“We’re almost guests in their clinical care”: Inpatient provider attitudes toward chronic disease management
BACKGROUND
Many hospitalized patients have at least 1 chronic disease that is not optimally controlled. The purpose of this study was to explore inpatient provider attitudes about chronic disease management and, in particular, barriers and facilitators of chronic disease management in the hospital.
METHODS
We conducted a qualitative study of semi-structured interviews of 31 inpatient providers from an academic medical center. We interviewed attending physicians, resident physicians, physician assistants, and nurse practitioners from various specialties about attitudes, experiences with, and barriers and facilitators towards chronic disease management in the hospital. Qualitative data were analyzed using constant comparative analysis.
RESULTS
Providers perceived that hospitalizations offer an opportunity to improve chronic disease management, as patients are evaluated by a new care team and observed in a controlled environment. Providers perceived clinical benefits to in-hospital chronic care, including improvements in readmission and length of stay, but expressed concerns for risks related to adverse events and distraction from the acute problem. Barriers included provider lack of comfort with managing chronic diseases, poor communication between inpatient and outpatient providers, and hospital-system focus on patient discharge. A strong relationship with the outpatient provider and involvement of specialists were facilitators of inpatient chronic disease management.
CONCLUSIONS
Providers perceived benefits to in-hospital chronic disease management for both processes of care and clinical outcomes. Efforts to increase inpatient chronic disease management will need to overcome barriers in multiple domains. Journal of Hospital Medicine 2017;12:162-167. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
RESULTS
We conducted interviews with 31 providers. Of these, 12 were on the medicine service, 12 were on the surgery or a surgical subspecialty service, and 7 were on other services; 11 were attending physicians, 12 were resident physicians, 5 were NPs, and 3 were PAs. Only 2 providers—an attending in medicine and a resident in surgery—had a specialty focus that was cardiac-related. Median time in current position was 4 years (Table 1). Seventeen of the interviews were in person, and 14 were conducted by telephone. The mean interview time was 20 minutes and ranged from 11 to 41 minutes.
We identified 5 main themes with 29 supporting codes (Table 2) describing provider attitudes towards the management of chronic disease for hospitalized patients. These themes, with related CFIR constructs, were: 1) perceived impact on patient outcomes (CFIR construct: intervention characteristics, relative advantage); 2) hospital structural characteristics (inner setting, structural characteristics); 3) provider knowledge and self-efficacy (characteristic of individual, knowledge and beliefs about the intervention and self-efficacy); 4) hospital priorities (inner setting, implementation climate, relative priority); and 5) continuity and communication (inner setting, networks and communications). For most themes, subjects described both positive and negative aspects of chronic disease management, as well as related facilitators and barriers to delivery of chronic disease care for hospitalized patients. Illustrative quotes for each theme are shown in Table 3.
Perceived Impact on Patient Outcomes
Perceived impact on patient outcomes was mixed. Most providers believed the management of chronic diseases could lead to improvement in important patient outcomes, including decreased length of stay (LOS), prevention of hospital complication, and decreased readmissions. Surgical providers focused particularly on the benefits of preventing surgical complications and noted that they were more likely to manage chronic conditions—primarily through use of specialist consultation—when they perceived a benefit to prevention of surgical outcomes or a fear that surgery may worsen a stable chronic condition:
“Most of the surgery I do is pretty stressful on the body and is very likely to induce acute on chronic exacerbations of heart failure. For someone with Class II or higher heart failure, I’m definitely gonna have cardiology on board or at least internal medicine on board right from the beginning.”
However, some providers acknowledged that there were potential risks to such management, including “prolonging hospital stays for nonemergent indications” and treatment with therapies that had previously led to an “adverse reaction that wasn’t clearly documented.” Providers were also concerned that treating chronic conditions may take focus away from acute conditions, which could lead to worse patient-centered outcomes. One attending in medicine described it:
“If you do potentially focus on those chronic issues, and there’s already a lot of other stuff going on with the patient, you might not be prioritizing the patient’s active issues appropriately. The patient’s saying, ‘I’m in pain. I’m in pain. I’m in pain,’ and you’re saying, ‘Thank you very much. Look, your heart failure, you didn’t get your beta-blocker.’ There could be a disconnect between patient’s goals, expectations, and your goals and expectations.”
Hospital Structural Characteristics
For many providers, the hospital setting provides a unique opportunity for care of patients with chronic disease. First, a hospitalization is a time for a patient’s management to be reviewed by a new care team. The hospital team reviews the management plan for patients at admission, which is a time to reevaluate whether patients are on evidence-based therapies: “It’s helpful to have a new set of eyes on somebody, like fresh information.” According to providers, this reevaluation can overcome instances of therapeutic inertia by the outpatient physician. Second, the hospital has many resources, including readily available specialist services and diagnostic tests, which can allow a patient-centered approach that coordinates care in 1 place, as a surgery NP described: “I think the advantage for the patient is that they wind up stopping in for 1 thing but we wind up taking care of a few without requiring the need for him or her to go to all these different specialists on the outside. They’re mostly elderly and not able to get around.” Third, the high availability of services and frequent monitoring allows rapid titration of evidence-based medicines, as discussed by a medicine resident: “It’s easier and faster to titrate medication—they’re in a monitored setting; you can ensure compliance.”
Patients may also differ from their usual state while hospitalized, creating both risks and benefits. The hospital setting can provide an opportunity to educate patients on their chronic disease(s) because they are motivated: “They’re in an office visit and their sugars are out of whack or something, they may take it a little bit more seriously if they were just in the hospital even though it was on an unrelated issue. I think it probably just changes their perspective on their disease.” However, in the hospital, patients are in an unusual environment with a restricted diet and forced medication compliance. Furthermore, the acute condition can lead to changes in their chronic disease, as described by 1 medicine attending: “their sugar is high because they’re acutely ill.” Providers expressed concern that changing medications in this setting may lead to adverse events (AEs) when patients return to their usual environment.
