PEDIATRICS Vol. 115 No. 1 January 2005, pp. 34-38 (doi:10.1542/peds.2004-0855)
Community and Hospital-Based Physicians' Attitudes Regarding Pediatric Hospitalist Systems
* Department of Pediatrics, University of Utah, Salt Lake City, Utah
Intermountain Health Care, Salt Lake City, Utah
Department of Medicine, Harvard Medical School, Boston, Massachusetts
|| Department of Medicine Hospitalist Group, University of San Francisco, San Francisco, San Francisco, California
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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Objective. Pediatric hospitalist systems are being implemented widely. Their implementation may be influenced by physician attitudes, which may vary according to practice type (eg, community or hospital-based practice) and personal characteristics (eg, age and practice location). Little evidence exists to describe factors relevant to pediatric systems. The objective of this study was to determine physicians' attitudes regarding hospitalists and associated physician and practice characteristics.
Methods. We used a cross-sectional survey of all physicians with admitting privileges at a tertiary-care, pediatric, teaching hospital in the Intermountain West in April 2002. Outcomes included survey responses indicating attitudes toward the effects of the hospitalist system on quality of care, patient satisfaction, and teaching.
Results. A total of 313 of 368 physicians (85%) responded, 191 of whom (61%) were community physicians; 224 respondents (72%) spent the majority of their time in outpatient care. Community physicians more often characterized inpatient care as an inefficient use of time (45% vs 25%) but were less likely to think that hospitalists would improve the quality of care (49% vs 68%) or increase patient satisfaction (10% vs 30%). In multivariate models examining predictors of overall attitudes toward hospitalists, being a community physician (6.4 points more negative) and admitting patients at >1 hospital (3.3 points more negative) were associated with less favorable attitudes. Being <40 years of age (4.5 points more positive) and practicing >13 miles from the hospital (4.3 points more positive) were associated with more positive attitudes.
Conclusions. Attitudes regarding hospitalist systems differ between physician groups and are influenced by practice characteristics. Understanding these differences and tailoring hospitalist systems to address them will be important as pediatric hospitalist systems are implemented nationwide.
Key Words: hospitalists • pediatrics • physician attitudes
Abbreviations: PCP, primary care physician • PCMC, Primary Children's Medical Center
Pediatric hospitalist systems are being developed in the majority of children's hospitals in the United States,1 and several studies have assessed the impact on resource utilization and teaching in academic pediatric centers.2–5 Despite the widespread adoption of academic pediatric hospitalists, the concept of replacing the primary care physician (PCP) with a hospitalist during a patient's hospitalization remains controversial.6 Legitimate concerns exist regarding the effectiveness of communication to overcome the loss of continuity with the patient's hospital course and to ensure sufficient PCP involvement to provide for optimal follow-up care. The attitudes of physicians, many of whom are PCPs who care currently for hospitalized children, may enhance or impede the implementation and success of a hospitalist system.7 Opinions regarding hospitalists may differ between hospital-based physicians (many of whom serve as consultants to hospitalists) and community physicians (who refer patients to hospitalists) and among those with positive versus negative attitudes regarding their experiences with providing inpatient care. During the creation of a new hospitalist system at a children's hospital, we conducted a study of the attitudes of community- and hospital-based physicians, to identify concerns and to guide implementation. The objectives of our study were to evaluate community- and hospital-based physicians' attitudes regarding caring for inpatients, to determine their beliefs regarding hospitalist systems and to identify predictors of positive and negative attitudes toward the hospitalist system.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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We conducted a cross-sectional survey of the cohort of physicians with medical staff privileges at a tertiary-care, pediatric, teaching hospital (Primary Children's Medical Center [PCMC], Salt Lake City, UT). The hospital medical staff office provided a list of eligible respondents, including all general community physicians and hospital-based medical physicians (excluding surgeons, anesthesiologists, and radiologists) with admitting privileges. Our survey was adapted from a previously published survey that examined attitudes toward adult-care hospitalists.8,9 The survey was modified to fit a pediatric setting and then pilot tested with a small group of representative physicians. We sent the final 38-item survey (with an endorsement letter from the hospital administration and assurances of confidentiality) to all physicians eligible for the study in April 2002, excluding the department chair/medical director and the principal investigator. At week 1, a reminder postcard was sent to all nonresponders; at weeks 3 and 7, complete surveys were sent again to all nonresponders. The institutional review board of the University of Utah Health Sciences Center and PCMC approved the study.
Almost all hospital-based physicians were faculty members in the department of pediatrics of the University of Utah School of Medicine. The majority had their primary practice sites at PCMC, although many also cared for patients at the University Hospital (on the same campus as PCMC). We analyzed the responses with descriptive statistics and compared them with nonparametric univariate methods. Items designed to measure physician attitudes toward the hospitalist system were analyzed with Spearman correlation analyses. Highly correlated items were analyzed with factor analysis and Cronbach 
and then were used to calculate a summary attitude score as follows. Individual responses to highly correlated items were summed, divided by the maximal point total for this sum, and then multiplied by 100, resulting in a score between 0 and 100, representing the percent total score for each respondent. Multivariate linear regression models were used to determine factors related to the summary attitude score, such as physician type, age, distance from the practice to the hospital, number of hospitals to which the physician admits patients, and whether the physician performs in-hospital consultations. Driving distances from the practice office addresses of community physicians to the children's hospital were estimated by using Yahoo! Maps (http://maps.yahoo.com).
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Characteristics of Respondents
Surveys were returned by 313 of 368 physicians (85%); 191 respondents (62%) were community physicians. Response rates were comparable for hospital-based (87%) and community (83%) physicians. Of the 122 hospital-based physician respondents, 16% were generalists and 84% were pediatric subspecialists. The hospitalist team at the time of the survey included the principal investigator and 3 other general hospital-based pediatricians. Eight respondents were excluded because they reported that they no longer cared for patients and another 5 respondents were excluded because of missing data, leaving a total of 300 surveys for analysis. There were no significant differences between community and hospital-based physicians in terms of age or gender. Community physicians were less likely than hospital-based physicians to be board certified (69% vs 96%, P < .001), to work in an inpatient setting >10 hours per week (22% vs 48%, P < .001), and to spend >50% of their time in nonclinical activities (4% vs 38%, P < .001). Community physicians were more likely than hospital-based physicians to work part-time (26% vs 13%, P = .005) and to admit patients to >2 hospitals (90% vs 53%, P < .001). The median distance from their practices to the PCMC was 13 miles for the community physicians.
Attitudes Toward Hospitalists
Responses to the questionnaire demonstrated that community physicians were less likely than hospital-based physicians to think that the hospitalist service would increase patient satisfaction (10% vs 30%, P < .001), improve the quality of patient care (49% vs 68%, P = .002), or provide more effective teaching of housestaff members (58% vs 75%, P = .004) (Table 1). Community physicians were more likely than hospital-based physicians to think that care of inpatients was best directed by the physician who maintained a long-term relationship with the patient (66% vs 51%, P = .02) and that a hospitalist system might impair communication with the PCP (60% vs 30%, P < .001). Despite these attitudes suggesting that they could provide better care, community physicians more often characterized inpatient care as an inefficient use of their time (45% vs 25%, P < .001). The proportions of responding physicians, according to physician type, who agreed or strongly agreed with the questionnaire statements are presented in Table 1.
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Predictors of Attitudes Toward the Hospitalist Model
The summary attitude score toward the hospitalist model used 8 highly correlated items from the questionnaire (Cronbach
= .77) (Table 2). Linear regression models yielded predictors of physician attitudes associated with differences in summary scores (Table 2). In the multivariate models, physicians were less likely to have favorable opinions of the hospitalist model if they were community physicians (6.4 points more negative attitude score, P = .008) or admitted patients to >1 hospital (3.3 points more negative attitude score, P = .003). Physicians whose practice sites were >13 miles from the hospital and those who were <40 years of age were more likely to have favorable opinions, with attitude scores 4.3 points more positive for distance (P = .04) and 4.5 points more positive for age (P = .011). The variables of providing inpatient consultations, gender, and working part-time were not significantly associated with the summary attitude scores.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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We found important differences in the opinions of community and hospital-based physicians regarding a hospitalist system and in their attitudes regarding the best care for hospitalized children. Community physicians were less likely than hospital-based physicians to think that hospitalists would improve the quality of care, increase patient satisfaction, or provide more effective teaching to trainees. However, community physicians also tended to characterize inpatient care as an inefficient use of their time.
Although pediatric inpatient care differs in some important ways from adult inpatient care,7 surveys of attitudes of physicians toward adult hospitalist systems reported findings similar to ours, ie, that community physicians have concerns regarding the quality of care, the direction of care by someone other than the PCP, and the quality of teaching.8,9 A study of an established pediatric hospitalist system reported physician attitudes toward the system.10 In that study, community physicians and residents thought that the hospitalist system was providing excellent care, whereas subspecialty physicians rated the quality as only average. The authors suggested that the less positive views expressed by subspecialists might be related to their concerns regarding loss of control or income.
In our study, we found that community physicians were ambivalent about a hospitalist system. They were more likely to have concerns about a hospitalist approach to inpatient care than were hospital-based physicians. More than one half worried that a hospitalist system would impair communication with the PCP, and two thirds thought that the physician with a long-term patient relationship would provide the best inpatient care. However, they reported having feelings of discomfort with inpatient care and described inpatient care as an inefficient use of their time. Almost one half of the community physicians stated that a hospitalist system improved the quality of care for inpatients, and slightly more than one half thought that a hospitalist system was needed at the study hospital. These findings echo those of previous research involving adult hospitalist services. Although adult and pediatric generalists continue to aspire to provide care in both inpatient and outpatient settings, their acceptance of hospitalist systems may be accelerated by the changing health care environment and a growing body of literature suggesting beneficial outcomes of hospitalist programs.11,12
As in the survey studies of adult hospitalist programs,8,9 community physicians in our study were concerned about the quality of teaching by hospitalists. The fact that most of the hospital-based physicians in our study were faculty members might explain their more favorable expectations regarding the quality of teaching by hospitalists, who would also be faculty members and do much of their teaching in inpatient settings. Community physicians might have concerns regarding reduced exposure of students and residents to PCP perspectives on inpatient care. Other studies noted similar concerns regarding the effect of reduced exposure to specialists on the quality of training.13,14
Physicians <40 years of age had more positive attitudes toward the hospitalist system. This finding may reflect the changing nature of the practice and training of pediatricians in the United States. Older physicians were trained and began practice in an era in which general pediatricians provided care for their patients in virtually all settings. In the past 2 decades, general pediatricians have seen their scope of practice become increasingly limited, with full-time specialists taking over neonatal intensive care, critical care, and emergency care. Older physicians may view the development of hospitalist programs as additionally eroding their ability to provide comprehensive care to their patients. Younger physicians who were trained in residency programs in which patients in intensive care units are treated exclusively by neonatologists and intensivists may have different expectations regarding inpatient care and may be more receptive to a hospitalist system. Trained in the era of managed care, younger physicians may feel greater pressure regarding outpatient productivity and the need to balance work and family life more effectively; therefore, they may be more willing to forego inpatient responsibilities, which are usually added to the beginning and end of the work day.
The hospitalist system, although first described for an adult hospital only 7 years ago, has probably existed in adult and pediatric medical services for far longer.15 Perhaps because of the relatively small burden of inpatient care for average pediatricians, formal pediatric programs have been latecomers to this movement.16 The inpatient population at our hospital increasingly consists of children with chronic and complex illnesses, many of whom are in medically unstable condition. This change and continued increases in patient numbers, increasing discomfort of community physicians with inpatient care, and new limitations on resident work hours were the factors that prompted the development of the hospitalist program at PCMC. Similar factors are likely to prompt the development of programs elsewhere.17 Because residency programs cannot, and probably should not, expand sufficiently to meet these growing service demands, alternatives such as hospitalist systems or other service models (perhaps involving midlevel providers) will almost certainly be an increasing part of pediatric care.
Factors that have led to the development of pediatric hospitalist systems are unlikely to be transient, and hospitalist programs will be a permanent part of pediatric health care. It is probable that acceptance of and satisfaction with hospitalist services will increase with time, as referring physicians become more familiar with local hospitalists and as hospitalists develop their practice (eg, refine referral relationships, develop clinical reputations, and establish financial viability).8,18 Furthermore, because pediatric hospitalist programs are at a very early stage in their development, their organization and scope are likely to change significantly as the programs mature and grow. Most programs of which we are aware are based in academic centers and are being developed by hospital-based physicians. Our study indicates that hospital-based physicians may perceive some of the issues differently than do community physicians, which suggests the need for conscious proactive inclusion of community physicians in the planning and development of hospitalist programs, to ensure optimal support and ongoing collaboration in patient care.
As in other pediatric programs based in academic centers, our hospitalists are hired as faculty members and have significant teaching responsibilities and expectations for scholarly productivity. The concentration of general inpatient teaching among a relatively small group of dedicated hospitalists (as opposed to many faculty members, each teaching a few weeks per year) offers opportunities for greater consistency in teaching style, better use of available "teaching moments," enhanced coordination of longitudinal curricula, and more effective evaluation of residents and students.3 Disadvantages include limited trainee contact with other generalist faculty members and community physicians, reduced breadth of exposure to different practice styles and approaches to clinical problems, and fewer opportunities for trainees to develop relationships with community physicians who may later recruit them as partners. Pediatric training programs should seek innovative ways to maintain the mutually beneficial contacts between practicing pediatricians and trainees.
Our study has several limitations. The responses were from physicians at a single pediatric tertiary-care hospital and might not be generalizable to other settings. The study hospital is the only children's hospital serving the Intermountain West, with a catchment area that includes >1 million children.19 It also serves as the local hospital for children in an urban area with >270 000 children.20 Payer mixture information was not collected; attitudes of community and hospital-based physicians might be affected by financial reimbursement. Because the survey was mailed several months after implementation of the hospitalist system, some responders' opinions might have been shaped by personal experience with it. However, most physicians who used the hospitalist system during its start-up period were from other states and were not surveyed.
This study demonstrates how community and hospital-based physicians perceive a pediatric hospitalist system and suggests potential problems that such systems should address. The increasing complexity of pediatric inpatient cases is one factor underlying the development of hospitalist programs. Many cases were medically complex before patient admission and remained so after patient discharge. Effective communication and coordination of care with PCPs (the medical home)21 and with subspecialists should facilitate optimal care delivery and patient outcomes. The evolution of hospitalist systems should involve a conscientious approach to continued improvements in the quality of patient care in inpatient and outpatient settings. Hospitalist systems should enable active collaboration with PCPs in support of a medical home model, to achieve the best patient outcomes.21 Measures of communication and collaboration between hospitalists and PCPs and of continuity in patient treatment plans across inpatient and outpatient settings should be among the key quality indicators used in ongoing evaluations of patient care, teaching, and patient/parent satisfaction with inpatient care systems.
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ACKNOWLEDGMENTS |
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This study was supported by grant P20 HS11826 from the Agency for Healthcare Research and Quality.
We thank Nicole Frei, MD, Tiffany S. Glasgow, MD, and Ben Mizell, MD, as participants in the original hospitalist system and Christopher G. Maloney, MD, for his leadership in the new hospitalist system.
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FOOTNOTES |
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Accepted Jul 8, 2004.
Reprint requests to (R.S.) Division of General Pediatrics, University of Utah, 100 North Medical Dr, MAPS, Salt Lake City, UT 84113. E-mail: raj.srivastava{at}hsc.utah.edu
This work was presented in part at the Pediatric Academic Societies Meeting; May 3–6, 2003; Seattle, WA.
No conflict of interest declared.
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