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

Provider Knowledge and Self-Efficacy

Insufficient knowledge of treatments for chronic conditions was cited as a barrier to some providers’ ability to actively manage chronic disease for hospitalized patients. Some providers described management of conditions outside their area as less satisfying than their primary focus. For example, an orthopedic surgeon explained: “…it’s very simple. You see your bone is broken, you fix it, that’s it…it’s intellectually satisfying…managing chronic diseases is less like that.” Reliance on consultants was 1 approach to deal with knowledge gaps in areas outside a provider’s expertise.

For a number of providers, management of stable chronic disease is the responsibility of the outpatient provider. Providers expressed concern that inpatient management was a reach into the domain of the primary care provider (PCP) and might take “away from the primary focus” of the hospitalization. Nonetheless, some providers noted an “ethical responsibility to manage [a] patient correctly,” and some providers believed that engaging in chronic disease management in the hospital would present an opportunity to expand their own expertise.

A few providers were worried about legal risk related to chronic disease management: “we don’t typically deal too much with managing some of these other medical issues for medical and legal reasons.” Providers again suggested that consults can help overcome this concern for risk, as discussed by 1 surgical attending: “We’re all not wanting to be sued, and we want to do the right thing. It costs me nothing to have a cardiologist on board, so like—why not.”

Hospital Priorities

Providers explained that the hospital has strong interests in early discharge and minimizing LOS. These priorities are based on goals of improving patient outcomes, increasing bed availability and hospital volume, and reducing costs. Providers perceive these hospital priorities as potential barriers to chronic disease management, which can increase LOS and costs through additional testing and treatment. As a medicine resident described: “The DBN philosophy, ‘discharge before noon’ philosophy, which is part of the hospital efficiency to get people in and out of the hospital as quickly as [is] safe, or maybe faster. And I think that there’s a culture where you’re encouraged to only focus on the acute issue and tend to defer everything else.”

Continuity and Communication

According to many providers, care continuity between the outpatient setting and the hospital played a major role in management of chronic disease. One barrier to starting a new evidence-based medication was lack of knowledge of patient history. As noted, providers expressed concern that a patient may not be on a given therapy because of an adverse reaction that was not documented in the hospital chart. This is particularly true because, as discussed by a surgery resident, patients with “PCPs outside the system [in which providers] don’t have access to the electronic medical record.” To overcome this barrier, providers attempt to communicate with the outpatient provider to confirm a lack of contraindications to therapies prior to any changes; notably, communication is easier if the inpatient provider has a relationship with the outpatient PCP.

Some providers were more likely to start chronic disease therapies if the patient had no prior outpatient care, because the provider was reassured that there was no rationale for missing therapies. One neurology attending noted that if a patient had newly documented “hypertension even if they were in for something else, I might start them on an antihypertensive, but then arrange for a close follow-up with a new PCP.”

Following hospitalization, providers wanted assurance that any changes to chronic disease management would be followed up by an outpatient physician. Any changes are relayed to the outpatient provider and the “level of communication…with the outpatient provider who’s gonna inherit” these changes can influence how aggressively the inpatient provider manages chronic diseases. Providers may be reluctant to start therapy for patients if they are concerned about outpatient follow up: “they have diabetes and they should really technically be on an ACE [angiotensin converting enzyme]inhibitor and aspirin, but they’re not. I might send them out on the aspirin but I might either start ACE inhibitor and have them follow up with their PCP in 2 weeks if I’m confident that they’ll do it or if I’m really confident that they’ll not follow up, I will help them get the appointment and then the discharge instruction is to the PCP is ‘Please start this patient on ACE inhibitor if they show up.’”

Providers frequently perceive benefit to chronic disease management in the hospital, including improvements in clinical outcomes. Notably, providers see opportunities to improve compliance with evidence-based care to overcome potential barriers to managing chronic disease in the outpatient setting, which can be limited by pressure for brief encounters,¹³ clinical inertia,¹⁴ difficulty with close monitoring of patients,¹⁵ and care fragmentation.¹⁶ Concurrently, inpatient providers are concerned about potential for patient harm related to chronic disease management, primarily related to AEs from medications. Similar to a case study about a patient with outpatient hypotension following aggressive inpatient hypertension management,⁷ providers fear that changing a patient’s chronic disease management in a hospital setting may cause harm when the patient returns home.