Hospitalist ICU care and locum tenens outcomes

Summaries from ACP Hospitalist Weekly.

Most hospitalists are providing ICU care, many feel training insufficient, survey finds

In a recent survey, about three-quarters of hospitalists reported providing critical care services, and almost two-thirds said they serve as primary physicians in the ICU.

A total of 425 hospitalists completed the survey, which was conducted as a needs assessment for the Critical Care Task Force of the Society of Hospital Medicine Education Committee (an approximate response rate of 10%). Of the respondents, 77% said they provide critical care services. The majority of hospitalists (66%) also reported serving as primary physicians in the ICU, but this was significantly more common in rural hospitals than nonrural (85% of rural respondents vs. 62% of nonrural; P<0.001). Results were published online on Dec. 6, 2017, by the Journal of Hospital Medicine and appeared in the January 2018 issue.

Many of the surveyed hospitalists also reported insufficient training or support for their ICU care. More than 40% of rural hospitalists said that they were expected to practice beyond the scope of their expertise at least some of the time that they cared for ICU patients, including half of those who reported being primary physicians for ICU patients. More than a third of rural respondents reported that board-certified intensivist support was never or rarely sufficient to support their care. Transfers to higher levels of care were also described as a problem: 67% of hospitalists who served as primary physicians for ICU patients reported at least moderate difficulty arranging transfers to higher levels of care, and difficulty transferring was the only factor in the survey that significantly correlated with being expected to practice beyond one's scope.

The study confirms that “either by intent or by default, hospitalists have become the major and often sole providers of critical care services in many hospitals without robust intensivist support,” the study authors said. “We suspect that this phenomenon has been consistently underreported in the literature because academic hospitalists generally do not practice critical care.” Given that this situation is unlikely to change and the majority of survey respondents expressed interest in augmenting their critical care skills and knowledge, the hospital medicine and critical care communities should take action to help hospitalists provide safe, high-quality care to ICU patients, the authors said. The study was limited by its low response rate and potential bias resulting from voluntary participation in the survey, among other factors.

Prior studies have found similar rates of hospitalists providing ICU care, according to an accompanying editorial. “A novel finding is the high level of angst and lack of support hospitalists perceived in caring for these critically ill patients,” the editorialists said. They offered several potential strategies for improving hospitalists' comfort in the ICU, including having healthier ICU patients managed by physician assistants or nurse practitioners, using ICU telemedicine, transferring the sickest patients to high-volume centers, and reducing the number of patients admitted to the ICU.

Mortality rates similar, readmissions lower in hospital patients cared for by locum tenens

Hospital patients cared for by locum tenens internists had similar mortality rates, but longer lengths of stay and lower readmission rates than those cared for by non-locum internists, a recent study found.

The retrospective study used a random sample of Medicare fee-for-service beneficiaries hospitalized during 2009 to 2014. Of the 1.8 million medical inpatients included in the study, 2.1% received care from a locum tenens physician. Of the 44,520 general internists included in the data, 9.3% were temporarily covered by a locum tenens at some point. The study's primary outcome was 30-day mortality, and no significant difference was found based on whether a patient was cared for by a locum tenens or not (8.83% vs. 8.70%; adjusted difference, 0.14%; 95% CI, −0.18% to 0.45%).

Photo by Thinkstock
Photo by Thinkstock.

Patients treated by locums did have significantly higher Medicare Part B spending ($1,836 vs. $1,712; adjusted difference, $124; 95% CI, $93 to $154) and longer length of stay (5.64 days vs. 5.21 days; adjusted difference, 0.43 days; 95% CI, 0.34 to 0.52). However, they also had significantly lower rates of readmission within 30 days (22.80% vs. 23.83%; adjusted difference, −1.00%; 95% CI, −1.57% to −0.54%). Results were published in the Dec. 5, 2017, JAMA.

“The lack of a significant overall difference in mortality rates between patients treated by locum tenens and non-locum tenens physicians is reassuring, and it argues against the presence of systematic differences in the quality of care administered by these 2 groups of physicians,” the study authors said. They noted that a subgroup analysis found higher mortality in patients treated by locum tenens at hospitals that used such doctors infrequently, but that this result should be considered hypothesis-generating and was not present in the most recent years' data.

The higher costs and longer lengths of stay may indicate that temporary physicians “struggle to efficiently and effectively deliver care or coordinate care transitions” due to lack of institution-specific experience, the authors said. The findings regarding readmission rates are consistent with existing evidence that 30-day readmissions and mortality do not correlate and may suggest that the higher costs associated with locum tenens care are offset by reductions in readmissions, they added. The study was limited by its retrospective design and additional research could help to determine hospital-level factors associated with locums' cost and quality of care, the authors concluded.