BACKGROUND/RATIONALE:
Over the past decade, significant changes have occurred in the organization and delivery of inpatient medical care. One of the most striking changes has been the emergence of hospitalists - physicians who spend the majority of their time in the care of hospitalized patients. As an innovation to inpatient care, hospitalist models have been adopted by 64% of VAMCs, in response to pressures to improve inpatient efficiency and recent mandates to restrict resident work hours. Early studies suggested that hospitalist models decreased length of stay and costs, while maintaining or improving quality. However, a recent multi-center trial found hospitalist models were not associated with improved outcomes. In light of these contradictory findings, a closer look at the impact of hospitalist care models in VHA is warranted, as well as an examination of how the effects of hospitalist models may be modified by other organizational factors such as teaching status, intensive care staffing, and 24-hour in-house physician coverage.

OBJECTIVE(S):
The objective of this study is to systematically study the impact of hospitalists and other organizational factors on the quality and efficiency of inpatient medicine services. This will be accomplished through three specific aims: (1) Describe practice characteristics and organizational features of inpatient medicine services, (2) Determine the associations of these practice characteristics on quality and efficiency, adjusting for potentially confounding patient and hospital characteristics, (3) Determine associations of organizational features identified in Aim 1 with quality and efficiency of care, and degree to which these features moderate the effectiveness of hospitalists.

METHODS:
This study has two phases,(1) a data collection phase that will involve the administration of surveys and (2) data analysis based on a patient cohort identified from inpatient administrative data. The surveys in phase one will collect both administrative and provider level responses. Assessment of organizational factors from administrative level individuals will occur at all 125 VAMCs, with surveys administered to chiefs of medicine(COM), medicine unit nurse managers (NM), and medical ICU directors (MICU). Provider level surveys of all inpatient physicians will be administered at a sampling of 36 VAMCs stratified to best represent the geographic and sociodemographic variation within VA. The phase 2 analyses will utilize survey responses and inpatient administrative data in the development of hierarchical models for the following outcome measures: LOS, costs, ICU transfer, mortality rates, readmission rates, time of discharge, and Patient Safety Indicators. All models will be risk adjusted for any patient, physician, and facility level characteristics that may confound the relationship between the process measures and outcomes.

FINDINGS/RESULTS:
The project is complete and a number of manuscripts and reports have been prepared and published (see below). Additional papers are in preparation and review.

IMPACT:
By providing descriptive information on the range of inpatient medicine services and how organizational factors within each structure relate to quality and efficiency, this study will help VA refine inpatient medicine services to best provide high quality care. The identification of practice and organizational factors that support inpatient quality improvement programs will help clinical and administrative leaders maximize the quality and efficiency of their programs.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Kaboli PJ, Go JT, Hockenberry J, Glasgow JM, Johnson SR, Rosenthal GE, Jones MP, Vaughan-Sarrazin M. Associations between reduced hospital length of stay and 30-day readmission rate and mortality: 14-year experience in 129 Veterans Affairs hospitals. Annals of internal medicine. 2012 Dec 18; 157(12):837-45. [view]
2. Liu CF, Burgess JF, Manning WG, Maciejewski ML. Beta-binomial regression and bimodal utilization. Health services research. 2013 Oct 1; 48(5):1769-78. [view]
3. Hockenberry JM, Burgess JF, Glasgow J, Vaughan-Sarrazin M, Kaboli PJ. Cost of readmission: can the Veterans Health Administration (VHA) experience inform national payment policy? Medical care. 2013 Jan 1; 51(1):13-9. [view]
4. Go JT, Vaughan-Sarrazin M, Auerbach A, Schnipper J, Wetterneck TB, Gonzalez D, Meltzer D, Kaboli PJ. Do hospitalists affect clinical outcomes and efficiency for patients with acute upper gastrointestinal hemorrhage (UGIH)? Journal of hospital medicine (Online). 2010 Mar 1; 5(3):133-9. [view]
5. Glasgow JM, Davies ML, Kaboli PJ. Findings from a national improvement collaborative: are improvements sustained? BMJ quality & safety. 2012 Aug 1; 21(8):663-9. [view]
6. Glasgow JM, Scott-Caziewell JR, Kaboli PJ. Guiding inpatient quality improvement: a systematic review of Lean and Six Sigma. Joint Commission Journal on Quality and Patient Safety. 2010 Dec 1; 36(12):533-40. [view]
7. McIntosh N, Burgess JF, Meterko M, Restuccia JD, Alt-White AC, Kaboli P, Charns M. Impact of provider coordination on nurse and physician perceptions of patient care quality. Journal of nursing care quality. 2014 Jul 1; 29(3):269-79. [view]
8. Glasgow JM, Yano EM, Kaboli PJ. Impacts of organizational context on quality improvement. American journal of medical quality : the official journal of the American College of Medical Quality. 2013 May 1; 28(3):196-205. [view]
9. Glasgow JM, Vaughn-Sarrazin M, Kaboli PJ. Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission. Journal of general internal medicine. 2010 Sep 1; 25(9):926-9. [view]
10. Kartha A, Restuccia JD, Burgess JF, Benzer J, Glasgow J, Hockenberry J, Mohr DC, Kaboli PJ. Nurse practitioner and physician assistant scope of practice in 118 acute care hospitals. Journal of hospital medicine. 2014 Oct 1; 9(10):615-20. [view]
11. Benzer JK, Sullivan JL, Williams S, Burgess JF. One-year cost implications of using mental health care after discharge from a general medical hospitalization. Psychiatric services (Washington, D.C.). 2012 Jul 1; 63(7):672-8. [view]
12. McIntosh N, Meterko M, Burgess JF, Restuccia JD, Kartha A, Kaboli P, Charns M. Organizational predictors of coordination in inpatient medicine. Health care management review. 2014 Oct 1; 39(4):279-92. [view]
13. Meterko M, Restuccia JD, Stolzmann K, Mohr D, Brennan C, Glasgow J, Kaboli PJ. Response rates, nonresponse bias, and data quality. Results from a national survey of senior healthcare leaders. Public opinion quarterly. 2015 Jan 27; 79(1):130-144. [view]
14. Benzer JK, Young GJ, Burgess JF, Baker E, Mohr DC, Charns MP, Kaboli PJ. Sustainability of quality improvement following removal of pay-for-performance incentives. Journal of general internal medicine. 2014 Jan 1; 29(1):127-32. [view]
15. Restuccia JD, Mohr D, Meterko M, Stolzmann K, Kaboli P. The association of hospital characteristics and quality improvement activities in inpatient medical services. Journal of general internal medicine. 2014 May 1; 29(5):715-22. [view]
16. Maciejewski ML, Wang V, Burgess JF, Bryson CL, Perkins M, Liu CF. The continuity and quality of primary care. Medical care research and review : MCRR. 2013 Oct 1; 70(5):497-513. [view]

Magazine/Popular Press Articles

1. Kaboli PJ. VA Study Finds that Shorter Hospital Stays are Usually Better for Patients. VAnguard, Serving Amerca's Veterans. 2013 Mar 21; 1(1):24. [view]

VA Cyberseminars

1. Kaboli PJ. Hospital Readmission: A Measure of Hospital Quality? [Cyberseminar]. 2013 Feb 20. [view]
2. Kaboli PJ. Research Panel on Medication Information Management and Reconciliation. [Cyberseminar]. 2012 May 22. [view]

Conference Presentations

1. Kaboli PJ, Lund BC, Abramoff MD, Alexander GC, Cowan C, Ross JS. Adverse Events after Intravitreal Injection of Ranibizumab and Bevacizuman for Age-related Macular Degeneration. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 17; National Harbor, MD. [view]
2. Kaboli PJ. Bridging the Quality Improvement and Research Divide. Paper presented at: Society of General Internal Medicine Annual Meeting; 2012 May 9; Orlando, FL. [view]
3. Kaboli PJ, Glasgow J, Johnson S, Vaughan-Sarrazin MS, White R, Meterko M, Restuccia J. Computerized Patient Record Order Sets for Venous Thromboembolism (VTE) Prophylaxis and Associated Rates of VTE. Poster session presented at: Society of Hospital Medicine Annual Meeting; 2012 Apr 2; San Diego, CA. [view]
4. Richardson KK, Vaughan-Sarrazin MS, Cram PM. Cost of Post-Operative Complications after Total Hip and Total Knee Replacement Surgery. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 17; National Harbor, MD. [view]
5. Richardson KK, Kaboli PJ, Cram PM, Vaughan-Sarrazin MS. Difference in the Receipt of Hip Repair in VA Patients Admitted to VA and Non-VA Contact Care Hospitals for Hip Fracture. Poster session presented at: VA HSR&D Rural Health / VA Office of Rural Health Field-Based Meeting; 2010 May 6; Portland, ME. [view]
6. Glasgow J, Johnson S, Kartha A, Merterko M, McIntosh N, Restuccia J, Kaboli PJ. Hospitalist Practice Characteristics: The VHA Experience. Poster session presented at: Society of Hospital Medicine Annual Meeting; 2012 Apr 2; San Diego, CA. [view]
7. Glasgow J, Smith AR, Kaboli PJ. Impact of Observation Status on Hospital Outcomes. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 16; National Harbor, MD. [view]
8. Kaboli PJ, Estrada C, Ogrinc G, Glasgow J. Initiating QI Projects with Built in Sustainment: Workshop. Presented at: Society of Hospital Medicine Annual Meeting; 2013 May 19; Washington, DC. [view]
9. Estrada C, Taylor B, Glasgow J, Kaboli PJ. Making your Work Count Twice: Workshop. Presented at: Society of Hospital Medicine Annual Meeting; 2013 May 19; Washington, DC. [view]
10. Meterko M, Restuccia JD, Anand K, Kaboli PJ, Charns M, Burgess JF. Organizational Predictors of Coordination in Inpatient Medicine. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 24; Baltimore, MD. [view]
11. Charlton ME, Mengeling M, Halfdanarson T, Kaboli PJ. Randomized Trial of a Home-Based Intervention to Improve Colon Cancer Screening Rates. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 16; National Harbor, MD. [view]
12. Meterko M, Restuccia J, Stolzmann K, Mohr D, Glasgow J, Brennan C, Kaboli PJ. Response Rates, Non-Response Bias, and Data Quality: Results from a National Survey of Senior Healthcare Leaders. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 24; Baltimore, MD. [view]
13. Ohl M, Guggal M, Skanderson M, Scothch M, Kaboli PJ, Vaughan-Sarrazin MS. Rural Residence is Associated with Increased Mortality among Veterans Initiating Highly Active Antiretroviral Therapy for HIV Infection. Paper presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 29; Minneapolis, MN. [view]
14. Restuccia J, Mohr D, Meterko M, Stolzmann K, Kaboli PJ. The Association of Hospital Characteristics and Quality Improvement Activities in Inpatient Mediclal Services. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 24; Baltimore, MD. [view]
15. Schnipper J, Kripalani S, Stein J, Wetterneck TB, Kaboli PJ, Mueller S, Salanitro A, Minahan JA, Nolido NV, Burdick E. The Effects of a Multi-Faceted Medication Reconciliation Quality Improvement Intervention on Patient Safety: Preliminary Results of the MARQUIS Study. Paper presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 24; San Diego, CA. [view]

DRA: Health Systems
DRE: none
Keywords: Management, Organizational issues, Practice patterns
MeSH Terms: none