Defining hospitalist physicians using clinical practice data: a systems-level pilot study of Ontario physicians

Abstract

Background: Hospitalists have become dominant providers of inpatient care in many North American hospitals. Despite the global growth of hospital medicine, no objective method has been proposed for defining the hospitalist discipline and delineating among inpatient practices on the basis of physicians' clinical volumes. We propose a functional method of identifying hospital-based physicians using aggregated measures of inpatient volume and apply this method to a retrospective, population-based cohort to describe the growth of the hospitalist movement, as well as the prevalence and practice characteristics of hospital-based generalists in one Canadian province.

Methods: We used human resource databases and financial insurance claims to identify all active fee-for-service physicians working in Ontario, Canada, between fiscal year 1996/1997 and fiscal year 2010/2011. We constructed 3 measures of inpatient volume from the insurance claims to reflect the time that physicians spent delivering inpatient care in each fiscal year. We then examined how inpatient volumes have changed for Ontario physicians over time and described the prevalence of full-time and part-time hospital-based generalists working in acute care hospitals in fiscal year 2010/2011.

Results: Our analyses showed a significant increase since fiscal year 2000/2001 in the number of high-volume hospital-based family physicians practising in Ontario (p < 0.001) and associated decreases in the numbers of high-volume internists and specialists (p = 0.03), where high volume was defined as ≥ 2000 inpatient services/ year. We estimated that 620 full-time and 520 part-time hospital-based physicians were working in Ontario hospitals in 2010/2011, accounting for 4.5% of the active physician workforce (n = 25 434). Hospital-based generalists, consisting of 207 family physicians and 130 general internists, were prevalent in all geographic regions and hospital types and collectively delivered 10% of all inpatient evaluation and care coordination for Ontario residents who had been admitted to hospital.

Interpretation: These analyses confirmed a substantial increase in the prevalence of general hospitalists in Ontario from 1996 to 2011. Systems-level analyses of clinical practice data represent a practical and valid method for defining and identifying hospital-based physicians.

Figure 1

Distribution of active Ontario physicians, according to annual number of inpatient evaluation-andmanagement claims billed to the Ontario Health Insurance Plan (OHIP), fiscal year 1996/1997 to fiscal year 2010/2011. (A) General practitioners and family physicians, (B) general internists, and (C) internal medicine specialists. Significant increases (*) and significant decreases (†) in the proportion of physicians achieving each billing level over time, based on autoregressive models with a lag set to 1 (p < 0.05), are marked.

Figure 2

Relationship between workforce density and service volume, represented as current distribution of inpatient physician workforce by medical specialty and annual inpatient volume, overlaid with the cumulative distribution of total inpatient evaluation-and-management (E&M) claims billed in Ontario, for fiscal year 2010/2011.