Characterizing Hospitalist Practice and Perceptions of Critical Care Delivery

RESULTS

Objective 1: Demographics and Practice Role

Four hundred and twenty-five hospitalists responded to the survey. The first 2 phases (pilot survey and distribution via professional networks) generated 101 responses, and the third phase (via SHM’s listserv) generated an additional 324 responses. As the survey was anonymous, we could not determine which hospitals or geographic regions were represented. Three hundred and twenty-five of the 425 hospitalists who completed the survey (77%) reported that they delivered care in the ICU. Of these 325 hospitalists, 45 served only as consultants, while the remaining 280 (66% of the total sample) served as the primary attending physician in the ICU. Among these primary providers of care in the ICU, 60 (21%) practiced in rural settings and 220 (79%) practiced in nonrural settings (Figure 1).

The demographics of our respondents were similar to those of the SHM annual survey,¹³ in which 66% of respondents delivered ICU care. Forty-one percent of our respondents worked in critical access or small community hospitals, 24% in academic medical centers, and 34% in large community centers with an academic affiliation. The SHM annual survey cohort included more physicians from nonteaching hospitals (58.7%) and fewer from academic medical centers (14.8%).¹³

Hospitalists’ presence in the ICU varied by practice setting (Table 1).

Seventy-eight percent of respondents practicing outside of academic medical centers served as primary ICU physicians, compared with less than 30% of hospitalists practicing at an academic medical center. Hospitalists reported substantial variability in their volumes of ICU procedures (eg, central lines, intubation), the number of mechanically ventilated patients for whom they delivered care, and who was responsible for making ventilator management decisions (Table 1).

Hospitalists were significantly more prevalent in rural ICUs than in nonrural settings (96% vs 73%; Table 2).

Rural hospitalists were also more likely to serve as primary physicians for ICU patients (85% vs 62%) and were more likely to deliver all critical care services (55% vs 10%). Seventy-five percent of respondents from rural settings reported that hospitalists manage all or most ICU patients in their hospital as opposed to 36% for nonrural respondents. The associations between hospitalist roles in the ICU care and practice setting were significantly different for rural and nonrural hospitalists (χ²P value for association <.001). Intensivist availability (measured both in hours per day and by perception of whether such support was sufficient) was significantly lower in rural ICUs (Table 2).

We found similar results when comparing academic hospitalists (those working in an academic medical center or academic-affiliated hospital) with nonacademic hospitalists (those working in critical access or small community centers). Specifically, hospitalists in nonacademic settings were significantly more prevalent in ICUs (90% vs 67%; Table 2), more likely to serve as the primary attending (81% vs 55%), and more likely to deliver all critical care services (64% vs 25%). Sixty-four percent of respondents from nonacademic settings reported that hospitalists manage all or most ICU patients in their hospital as opposed to 25% for academic respondents (χ²P value for association <.001). Intensivist availability was also significantly lower in nonacademic ICUs (Table 2).

We also sought to determine whether the ability to transfer critically ill patients to higher levels of care effectively mitigated shortfalls in intensivist staffing. When restricted to hospitalists who served as primary providers for ICU patients, 28% of all respondents and 51% of rural hospitalists reported transferring patients to a higher level of care.

Sixty-seven percent of hospitalists who served as primary physicians for ICU patients in any setting reported at least moderate difficulty arranging transfers to higher levels of care.

Objective 2: Identifying the Practice Gap

Hospitalists’ perceptions of practicing critical care beyond their skill level and without sufficient board-certified intensivist support varied by both practice location and practice type (Table 3).

In marked contrast to nonrural hospitalists, 43% of rural hospitalists reported feeling expected to practice beyond their perceived scope of expertise at least some of the time, and 31% reported never having sufficient board-certified intensivist support. Both these results were statistically significantly different when compared with nonrural hospitalists. When restricted to rural hospitalists who are primary providers for ICU patients, 90% reported that board-certified intensivist support was at least occasionally insufficient.

There were similar discrepancies between academic and nonacademic respondents. Forty-two percent of respondents practicing in nonacademic settings reported being expected to practice beyond their scope at least some of the time, and 18% reported that intensivist support was never sufficient. This contrasts with academic hospitalists, of whom 35% reported feeling expected to practice outside their scope, and less than 4% reported the available support from intensivists was never sufficient. For comparisons of academic and nonacademic respondents, only perceptions of sufficient board-certified intensivist support reached statistical significance (Table 3).

The role of intensivists in making management decisions and the strategy for ventilator management decisions correlated significantly with perception of intensivist support (P < .001) but not with the perception of practicing beyond one’s scope. The number of ventilated patients did not correlate significantly with either perception of intensivist support or of being expected to practice beyond scope.

Difficulty transferring patients to a higher level of care was the only attribute that significantly correlated with hospitalists’ perceptions of having to practice beyond their skill level (P < .05; Table 3). Difficulty of transfer was also significantly associated with perceived adequacy of board-certified intensivist support (P < .001). Total hours of intensivist coverage, intensivist role in decision making, and ventilator management arrangements also correlated significantly with the perceived adequacy of board-certified intensivist support (P < .001 for all; Table 3).