Comparison of Resident, Advanced Practice Clinician, and Hospitalist Teams in an Academic Medical Center: Association With Clinical Outcomes and Resource Utilization

Abstract

BACKGROUND: Academic medical centers have expanded their inpatient medicine services with advanced practice clinicians (APCs) or nonteaching hospitalists in response to patient volumes, residency work hour restrictions, and recently, COVID-19. Reports of clinical outcomes, cost, and resource utilization differ among inpatient team structures. OBJECTIVE: Directly compare outcomes among resident, APC, and solo hospitalist inpatient general medicine teams. DESIGN: Retrospective cohort study using multivariable analysis adjusted for time of admission, interhospital transfer, and comorbidities that compares clinical outcomes, cost, and resource utilization. SUBJECTS: Patients 18 years or older discharged from an inpatient medicine service between July 2015 and July 2018 (N = 12,716). MAIN MEASURES: Length of stay (LOS), 30-day readmission, inpatient mortality, normalized total direct cost, discharge time, and consultation utilization. KEY RESULTS: Resident teams admitted fewer patients at night (32.0%; P < .001) than did APC (49.5%) and hospitalist (48.6%) teams. APCs received nearly 4% more outside transfer patients (P = .015). Hospitalists discharged patients 26 minutes earlier than did residents (mean hours after midnight [95% CI], 14.58 [14.44-14.72] vs 15.02 [14.97-15.08]). Adjusted consult utilization was 15% higher for APCs (adjusted mean consults per admission [95% CI], 1.00 [0.96-1.03]) and 8% higher for residents (0.93 [0.90-0.95]) than it was for hospitalists (0.85 [0.80-0.90]). No differences in LOS, readmission, mortality, or cost were observed between the teams. CONCLUSION: We observed similar costs, LOS, 30-day readmission, and mortality among hospitalist, APC, and resident teams. Our results suggest clinical outcomes are not significantly affected by team structure. The addition of APC or hospitalist teams represent safe and effective alternatives to traditional inpatient resident teams.

Patterns of utilization and evaluation of advanced practice providers on academic hospital medicine teams: A national survey

“…Given this heterogeneity in how APPs are utilized, in combination with the limited literature on the subject, it is difficult to determine the best models for APP integration to achieve the highest quality patient care. What renders this more challenging is that AMCs have not been systematically gathering data on outcomes, including mortality, ICU transfers, readmissions, relative value units generated, estimated associated costs, ratings of physician burnout, and patient satisfaction, for teams staffed by APPs compared with traditional team models 3,4,9 . Ideally, further research should be performed that compares clinical and non‐clinical outcomes between different APP team models to determine how to best leverage the strength and skillset of APPs.…”

“…Over the past two decades, APPs have been integrated into team‐based models in HM groups 2–5 with approximately 4% of the 325,000 licensed NPs 1 and 3.1% of the 139,000 certified PAs 6 practicing HM. Studies evaluating the impact of APP staffing on patient outcomes, including mortality, intensive care unit (ICU) transfer, length of stay, costs and patient satisfaction, have had mixed results, but mostly suggest that APP‐staffed teams provide equal quality of care compared to teams staffed by resident physicians 2,4,7–9 …”

“…Studies evaluating the impact of APP staffing on patient outcomes, including mortality, intensive care unit (ICU) transfer, length of stay, costs and patient satisfaction, have had mixed results, but mostly suggest that APP-staffed teams provide equal quality of care compared to teams staffed by resident physicians. 2,4,[7][8][9] Despite the integration of APPs into HM groups at academic medical centers (AMCs), much remains unknown about the various roles performed and contributions of APPs to these groups. 2,3 We undertook this survey-based study with the goal of providing a contemporary appraisal of APP roles and to summarize perceptions of the benefits and challenges related to the integration of APPs into adult HM groups at AMCs.…”

The scope of hospital medicine practice at night: a national survey of night shift hospitalists

“…In one tertiary care hospital staffed exclusively by nocturnists, there was no difference in hospitalization-relevant outcomes for patients admitted overnight, compared to those admitted during the day [6]. Also, the introduction of nocturnist nurse practitioners and physician assistants (NP/ PAs) demonstrated similar outcomes to traditional resident overnight coverage [7].…”

Development of a novel hospitalist advanced practice provider assessment instrument: A pilot study

“…Advanced practice providers (APPs), 1 defined as nurse practitioners (NPs) and physician assistants (PAs), form an integral part of the hospitalist workforce. The percent of hospital medicine groups (HMGs) that employ APPs has increased from 66% in 2014 to 83% in 2020 2 Experienced hospitalist APPs have achieved similar patient outcomes as hospitalist physicians 3 . APPs undergo variable training in hospital medicine prior to entering the workforce.…”