Standardising hospitalist practice in sepsis and COPD care

Abstract

Background: Hospitalist medicine was predicated on the belief that providers dedicated to inpatient care would deliver higher quality and more cost-effective care to acutely hospitalised patients. The literature shows mixed results and has identified care variation as a culprit for suboptimal quality and cost outcomes. Using a scientifically validated engagement and measurement approach such as Clinical Performance and Value (CPV), simulated patient vignettes may provide the impetus to change provider behaviour, improve system cohesion, and improve quality and cost efficiency for hospitalists.

Methods: We engaged 33 hospitalists from four disparate hospitalist groups practising at Penn Medicine Princeton Health. Over 16 months and four engagement rounds, participants cared for two patients per round (with a diagnosis of chronic obstructive pulmonary disease [COPD] and sepsis), then received feedback, followed by a group discussion. At project end, we evaluated both simulated and real-world data to measure changes in clinical practice and patient outcomes.

Results: Participants significantly improved their evidence-based practice (+13.7% points, p<0.001) while simultaneously reducing their variation (-1.4% points, p=0.018), as measured by the overall CPV score. Correct primary diagnosis increased significantly for both sepsis (+19.1% points, p=0.004) and COPD (+22.7% points, p=0.001), as did adherence to the sepsis 3-hour bundle (+33.7% points, p=0.010) and correct admission levels for COPD (+26.0% points, p=0.042). These CPV changes coincided with real-world improvements in length of stay and mortality, along with a calculated $5 million in system-wide savings for both disease conditions.

Conclusion: This study shows that an engagement system-using simulated patients, benchmarking and feedback to drive provider behavioural change and group cohesion, using parallel tracking of hospital data-can lead to significant improvements in patient outcomes and health system savings for hospitalists.

Keywords: evidence-based medicine; hospital medicine; implementation science; quality improvement.