“My Opinion on How to Improve Outcomes at Non-Academic Community Hospitals” by Steven P. LaRosa, M.D.

I recently read a publication in JAMA (JAMA. 2017;317(20):2105-2113) comparing outcomes in academic hospitals and non-teaching community hospitals for Medicare recipients. A statistically significant 1.5% higher mortality was observed in the non-teaching community hospitals than in academic centers. This higher mortality rate was observed for such routine infectious disease conditions including pneumonia (1.5%) and urinary tract infections (1%). As an ID physician who worked at academic centers for 11 years and in a non-teaching community hospital for the last 5 years this sent me into deep thought regarding why this difference existed.  There are no special diagnostic modalities or treatments for pneumonia and UTIs available at academic centers. There may be experts or “key opinion leaders” in pneumonia and UTIs at academic centers but they certainly would not be on hospital service enough to influence outcomes to this extent.

My hypothesis is that that the increase in mortality in non-teaching hospitals is due to the structure and workflow differences. At a teaching hospital you typically have a team taking care of the patient. This is comprised of 2 first year medical interns (one of whom is directly responsible for the patient), a third year senior medical resident and a seasoned Internal Medicine Attending Physician. This gives three sets of eyes and brains examining the patient, radiographs and data creating a redundancy such that it becomes highly unlikely that something is missed. The intern leads a harried existence writing H&Ps, discharges summaries, ordering labs and medications and answering countless pages all while learning to become a real doctor. These individuals usually have the “bandwidth” to do critical thinking about diagnosis and treatment. The senior medical resident who is not as mired in the logistics can see things at more of a 35,000 foot view and can think about needed changes in testing and treatment. The seasoned attending has time to consult the literature and bring the latest thinking to the team. The attending also has frequent access to specialist peers to chat about tough cases. These internal medicine teams typically stay intact for 2-4 weeks providing an important continuity of care. The covering resident at night may either be a member of the team or someone with a familiarity with the patient providing added safety.

The structure of a non-teaching community hospital is very different. Patients at these hospitals are generally admitted to Hospitalists. Hospitalists are physicians who have completed a 3 year internal medicine residency program. These positions are very attractive to recent graduates from residency programs because they entail 12 hour shift work with no call and because they are in high demand often command competitive salaries. The schedules for such positions are usually 7 days on and 7 days off allowing individuals to pursue either additional professional activities to further augment their salary or pursue hobbies or travel.

Due to changes in the way Internal Medicine residency programs are structured the new graduates who become hospitalists often neither have the seasoning or knowledge base to independently care for patients. Work hour restrictions prevent residents from seeing the same volume of patients in a 3 year period or to be able to observe the natural history of the disease. An increased emphasis on primary care also further decreases the inpatient hospital experience of a resident. As such, the physicians filling these hospitalist positions are often at a second year resident level at the completion of a 3 year program. Due to this lack of seasoning these new hospitalists are more dependent on consultants for what used to be considered “bread and butter” internal medicine admissions. Furthermore since they may “not know what they don’t know” hospitalists may not entertain diagnoses that truly require a specialist consultation.

Additional differences in the structure of non-teaching community hospitals may contribute to the increased mortality. Unlike the team structure in academic hospitals, one hospitalist is responsible for all aspects of 15-20 inpatients leaving little reflective time to consider a patient’s diagnosis or an alternate treatment strategy. The hospitalist is pulled in multiple different directions during the day answering case manager and nursing questions and pages, calling families and primary care physicians and of course of attending to all the requirements of the electronic medical record.  These issues can be accentuated in hospitals that are understaffed and need to utilize locum tenens or per diem hospitalists to fill open shifts for a day or two. Continuity of care is lost in this setting with likely consequences on patient outcomes.

It is my opinion that all of these factors contribute to the increased mortality at non-teaching community hospitals. How could we fix this? The answer, I believe is to put in place a “pseudo academic “structure in place at non-teaching hospitals. I would put in place subspecialty wards at community hospitals. When I was in residency at Cleveland Clinic we had distinct cardiology, Renal/GI, Pulmonary/ID, and Heme/ONC wards. Patients would still be admitted and primarily cared for by the hospitalist but there would be a specialist “Attending Physician” for each of these wards responsible for overseeing the care of these patients. This structure would be more likely to assure that an appropriate diagnostic and treatment plan is instituted early rather than waiting days for failure and the desperation consult. To do this the whole structure of specialist reimbursement would need to be changed. A specialist would need to receive an appropriate salary from the hospital commensurate with the responsibility of being a supervisory physician. The specialist would no longer be paid based on an RVU basis.

I do not have any data to prove that these changes would improve outcomes at non-teaching community hospitals. A pilot study in a single specialty examining outcomes before and after the proposed change could be conducted. An example would be admitting patients with UTIs and pneumonia to an ID service and examining outcomes. I eagerly await your comments on this proposal.