1. 
   

   What are the reasons behind the growth of hospitalists in the Veterans Administration System?

   
   
2. 
   

   How can an integrated health system serve as a conduit for disseminating best practices across facilities?

Since the term hospitalist was coined more than 10 years ago the field of Hospital Medicine has seen dramatic growth. The Society of Hospital Medicine (SHM) has more than 10,000 members and estimates that there are 30,000 hospitalists nationwide, with that number likely to grow to 40,000 by 2015. The rapid growth of the field was driven by a number of factors. Initial studies comparing hospitalists and nonhospitalists revealed that care by hospitalists was associated with reductions in length of stay (LOS) by roughly one day and costs by 10–15%. A review of these earlier reports concluded that “hospitalists improve inpatient efficiency without harmful effects on quality or patient satisfaction.” These improvements in efficiency stimulated hospitals to hire hospitalists, thus driving supply. With a new crop of graduating residents every year who were comfortable caring for sick hospitalized patients, the field expanded.

Following studies that showed improvements in efficiency, studies emerged showing improved clinical outcomes for mortality, readmissions, and disease-specific outcomes for congestive heart failure and pneumonia. However, a more recent multicenter trial of hospitalists in six academic centers found that hospitalist care was not associated with lower LOS, costs, or mortality. Regardless, growth of hospitalists has continued and may be impacted by other institutional and/or physician needs. Hospitalists have been champions of quality improvement initiatives for institutional priorities such as deep venous thrombosis prophylaxis and initiation of rapid response teams. In academic medical centers, hospitalists have improved inpatient teaching and may have expanded roles due to residency work hour reform. Physicians are also choosing this field as a career in greater numbers, especially at the completion of residency.

The growth of hospitalists in an integrated health care system has not been well described. The Veterans Health Administration (VHA) is the largest single provider of health care in the U.S. with more than 125 hospitals providing acute medical care. Due to the rapid expansion of hospitalist models of care in the private sector, describing the growth and drivers of expansion of Hospital Medicine in VHA could provide insights for hospital leadership and help new hospitalist programs learn from the experience of more seasoned programs.

In order to better understand the roll of hospitalists in the Veterans Administration (VA), a survey of inpatient medical services was sent to chiefs of medicine or chiefs of staff at 129 Veterans Administration Medical Centers (VAMCs) that provide inpatient medical care. Survey results were tallied and responses reported for all respondents as well as by academic and nonacademic-affiliated VAMCs. This designation was due to the close relationship that academic-affiliated VAMCs have with residency training programs and the potential impact this could have on the adoption of hospitalist models of care.

The survey consisted of 24 multiple choice and free text questions including four domains: (1) structure of inpatient general medical services, (2) structure of medical intensive care unit (MICU) services, (3) existence of a hospitalist program, and (4) impact of residency work hour reform on inpatient general medical services. To query the existence of a hospitalist program, respondents were asked, “Does your VAMC have a ‘hospitalist’ service?” The following definition of hospitalists was provided: “Hospitalists have been defined as physicians who spend all or the majority of their clinical, administrative, educational, or research activities in the care of hospitalized patients. This could include a formal hospitalist program or physicians who would consider themselves hospitalists based upon their proportion of inpatient medicine service.” The year of initiation of the hospitalist program was asked and if the reported date was prior to 1996, the year the term hospitalist was introduced, the year 1995 was assigned to the response. The size of the hospitalist program was assessed using three questions: (1) how many hospitalists worked at the VAMC, (2) how many total full-time equivalent (FTE) hospitalists there were, and (3) an estimate of the percentage of medical patients who are cared for by hospitalists.

Features of VAMC Medical Services

Of 129 surveys sent, complete surveys were returned by 118 respondents (91.5%). Hospitalist programs were reported at 76 VAMCs (64.4%), including 62% of academic-affiliated VAMCs and 75% of nonacademic-affiliated VAMCs. Of all respondents, 71% had teaching services with resident physicians, 25% had staff-only services, and 20% utilized midlevel providers. Twenty-four hour in-house coverage was available in 97% of VAMCs with resident physicians providing coverage at 67% and hospitalists at 11%. A medical intensive care unit (MICU) was available at 97% of hospitals with 74% staffed by board-certified intensivists. Half were “open” and allowed noncritical care physicians to admit patients, most commonly by cardiologists (63%); 54% allowed hospitalists. A description of the general medicine and MICU services, categorized by academic and nonacademic VAMCs is detailed in Table 269-1.