Hospitalizations are increasingly viewed as an opportunity to optimize issues related and unrelated to a patient's reason for admission. The degree to which hospitalists and primary care physicians (PCPs) are comfortable with hospital‐based chronic disease management during a discrete episode of illness has not yet been examined. Through a case‐based survey, we compared PCP and hospitalist attitudes regarding inpatient management of issues both related and unrelated to a patient's reason for admission.
PCPs and hospitalists at 3 academic medical centers in Boston, Massachusetts, were e‐mailed 6 pairs of clinical cases, each consisting of (1) a management decision related to a patient's reason for admission and (2) the same management decision presented as unrelated to the patient's reason for admission (see Table). Respondents were asked to assume an absence of medical contraindications and rate the appropriateness of each intervention in the absence of prior discussion with the patient's PCP. Unadjusted comparisons of responses were performed using chi‐square tests.
One hundred sixty‐six of 300 surveys (55%) were returned. Response rates did not vary between hospitalists and PCPs. Median age was 46.5 years for PCPs and 37.4 years for hospitalists. Male respondents made up 42.7% of PCP respondents and 50% of hospitalist respondents. Of PCP respondents, 63.2% always used hospitalists for inpatient admissions. Overall physician respondents felt inpatient management of issues related to the reason for admission were more appropriate than inpatient management of issues unrelated to the reason for admission (78.9% vs. 38.7%, P < 0.001). Hospitalists were less likely than PCPs to feel that the surveyed inpatient management decisions were appropriate (64% vs. 52%, P < 0.001). This held for both issues related to (44.6% vs. 31.1%, P < 0.001) and unrelated to the reason for admission (83.4% vs. 73%; P < 0.001). The difference remained significant on subgroup analysis comparing hospitalists with PCPs who always used hospitalists for inpatient admissions (P < 0.001).
Hospitalists were significantly less likely than PCPs to rate surveyed management decisions as appropriate. These results suggest that hospitalists may feel inappropriately constrained in their clinical management, regardless of acuity, and may not be meeting the expectations of primary care physicians. Potential explanations for this disparity include clinical experience, practical concerns about postdischarge follow‐up, preconceived expectations regarding the role of the hospitalist, or response to criticism from a vocal minority of primary care physicians. Understanding the attitudes of physicians on this topic may improve the coordination of future inpatient–outpatient integrated care teams.
Example Clinical Case Set
|Set 1, Case 1 (Related Issue): A 60-year-old patient is admitted with a non-ST-elevation MI, medically managed without cardiac catheterization or percutaneous coronary intervention. Knowing that aspirin reduces mortality as part of secondary prevention in cardiovascular disease, how appropriate is it for the hospitalist to start the patient on this medication without discussing it with the primary care physician?|
|Set 1, Case 2 (Unrelated Issue):A 60-year-old patient with a medical history of a prior non-ST-elevation MI that was medically managed is admitted to the hospital for treatment of cellulitis. The hospitalist notes the patient is not on aspirin at home. Knowing that aspirin reduces mortality as part of secondary prevention in cardiovascular disease, how appropriate is it for the hospitalist to start the patient on this medication without discussing it with the primary care physician?|