Management of Chronic Conditions

Over the past 2 decades, the care of the hospitalized patient has changed dramatically. Hospitalists now account for the care of more than one‐third of general medicine inpatients, and this number is likely to grow.[1] The emergence of hospital medicine has resulted in a partnership between primary care physicians (PCPs) and hospitalists wherein hospitalists focus on acute medical issues requiring hospitalization, whereas more chronic issues unrelated to the reason for hospitalization remain largely the domain of the PCP.[2, 3]

However, several evolving financial and quality incentives have already begun to blur the distinction between inpatient and outpatient care. First, as private and public payers increasingly scrutinize readmission rates, it has become clear that the responsibility for patient outcomes extends beyond the day of discharge.[4] The birth of Accountable Care Organizations and patient‐centered medical homes may further blur distinctions between what has traditionally constituted inpatient and outpatient care.[5] Bundled payments may force providers to ensure that each visit, whether hospital‐ or clinic‐based, is taken as an opportunity to enact meaningful change.[6] The Centers for Medicare and Medicaid Services (CMS) are already tracking hospital performance on institution of medical therapy for certain conditions regardless of their relatedness to the reason for hospitalization.[7]

No published literature has yet examined the attitudes of inpatient and outpatient providers regarding this issue. Through a case‐based survey conducted at 3 large urban academic medical centers, we aimed to assess opinions among hospitalists and PCPs regarding the role of hospitalists in the management of conditions unrelated to the reason for admission. Our study had 2 main objectives: (1) to determine whether surveyed physicians were more likely to rate an inpatient intervention as appropriate when it related to the reason for admission as compared to interventions unrelated to the reason for admission; and (2) to determine whether these attitudes differed between PCPs and hospitalists.

METHODS

Survey Administration

Between October 23, 2012 and November 10, 2012, 3 emails containing a link to the online survey were sent to all hospitalist and hospital‐based PCPs at the 3 study institutions. The BIDMC Committee on Clinical Investigations, to whom authority was ceded by the remaining 2 study institutions, certified this research protocol as exempt.

RESULTS

DISCUSSION

In this survey‐based study of PCPs and hospitalists across 3 Boston‐area academic medical centers, we found that: (1) physicians were more likely to see inpatient interventions as appropriate when those interventions dealt with the reason for admission as compared to interventions unrelated to the reason for admission; and (2) PCPs were more likely than hospitalists to feel that inpatient interventions were appropriate, even when they targeted chronic conditions unrelated to the reason for admission. To our knowledge, this study represents the first investigation into the attitudes of PCPs and hospitalists regarding the inpatient management of conditions unrelated to the reason for admission.

That surveyed physicians, regardless of role, were less likely to report an intervention unrelated to the reason for hospitalization as appropriateeven those with likely mortality benefitsuggests that opportunities to affect meaningful change may be missed in a healthcare system that adheres to strict inpatient and outpatient roles. For several of the cases, a change in therapy could lead to benefit soon after implementation. For example, aldosterone antagonists reduce mortality as early as 1 month after initiation in select patients.[8] If a major goal of inpatient care is to reduce 30‐day mortality, it could be argued that hospitalists should more actively adjust congestive heart failure therapy in appropriate inpatients, even when this is not their admitting diagnosis.

For some conditions, CMS is already tracking hospital performance. Since 2003, hospitals have been required to document whether a patient with congestive heart failure (either acute or chronic and regardless of the relationship to admission) was prescribed an angiotensin‐converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) at the time of discharge.[7] CMS has determined that the proven benefits of ACE inhibitors and ARBs confer hospital accountability for their inclusion in appropriate patients, independent of the acuity of heart failure. There are many potential therapeutic maneuvers on which health systems (and their physicians) may be graded, and accepting the view that a hospitalization provides a window of opportunity for medical optimization may allow for more fruitful interventions and more patient‐centered care.

Despite the potential benefits of addressing chronic medical issues during hospitalization, there are important limitations on what can and/or should be done in the hospital setting. Hospitalizations are a time of fluctuating clinical status, which continues beyond discharge and is often accompanied by several medication changes.[9] In our study, more than 20% of those who believed that a medication intervention was inappropriate selected I do not believe hospitalization is the right time to start this new medication as one of their explanations. Although some medication interventions have been shown in randomized controlled trials to reduce short‐term mortality, the ability to generalize these findings to the average hospitalized patient with multiple comorbidities, concurrent medication changes, and rapidly fluctuating clinical status is limited. Furthermore, there are interventions most would agree should not be dealt with in the hospital (eg, screening colonoscopy) and encounters that may be too short to allow for change (eg, 24‐hour observation). These issues notwithstanding, the average 4‐day hospitalization likely provides an opportunity for monitored change that may currently be underutilized.

Our study suggests several additional explanations for physicians' current practice and opinions. Only 6.5% of respondents who answered that an intervention was inappropriate indicated as a justification that I do not believe this is an appropriate pharmacologic intervention for this particular medical problem. This suggests that the hesitancy has little to do with a lack of benefit but instead relates to systems issues (eg, access to all pertinent records and concerns regarding follow‐up testing) and perceived limitations to what a hospitalist should and should not do without actively involving the PCP. There are likely additional concerns that the medical record and/or patient histories do not fully outline the rationale for exclusion or inclusion of particular medications. Advances in information technology that enhance information exchange and enable streamlined communication may help to address these perceived barriers. However, an additional barrier may be trust, as PCPs appear more concerned that hospitalists will not review all the pertinent records or discuss risks and benefits before enacting important medication changes. Increased attempts at communication between hospitalists and outpatient providers may help to build trust and alleviate concerns regarding the loss of information that often occurs both on admission and at discharge.

We also noted that PCPs were more likely than hospitalists to feel that inpatient interventions were appropriate, even when targeting chronic conditions unrelated to the reason for admission. It may be that PCPs, with an increasing number of problems to address per outpatient visit,[10, 11] are more open to hospitalists managing any medical problems during their patients' admissions. At the same time, with increased acuity[12, 13, 14] and shortened length of stays,[15, 16] hospitalists have only a finite amount of time to ensure acute issues are managed, leaving potentially modifiable chronic conditions to the outpatient setting. These differences aside, a minority of both PCPs and hospitalists in our study were ready to embrace the idea of hospitalists playing a larger role in the management of conditions unrelated to the reason for hospitalization.

Even though our study benefits from its multisite design, there are a number of limitations. First, although we crafted our survey with input from general medicine focus groups, our survey instrument has not been validated. In addition, the cases are necessarily contrived and do not take into account the complexities of inpatient medicine. Furthermore, though our goal was to create paired cases that isolate a management decision as being simply based on whether it was related or unrelated to the reason for admission, it is possible that other factors, not captured by our survey, influenced the responses. For example, the benefits of aspirin as part of secondary prevention are not equal to the benefits in an acute MI.[17]

In an attempt to isolate the hospitalists' role in these management decisions, respondents were instructed to assume that the decisions were being made without discussing it with the primary care physician, but that the hospitalist would communicate the details of any hospitalization at the time of discharge. They were also instructed to assume that the hospitalist has access to the patient's outpatient electronic medical record. These assumptions were made to address concerns regarding the flow of information and communication, and to simulate the ideal system from a communication and information accessibility standpoint. Had these assumptions not been placed, the responses may have differed. It is likely that PCPs and hospitalists practicing in systems without shared, accessible inpatient/outpatient medical records would be even more reluctant to enact medication changes unrelated to the reason for admission.

Along the same lines, our physician cohort consisted of several metropolitan academic physician groups, in which hospitalists have had a presence for almost 20 years. As a result, our findings may not be generalizable to other academic hospitals, community‐based hospitalist programs, or nonhospital‐based PCP practices. Finally, we do not know whether survey nonresponders differed from responders in ways that could have meaningfully affected our results.

In conclusion, our findings suggest that both PCPs and hospitalists see the management of conditions unrelated to the reason for admission as less appropriate than the management of conditions related to the reason for admission. Our findings also suggest that PCPs may be more open to this practice when compared to hospitalists. Failure to capitalize on opportunities for meaningful medical interventions, independent of patient location, suggests a possible lack of patient centeredness in the current partnership between PCPs and hospitalists. Further studies should examine existing barriers and investigate interventions designed to address those barriers, in an effort to improve both quality of care and the degree of patient‐centeredness in our current healthcare system.

Disclosures: Dr. Herzig is supported by a grant from the National Institute on Aging (K23 AG042459). Dr. Herzig had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Author contributions: study concept and design, Breu, Allen‐Dicker, Mueller, Herzig; acquisition of data, Breu, Allen‐Dicker, Mueller, Palamara, Herzig; analysis and interpretation of data, Breu, Allen‐Dicker, Hinami, Herzig; drafting of the manuscript, Breu; critical revision of the manuscript for important intellectual content, Breu, Allen‐Dicker, Mueller, Palamara, Hinami, Herzig; statistical analysis, Allen‐Dicker, Hinami, Herzig; study supervision, Breu, Herzig. This study was presented as a poster at the Society of Hospital Medicine National Meeting, Washington, DC, May 17, 2013.

Over the past 2 decades, the care of the hospitalized patient has changed dramatically. Hospitalists now account for the care of more than one‐third of general medicine inpatients, and this number is likely to grow.[1] The emergence of hospital medicine has resulted in a partnership between primary care physicians (PCPs) and hospitalists wherein hospitalists focus on acute medical issues requiring hospitalization, whereas more chronic issues unrelated to the reason for hospitalization remain largely the domain of the PCP.[2, 3]

However, several evolving financial and quality incentives have already begun to blur the distinction between inpatient and outpatient care. First, as private and public payers increasingly scrutinize readmission rates, it has become clear that the responsibility for patient outcomes extends beyond the day of discharge.[4] The birth of Accountable Care Organizations and patient‐centered medical homes may further blur distinctions between what has traditionally constituted inpatient and outpatient care.[5] Bundled payments may force providers to ensure that each visit, whether hospital‐ or clinic‐based, is taken as an opportunity to enact meaningful change.[6] The Centers for Medicare and Medicaid Services (CMS) are already tracking hospital performance on institution of medical therapy for certain conditions regardless of their relatedness to the reason for hospitalization.[7]

No published literature has yet examined the attitudes of inpatient and outpatient providers regarding this issue. Through a case‐based survey conducted at 3 large urban academic medical centers, we aimed to assess opinions among hospitalists and PCPs regarding the role of hospitalists in the management of conditions unrelated to the reason for admission. Our study had 2 main objectives: (1) to determine whether surveyed physicians were more likely to rate an inpatient intervention as appropriate when it related to the reason for admission as compared to interventions unrelated to the reason for admission; and (2) to determine whether these attitudes differed between PCPs and hospitalists.

METHODS

Survey Administration

Between October 23, 2012 and November 10, 2012, 3 emails containing a link to the online survey were sent to all hospitalist and hospital‐based PCPs at the 3 study institutions. The BIDMC Committee on Clinical Investigations, to whom authority was ceded by the remaining 2 study institutions, certified this research protocol as exempt.

RESULTS

DISCUSSION

In this survey‐based study of PCPs and hospitalists across 3 Boston‐area academic medical centers, we found that: (1) physicians were more likely to see inpatient interventions as appropriate when those interventions dealt with the reason for admission as compared to interventions unrelated to the reason for admission; and (2) PCPs were more likely than hospitalists to feel that inpatient interventions were appropriate, even when they targeted chronic conditions unrelated to the reason for admission. To our knowledge, this study represents the first investigation into the attitudes of PCPs and hospitalists regarding the inpatient management of conditions unrelated to the reason for admission.

That surveyed physicians, regardless of role, were less likely to report an intervention unrelated to the reason for hospitalization as appropriateeven those with likely mortality benefitsuggests that opportunities to affect meaningful change may be missed in a healthcare system that adheres to strict inpatient and outpatient roles. For several of the cases, a change in therapy could lead to benefit soon after implementation. For example, aldosterone antagonists reduce mortality as early as 1 month after initiation in select patients.[8] If a major goal of inpatient care is to reduce 30‐day mortality, it could be argued that hospitalists should more actively adjust congestive heart failure therapy in appropriate inpatients, even when this is not their admitting diagnosis.

For some conditions, CMS is already tracking hospital performance. Since 2003, hospitals have been required to document whether a patient with congestive heart failure (either acute or chronic and regardless of the relationship to admission) was prescribed an angiotensin‐converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) at the time of discharge.[7] CMS has determined that the proven benefits of ACE inhibitors and ARBs confer hospital accountability for their inclusion in appropriate patients, independent of the acuity of heart failure. There are many potential therapeutic maneuvers on which health systems (and their physicians) may be graded, and accepting the view that a hospitalization provides a window of opportunity for medical optimization may allow for more fruitful interventions and more patient‐centered care.

Despite the potential benefits of addressing chronic medical issues during hospitalization, there are important limitations on what can and/or should be done in the hospital setting. Hospitalizations are a time of fluctuating clinical status, which continues beyond discharge and is often accompanied by several medication changes.[9] In our study, more than 20% of those who believed that a medication intervention was inappropriate selected I do not believe hospitalization is the right time to start this new medication as one of their explanations. Although some medication interventions have been shown in randomized controlled trials to reduce short‐term mortality, the ability to generalize these findings to the average hospitalized patient with multiple comorbidities, concurrent medication changes, and rapidly fluctuating clinical status is limited. Furthermore, there are interventions most would agree should not be dealt with in the hospital (eg, screening colonoscopy) and encounters that may be too short to allow for change (eg, 24‐hour observation). These issues notwithstanding, the average 4‐day hospitalization likely provides an opportunity for monitored change that may currently be underutilized.

Our study suggests several additional explanations for physicians' current practice and opinions. Only 6.5% of respondents who answered that an intervention was inappropriate indicated as a justification that I do not believe this is an appropriate pharmacologic intervention for this particular medical problem. This suggests that the hesitancy has little to do with a lack of benefit but instead relates to systems issues (eg, access to all pertinent records and concerns regarding follow‐up testing) and perceived limitations to what a hospitalist should and should not do without actively involving the PCP. There are likely additional concerns that the medical record and/or patient histories do not fully outline the rationale for exclusion or inclusion of particular medications. Advances in information technology that enhance information exchange and enable streamlined communication may help to address these perceived barriers. However, an additional barrier may be trust, as PCPs appear more concerned that hospitalists will not review all the pertinent records or discuss risks and benefits before enacting important medication changes. Increased attempts at communication between hospitalists and outpatient providers may help to build trust and alleviate concerns regarding the loss of information that often occurs both on admission and at discharge.

We also noted that PCPs were more likely than hospitalists to feel that inpatient interventions were appropriate, even when targeting chronic conditions unrelated to the reason for admission. It may be that PCPs, with an increasing number of problems to address per outpatient visit,[10, 11] are more open to hospitalists managing any medical problems during their patients' admissions. At the same time, with increased acuity[12, 13, 14] and shortened length of stays,[15, 16] hospitalists have only a finite amount of time to ensure acute issues are managed, leaving potentially modifiable chronic conditions to the outpatient setting. These differences aside, a minority of both PCPs and hospitalists in our study were ready to embrace the idea of hospitalists playing a larger role in the management of conditions unrelated to the reason for hospitalization.

Even though our study benefits from its multisite design, there are a number of limitations. First, although we crafted our survey with input from general medicine focus groups, our survey instrument has not been validated. In addition, the cases are necessarily contrived and do not take into account the complexities of inpatient medicine. Furthermore, though our goal was to create paired cases that isolate a management decision as being simply based on whether it was related or unrelated to the reason for admission, it is possible that other factors, not captured by our survey, influenced the responses. For example, the benefits of aspirin as part of secondary prevention are not equal to the benefits in an acute MI.[17]

In an attempt to isolate the hospitalists' role in these management decisions, respondents were instructed to assume that the decisions were being made without discussing it with the primary care physician, but that the hospitalist would communicate the details of any hospitalization at the time of discharge. They were also instructed to assume that the hospitalist has access to the patient's outpatient electronic medical record. These assumptions were made to address concerns regarding the flow of information and communication, and to simulate the ideal system from a communication and information accessibility standpoint. Had these assumptions not been placed, the responses may have differed. It is likely that PCPs and hospitalists practicing in systems without shared, accessible inpatient/outpatient medical records would be even more reluctant to enact medication changes unrelated to the reason for admission.

Along the same lines, our physician cohort consisted of several metropolitan academic physician groups, in which hospitalists have had a presence for almost 20 years. As a result, our findings may not be generalizable to other academic hospitals, community‐based hospitalist programs, or nonhospital‐based PCP practices. Finally, we do not know whether survey nonresponders differed from responders in ways that could have meaningfully affected our results.

In conclusion, our findings suggest that both PCPs and hospitalists see the management of conditions unrelated to the reason for admission as less appropriate than the management of conditions related to the reason for admission. Our findings also suggest that PCPs may be more open to this practice when compared to hospitalists. Failure to capitalize on opportunities for meaningful medical interventions, independent of patient location, suggests a possible lack of patient centeredness in the current partnership between PCPs and hospitalists. Further studies should examine existing barriers and investigate interventions designed to address those barriers, in an effort to improve both quality of care and the degree of patient‐centeredness in our current healthcare system.

Disclosures: Dr. Herzig is supported by a grant from the National Institute on Aging (K23 AG042459). Dr. Herzig had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Author contributions: study concept and design, Breu, Allen‐Dicker, Mueller, Herzig; acquisition of data, Breu, Allen‐Dicker, Mueller, Palamara, Herzig; analysis and interpretation of data, Breu, Allen‐Dicker, Hinami, Herzig; drafting of the manuscript, Breu; critical revision of the manuscript for important intellectual content, Breu, Allen‐Dicker, Mueller, Palamara, Hinami, Herzig; statistical analysis, Allen‐Dicker, Hinami, Herzig; study supervision, Breu, Herzig. This study was presented as a poster at the Society of Hospital Medicine National Meeting, Washington, DC, May 17, 2013.

Over the past 2 decades, the care of the hospitalized patient has changed dramatically. Hospitalists now account for the care of more than one‐third of general medicine inpatients, and this number is likely to grow.[1] The emergence of hospital medicine has resulted in a partnership between primary care physicians (PCPs) and hospitalists wherein hospitalists focus on acute medical issues requiring hospitalization, whereas more chronic issues unrelated to the reason for hospitalization remain largely the domain of the PCP.[2, 3]

However, several evolving financial and quality incentives have already begun to blur the distinction between inpatient and outpatient care. First, as private and public payers increasingly scrutinize readmission rates, it has become clear that the responsibility for patient outcomes extends beyond the day of discharge.[4] The birth of Accountable Care Organizations and patient‐centered medical homes may further blur distinctions between what has traditionally constituted inpatient and outpatient care.[5] Bundled payments may force providers to ensure that each visit, whether hospital‐ or clinic‐based, is taken as an opportunity to enact meaningful change.[6] The Centers for Medicare and Medicaid Services (CMS) are already tracking hospital performance on institution of medical therapy for certain conditions regardless of their relatedness to the reason for hospitalization.[7]

No published literature has yet examined the attitudes of inpatient and outpatient providers regarding this issue. Through a case‐based survey conducted at 3 large urban academic medical centers, we aimed to assess opinions among hospitalists and PCPs regarding the role of hospitalists in the management of conditions unrelated to the reason for admission. Our study had 2 main objectives: (1) to determine whether surveyed physicians were more likely to rate an inpatient intervention as appropriate when it related to the reason for admission as compared to interventions unrelated to the reason for admission; and (2) to determine whether these attitudes differed between PCPs and hospitalists.

METHODS

Survey Administration

Between October 23, 2012 and November 10, 2012, 3 emails containing a link to the online survey were sent to all hospitalist and hospital‐based PCPs at the 3 study institutions. The BIDMC Committee on Clinical Investigations, to whom authority was ceded by the remaining 2 study institutions, certified this research protocol as exempt.

RESULTS

DISCUSSION

In this survey‐based study of PCPs and hospitalists across 3 Boston‐area academic medical centers, we found that: (1) physicians were more likely to see inpatient interventions as appropriate when those interventions dealt with the reason for admission as compared to interventions unrelated to the reason for admission; and (2) PCPs were more likely than hospitalists to feel that inpatient interventions were appropriate, even when they targeted chronic conditions unrelated to the reason for admission. To our knowledge, this study represents the first investigation into the attitudes of PCPs and hospitalists regarding the inpatient management of conditions unrelated to the reason for admission.

That surveyed physicians, regardless of role, were less likely to report an intervention unrelated to the reason for hospitalization as appropriateeven those with likely mortality benefitsuggests that opportunities to affect meaningful change may be missed in a healthcare system that adheres to strict inpatient and outpatient roles. For several of the cases, a change in therapy could lead to benefit soon after implementation. For example, aldosterone antagonists reduce mortality as early as 1 month after initiation in select patients.[8] If a major goal of inpatient care is to reduce 30‐day mortality, it could be argued that hospitalists should more actively adjust congestive heart failure therapy in appropriate inpatients, even when this is not their admitting diagnosis.

For some conditions, CMS is already tracking hospital performance. Since 2003, hospitals have been required to document whether a patient with congestive heart failure (either acute or chronic and regardless of the relationship to admission) was prescribed an angiotensin‐converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) at the time of discharge.[7] CMS has determined that the proven benefits of ACE inhibitors and ARBs confer hospital accountability for their inclusion in appropriate patients, independent of the acuity of heart failure. There are many potential therapeutic maneuvers on which health systems (and their physicians) may be graded, and accepting the view that a hospitalization provides a window of opportunity for medical optimization may allow for more fruitful interventions and more patient‐centered care.

Despite the potential benefits of addressing chronic medical issues during hospitalization, there are important limitations on what can and/or should be done in the hospital setting. Hospitalizations are a time of fluctuating clinical status, which continues beyond discharge and is often accompanied by several medication changes.[9] In our study, more than 20% of those who believed that a medication intervention was inappropriate selected I do not believe hospitalization is the right time to start this new medication as one of their explanations. Although some medication interventions have been shown in randomized controlled trials to reduce short‐term mortality, the ability to generalize these findings to the average hospitalized patient with multiple comorbidities, concurrent medication changes, and rapidly fluctuating clinical status is limited. Furthermore, there are interventions most would agree should not be dealt with in the hospital (eg, screening colonoscopy) and encounters that may be too short to allow for change (eg, 24‐hour observation). These issues notwithstanding, the average 4‐day hospitalization likely provides an opportunity for monitored change that may currently be underutilized.

Our study suggests several additional explanations for physicians' current practice and opinions. Only 6.5% of respondents who answered that an intervention was inappropriate indicated as a justification that I do not believe this is an appropriate pharmacologic intervention for this particular medical problem. This suggests that the hesitancy has little to do with a lack of benefit but instead relates to systems issues (eg, access to all pertinent records and concerns regarding follow‐up testing) and perceived limitations to what a hospitalist should and should not do without actively involving the PCP. There are likely additional concerns that the medical record and/or patient histories do not fully outline the rationale for exclusion or inclusion of particular medications. Advances in information technology that enhance information exchange and enable streamlined communication may help to address these perceived barriers. However, an additional barrier may be trust, as PCPs appear more concerned that hospitalists will not review all the pertinent records or discuss risks and benefits before enacting important medication changes. Increased attempts at communication between hospitalists and outpatient providers may help to build trust and alleviate concerns regarding the loss of information that often occurs both on admission and at discharge.

We also noted that PCPs were more likely than hospitalists to feel that inpatient interventions were appropriate, even when targeting chronic conditions unrelated to the reason for admission. It may be that PCPs, with an increasing number of problems to address per outpatient visit,[10, 11] are more open to hospitalists managing any medical problems during their patients' admissions. At the same time, with increased acuity[12, 13, 14] and shortened length of stays,[15, 16] hospitalists have only a finite amount of time to ensure acute issues are managed, leaving potentially modifiable chronic conditions to the outpatient setting. These differences aside, a minority of both PCPs and hospitalists in our study were ready to embrace the idea of hospitalists playing a larger role in the management of conditions unrelated to the reason for hospitalization.

Even though our study benefits from its multisite design, there are a number of limitations. First, although we crafted our survey with input from general medicine focus groups, our survey instrument has not been validated. In addition, the cases are necessarily contrived and do not take into account the complexities of inpatient medicine. Furthermore, though our goal was to create paired cases that isolate a management decision as being simply based on whether it was related or unrelated to the reason for admission, it is possible that other factors, not captured by our survey, influenced the responses. For example, the benefits of aspirin as part of secondary prevention are not equal to the benefits in an acute MI.[17]

In an attempt to isolate the hospitalists' role in these management decisions, respondents were instructed to assume that the decisions were being made without discussing it with the primary care physician, but that the hospitalist would communicate the details of any hospitalization at the time of discharge. They were also instructed to assume that the hospitalist has access to the patient's outpatient electronic medical record. These assumptions were made to address concerns regarding the flow of information and communication, and to simulate the ideal system from a communication and information accessibility standpoint. Had these assumptions not been placed, the responses may have differed. It is likely that PCPs and hospitalists practicing in systems without shared, accessible inpatient/outpatient medical records would be even more reluctant to enact medication changes unrelated to the reason for admission.

Along the same lines, our physician cohort consisted of several metropolitan academic physician groups, in which hospitalists have had a presence for almost 20 years. As a result, our findings may not be generalizable to other academic hospitals, community‐based hospitalist programs, or nonhospital‐based PCP practices. Finally, we do not know whether survey nonresponders differed from responders in ways that could have meaningfully affected our results.

In conclusion, our findings suggest that both PCPs and hospitalists see the management of conditions unrelated to the reason for admission as less appropriate than the management of conditions related to the reason for admission. Our findings also suggest that PCPs may be more open to this practice when compared to hospitalists. Failure to capitalize on opportunities for meaningful medical interventions, independent of patient location, suggests a possible lack of patient centeredness in the current partnership between PCPs and hospitalists. Further studies should examine existing barriers and investigate interventions designed to address those barriers, in an effort to improve both quality of care and the degree of patient‐centeredness in our current healthcare system.

Disclosures: Dr. Herzig is supported by a grant from the National Institute on Aging (K23 AG042459). Dr. Herzig had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Author contributions: study concept and design, Breu, Allen‐Dicker, Mueller, Herzig; acquisition of data, Breu, Allen‐Dicker, Mueller, Palamara, Herzig; analysis and interpretation of data, Breu, Allen‐Dicker, Hinami, Herzig; drafting of the manuscript, Breu; critical revision of the manuscript for important intellectual content, Breu, Allen‐Dicker, Mueller, Palamara, Hinami, Herzig; statistical analysis, Allen‐Dicker, Hinami, Herzig; study supervision, Breu, Herzig. This study was presented as a poster at the Society of Hospital Medicine National Meeting, Washington, DC, May 17, 2013.