Importance Improving the quality of health care for general medical patients is a priority, but the organization of general medical ward care receives less scrutiny than the management of specific diseases. Optimizing teams’ performance improves patient outcomes in other settings, and interdisciplinary practice is a major target for improvement efforts. However, the effect of interdisciplinary team interventions on general medical ward care has not been systematically reviewed. Objectives To describe the range of objective patient outcomes used in studies of general medical ward interdisciplinary team care, and to evaluate the performance of interdisciplinary interventions against them. Evidence Review We searched EMBASE, MEDLINE, and PsycINFO from January 1, 1998, through December 31, 2013, for interdisciplinary team care interventions in adult general medical wards using an objective patient outcome measure. Reference lists of included articles were also searched. The last search was conducted on January 29, 2014, and the narrative and statistical analysis was conducted through December 1, 2014. Study quality was assessed using the Cochrane Effective Practice and Organization of Care group’s tool. Findings Thirty of 6934 articles met the selection criteria. The studies included 66 548 patients, with a mean age of 63 years. Nineteen of 30 (63%) studies reported length of stay, readmission, or mortality rate as their primary outcome, or did not specify the primacy of their outcomes. The most commonly reported objective patient outcomes were length of stay (23 of 30 [77%]), complications of care (10 of 30 [33%]), in-hospital mortality rate (8 of 30 [27%]), and 30-day readmission rate (8 of 30 [27%]). Of 23 interventions, 16 (70%) had no effect on length of stay, 12 of 15 (80%) did not reduce readmissions, and 14 of 15 (93%) did not affect mortality. Five of 10 (50%) interventions reduced complications of care. In an exploratory quantitative analysis, the interventions did not consistently reduce the relative risk of early readmission or early mortality, or the weighted mean difference in length of stay. All studies had a medium or high risk of bias. Conclusions and Relevance Current evidence suggests that interdisciplinary team care interventions on general medical wards have little effect on traditional measures of health care quality. Complications of care or preventable adverse events may merit inclusion as quality indicators for general medical wards. Future study should clarify how best to implement interdisciplinary team care interventions and establish quality metrics that are credible to both health care professionals and patients in this setting.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/2301377/ioi150048.pdf

Effects of Interdisciplinary Team Care Interventions on General Medical Wards: A Systematic Review

Background The concept of the physician assistant (PA) was developed by US physicians in the 1960s as a workforce strategy to improve the delivery of medical services. Then as now there is an anticipated shortage of physicians, particularly in primary care. Use of PAs is viewed as 1 possible strategy to mitigate this growing gap in provider services. Objectives To describe the PA in US medicine for policy background and analysis. Description In January 2013, approximately 89,500 PAs were licensed: 65% were women. Four-fifths were under the age of 55 years. PAs are trained in 2.5 years at one-fourth the cost of a physician and begin producing patient care 4 years before a physician is independently functional. One-third of PAs work with primary care physicians; 65% work in non-primary care practices. Popular specialties are family medicine, emergency medicine, surgery, and orthopedics. PAs are revenue producers for employers and expand access and clinical productivity in most practice settings. Roles for PAs have expanded into hospital settings and graduate medical education programs. About 7300 PAs graduate annually, and this number is expected to grow to 9000 by the end of the decade. Predictive modeling suggests that demand for medical services will grow faster than the combined supply of physicians, PAs, and nurse practitioners, particularly in primary care. PA quality of care appears indistinguishable from that of physician-delivered services. Conclusions Optimal organizational efficiency and cost savings in health services delivery will depend on how well the PA can be utilized.

Physician Assistants in American Medicine: The Half-Century Mark

Background Advanced practice providers (APPs), including nurse practitioners (NPs) and physician assistants (PAs) are cost-effective substitutes for physicians, with similar outcomes in primary care and surgery. However, little is understood about APP roles in inpatient medicine. Objective Describe APPs role in inpatient medicine. Design Observational cross-sectional cohort study. Setting One hundred twenty-four Veterans Health Administration (VHA) hospitals. Participants Chiefs of medicine (COMs) and nurse managers. Measurements Surveys included inpatient medicine scope of practice for APPs and perceived healthcare quality. We conducted bivariate unadjusted and multivariable adjusted analyses. Results One hundred eighteen COMs (95.2%) and 198 nurse managers (75.0%) completed surveys. Of 118 medicine services, 56 (47.5%) employed APPs; 27 (48.2%) used NPs only, 15 (26.8%) PAs only, and 14 (25.0%) used both. Full-time equivalents for NPs was 0.5 to 7 (mean = 2.22) and PAs was 1 to 9 (mean = 2.23). Daily caseload was similar at 4 to 10 patients (mean = 6.5 patients). There were few significant differences between tasks. The presence of APPs was not associated with patient or nurse manager satisfaction. Presence of NPs was associated with greater overall inpatient and discharge coordination ratings by COMs and nurse managers, respectively; the presence of PAs was associated with lower overall inpatient coordination ratings by nurse managers. Conclusions NPs and PAs work on half of VHA inpatient medicine services with broad, yet similar, scopes of practice. There were few differences between their roles and perceptions of care. Given their very different background, regulation, and reimbursement, this has implications for inpatient medicine services that plan to hire NPs or PAs.

/pdf/nurse-practitioner-and-physician-assistant-scope-of-practice-137azu9dee.pdf

Nurse practitioner and physician assistant scope of practice in 118 acute care hospitals

PurposePatient care quality appears to be similar when delivered by trainee and attending physicians. The authors conducted a systematic review and meta-analysis to examine whether outcomes differ for general internal medicine (GIM) patients admitted to teaching versus nonteaching services.MethodThe

Patient outcomes in teaching versus nonteaching general internal medicine services: a systematic review and meta-analysis

Improving the quality and safety of care on the medical ward: A review and synthesis of the evidence base

BACKGROUND:

Residency reform in the form of work hour restrictions has forced academic medical centers to develop alternate models of care to provide inpatient care. One such model is the use of physician assistants (PAs) with hospitalists. However, these models of care have not been widely evaluated.



OBJECTIVE:

To compare the outcomes of inpatient care provided by a hospitalist-PA (H-PA) model with the traditional resident based model.



DESIGN, SETTING and PATIENTS:

We conducted a retrospective cohort study of 9681 general medical (GM) hospitalizations between January 2005 and December 2006 using a hospital administrative database. We used multivariable mixed models to adjust for a wide variety of potential confounders and account for multiple patient visits to the hospital to compare the outcomes of 2171 hospitalizations to H-PA teams with those of 7510 hospitalizations to resident teams (RES).



MEASUREMENTS:

Length of stay (LOS), charges, readmission within 7, 14, and 30 days and inpatient mortality.



RESULTS:

Inpatient care provided by H-PA teams was associated with a 6.73% longer LOS (P = 0.005) but charges, risk of readmission at 7, 14, and 30 days and inpatient mortality were similar to resident-based teams. The increase in LOS was dependent on the time of admission of the patients.



CONCLUSIONS:

H-PA team-based GM inpatient care was associated with a higher LOS but similar charges, readmission rates, and inpatient mortality to traditional resident-based teams, a finding that persisted in sensitivity analyses. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine.

https://cdn.mdedge.com/files/s3fs-public/pdfs/journals/826_ftp.pdf

A comparison of outcomes of general medical inpatient care provided by a hospitalist-physician assistant model vs a traditional resident-based model.

BACKGROUND:

Localization of general medical inpatient teams is an attractive way to improve inpatient care but has not been adequately studied.



OBJECTIVE:

To evaluate the impact of localizing general medical teams to a single nursing unit.



DESIGN:

Quasi-experimental study using historical and concurrent controls.



SETTING:

A 490-bed academic medical center in the midwestern United States.



PATIENTS:

Adult, general medical patients, other than those with sickle cell disease, admitted to medical teams staffed by a hospitalist and a physician assistant (PA).



INTERVENTION:

Localization of patients assigned to 2 teams to a single nursing unit.



MEASUREMENTS:

Length of stay (LOS), 30-day risk of readmission, charges, pages to teams, encounters, relative value units (RVUs), and steps walked by PAs.



RESULTS:

Localized teams had 0.89 (95% confidence interval [CI], 0.37–1.41) more patient encounters and generated 2.20 more RVUs per day (CI, 1.10–3.29) compared to historical controls; and 1.02 (CI, 0.46–1.58) more patient encounters and generated 1.36 more RVUs per day (CI, 0.17–2.55) compared to concurrent controls. Localized teams received 51% (CI, 48–54) fewer pages during the workday. LOS may have been approximately 10% higher for localized teams. Risk of readmission within 30 days and charges incurred were no different. PAs possibly walked fewer steps while localized.



CONCLUSION:

Localization of medical teams led to higher productivity and better workflow, but did not significantly impact readmissions or charges. It may have had an unintended negative impact on hospital efficiency; this finding deserves further study. Journal of Hospital Medicine 2012. © 2012 Society of Hospital Medicine

https://cdn.mdedge.com/files/s3fs-public/pdfs/journals/1948_ftp.pdf

Mary Conti

Papers

A comparison of outcomes of general medical inpatient care provided by a hospitalist-physician assistant model vs a traditional resident-based model.

Impact of localizing general medical teams to a single nursing unit