“We’re almost guests in their clinical care”: Inpatient provider attitudes toward chronic disease management

Millions of individuals with chronic diseases are hospitalized annually in the United States. More than 90% of hospitalized adults have at least 1 chronic disease,¹ and almost half of Medicare beneficiaries in the hospital have 4 or more chronic conditions.² While many patients are admitted for worsening of a single chronic disease, patients are hospitalized more commonly for other causes. For instance, although acute heart failure is among the most frequent causes of hospitalizations among older adults, three-fourths of hospitalizations of patients with heart failure are for reasons other than acute heart failure.³

When a patient with a chronic disease is hospitalized, the inpatient provider must consider whether to actively or passively manage the chronic disease. Studies have suggested that intervening in chronic diseases during hospitalizations can lead to long-term improvement in treatment;^4-6 for instance, stroke patients who were started on antihypertensive therapy at discharge were more likely to have their blood pressure controlled in the next year.⁵ However, some authors have argued that aggressive hypertension management by inpatient providers may result in patient harm.⁷ One case-based survey suggested that hospitalists were mixed in their interest in participating in chronic disease management in the hospital.⁸ This study found that providers were less likely to participate in chronic disease management if it was unrelated to the reason for hospitalization.⁸ However, to our knowledge, no studies have broadly evaluated inpatient provider attitudes, motivating factors, or barriers to participation in chronic disease management.

The purpose of this study was to understand provider attitudes towards chronic disease management for patients who are hospitalized for other causes. We were particularly interested in perceptions of barriers and facilitators to delivery of inpatient chronic disease management. Ultimately, such findings can inform future interventions to improve inpatient care of chronic disease.

In this qualitative study, we conducted in-depth interviews with providers to understand attitudes, barriers, and facilitators towards inpatient management of chronic disease; this study was part of a larger study to implement an electronic health record-based clinical decision-support system intervention to improve quality of care for hospitalized patients with heart failure.

We included providers who care for and can write medication orders for hospitalized adult patients at New York University (NYU) Langone Medical Center, an urban academic medical center. As patients with chronic conditions are commonly hospitalized for many reasons, we sought to interview providers from a range of clinical services without consideration of factors such as frequency of caring for patients with heart failure. We used a purposive sampling framework: we invited participants to ensure a range of services, including medicine, surgery, and neurology, and provider types, including attending physicians, resident physicians, nurse practitioners, and physician assistants. Potential participants, therefore, included all providers for adult hospitalized patients.

We identified potential participants through study team members, referrals from department heads and prior interviewees, and e-mails to department list serves. We did not formally track declinations to being interviewed, although we estimate them as fewer than 20% of providers directly approached. While we focused on inpatient providers at New York University Langone Medical Center, many of the attending physicians and residents spend a portion of their time at the Manhattan Veterans Affairs Hospital and Bellevue Hospital, a safety-net city hospital; providers could have outpatient responsibilities as well.

All participants provided verbal consent to participate. The study was approved by the New York University Institutional Review Board, which granted a waiver of documentation of consent. Participants received a $25 gift card following the interview.

We used a semi-structured interview guide (Appendix) to elicit in-depth accounts of provider attitudes, experiences with, and barriers and facilitators towards chronic disease management in the hospital. The interview began by asking about chronic disease in general and then asked more specific questions about heart failure; we included responses to both groups of questions in the current study. The interview also included questions related to the clinical decision-support system being developed as part of the larger implementation study, although we do not report on these results in the current study. The semi-structured interview guide was informed by the consolidated framework for advancing implementation science (CFIR), which offers an overarching typology for delineating factors that influence guideline implementation;⁹ we also used CFIR constructs in theme development. We conducted in-depth interviews with providers.

A priori, we estimated 25 interviews would be sufficient to include the purposive sample and achieve data saturation,¹⁰ which was reached after 31 interviews. Interviews were held in person or by telephone, at the convenience of the subject. All interviews were transcribed by a professional service. Transcriptions were reviewed against recordings with any mistakes corrected. Prior to each interview, we conducted a brief demographic survey.

Qualitative data were analyzed using a constant comparative analytic technique.¹¹ The investigative team met after reviewing the first 10 interviews and discussed emergent themes from these early transcripts, which led to the initial code list. Two investigators coded the transcripts. Reliability was evaluated by independent coding of a 20% subset of interviews. Differences were reviewed and discussed until consensus was reached. Final intercoder reliability was determined to be greater than 95%.¹² All investigators reviewed and refined the code list during the analysis phase. Codes were clustered into themes based on CFIR constructs.⁹ Analyses were performed using Atlas.ti v. 7 (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany).