Involving hospitalists in inpatient care improves patient outcomes, oncologist experience
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Enlisting hospitalists in the co-management of patients with cancer reduced hospital length of stay, increased hospital capacity for new inpatients and reduced stress among oncologists, according to a study in Journal of Hospital Medicine.
“Inpatient medicine has become increasingly complex over the last decade or so — the patients are sicker than they ever were, because we’re keeping more and more patients out of the hospital,” Kerin Adelson, MD, a medical oncologist specializing in breast cancer and chief quality officer at Yale Cancer Center and Smilow Cancer Hospital at the time of the study, told Healio. “Solid tumor oncologists spend their time focused on the ambulatory practice of oncology, giving chemotherapy and other disease-modifying treatments. As their careers advance, their training in inpatient internal medicine becomes more distant. We’re starting to recognize, as a field, that hospitalist medicine or inpatient medicine is a specialty in and of itself.”
Adelson, now chief quality and value officer at The University of Texas MD Anderson Cancer Center, and study co-author Jensa Morris, MD, an internal medicine specialist at Yale School of Medicine and director of Smilow Hospitalist Service at Smilow Cancer Hospital in New Haven, Connecticut, spoke with Healio about their study and its potential implications for clinical practice.
Healio: What inspired you to conduct this study?
Adelson: I spent many years attending as an oncologist on the inpatient solid tumor service, and we had a number of problems.
Our oncologist-run service had very long hospital stays and high readmission rates. Oncologists came in for the morning to round and teach trainees and then had to run to a busy clinic with patients waiting for treatment. Because they only attended on the service 4 weeks a year, the oncologists struggled with the complex coordination of inpatient care, were burned out from being pulled in multiple directions, and were increasingly uncomfortable with the complexity of the nononcologic medical issues.
Hospitalists spend all day on the floor working closely in a multidisciplinary manner with nurses and trainees, giving patients the time and attention they need. It became very clear that the care model would work better if hospitalists were the primary doctor on the team, with oncologists acting in a supportive role as consultants to provide oncologic expertise when needed. We wanted to make sure that those patients had the true inpatient expertise that a hospitalist could provide, all day, every day.
Healio: You compared a co-management model involving hospitalists with a traditional, oncologist-led inpatient care model. What did you find?
Morris: In the first year of the program, we were only funded to partially staff the service with hospitalists. We had two inpatient oncology services and put a hospitalist on one of them. Kerin recognized quickly that this set us up to do a real-time comparison, almost a clinical trial comparing the outcomes of the two services. We found in the first 6 months of the program that having a hospitalist leading the service reduced the length of stay, as Kerin had expected, by about three quarters of a day. Having hospitalists involved increased the rate of early discharge by about threefold. All of this was done without any impact on the readmission rate.
One surprising finding was that with this reduction in length of stay, and resulting increase in throughput, we were able to open up more beds at Smilow Cancer Hospital. Previously, patients who couldn’t get beds would be boarded on other general medical units that didn’t have either nursing specialty care or multidisciplinary care. In those first 6 months, we accommodated more than 150 additional patients within Smilow Cancer Hospital who otherwise would have been boarded on other units.
Healio: Why do you think more hospitalists are not involved in oncology care?
Adelson: I believe there is national recognition that solid tumor oncologists are probably not the optimal inpatient care providers. When we try to hire an oncologist and they find out they will have to serve as the primary inpatient attending, it can be a hindrance in recruitment. Many hospitalist programs have begun to spring up. The issue is, these programs all grew organically, and no one ever studied them in a comparative way.
Jensa and I were operating in a very resource-constrained environment at Yale New Haven. Nobody was going to spend money on a new program based on hearsay. We were held accountable to show that a program like this could have meaningful clinical and financial impact. We can see that from the increased throughput.
Morris: An assessment of burnout among all the clinical specialties at Yale New Haven showed oncologists ranked highest. One contributing factor was the multiple competing responsibilities: outpatient clinic, administrative work, research lab and inpatient time. Every time an oncologist rotated on the service, we sent them a survey that asked about their experience and perception of the quality of care. The responses were so overwhelmingly positive, we included them in our study. We wanted to demonstrate that the oncologists truly were pleased with their role as a consultant. They were also pleased to not be under the same stressful demands they had been under previously.
Healio: How do patients feel about a hospitalist-led inpatient oncology service?
Adelson: We have seen our patient experience scores improve. It turns out the one doctor patients really want and care about is their outpatient oncologist. It means less to them whether their inpatient provider is an oncologist or a hospitalist as long as there is close communication with their primary cancer doctor. They don’t know who is rotating in the service. They just want the communication and the involvement of their outpatient doctor.
When we launched the program, we didn’t fully understand how closely the hospitalists would be able to partner with the outpatient oncologists, but we learned quickly that this was a critical element of the hospitalist daily work.
The other thing we learned is that because patients are, unfortunately, admitted multiple times, and we have a smaller number of hospitalists who are more consistently present on the service, they often already know the doctor when they are readmitted. There is more continuity than we would have expected.
Healio: What is next in your work on this topic?
Morris: One of the things Kerin and I have been exploring is how we transition patients to end-of-life care and palliative care. We know if a patient with a solid tumor has an unexpected hospital admission, that’s a sentinel event and it’s prognostically very poor. Patients who are admitted to our service tend to have a prognosis of less than 6 months. Looking at our outcomes, it seems that hospitalists can be very effective at transitioning patients from aggressive cancer-directed therapy to more palliative therapy.
One of Kerin’s big initiatives most recently has been a review process for prescribing nonelective chemotherapy in the hospital. We are very closely monitoring who gets chemotherapy and trying to avoid chemotherapy in the last 30 days of life. We don’t want to give chemotherapy to people simply because we have nothing else to offer.
For more information:
Kerin Adelson, MD, can be reached at The University of Texas MD Anderson Cancer Center, 1 515 Holcombe Blvd., Houston, TX 12345; email: kbadelson@mdanderson.org.
Jensa Morris, MD, can be reached at Smilow Cancer Hospital, 20 York St., New Haven, CT 06510; email: jensa.morris@ynhh.org.
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