necessary information about the characteristics of the various MRP programs (eg, number of physicians involved in group practices, the schedule model of community FP call groups) and were not able to account for the potential impact of these on observed outcomes. Second, although our findings mirror prior studies from other parts of Canada, they may not be applicable to hospitalist programs in other jurisdictions or in health systems that are not regionalized or integrated. Third, our IM provider group is heterogeneous, with a number of different IM subspecialties (cardiologists, gastroenterologists, general internists) grouped under the IM category in our database. As a result, comparisons between the IM provider group and the other 2 provider groups, which are more homogenous, should be interpreted with caution.
Finally, we included only patients admitted to facilities in which a hospitalist service existed during the study period. As a result, a medium-size community hospital without a hospitalist service where patients are cared for exclusively by FPs and IM physicians was not included in the comparisons, and in 4 of the 10 facilities included, the number of FP patients was less than 10% of total hospitalized patients at the site (Appendix A). This may have resulted in an under-representation of FP patients.
Conclusion
Debates about the merits of the hospitalist model in Canada continue, and are in part fueled by a paucity of robust evidence about its impact on care outcomes compared to more traditional ways of providing inpatient care. In our evaluation, care provided by hospitalists is associated with lower mortality and readmission rates, despite similar LOS compared with FPs. Hospitalist care is also associated with lower mortality compared to IM providers. Hospitalists also demonstrated progressive improvement over time, with decreasing LOS and mortality rates and a stable readmission rate. Our results suggest that physicians with a focus on inpatient care can have positive contributions to quality and efficiency of care in Canada.
Corresponding author: Vandad Yousefi MD, CCFP, FHM, Fraser Health Authority, 400, 13450–102 Avenue, Surrey BC V3T 0H1, Canada.
Financial disclosures: None.
From the Fraser Health Authority, Surrey, British Columbia, Canada.
Abstract
- Objective: To study care outcomes associated with a network of hospitalist services compared to traditional providers.
- Design: Retrospective review of administrative data.
- Setting and participants: Patients from a large integrated health care system in British Columbia in western Canada admitted and cared for by 3 provider groups between April 1, 2012, and March 31, 2018: hospitalists, family physicians (FP), and internal medicine (IM) physicians:
- Measurements: Average total length of stay (LOS), 30-day readmission, in-hospital mortality, and hospital standardized mortality ratio (HSMR) were the study outcome measures. Multiple logistic regression or generalized regression were completed to determine the relationship between provider groups and outcomes.
- Results: A total of 248,412 hospitalizations were included. Compared to patients admitted to hospitalists, patients admitted to other providers had higher odds of mortality (odds ratio [OR] for FP, 1.29; 95% confidence interval [CI], 1.21-1.37; OR for IM, 1.24; 95% CI, 1.15-1.33). Compared to hospitalist care, FP care was associated with higher readmission (OR, 1.27; 95% CI, 1.22-1.33), while IM care showed lower odds of readmission (OR, 0.83; 95% CI, 0.79-0.87). Patients admitted to the IM group had significantly lower total LOS (mean, 5.13 days; 95% CI, 5.04-5.21) compared to patients admitted to hospitalists (mean, 7.37 days; CI, 7.26-7.49) and FPs (mean, 7.30 days; 95% CI, 7.19-7.41). In a subgroup analysis of patients presenting with congestive heart failure, chronic obstructive pulmonary disease, and pneumonia, these general tendencies broadly persisted for mortality and LOS comparisons between FPs and hospitalists, but results were mixed for hospital readmissions.
- Conclusion: Care provided by hospitalists was associated with lower mortality and readmission rates compared with care provided by FPs, despite similar LOS. These findings may reflect differences in volume of services delivered by individual physicians, on-site availability to address urgent medical issues, and evolving specialization of clinical and nonclinical care processes in the acute care setting.
Keywords: hospital medicine; length of stay; readmission; mortality.
The hospitalist model of care has undergone rapid growth globally in recent years.1 The first hospitalist programs in Canada began around the same time as those in the United States and share many similarities in design and operations with their counterparts.2-4 However, unlike in the United States, where the hospitalist model has successfully established itself as an emerging specialty, debates about the merits of the model and its value proposition continue among Canadian observers.5-9
Historically, the type of physicians who acted as the most responsible provider (MRP) in Canadian hospitals depended on setting and geography.10 In large urban areas, groups of general internists or specialists have historically looked after general medicine patients as part of university-affiliated teaching services.11,12 Patients admitted to community hospitals have traditionally been cared for by their own primary care providers, typically general practitioners or family physicians (FPs). In the mid-1990s, many primary care providers in urban centers began to withdraw from inpatient care and primarily focused their practices in the outpatient setting.13-15 Hospitalist programs emerged as health care administrators sought to fill the resulting gap in MRP coverage.2,10
To date, attempts to understand the impact of hospitalist programs in Canada have been limited. A number of early studies aimed to describe16 the role of hospitalists in Canada and suggested improvements in length of stay (LOS) and staff satisfaction.17 However, these studies relied on unadjusted before-after comparisons and lacked methodological rigor to draw robust conclusions. More recently, a few studies have evaluated care outcomes associated with hospitalists using administrative databases, which attempted to control for potential confounding factors.18-21
While these studies are beginning to shed some light on the impact of hospital medicine programs in Canada, there are a number of issues that limit their generalizability. For example, the majority of studies to date focus on hospital medicine programs in Canada’s largest province (Ontario), and most describe experiences from single institutions. Since each of the 13 provincial and territorial governments organizes its health care system differently,22 results from 1 province may not be generalizable to other parts of the country. Moreover, hospitalists in Ontario are more diverse in their training backgrounds, with a larger percentage having trained in general internal medicine (IM), as compared to other parts of Canada, where the majority of hospitalists are overwhelmingly trained as FPs.3
We aimed to study care outcomes associated with a network of hospitalist services compared to “traditional” providers (community-based FPs and IM specialists) in a large integrated health care system in the province of British Columbia in western Canada. The hospital medicine services in this network span a range of community and academic hospitals, and collectively constitute 1 of the largest regional programs in the country. This provides a unique opportunity to understand the impact of hospitalists on outcome measures across a range of acute care institutions.
Methods
Setting and Population
Fraser Health Authority is 1 of 5 regional health authorities in British Columbia that emerged in 2001.23,24 It operates a network of hospitalist programs in 10 of its 12 acute care hospitals. In addition to hospitalists, there are a variable number of “traditional” physician providers who continue to act as MRPs. These include community-based FPs who continue to see their own patients in the hospital, either as part of a solo-practice model or a clinic-based call group. There are also a number of general internists and other subspecialists who accept MRP roles for general medicine patients who may present with higher-acuity conditions. As a result, patients requiring hospitalization due to nonsurgical or noncritical care conditions at each Fraser Health hospital may be cared for by a physician belonging to 1 of 3 groups, depending on local circumstances: an FP, a hospitalist, or an internist.
Inclusion and Exclusion Criteria
In order to evaluate comparative outcomes associated with hospitalist care, we included all patients admitted to a physician in each of the 3 provider groups between April 1, 2012, and March 31, 2018. We chose this time period for 2 reasons: first, we wanted to ensure comparability over an extended period of time, given the methodological changes implemented in 2009 by the Canadian Institute for Health Information (CIHI), the federal organization in the country responsible for setting standards for health care measures.25 Second, previous internal reviews had suggested that data quality prior to this year was inconsistent. We only considered hospitalizations where patients were admitted to and discharged by the same service, and excluded 2 acute care facilities and 1 free-standing rehabilitation facility without a hospitalist service during this period. We also excluded patients who resided in a location beyond the geographic catchment area of Fraser Health. Further details about data collection are outlined in the Appendix.
Measures
We used the framework developed by White and Glazier26 to inform the selection of our outcome measures, as well as relevant variables that may impact them. This framework proposes that the design of the inpatient care model (structures and processes of care) directly affects care outcomes. The model also proposes that patient and provider attributes can modulate this relationship, and suggests that a comprehensive evaluation of hospitalist performance needs to take these factors into account. We identified average total LOS, 30-day readmission rate, in-hospital mortality, and hospital standardized mortality ratio (HSMR)27 as primary outcome measures. HSMR is defined as actual over expected mortality and is measured by CIHI through a formula that takes into account patient illness attributes (eg, the most responsible diagnosis, comorbidity levels) and baseline population mortality rates.27 We chose these measures because they are clinically relevant and easy to obtain and have been utilized in previous similar studies in Canada and the United States.18-21,26
Statistical Analysis
Baseline demographic and clinical differences in patient outcomes were examined using independent t-tests or chi-square tests. Furthermore, baseline differences based on provider groups were explored using analysis of variance or chi-square tests. Multiple logistic regression analyses were completed to determine the relationship between provider groups and readmission and mortality, while the relationship between provider groups and hospital LOS was determined with generalized linear regression (using gamma distribution and a log link). Gamma distribution with a log link analysis is appropriate with outcome measures that are positively skewed (eg, hospital LOS). It assumes that data are sampled from an exponential family of distributions, thus mimicking a log-normal distribution, and minimizes estimation bias and standard errors. These analyses were completed while controlling for the effects of age, gender, and other potential confounding factors.
We initially attempted to control for case mix by incorporating case-mix groups (CMGs) in our multivariate analysis. However, we identified 475 CMGs with at least 1 patient in our study population. We then explored the inclusion of major clinical categories (MCCs) that broadly group CMGs into various higher order/organ-system level categories (eg, diseases of the respiratory system); however, we could not aggregate them into sufficiently homogenous groups to be entered into regression models. Instead, we conducted subgroup analyses on patients in our study population who were hospitalized with 1 of the following 3 CMGs: chronic obstructive pulmonary disease (COPD, n = 11,404 patients), congestive heart failure without coronary angiography (CHF, n = 7680), and pneumonia (itself an aggregate of 3 separate CMGs: aspiration pneumonia, bacterial pneumonia, viral/unspecified pneumonia, n = 11,155). We chose these CMGs as they are among the top 8 presentations for all 3 provider groups.
For all outcome measures, we excluded atypical patients (defined by CIHI as those with atypically long stays) and patients who had been transferred between facilities. For the readmission analysis, we also excluded patients who died in the hospital (Appendix A). Data analyses were completed in IBM SPSS, version 21. For all analyses, significance was determined using 2-tailed test and alpha < 0.05.
Ethics
The Fraser Health Department of Research and Evaluation reviewed this project to determine need for formal Ethics Review Board review, and granted an exemption based on institutional guidelines for program evaluations.
Results
A total of 132,178 patients were admitted to and discharged by 1 of the 3 study provider groups during the study period, accounting for a total of 248,412 hospitalizations. After excluding patients cared for in Fraser Health facilities without a hospitalist service and those who resided in a geographic area beyond Fraser Health, a total of 224,214 admissions were included in the final analysis.
Patient Characteristics
The demographic and clinical characteristics of patients by provider group are summarized in Table 1. Patients admitted to IM providers were substantially younger than those admitted to either FPs or hospitalists (61.00 vs 70.86 and 71.22 years, respectively; P < 0.005). However, patients admitted to hospitalists had higher degrees of complexity (as measured by higher comorbidity levels, number of secondary diagnoses, and higher resource intensity weights [RIWs]; P < 000.1 for all comparisons). Overall, the most common CMGs seen by FPs and hospitalists were similar, while IM providers primarily saw patients with cardiac conditions (Table 2).
Trends Over Time
During the study period, the number of patients admitted to the hospitalist services increased by 24%, while admissions to FPs and IM providers declined steadily (Figure). During this time, LOS for hospitalists progressively declined, while LOS for FPs and IM providers increased. Similar trends were observed for measures of mortality, while readmission rates remained constant for FPs, despite a decline observed for other providers.
Mortality
Table 3 summarizes the relationship between provider groups and in-hospital mortality (n = 183,779). Controlling for other variables, patients admitted to FP and IM providers had higher odds of mortality when compared to hospitalists (odds ratio [OR] for FPs, 1.29; 95% confidence interval [CI], 1.21-1.37; OR for IM, 1.24; 95% CI, 1.15-1.33). Older age, higher comorbidity level, higher number of secondary diagnoses, higher use of hospital resources (as measured by RIWs), longer than expected hospital stay (as measured by conservable days), and male gender were also associated with higher mortality. Similarly, patients receiving palliative care and those who spent at least 1 day in a special care unit (critical care, observation, and monitored care units) also had higher odds of mortality. On the other hand, admission to nonteaching medium facilities and longer hospital stay were associated with lower mortality. Compared to the first year of this analysis, lower mortality rates were observed in subsequent fiscal years. Finally, there appear to be geographic variations in mortality within Fraser Health.
Our analysis of patients with COPD, CHF, and pneumonia showed mixed results (Table 4). Patients admitted to the FP provider group with CHF and pneumonia had higher mortality compared to hospitalists (OR for CHF, 1.77; 95% CI, 1.38-2.27; OR for pneumonia, 1.53; 95% CI, 1.25-1.88), with a similar but nonstatistically significant trend observed for patients with COPD (OR, 1.29; 95% CI, 0.99-1.70). On the other hand, the higher observed mortality associated with the IM provider group in the overall study population only persisted for patients with COPD (OR, 2.71; 95% CI, 1.94-3.80), with no statistically significant differences for patients with CHF (OR, 1.18; 95% CI, 0.84-1.65) and pneumonia (OR, 0.93; 95% CI, 0.69-1.25).
We also studied adjusted mortality as measured by HSMRs. Currently, our Health Information Management system calculates an HSMR value for each patient admitted to our acute care facilities using the methodology developed by CIHI. Prior internal audits demonstrated that our internal calculations closely approximate those reported nationally. Our analysis suggests that over time, HSMR rates for the 3 provider groups have diverged, with patients admitted to IM providers having a higher mortality rate than what would be expected based on the presenting clinical conditions and comorbidity levels (Figure, part D).
Readmission
The results of our multiple logistic regression for readmission are summarized in Table 5 (n = 166,042). The impact of provider group on 30-day readmission is mixed, with higher odds associated with FPs compared to hospitalists (OR, 1.27; 95% CI, 1.22-1.34) and lower odds associated with IM physicians (OR, 0.83; 95% CI, 0.79-0.87). Gender and RIW did not show any significant associations, but increasing age, higher number of secondary diagnoses, higher comorbidity levels, and longer than expected LOS (as measure by conservable days) were associated with higher odds of readmission. Conversely, longer hospitalization, admission to a large community hospital, palliative status, admission to a special care unit, geography, and fiscal year were associated with lower odds of readmission.
The above differences between provider groups were no longer consistently present when we analyzed patients presenting with COPD, CHF, and pneumonias (Table 6). Only patients admitted to the FP provider group with pneumonia had higher odds of readmission compared to hospitalists (OR, 1.27; 95% CI, 1.05-1.54). Conversely, only patients admitted to the IM provider group with CHF showed lower readmission (OR, 0.75; 95% CI, 0.62-0.92).
Total LOS
Results using generalized linear regressions for total LOS are presented in Table 7 (n = 183,779). Patients admitted to the IM provider group had significantly lower total LOS (mean, 5.13 days; 95% CI, 5.04-5.21) compared to the hospitalist (mean, 7.37 days; 95% CI, 7.26-7.49) and FP (mean, 7.30 days; 95% CI, 7.19-7.41) groups, with no significant differences between the latter 2 groups. Older patients, females, patients with higher comorbidity levels or number of secondary diagnoses, higher RIW, palliative patients, and discharge to a facility other than the patient’s home were associated with a significantly longer LOS. On the other hand, admission to nonteaching hospitals and admission to a special care unit was associated with lower LOS.
When we compared total LOS for patients admitted with COPD, CHF, and pneumonias, the same differences observed for the broader comparisons persisted: IM patients consistently showed shorter LOS compared to hospitalist patients, while LOS associated with FP patients was similar (Table 8).
Discussion
To our knowledge, our evaluation is the largest study to date designed to understand outcomes associated with hospitalist care in Canada. Our analyses suggest that patients admitted to our large network of hospitalist services present with clinical conditions that are very similar to those of general medicine patients in other Canadian provinces.28,29 They also show that patients cared for by hospitalists experience lower mortality rates compared to those cared for by FPs. Our findings are similar to previous studies, which have suggested a 12% to 75% reduction in odds of mortality associated with hospitalist care.18,19 These differences persisted even when we focused on patients presenting with specific clinical conditions (CHF, COPD, and pneumonias).
White and colleagues have previously demonstrated that generalist physicians who had higher volumes of inpatient care activity also had lower mortality rates compared to those who cared for hospitalized patients less frequently.19 An association between higher physician caseloads and better outcomes has been established for many surgical and medical conditions.30-32 Given that 85% of hospitalists in our program have post-graduate medical training in family medicine (internal department surveys, data not shown), it is less likely that training background can explain differences in outcomes. Instead, differences in patient volumes and the dedicated focus of hospitalists on acute care are likely more important contributors to lower mortality. In our program, a full-time hospitalist spends an average of 2000 hours annually providing services in the hospital setting. The continuous on-site presence of hospitalists enhances their clinical experience with regards to the management of common medical conditions, and increases their exposure to less common presentations of illnesses. The ability to respond to deteriorating patients in a timely manner may be another factor in explaining the differences in mortality rates between dedicated hospital-based generalist providers and similarly trained physicians with a primarily community-based focus.
In our study, hospitalist care was also broadly associated with lower mortality compared to the IM providers, although these differences were not consistently present when patients with specific diagnoses were compared. This may be partly explained by the relationship between caseload and outcomes, but other factors may also be important. For example, patients admitted by IM providers spend significantly more time in specialized units. They also predominantly present with cardiac conditions, and as such may have higher acuity levels and require more invasive interventions. While this may explain the higher observed mortality, a within-group comparison still suggests higher than expected mortality for IM patients. The HSMR methodology measures actual mortality rates compared to what would be expected based on clinical presentation and baseline population characteristics. Calculating HSMR is highly dependent on proper documentation and chart abstraction,33,34 and it is possible that some of the differences observed are due to incomplete physician documentation. However, a more in-depth analysis of care processes will be required to clarify the observed trends.
Compared to hospitalists, patients cared for by FPs also had higher odds of readmission within 30 days, which is consistent with prior studies.18,19 One of the criticisms of the hospitalist model has been the inherent discontinuity of care that is built into the model, which can contribute to suboptimal transitions of care between the acute and community settings.35 The expectation is that FPs who admit their own patients do not face this challenge, and as a result their patients should be readmitted less frequently after discharge. Our data and those from previous studies do not support this hypothesis. At the same time, when we studied patients with specific clinical diagnoses, only those hospitalized for pneumonias continued to demonstrate higher readmission odds. This suggests that hospital readmission rate is a complex measure that may be influenced by a multitude of hospital and community factors, and may be different for patients who present with different clinical diagnoses. Further research is required to better understand the relationship between provider type and experience with hospital readmission for patients with various clinical presentations.
Unlike the United States, where hospitalist care has been associated with reductions in LOS,26,36 studies in the Canadian health care setting have shown mixed results.17-21 In our evaluation, hospitalist care is not associated with reductions in total LOS compared to care provided by FPs or IM physicians. This could be due to a number of factors. First, unlike FPs, who know their patients, hospitalists may have a more conservative risk tolerance in discharging patients with whom they are not familiar. Similarly, physicians who have trained in IM may have a lower threshold for discharging patients than hospitalists, whose training background is mainly rooted in family medicine.3 Second, discontinuity of care has been associated with longer LOS for hospitalized patients.37,38 Hospitalists generally work for 7- to 10-day rotations. As a result, a patient may see a number of different hospitalists during the same hospital stay, which could nullify any gains in LOS that may be expected from better familiarity with hospital processes. Third, whereas a FP or an internist may only have a few inpatients under their care at any given time, each hospitalist typically cares for 17 to 22 patients every day. Increasing hospitalist workload has been shown to negatively impact LOS and may result in lower efficiency.39 Finally, many patients in our health system who require more time to recuperate or need complex discharge planning are usually transferred to the care of the hospitalist service from other services, or are preferentially admitted to hospitalists from the emergency department. As a result, hospitalists may look after a disproportionately higher number of long-stay patients. Despite all this, hospitalists in our population perform similarly to FPs, regardless of the clinical diagnoses of hospitalized patients.
Our study has a number of notable limitations. First, we used administrative data to conduct our evaluation and could only control for factors that are available in our data systems. As a result, some potential confounders may not have been taken into consideration. For example, our databases do not contain provider characteristics (eg, age, years of clinical experience) that have been deemed to be relevant by White and Glazier.26 Similarly, we did not have all the necessary information about the characteristics of the various MRP programs (eg, number of physicians involved in group practices, the schedule model of community FP call groups) and were not able to account for the potential impact of these on observed outcomes. Second, although our findings mirror prior studies from other parts of Canada, they may not be applicable to hospitalist programs in other jurisdictions or in health systems that are not regionalized or integrated. Third, our IM provider group is heterogeneous, with a number of different IM subspecialties (cardiologists, gastroenterologists, general internists) grouped under the IM category in our database. As a result, comparisons between the IM provider group and the other 2 provider groups, which are more homogenous, should be interpreted with caution.
Finally, we included only patients admitted to facilities in which a hospitalist service existed during the study period. As a result, a medium-size community hospital without a hospitalist service where patients are cared for exclusively by FPs and IM physicians was not included in the comparisons, and in 4 of the 10 facilities included, the number of FP patients was less than 10% of total hospitalized patients at the site (Appendix A). This may have resulted in an under-representation of FP patients.
Conclusion
Debates about the merits of the hospitalist model in Canada continue, and are in part fueled by a paucity of robust evidence about its impact on care outcomes compared to more traditional ways of providing inpatient care. In our evaluation, care provided by hospitalists is associated with lower mortality and readmission rates, despite similar LOS compared with FPs. Hospitalist care is also associated with lower mortality compared to IM providers. Hospitalists also demonstrated progressive improvement over time, with decreasing LOS and mortality rates and a stable readmission rate. Our results suggest that physicians with a focus on inpatient care can have positive contributions to quality and efficiency of care in Canada.
Corresponding author: Vandad Yousefi MD, CCFP, FHM, Fraser Health Authority, 400, 13450–102 Avenue, Surrey BC V3T 0H1, Canada.
Financial disclosures: None.
1. Kisuule F, Howell E. Hospital medicine beyond the United States. Int J Gen Med. 2018;11:65-71.
2. Yousefi V, Wilton D. Dedesigning hospital care: learning from the experience of hospital medicine in Canada. J Global Health Care Syst. 2011;1(3).
3. Soong C, Fan E, Howell E, et al. Characteristics of hospitalists and hospitalist programs in the United States and Canada. J Clin Outcomes Manag. 2009;16:69-76.
4. Yousefi V. How Canadian hospitalists spend their time - A work-sampling study within a hospital medicine program in Ontario. J Clin Outcomes Manag. 2011;18:159-166.
5. Wilson G. Are inpatients’ needs better served by hospitalists than by their family doctors? No. Can Fam Physician. 2008;54:1101-1103.
6. Samoil D. Are inpatients’ needs better served by hospitalists than by their family doctors: Yes? Can Fam Physician. 2008;54:1100-1101.
7. Nicolson B. Where’s Marcus Welby when you need him? BC Medical J. 2016;58:63-64.
8. Lemire F. Enhanced skills in family medicine: Update. Can Fam Physician. 2018;64:160.
9. Lerner J. Wanting family medicine without primary care. Can Fam Physician. 2018; 64:155.
10. Canadian Society of Hospital Medicine. Core Competencies in Hospital Medicine - Care of the Medical Inpatient. 2015.
11. Redelmeier DA. A Canadian perspective on the American hospitalist movement. Arch Intern Med. 1999;159:1665-1668.
12. Ghali WA, Greenberg PB, Mejia R, et al. International perspectives on general internal medicine and the case for “globalization” of a discipline. J Gen Intern Med. 2006;21:197-200.
13. Day A, MacMillan L. Neglect of the inpatient: The hospitalist movement in Canada responds. Hosp Q. 2001;4:36.
14. Sullivan P. Enter the hospitalist: New type of patient creating a new type of specialist. CMAJ. 2000;162:1345-1346.
15. Chan BTB. The declining comprehensiveness of primary care. CMAJ. 2002;166:429-434.
16. Abenhaim HA, Kahn SR, Raffoul J, Becker MR. Program description: A hospitalist-run, medical short-stay unit in a teaching hospital. CMAJ. 2000;163:1477-1480.
17. McGowan B, Nightingale M. The hospitalist program a new specialty on the horizon in acute care medicine a hospital case study. BC Med J. 2003;45:391-394.
18. Yousefi V, Chong C. Does implementation of a hospitalist program in a Canadian community hospital improve measures of quality of care and utilization? An observational comparative analysis of hospitalists vs. traditional care providers. BMC Health Serv Res. 2013;13:204.
19. White HL. Assessing the prevalence, penetration and performance of hospital physicians in Ontario: Implications for the quality and efficiency of inpatient care. ProQuest Dissertations Publishing; 2016.
20. Gutierrez CA, Norris M, Chail M. Impact of a newly established hospitalist training program on patient LOS and RIW. Poster presented at the 9th Annual Canadian Society of Hospital Medicine Conference, September 23-25, 2011; Banff, Alberta.
21. Seth P, Nicholson K, Habbous S, Menard J. Implementation of a hospitalist medicine model in a full-service community hospital: Examining impact two years post-implementation on health resource use andpatient satisfaction. Poster presented at the 13th Annual Canadian Society of Hospital Medicine Conference. 2015; Niagara Falls, Ontario.
22. Lewis S. A system in name only--access, variation, and reform in Canada’s provinces. N Engl J Med. 2015;372:497-500.
23. Lewis S, Kouri D. Regionalization: Making sense of the Canadian experience. Healthcare Papers. 2004;5:12-31.
24. Fraser Health Authority. About Fraser health. www.fraserhealth.ca/about-us/about-fraser-health#.XFJrl9JKiUk. Updated 2018. Accessed January 30, 2019.
25. Canadian Institute for Health Information. CMG+. https://www.cihi.ca/en/cmg. Accessed January 30, 2019.
26. White HL, Glazier RH. Do hospitalist physicians improve the quality of inpatient care delivery? A systematic review of process, efficiency and outcome measures. BMC Med. 2011;9:58.
27. Canadian Institute for Health Information. Hospital standardized mortality ratio technical notes. 2008. www.cihi.ca/sites/default/files/document/hsmr-tech-notes_en_0.pdf.
28. McAlister FA, Youngson E, Bakal JA, et al. Physician experience and outcomes among patients admitted to general internal medicine teaching wards. CMAJ. 2015;187:1041-1048.
29. Verma AA, Guo Y, Kwan JL, et al. Patient characteristics, resource use and outcomes associated with general internal medicine hospital care: The general medicine inpatient initiative (GEMINI) retrospective cohort study. CMAJ Open. 2017;5:E849.
30. Morche J, Mathes T, Pieper D. Relationship between surgeon volume and outcomes: A systematic review of systematic reviews. Syst Rev. 2016;5:204.
31. Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med. 2002;137:511-520.
32. Chen CH, Chen YH, Lin HC, Lin HC. Association between physician caseload and patient outcome for sepsis treatment. Infect Control Hosp Epidemiol. 2009;30:556-562.
33. van Gestel YR, Lemmens VE, Lingsma HF, et al. The hospital standardized mortality ratio fallacy: A narrative review. Med Care. 2012;50:662-667.
34. Scott IA, Brand CA, Phelps GE, et al. Using hospital standardised mortality ratios to assess quality of care—proceed with extreme caution. Med J Aust. 2011; 194:645-648.
35. Wachter RM. Hospitalists in the United States -- mission accomplished or work in progress? N Engl J Med. 2004;350:1935-1936.
36. Peterson MC. A systematic review of outcomes and quality measures in adult patients cared for by hospitalists vs nonhospitalists. Mayo Clin Proc. 2009;84:248-254.
37. Chandra S, Wright SM, Howell EE. The creating incentives and continuity leading to efficiency staffing model: A quality improvement initiative in hospital medicine. Mayo Clin Proc. 2012;87:364-371.
38. Epstein K, Juarez E, Epstein A, et al. The impact of fragmentation of hospitalist care on length of stay. J Hosp Med. 2010;5:335-338.
39. Elliott DJ, Young RS, Brice J, et al. Effect of hospitalist workload on the quality and efficiency of care. JAMA Intern Med. 2014;174:786-793.
1. Kisuule F, Howell E. Hospital medicine beyond the United States. Int J Gen Med. 2018;11:65-71.
2. Yousefi V, Wilton D. Dedesigning hospital care: learning from the experience of hospital medicine in Canada. J Global Health Care Syst. 2011;1(3).
3. Soong C, Fan E, Howell E, et al. Characteristics of hospitalists and hospitalist programs in the United States and Canada. J Clin Outcomes Manag. 2009;16:69-76.
4. Yousefi V. How Canadian hospitalists spend their time - A work-sampling study within a hospital medicine program in Ontario. J Clin Outcomes Manag. 2011;18:159-166.
5. Wilson G. Are inpatients’ needs better served by hospitalists than by their family doctors? No. Can Fam Physician. 2008;54:1101-1103.
6. Samoil D. Are inpatients’ needs better served by hospitalists than by their family doctors: Yes? Can Fam Physician. 2008;54:1100-1101.
7. Nicolson B. Where’s Marcus Welby when you need him? BC Medical J. 2016;58:63-64.
8. Lemire F. Enhanced skills in family medicine: Update. Can Fam Physician. 2018;64:160.
9. Lerner J. Wanting family medicine without primary care. Can Fam Physician. 2018; 64:155.
10. Canadian Society of Hospital Medicine. Core Competencies in Hospital Medicine - Care of the Medical Inpatient. 2015.
11. Redelmeier DA. A Canadian perspective on the American hospitalist movement. Arch Intern Med. 1999;159:1665-1668.
12. Ghali WA, Greenberg PB, Mejia R, et al. International perspectives on general internal medicine and the case for “globalization” of a discipline. J Gen Intern Med. 2006;21:197-200.
13. Day A, MacMillan L. Neglect of the inpatient: The hospitalist movement in Canada responds. Hosp Q. 2001;4:36.
14. Sullivan P. Enter the hospitalist: New type of patient creating a new type of specialist. CMAJ. 2000;162:1345-1346.
15. Chan BTB. The declining comprehensiveness of primary care. CMAJ. 2002;166:429-434.
16. Abenhaim HA, Kahn SR, Raffoul J, Becker MR. Program description: A hospitalist-run, medical short-stay unit in a teaching hospital. CMAJ. 2000;163:1477-1480.
17. McGowan B, Nightingale M. The hospitalist program a new specialty on the horizon in acute care medicine a hospital case study. BC Med J. 2003;45:391-394.
18. Yousefi V, Chong C. Does implementation of a hospitalist program in a Canadian community hospital improve measures of quality of care and utilization? An observational comparative analysis of hospitalists vs. traditional care providers. BMC Health Serv Res. 2013;13:204.
19. White HL. Assessing the prevalence, penetration and performance of hospital physicians in Ontario: Implications for the quality and efficiency of inpatient care. ProQuest Dissertations Publishing; 2016.
20. Gutierrez CA, Norris M, Chail M. Impact of a newly established hospitalist training program on patient LOS and RIW. Poster presented at the 9th Annual Canadian Society of Hospital Medicine Conference, September 23-25, 2011; Banff, Alberta.
21. Seth P, Nicholson K, Habbous S, Menard J. Implementation of a hospitalist medicine model in a full-service community hospital: Examining impact two years post-implementation on health resource use andpatient satisfaction. Poster presented at the 13th Annual Canadian Society of Hospital Medicine Conference. 2015; Niagara Falls, Ontario.
22. Lewis S. A system in name only--access, variation, and reform in Canada’s provinces. N Engl J Med. 2015;372:497-500.
23. Lewis S, Kouri D. Regionalization: Making sense of the Canadian experience. Healthcare Papers. 2004;5:12-31.
24. Fraser Health Authority. About Fraser health. www.fraserhealth.ca/about-us/about-fraser-health#.XFJrl9JKiUk. Updated 2018. Accessed January 30, 2019.
25. Canadian Institute for Health Information. CMG+. https://www.cihi.ca/en/cmg. Accessed January 30, 2019.
26. White HL, Glazier RH. Do hospitalist physicians improve the quality of inpatient care delivery? A systematic review of process, efficiency and outcome measures. BMC Med. 2011;9:58.
27. Canadian Institute for Health Information. Hospital standardized mortality ratio technical notes. 2008. www.cihi.ca/sites/default/files/document/hsmr-tech-notes_en_0.pdf.
28. McAlister FA, Youngson E, Bakal JA, et al. Physician experience and outcomes among patients admitted to general internal medicine teaching wards. CMAJ. 2015;187:1041-1048.
29. Verma AA, Guo Y, Kwan JL, et al. Patient characteristics, resource use and outcomes associated with general internal medicine hospital care: The general medicine inpatient initiative (GEMINI) retrospective cohort study. CMAJ Open. 2017;5:E849.
30. Morche J, Mathes T, Pieper D. Relationship between surgeon volume and outcomes: A systematic review of systematic reviews. Syst Rev. 2016;5:204.
31. Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med. 2002;137:511-520.
32. Chen CH, Chen YH, Lin HC, Lin HC. Association between physician caseload and patient outcome for sepsis treatment. Infect Control Hosp Epidemiol. 2009;30:556-562.
33. van Gestel YR, Lemmens VE, Lingsma HF, et al. The hospital standardized mortality ratio fallacy: A narrative review. Med Care. 2012;50:662-667.
34. Scott IA, Brand CA, Phelps GE, et al. Using hospital standardised mortality ratios to assess quality of care—proceed with extreme caution. Med J Aust. 2011; 194:645-648.
35. Wachter RM. Hospitalists in the United States -- mission accomplished or work in progress? N Engl J Med. 2004;350:1935-1936.
36. Peterson MC. A systematic review of outcomes and quality measures in adult patients cared for by hospitalists vs nonhospitalists. Mayo Clin Proc. 2009;84:248-254.
37. Chandra S, Wright SM, Howell EE. The creating incentives and continuity leading to efficiency staffing model: A quality improvement initiative in hospital medicine. Mayo Clin Proc. 2012;87:364-371.
38. Epstein K, Juarez E, Epstein A, et al. The impact of fragmentation of hospitalist care on length of stay. J Hosp Med. 2010;5:335-338.
39. Elliott DJ, Young RS, Brice J, et al. Effect of hospitalist workload on the quality and efficiency of care. JAMA Intern Med. 2014;174:786-793.