Ashish K. Jha, MD, MPH

Although hospital readmissions have been a problem for at least the past 5 decades, they are now receiving more attention than ever before. Starting with the 2007 Medicare Payment Advisory Commission report detailing the vast scope of the problem,[1] readmissions have garnered substantial policy interest, culminating with Congress' inclusion of a penalty for hospitals with excessive readmission rates in the Affordable Care Act. Clinical leaders have become increasingly active in this issue as well, and hospitals around the nation have become engaged in finding ways to reduce the number of times patients return after discharge.

The Hospital Readmissions Reduction Program (HRRP), which is the penalty program put in place by Congress to address readmissions, has been controversial from its inception. Supporters point to the large number of patients whose discharge is fraught with poor communication, ineffective medication management, and inadequate handoffs to the primary care physician. Critics have countered that only a small proportion of readmissions are likely preventable by what hospitals can control,[2] and that patient factors, especially social and economic circumstances,[3] primarily drive readmissions. Despite this debate, we can all agree there is ample opportunity to improve the care of patients at the time of discharge.

In this context, we see important evidence emerging from the Better Outcomes by Optimizing Safe Transitions (BOOST) program. Funded by the Hartford Foundation among others, BOOST is specifically aimed at improving care transitions among older hospitalized adults. BOOST focuses on identifying those at highest risk for readmissions, communicating the discharge plan effectively, and ensuring close follow‐up, both through phone calls after discharge and timely appointments with primary care providers. These are all interventions that seem intuitively like good ideas. In this issue of the Journal of Hospital Medicine, leaders of the BOOST program report on the impact on readmissions rate.[4] However, as the accompanying editorial points out, the data are disappointing.[5] The evidence, seen in the best possible light, suggests a small improvement among a very select group of hospitals. Although the authors should be commended for writing up their findings, the fact that 19 of the 30 hospitals that received substantial training and assistance through the BOOST program chose not to report their data is unconscionable. The decision by those 19 hospitals to withhold data makes the results nearly uninterpretable and jeopardizes the hard work that so many others have engaged in. BOOST should require that hospitals agree to share data as a condition of participation in the program.

The Hansen study,[4] despite its disappointing findings, may signal that it is time for a new approach. First of all, we may need to focus on different metrics. Looking ahead, the most important question may not be Does BOOST lower readmission rates? but rather Does BOOST improve the care for patients at the time of discharge from the hospital? There are several good measures of the quality of a care transition, such as those by Coleman and colleagues,[6] and these could be used to measure the quality of care hospitals deliver at discharge. We could also develop new metrics of transitions of care. For example, hospitals truly committed to improvement could field an ongoing survey of primary care physicians in their community to ensure that care transitions are happening smoothly from the primary care providers' perspective. Patient experience metrics, beyond those captured in the Hospital Consumer Assessment of Healthcare Providers and Systems survey, may be necessary to better assess patient and family perspectives on the transition from the hospital to home. These and other approaches can help hospitals better understand how effectively they manage the handoff as patients leave their doors.

However, we should also recognize that although such approaches may improve care transitions, they are unlikely to substantially reduce readmissions. Instead, hospitals serious about reducing readmissions may need to reconsider their business model.[7] In the days following a discharge, patients are medically and socially vulnerable. Patients without robust social support at home may need more than just the right medications, a phone call, or a follow‐up appointment. They may need help with groceries, having their meals prepared, or getting a ride to the doctor's office. Hospitals that want to reduce readmissions may need to make investments in creating the community and social support that so many patients lack when they leave the hospital. This has never been part of the hospital business model before, but it may be time for a change.

The HRRP, an effort by federal policymakers to drive down readmissions through penalties, has clearly begun to make hospitals think about changing their business models in precisely these ways. Readmission rates are falling, although a concurrent increase in the number of patients being admitted to observation status makes it unclear whether patient care has actually improved. More data and time will tell. Furthermore, the program as currently designed targets hospitals that care for the sickest and poorest patients for penalties.[8] There are plenty of good options for addressing these unintended consequences, such as comparing safety‐net hospitals' performance to other similar institutions, or focusing only on preventable readmissions. However, regardless of its limitations, the HRRP in some form or another is here to stay. Therefore, hospitals will need to find ways to reduce readmissions, and programs like BOOST, even when executed perfectly, will be necessary but likely insufficient. Improving the quality of care transitions is critically important. But to truly get to better outcomes for older Americans, hospitals will need to think beyond their 4 walls.

Although hospital readmissions have been a problem for at least the past 5 decades, they are now receiving more attention than ever before. Starting with the 2007 Medicare Payment Advisory Commission report detailing the vast scope of the problem,[1] readmissions have garnered substantial policy interest, culminating with Congress' inclusion of a penalty for hospitals with excessive readmission rates in the Affordable Care Act. Clinical leaders have become increasingly active in this issue as well, and hospitals around the nation have become engaged in finding ways to reduce the number of times patients return after discharge.

The Hospital Readmissions Reduction Program (HRRP), which is the penalty program put in place by Congress to address readmissions, has been controversial from its inception. Supporters point to the large number of patients whose discharge is fraught with poor communication, ineffective medication management, and inadequate handoffs to the primary care physician. Critics have countered that only a small proportion of readmissions are likely preventable by what hospitals can control,[2] and that patient factors, especially social and economic circumstances,[3] primarily drive readmissions. Despite this debate, we can all agree there is ample opportunity to improve the care of patients at the time of discharge.

In this context, we see important evidence emerging from the Better Outcomes by Optimizing Safe Transitions (BOOST) program. Funded by the Hartford Foundation among others, BOOST is specifically aimed at improving care transitions among older hospitalized adults. BOOST focuses on identifying those at highest risk for readmissions, communicating the discharge plan effectively, and ensuring close follow‐up, both through phone calls after discharge and timely appointments with primary care providers. These are all interventions that seem intuitively like good ideas. In this issue of the Journal of Hospital Medicine, leaders of the BOOST program report on the impact on readmissions rate.[4] However, as the accompanying editorial points out, the data are disappointing.[5] The evidence, seen in the best possible light, suggests a small improvement among a very select group of hospitals. Although the authors should be commended for writing up their findings, the fact that 19 of the 30 hospitals that received substantial training and assistance through the BOOST program chose not to report their data is unconscionable. The decision by those 19 hospitals to withhold data makes the results nearly uninterpretable and jeopardizes the hard work that so many others have engaged in. BOOST should require that hospitals agree to share data as a condition of participation in the program.

The Hansen study,[4] despite its disappointing findings, may signal that it is time for a new approach. First of all, we may need to focus on different metrics. Looking ahead, the most important question may not be Does BOOST lower readmission rates? but rather Does BOOST improve the care for patients at the time of discharge from the hospital? There are several good measures of the quality of a care transition, such as those by Coleman and colleagues,[6] and these could be used to measure the quality of care hospitals deliver at discharge. We could also develop new metrics of transitions of care. For example, hospitals truly committed to improvement could field an ongoing survey of primary care physicians in their community to ensure that care transitions are happening smoothly from the primary care providers' perspective. Patient experience metrics, beyond those captured in the Hospital Consumer Assessment of Healthcare Providers and Systems survey, may be necessary to better assess patient and family perspectives on the transition from the hospital to home. These and other approaches can help hospitals better understand how effectively they manage the handoff as patients leave their doors.

However, we should also recognize that although such approaches may improve care transitions, they are unlikely to substantially reduce readmissions. Instead, hospitals serious about reducing readmissions may need to reconsider their business model.[7] In the days following a discharge, patients are medically and socially vulnerable. Patients without robust social support at home may need more than just the right medications, a phone call, or a follow‐up appointment. They may need help with groceries, having their meals prepared, or getting a ride to the doctor's office. Hospitals that want to reduce readmissions may need to make investments in creating the community and social support that so many patients lack when they leave the hospital. This has never been part of the hospital business model before, but it may be time for a change.

The HRRP, an effort by federal policymakers to drive down readmissions through penalties, has clearly begun to make hospitals think about changing their business models in precisely these ways. Readmission rates are falling, although a concurrent increase in the number of patients being admitted to observation status makes it unclear whether patient care has actually improved. More data and time will tell. Furthermore, the program as currently designed targets hospitals that care for the sickest and poorest patients for penalties.[8] There are plenty of good options for addressing these unintended consequences, such as comparing safety‐net hospitals' performance to other similar institutions, or focusing only on preventable readmissions. However, regardless of its limitations, the HRRP in some form or another is here to stay. Therefore, hospitals will need to find ways to reduce readmissions, and programs like BOOST, even when executed perfectly, will be necessary but likely insufficient. Improving the quality of care transitions is critically important. But to truly get to better outcomes for older Americans, hospitals will need to think beyond their 4 walls.

Although hospital readmissions have been a problem for at least the past 5 decades, they are now receiving more attention than ever before. Starting with the 2007 Medicare Payment Advisory Commission report detailing the vast scope of the problem,[1] readmissions have garnered substantial policy interest, culminating with Congress' inclusion of a penalty for hospitals with excessive readmission rates in the Affordable Care Act. Clinical leaders have become increasingly active in this issue as well, and hospitals around the nation have become engaged in finding ways to reduce the number of times patients return after discharge.

The Hospital Readmissions Reduction Program (HRRP), which is the penalty program put in place by Congress to address readmissions, has been controversial from its inception. Supporters point to the large number of patients whose discharge is fraught with poor communication, ineffective medication management, and inadequate handoffs to the primary care physician. Critics have countered that only a small proportion of readmissions are likely preventable by what hospitals can control,[2] and that patient factors, especially social and economic circumstances,[3] primarily drive readmissions. Despite this debate, we can all agree there is ample opportunity to improve the care of patients at the time of discharge.

In this context, we see important evidence emerging from the Better Outcomes by Optimizing Safe Transitions (BOOST) program. Funded by the Hartford Foundation among others, BOOST is specifically aimed at improving care transitions among older hospitalized adults. BOOST focuses on identifying those at highest risk for readmissions, communicating the discharge plan effectively, and ensuring close follow‐up, both through phone calls after discharge and timely appointments with primary care providers. These are all interventions that seem intuitively like good ideas. In this issue of the Journal of Hospital Medicine, leaders of the BOOST program report on the impact on readmissions rate.[4] However, as the accompanying editorial points out, the data are disappointing.[5] The evidence, seen in the best possible light, suggests a small improvement among a very select group of hospitals. Although the authors should be commended for writing up their findings, the fact that 19 of the 30 hospitals that received substantial training and assistance through the BOOST program chose not to report their data is unconscionable. The decision by those 19 hospitals to withhold data makes the results nearly uninterpretable and jeopardizes the hard work that so many others have engaged in. BOOST should require that hospitals agree to share data as a condition of participation in the program.

The Hansen study,[4] despite its disappointing findings, may signal that it is time for a new approach. First of all, we may need to focus on different metrics. Looking ahead, the most important question may not be Does BOOST lower readmission rates? but rather Does BOOST improve the care for patients at the time of discharge from the hospital? There are several good measures of the quality of a care transition, such as those by Coleman and colleagues,[6] and these could be used to measure the quality of care hospitals deliver at discharge. We could also develop new metrics of transitions of care. For example, hospitals truly committed to improvement could field an ongoing survey of primary care physicians in their community to ensure that care transitions are happening smoothly from the primary care providers' perspective. Patient experience metrics, beyond those captured in the Hospital Consumer Assessment of Healthcare Providers and Systems survey, may be necessary to better assess patient and family perspectives on the transition from the hospital to home. These and other approaches can help hospitals better understand how effectively they manage the handoff as patients leave their doors.

However, we should also recognize that although such approaches may improve care transitions, they are unlikely to substantially reduce readmissions. Instead, hospitals serious about reducing readmissions may need to reconsider their business model.[7] In the days following a discharge, patients are medically and socially vulnerable. Patients without robust social support at home may need more than just the right medications, a phone call, or a follow‐up appointment. They may need help with groceries, having their meals prepared, or getting a ride to the doctor's office. Hospitals that want to reduce readmissions may need to make investments in creating the community and social support that so many patients lack when they leave the hospital. This has never been part of the hospital business model before, but it may be time for a change.

The HRRP, an effort by federal policymakers to drive down readmissions through penalties, has clearly begun to make hospitals think about changing their business models in precisely these ways. Readmission rates are falling, although a concurrent increase in the number of patients being admitted to observation status makes it unclear whether patient care has actually improved. More data and time will tell. Furthermore, the program as currently designed targets hospitals that care for the sickest and poorest patients for penalties.[8] There are plenty of good options for addressing these unintended consequences, such as comparing safety‐net hospitals' performance to other similar institutions, or focusing only on preventable readmissions. However, regardless of its limitations, the HRRP in some form or another is here to stay. Therefore, hospitals will need to find ways to reduce readmissions, and programs like BOOST, even when executed perfectly, will be necessary but likely insufficient. Improving the quality of care transitions is critically important. But to truly get to better outcomes for older Americans, hospitals will need to think beyond their 4 walls.

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

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

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

METHODS

RESULTS

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

Figure 1

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

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

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

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

Figure 2

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

DISCUSSION

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

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

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

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

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

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

Disclosures

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

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

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

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

METHODS

RESULTS

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

Figure 1

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

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

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

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

Figure 2

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

DISCUSSION

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

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

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

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

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

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

Disclosures

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

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

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

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

METHODS

RESULTS

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

Figure 1

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

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

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

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

Figure 2

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

DISCUSSION

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

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

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

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

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

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

Disclosures

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