Sanjay Saint, MD, MPH

Peripherally inserted central catheters (PICCs) are central venous catheters that are inserted through peripheral veins of the upper extremities in adults. Because they are safer to insert than central venous catheters (CVCs) and have become increasingly available at the bedside through the advent of specially trained vascular access nurses,[1] the use of PICCs in hospitalized patients has risen across the United States.[2] As the largest group of inpatient providers, hospitalists play a key role in the decision to insert and subsequently manage PICCs in hospitalized patients. Unfortunately, little is known about national hospitalist experiences, practice patterns, or knowledge when it comes to these commonly used devices. Therefore, we designed a 10‐question survey to investigate PICC‐related practices and knowledge among adult hospitalists practicing throughout the United States.

PATIENTS AND METHODS

Questions for this survey were derived from a previously published study conducted across 10 hospitals in the state of Michigan.[3] To assess external validity and test specific hypotheses formulated from the Michigan study, those questions with the greatest variation in response or those most amenable to interventions were chosen for inclusion in this survey.

To reach a national audience of practicing adult hospitalists, we submitted a survey proposal to the Society of Hospital Medicine's (SHM) Research Committee. The SHM Research Committee reviews such proposals using a peer‐review process to ensure both scientific integrity and validity of the survey instrument. Because the survey was already distributed to many hospitalists in Michigan, we requested that only hospitalists outside of Michigan be invited to participate in the national survey. All responses were collected anonymously, and no identifiable data were collected from respondents. Between February 1, 2013 and March 15, 2013, data were collected via an e‐mail sent directly from the SHM to members that contained a link to the study survey administered using SurveyMonkey. To augment data collection, nonresponders to the original e‐mail invitation were sent a second reminder e‐mail midway through the study. Descriptive statistics (percentages) were used to tabulate responses. The institutional review board at the University of Michigan Health System provided ethical and regulatory approval for this study.

RESULTS

A total of 2112 electronic survey invitations were sent to non‐Michigan adult hospitalists, with 381 completing the online survey (response rate 18%). Among respondents to the national survey, 86% reported having placed a PICC solely to obtain venous access in a hospitalized patient (rather than for specific indications such as long‐term intravenous antibiotics, chemotherapy, or parenteral nutrition), whereas 82% reported having cared for a patient who specifically requested a PICC (Table 1). PICC‐related deep vein thrombosis (DVT) and bloodstream infections were reported as being the most frequent PICC complications encountered by hospitalists, followed by superficial thrombophlebitis and mechanical complications such as coiling, kinking, and migration of the PICC tip.

Several potentially important safety concerns regarding hospitalist PICC practices were observed in this survey. For instance, only 25% of hospitalists reported examining PICCs on daily rounds for external problems. When alerted by nurses or patients about problems with the device, this number doubled to 50%. In addition, 57% of respondents admitted to having at least once forgotten about the presence of a PICC in their hospitalized patient.

Participants also reported significant variation in duration of anticoagulation therapy for PICC‐related DVT, with only half of all respondents selecting the guideline‐recommended 3 months of anticoagulation.[4, 5] With respect to knowledge regarding PICCs, only 9% of respondents recognized that tip verification performed after PICC insertion was conducted to lower risk of venous thromboembolism, not that of arrhythmia.[6] Hospitalists were ambivalent about being trained on how to place PICCs, with only 43% indicating this skill was necessary. Finally, as many as 10% to 25% of PICCs inserted in their hospitals were felt to be inappropriately placed and/or avoidable by 42% of those surveyed.

DISCUSSION

As the use of PICCs rises in hospitalized patients, variability in practices associated with the use of these indwelling vascular catheters is being increasingly recognized. For instance, Tejedor and colleagues reported that PICCs placed in hospitalized patients at their academic medical center were often idle or inserted in patients who simultaneously have peripheral intravenous catheters.[7] Recent data from a tertiary care pediatric center found significantly greater PICC utilization rates over the past decade in association with shorter dwell times, suggesting important and dynamic changes in patterns of use of these devices.[2] Our prior survey of hospitalists in 10 Michigan hospitals also found variations in reported hospitalist practices, knowledge, and experiences related to PICCs.[3] However, the extent to which the Michigan experience portrayed a national trend remained unclear and was the impetus behind this survey. Results from this study appear to support findings from Michigan and highlight several potential opportunities to improve hospitalist PICC practices on a national scale.

In particular, 57% of respondents in this study (compared to 51% of Michigan hospitalists) stated they had at least once forgotten that their patient had a PICC. As early removal of PICCs that are clinically no longer necessary is a cornerstone to preventing thrombosis and infection,[4, 5, 6, 8] the potential impact of such forgetfulness on clinical outcomes and patient safety is of concern. Notably, PICC‐related DVT and bloodstream infection remained the 2 most commonly encountered complications in this survey, just as in the Michigan study.

Reported variations in treatment duration for PICC‐related DVT were also common in this study, with only half of all respondents in both surveys selecting the guideline‐recommended minimum of 3 months of anticoagulation. Finally, a substantial proportion (42%) of participants felt that 10% to 25% of PICCs placed in their hospitals might be inappropriately placed and avoidable, again echoing the sentiments of 51% of the participants in the Michigan survey. These findings strengthen the call to develop a research agenda focused on PICC use in hospitalized patients across the United States.

Why may hospitalists across the country demonstrate such variability when it comes to these indwelling vascular devices? PICCs have historically been viewed as safer with respect to complications such as infection and thrombosis than other central venous catheters, a viewpoint that has likely promulgated their use in the inpatient setting. However, as we and others have shown,[8, 9, 10, 11, 12] this notion is rapidly vanishing and being replaced by the recognition that severity of illness and patient comorbidities are more important determinants of complications than the device itself. Additionally, important knowledge gaps exist when it comes to the safe use of PICCs in hospitalized patients, contributing to variation in indications for insertion, removal, and treatment of complications related to these devices.

Our study is notably limited by a low response rate. Because the survey was administered directly by SHM without collection of respondent data (eg, practice location, years in practice), we are unable to adjust or weight these data to represent a national cohort of adult hospitalists. However, as responses to questions are consistent with our findings from Michigan, and the response rates of this survey are comparable to observed response rates from prior SHM‐administered nationwide surveys (10%40%),[13, 14, 15] we do not believe our findings necessarily represent systematic deviations from the truth and assumed that these responses were missing at random. In addition, owing to use of a survey‐based design, our study is inherently limited by a number of biases, including the use of a convenience sample of SHM members, nonresponse bias, and recall bias. Given these limitations, the association between the available responses and real‐world clinical practice is unclear and deserving of further investigation.

These limitations notwithstanding, our study has several strengths. We found important national variations in reported practices and knowledge related to PICCs, affirming the need to develop a research agenda to improve practice. Further, because a significant proportion of hospitalists may forget their patients have PICCs, our study supports the role of technologies such as catheter reminder systems, computerized decision aids, and automatic stop orders to improve PICC use. These technologies, if utilized in a workflow‐sensitive fashion, could improve PICC safety in hospitalized settings and merit exploration. In addition, our study highlights the growing need for criteria to guide the use of PICCs in hospital settings. Although the Infusion Nursing Society of America has published indications and guidelines for use of vascular devices,[6] these do not always incorporate clinical nuances such as necessity of intravenous therapy or duration of treatment in decision making. The development of evidence‐based appropriateness criteria to guide clinical decision making is thus critical to improving use of PICCs in inpatient settings.[16]

With growing recognition of PICC‐related complications in hospitalized patients, an urgent need to improve practice related to these devices exists. This study begins to define the scope of such work across the United States. Until more rigorous evidence becomes available to guide clinical practice, hospitals and hospitalists should begin to carefully monitor PICC use to safeguard and improve patient safety.

Peripherally inserted central catheters (PICCs) are central venous catheters that are inserted through peripheral veins of the upper extremities in adults. Because they are safer to insert than central venous catheters (CVCs) and have become increasingly available at the bedside through the advent of specially trained vascular access nurses,[1] the use of PICCs in hospitalized patients has risen across the United States.[2] As the largest group of inpatient providers, hospitalists play a key role in the decision to insert and subsequently manage PICCs in hospitalized patients. Unfortunately, little is known about national hospitalist experiences, practice patterns, or knowledge when it comes to these commonly used devices. Therefore, we designed a 10‐question survey to investigate PICC‐related practices and knowledge among adult hospitalists practicing throughout the United States.

PATIENTS AND METHODS

Questions for this survey were derived from a previously published study conducted across 10 hospitals in the state of Michigan.[3] To assess external validity and test specific hypotheses formulated from the Michigan study, those questions with the greatest variation in response or those most amenable to interventions were chosen for inclusion in this survey.

To reach a national audience of practicing adult hospitalists, we submitted a survey proposal to the Society of Hospital Medicine's (SHM) Research Committee. The SHM Research Committee reviews such proposals using a peer‐review process to ensure both scientific integrity and validity of the survey instrument. Because the survey was already distributed to many hospitalists in Michigan, we requested that only hospitalists outside of Michigan be invited to participate in the national survey. All responses were collected anonymously, and no identifiable data were collected from respondents. Between February 1, 2013 and March 15, 2013, data were collected via an e‐mail sent directly from the SHM to members that contained a link to the study survey administered using SurveyMonkey. To augment data collection, nonresponders to the original e‐mail invitation were sent a second reminder e‐mail midway through the study. Descriptive statistics (percentages) were used to tabulate responses. The institutional review board at the University of Michigan Health System provided ethical and regulatory approval for this study.

RESULTS

A total of 2112 electronic survey invitations were sent to non‐Michigan adult hospitalists, with 381 completing the online survey (response rate 18%). Among respondents to the national survey, 86% reported having placed a PICC solely to obtain venous access in a hospitalized patient (rather than for specific indications such as long‐term intravenous antibiotics, chemotherapy, or parenteral nutrition), whereas 82% reported having cared for a patient who specifically requested a PICC (Table 1). PICC‐related deep vein thrombosis (DVT) and bloodstream infections were reported as being the most frequent PICC complications encountered by hospitalists, followed by superficial thrombophlebitis and mechanical complications such as coiling, kinking, and migration of the PICC tip.

Several potentially important safety concerns regarding hospitalist PICC practices were observed in this survey. For instance, only 25% of hospitalists reported examining PICCs on daily rounds for external problems. When alerted by nurses or patients about problems with the device, this number doubled to 50%. In addition, 57% of respondents admitted to having at least once forgotten about the presence of a PICC in their hospitalized patient.

Participants also reported significant variation in duration of anticoagulation therapy for PICC‐related DVT, with only half of all respondents selecting the guideline‐recommended 3 months of anticoagulation.[4, 5] With respect to knowledge regarding PICCs, only 9% of respondents recognized that tip verification performed after PICC insertion was conducted to lower risk of venous thromboembolism, not that of arrhythmia.[6] Hospitalists were ambivalent about being trained on how to place PICCs, with only 43% indicating this skill was necessary. Finally, as many as 10% to 25% of PICCs inserted in their hospitals were felt to be inappropriately placed and/or avoidable by 42% of those surveyed.

DISCUSSION

As the use of PICCs rises in hospitalized patients, variability in practices associated with the use of these indwelling vascular catheters is being increasingly recognized. For instance, Tejedor and colleagues reported that PICCs placed in hospitalized patients at their academic medical center were often idle or inserted in patients who simultaneously have peripheral intravenous catheters.[7] Recent data from a tertiary care pediatric center found significantly greater PICC utilization rates over the past decade in association with shorter dwell times, suggesting important and dynamic changes in patterns of use of these devices.[2] Our prior survey of hospitalists in 10 Michigan hospitals also found variations in reported hospitalist practices, knowledge, and experiences related to PICCs.[3] However, the extent to which the Michigan experience portrayed a national trend remained unclear and was the impetus behind this survey. Results from this study appear to support findings from Michigan and highlight several potential opportunities to improve hospitalist PICC practices on a national scale.

In particular, 57% of respondents in this study (compared to 51% of Michigan hospitalists) stated they had at least once forgotten that their patient had a PICC. As early removal of PICCs that are clinically no longer necessary is a cornerstone to preventing thrombosis and infection,[4, 5, 6, 8] the potential impact of such forgetfulness on clinical outcomes and patient safety is of concern. Notably, PICC‐related DVT and bloodstream infection remained the 2 most commonly encountered complications in this survey, just as in the Michigan study.

Reported variations in treatment duration for PICC‐related DVT were also common in this study, with only half of all respondents in both surveys selecting the guideline‐recommended minimum of 3 months of anticoagulation. Finally, a substantial proportion (42%) of participants felt that 10% to 25% of PICCs placed in their hospitals might be inappropriately placed and avoidable, again echoing the sentiments of 51% of the participants in the Michigan survey. These findings strengthen the call to develop a research agenda focused on PICC use in hospitalized patients across the United States.

Why may hospitalists across the country demonstrate such variability when it comes to these indwelling vascular devices? PICCs have historically been viewed as safer with respect to complications such as infection and thrombosis than other central venous catheters, a viewpoint that has likely promulgated their use in the inpatient setting. However, as we and others have shown,[8, 9, 10, 11, 12] this notion is rapidly vanishing and being replaced by the recognition that severity of illness and patient comorbidities are more important determinants of complications than the device itself. Additionally, important knowledge gaps exist when it comes to the safe use of PICCs in hospitalized patients, contributing to variation in indications for insertion, removal, and treatment of complications related to these devices.

Our study is notably limited by a low response rate. Because the survey was administered directly by SHM without collection of respondent data (eg, practice location, years in practice), we are unable to adjust or weight these data to represent a national cohort of adult hospitalists. However, as responses to questions are consistent with our findings from Michigan, and the response rates of this survey are comparable to observed response rates from prior SHM‐administered nationwide surveys (10%40%),[13, 14, 15] we do not believe our findings necessarily represent systematic deviations from the truth and assumed that these responses were missing at random. In addition, owing to use of a survey‐based design, our study is inherently limited by a number of biases, including the use of a convenience sample of SHM members, nonresponse bias, and recall bias. Given these limitations, the association between the available responses and real‐world clinical practice is unclear and deserving of further investigation.

These limitations notwithstanding, our study has several strengths. We found important national variations in reported practices and knowledge related to PICCs, affirming the need to develop a research agenda to improve practice. Further, because a significant proportion of hospitalists may forget their patients have PICCs, our study supports the role of technologies such as catheter reminder systems, computerized decision aids, and automatic stop orders to improve PICC use. These technologies, if utilized in a workflow‐sensitive fashion, could improve PICC safety in hospitalized settings and merit exploration. In addition, our study highlights the growing need for criteria to guide the use of PICCs in hospital settings. Although the Infusion Nursing Society of America has published indications and guidelines for use of vascular devices,[6] these do not always incorporate clinical nuances such as necessity of intravenous therapy or duration of treatment in decision making. The development of evidence‐based appropriateness criteria to guide clinical decision making is thus critical to improving use of PICCs in inpatient settings.[16]

With growing recognition of PICC‐related complications in hospitalized patients, an urgent need to improve practice related to these devices exists. This study begins to define the scope of such work across the United States. Until more rigorous evidence becomes available to guide clinical practice, hospitals and hospitalists should begin to carefully monitor PICC use to safeguard and improve patient safety.

Peripherally inserted central catheters (PICCs) are central venous catheters that are inserted through peripheral veins of the upper extremities in adults. Because they are safer to insert than central venous catheters (CVCs) and have become increasingly available at the bedside through the advent of specially trained vascular access nurses,[1] the use of PICCs in hospitalized patients has risen across the United States.[2] As the largest group of inpatient providers, hospitalists play a key role in the decision to insert and subsequently manage PICCs in hospitalized patients. Unfortunately, little is known about national hospitalist experiences, practice patterns, or knowledge when it comes to these commonly used devices. Therefore, we designed a 10‐question survey to investigate PICC‐related practices and knowledge among adult hospitalists practicing throughout the United States.

PATIENTS AND METHODS

Questions for this survey were derived from a previously published study conducted across 10 hospitals in the state of Michigan.[3] To assess external validity and test specific hypotheses formulated from the Michigan study, those questions with the greatest variation in response or those most amenable to interventions were chosen for inclusion in this survey.

To reach a national audience of practicing adult hospitalists, we submitted a survey proposal to the Society of Hospital Medicine's (SHM) Research Committee. The SHM Research Committee reviews such proposals using a peer‐review process to ensure both scientific integrity and validity of the survey instrument. Because the survey was already distributed to many hospitalists in Michigan, we requested that only hospitalists outside of Michigan be invited to participate in the national survey. All responses were collected anonymously, and no identifiable data were collected from respondents. Between February 1, 2013 and March 15, 2013, data were collected via an e‐mail sent directly from the SHM to members that contained a link to the study survey administered using SurveyMonkey. To augment data collection, nonresponders to the original e‐mail invitation were sent a second reminder e‐mail midway through the study. Descriptive statistics (percentages) were used to tabulate responses. The institutional review board at the University of Michigan Health System provided ethical and regulatory approval for this study.

RESULTS

A total of 2112 electronic survey invitations were sent to non‐Michigan adult hospitalists, with 381 completing the online survey (response rate 18%). Among respondents to the national survey, 86% reported having placed a PICC solely to obtain venous access in a hospitalized patient (rather than for specific indications such as long‐term intravenous antibiotics, chemotherapy, or parenteral nutrition), whereas 82% reported having cared for a patient who specifically requested a PICC (Table 1). PICC‐related deep vein thrombosis (DVT) and bloodstream infections were reported as being the most frequent PICC complications encountered by hospitalists, followed by superficial thrombophlebitis and mechanical complications such as coiling, kinking, and migration of the PICC tip.

Several potentially important safety concerns regarding hospitalist PICC practices were observed in this survey. For instance, only 25% of hospitalists reported examining PICCs on daily rounds for external problems. When alerted by nurses or patients about problems with the device, this number doubled to 50%. In addition, 57% of respondents admitted to having at least once forgotten about the presence of a PICC in their hospitalized patient.

Participants also reported significant variation in duration of anticoagulation therapy for PICC‐related DVT, with only half of all respondents selecting the guideline‐recommended 3 months of anticoagulation.[4, 5] With respect to knowledge regarding PICCs, only 9% of respondents recognized that tip verification performed after PICC insertion was conducted to lower risk of venous thromboembolism, not that of arrhythmia.[6] Hospitalists were ambivalent about being trained on how to place PICCs, with only 43% indicating this skill was necessary. Finally, as many as 10% to 25% of PICCs inserted in their hospitals were felt to be inappropriately placed and/or avoidable by 42% of those surveyed.

DISCUSSION

As the use of PICCs rises in hospitalized patients, variability in practices associated with the use of these indwelling vascular catheters is being increasingly recognized. For instance, Tejedor and colleagues reported that PICCs placed in hospitalized patients at their academic medical center were often idle or inserted in patients who simultaneously have peripheral intravenous catheters.[7] Recent data from a tertiary care pediatric center found significantly greater PICC utilization rates over the past decade in association with shorter dwell times, suggesting important and dynamic changes in patterns of use of these devices.[2] Our prior survey of hospitalists in 10 Michigan hospitals also found variations in reported hospitalist practices, knowledge, and experiences related to PICCs.[3] However, the extent to which the Michigan experience portrayed a national trend remained unclear and was the impetus behind this survey. Results from this study appear to support findings from Michigan and highlight several potential opportunities to improve hospitalist PICC practices on a national scale.

In particular, 57% of respondents in this study (compared to 51% of Michigan hospitalists) stated they had at least once forgotten that their patient had a PICC. As early removal of PICCs that are clinically no longer necessary is a cornerstone to preventing thrombosis and infection,[4, 5, 6, 8] the potential impact of such forgetfulness on clinical outcomes and patient safety is of concern. Notably, PICC‐related DVT and bloodstream infection remained the 2 most commonly encountered complications in this survey, just as in the Michigan study.

Reported variations in treatment duration for PICC‐related DVT were also common in this study, with only half of all respondents in both surveys selecting the guideline‐recommended minimum of 3 months of anticoagulation. Finally, a substantial proportion (42%) of participants felt that 10% to 25% of PICCs placed in their hospitals might be inappropriately placed and avoidable, again echoing the sentiments of 51% of the participants in the Michigan survey. These findings strengthen the call to develop a research agenda focused on PICC use in hospitalized patients across the United States.

Why may hospitalists across the country demonstrate such variability when it comes to these indwelling vascular devices? PICCs have historically been viewed as safer with respect to complications such as infection and thrombosis than other central venous catheters, a viewpoint that has likely promulgated their use in the inpatient setting. However, as we and others have shown,[8, 9, 10, 11, 12] this notion is rapidly vanishing and being replaced by the recognition that severity of illness and patient comorbidities are more important determinants of complications than the device itself. Additionally, important knowledge gaps exist when it comes to the safe use of PICCs in hospitalized patients, contributing to variation in indications for insertion, removal, and treatment of complications related to these devices.

Our study is notably limited by a low response rate. Because the survey was administered directly by SHM without collection of respondent data (eg, practice location, years in practice), we are unable to adjust or weight these data to represent a national cohort of adult hospitalists. However, as responses to questions are consistent with our findings from Michigan, and the response rates of this survey are comparable to observed response rates from prior SHM‐administered nationwide surveys (10%40%),[13, 14, 15] we do not believe our findings necessarily represent systematic deviations from the truth and assumed that these responses were missing at random. In addition, owing to use of a survey‐based design, our study is inherently limited by a number of biases, including the use of a convenience sample of SHM members, nonresponse bias, and recall bias. Given these limitations, the association between the available responses and real‐world clinical practice is unclear and deserving of further investigation.

These limitations notwithstanding, our study has several strengths. We found important national variations in reported practices and knowledge related to PICCs, affirming the need to develop a research agenda to improve practice. Further, because a significant proportion of hospitalists may forget their patients have PICCs, our study supports the role of technologies such as catheter reminder systems, computerized decision aids, and automatic stop orders to improve PICC use. These technologies, if utilized in a workflow‐sensitive fashion, could improve PICC safety in hospitalized settings and merit exploration. In addition, our study highlights the growing need for criteria to guide the use of PICCs in hospital settings. Although the Infusion Nursing Society of America has published indications and guidelines for use of vascular devices,[6] these do not always incorporate clinical nuances such as necessity of intravenous therapy or duration of treatment in decision making. The development of evidence‐based appropriateness criteria to guide clinical decision making is thus critical to improving use of PICCs in inpatient settings.[16]

With growing recognition of PICC‐related complications in hospitalized patients, an urgent need to improve practice related to these devices exists. This study begins to define the scope of such work across the United States. Until more rigorous evidence becomes available to guide clinical practice, hospitals and hospitalists should begin to carefully monitor PICC use to safeguard and improve patient safety.

Healthcare‐associated infections affect 5% to 10% of all hospitalized patients each year in the United States, account for nearly $45 billion in direct hospital costs, and cause nearly 100,000 deaths annually.[1, 2] Because catheter‐associated urinary tract infection (CAUTI) is one of the most common healthcare‐associated infections in the United States and is reasonably preventable, the Centers for Medicare and Medicaid Services stopped reimbursing hospitals in 2008 for the additional costs of caring for patients who develop CAUTI during hospitalization.[3] Still, strategies for reducing inappropriate urinary catheterization are infrequently implemented in practice; this is despite a consensus that such strategies are effective.[4]

To help motivate hospitals to reduce inappropriate urinary catheter use, we present a tool for estimating costs of CAUTI for individual hospitals. Although other tools for estimating the excess costs of healthcare‐associated infections are available (eg, the APIC Cost of Healthcare‐Associated Infections Model available at http://www.apic.org/Resources/Cost‐calculators), they do not provide estimates of potential cost savings. Our approach adds to the literature by providing estimates of a hospital's current costs based on a few simple inputs (eg, annual admissions and catheterization rate), and also yields projected costs after a hypothetical intervention to prevent infections. Results are derived by combining appropriate cost and risk estimates from the literature. Importantly, an online implementation of our approach is available that can be easily used by clinicians, hospital administrators, and national policymakers. Our implementation nicely complements efforts like the Society of Hospital Medicine's Choosing Wisely campaign, which highlights avoiding inappropriate urinary catheter use first on its list of Five Things Physicians and Patients Should Question, and aims to increase awareness about issues that could improve patient outcomes and reduce healthcare costs.[5] Although accounting for the full spectrum of institution‐specific costs (eg, actual intervention costs, opportunity costs) was beyond the scope of this work, the simple tool we present helps meet the primary goal of generating an awareness of the potential cost savings stemming from CAUTI prevention efforts.

METHODS

General Setup

We consider 4 possible events after urinary catheter placement: bacteriuria, symptomatic urinary tract infection (SUTI), bloodstream infection (BSI), and catheter removal. Conservatively, assuming that bacteriuria must precede SUTI and BSI, there are 5 possible trajectories for any hospitalized patient (Figure 1): (1) no infection, (2) only bacteriuria, (3) bacteriuria and SUTI, (4) bacteriuria and BSI, or (5) bacteriuria, SUTI, and BSI. The cost of CAUTI for a particular hospital is therefore the per‐patient cost of each trajectory multiplied by the number of patients experiencing each trajectory. Our approach for estimating hospital costs is based on factorizing the number of patients experiencing each trajectory into a product of terms for which estimates are available from the literature (see the Supporting Information, Appendix, in the online version of this article for all technical details).

Figure 1

RESULTS

Figure 2 shows the projected savings in hospital costs due to CAUTI across a range of interventions defined by percent decreases in placement and duration, for a hypothetical hospital with 3000 total patients, 15% with urinary catheters preintervention, and with all other default values listed in Table 1. The current costs for this hospital (ie, the costs when the percent reduction in placement and duration is zero) are estimated to be $37,868 (95% confidence interval [CI]: $9159‐$156,564). After an intervention resulting in 40% reductions in both urinary catheter placement and duration, this hospital would be expected to save $22,653 (95% CI: $5479‐$93,656). A less effective intervention yielding a 10% reduction in both urinary catheter placement and duration would result in more modest savings of $6376 (95% CI: $1542‐$26,360).

Figure 2

After an intervention resulting in 29% and 37% reductions in placement and duration, respectively, reflecting reductions seen in practice,[10, 11] our hypothetical hospital is estimated to save $19,126 (95% CI: $4626‐$79,074). This reflects an estimated savings of nearly 50%.

DISCUSSION

We have presented a tool for estimating customized hospital costs of CAUTI, both before and after a hypothetical intervention to reduce risk of infection. Our approach relies on mostly conservative assumptions, incorporates published risk estimates (properly accounting for their associated variability), and has easy‐to‐use online implementation. We believe this can play an important role in motivating hospitals to reduce inappropriate urinary catheter use.

The methodology employed here does have a few limitations. First and foremost, our results depend on the reliability of the input values, which are either provided by users or are based on estimates from the literature (see Table 1 for a complete list of suggested defaults). New information could potentially be incorporated if and when available. For example, substitution of more precise risk estimates could help reduce confidence interval length. Second, our approach essentially averages over hospital quality; we do not directly take into account quality of care or variation in underlying infection risk across hospitals in computing estimated costs. Finally, we only compute direct costs due to infection; other costs (eg, intervention costs) would typically also need to be considered for decision making.

Despite these limitations, we believe that our tool can help infection control professionals demonstrate the values of CAUTI prevention efforts to key administrators, particularly at a time where it has become increasingly necessary to develop a business case to initiate new interventions or justify the continued support for ongoing programs.[12] Additionally, we believe the proposed approach can be an important supplement to initiatives like the Society of Hospital Medicine's Choosing Wisely campaign, which aims to help reduce inappropriate urinary catheter use. Reducing catheter utilization has the potential to reduce costs associated with caring for CAUTI patients, but more importantly would help reduce CAUTI incidence as well as catheter‐related, noninfectious complications.[13, 14] We hope that our tool will greatly assist hospitals in promoting their CAUTI prevention efforts and improve the overall safety of hospitalized patients.

Healthcare‐associated infections affect 5% to 10% of all hospitalized patients each year in the United States, account for nearly $45 billion in direct hospital costs, and cause nearly 100,000 deaths annually.[1, 2] Because catheter‐associated urinary tract infection (CAUTI) is one of the most common healthcare‐associated infections in the United States and is reasonably preventable, the Centers for Medicare and Medicaid Services stopped reimbursing hospitals in 2008 for the additional costs of caring for patients who develop CAUTI during hospitalization.[3] Still, strategies for reducing inappropriate urinary catheterization are infrequently implemented in practice; this is despite a consensus that such strategies are effective.[4]

To help motivate hospitals to reduce inappropriate urinary catheter use, we present a tool for estimating costs of CAUTI for individual hospitals. Although other tools for estimating the excess costs of healthcare‐associated infections are available (eg, the APIC Cost of Healthcare‐Associated Infections Model available at http://www.apic.org/Resources/Cost‐calculators), they do not provide estimates of potential cost savings. Our approach adds to the literature by providing estimates of a hospital's current costs based on a few simple inputs (eg, annual admissions and catheterization rate), and also yields projected costs after a hypothetical intervention to prevent infections. Results are derived by combining appropriate cost and risk estimates from the literature. Importantly, an online implementation of our approach is available that can be easily used by clinicians, hospital administrators, and national policymakers. Our implementation nicely complements efforts like the Society of Hospital Medicine's Choosing Wisely campaign, which highlights avoiding inappropriate urinary catheter use first on its list of Five Things Physicians and Patients Should Question, and aims to increase awareness about issues that could improve patient outcomes and reduce healthcare costs.[5] Although accounting for the full spectrum of institution‐specific costs (eg, actual intervention costs, opportunity costs) was beyond the scope of this work, the simple tool we present helps meet the primary goal of generating an awareness of the potential cost savings stemming from CAUTI prevention efforts.

METHODS

General Setup

We consider 4 possible events after urinary catheter placement: bacteriuria, symptomatic urinary tract infection (SUTI), bloodstream infection (BSI), and catheter removal. Conservatively, assuming that bacteriuria must precede SUTI and BSI, there are 5 possible trajectories for any hospitalized patient (Figure 1): (1) no infection, (2) only bacteriuria, (3) bacteriuria and SUTI, (4) bacteriuria and BSI, or (5) bacteriuria, SUTI, and BSI. The cost of CAUTI for a particular hospital is therefore the per‐patient cost of each trajectory multiplied by the number of patients experiencing each trajectory. Our approach for estimating hospital costs is based on factorizing the number of patients experiencing each trajectory into a product of terms for which estimates are available from the literature (see the Supporting Information, Appendix, in the online version of this article for all technical details).

Figure 1

RESULTS

Figure 2 shows the projected savings in hospital costs due to CAUTI across a range of interventions defined by percent decreases in placement and duration, for a hypothetical hospital with 3000 total patients, 15% with urinary catheters preintervention, and with all other default values listed in Table 1. The current costs for this hospital (ie, the costs when the percent reduction in placement and duration is zero) are estimated to be $37,868 (95% confidence interval [CI]: $9159‐$156,564). After an intervention resulting in 40% reductions in both urinary catheter placement and duration, this hospital would be expected to save $22,653 (95% CI: $5479‐$93,656). A less effective intervention yielding a 10% reduction in both urinary catheter placement and duration would result in more modest savings of $6376 (95% CI: $1542‐$26,360).

Figure 2

After an intervention resulting in 29% and 37% reductions in placement and duration, respectively, reflecting reductions seen in practice,[10, 11] our hypothetical hospital is estimated to save $19,126 (95% CI: $4626‐$79,074). This reflects an estimated savings of nearly 50%.

DISCUSSION

We have presented a tool for estimating customized hospital costs of CAUTI, both before and after a hypothetical intervention to reduce risk of infection. Our approach relies on mostly conservative assumptions, incorporates published risk estimates (properly accounting for their associated variability), and has easy‐to‐use online implementation. We believe this can play an important role in motivating hospitals to reduce inappropriate urinary catheter use.

The methodology employed here does have a few limitations. First and foremost, our results depend on the reliability of the input values, which are either provided by users or are based on estimates from the literature (see Table 1 for a complete list of suggested defaults). New information could potentially be incorporated if and when available. For example, substitution of more precise risk estimates could help reduce confidence interval length. Second, our approach essentially averages over hospital quality; we do not directly take into account quality of care or variation in underlying infection risk across hospitals in computing estimated costs. Finally, we only compute direct costs due to infection; other costs (eg, intervention costs) would typically also need to be considered for decision making.

Despite these limitations, we believe that our tool can help infection control professionals demonstrate the values of CAUTI prevention efforts to key administrators, particularly at a time where it has become increasingly necessary to develop a business case to initiate new interventions or justify the continued support for ongoing programs.[12] Additionally, we believe the proposed approach can be an important supplement to initiatives like the Society of Hospital Medicine's Choosing Wisely campaign, which aims to help reduce inappropriate urinary catheter use. Reducing catheter utilization has the potential to reduce costs associated with caring for CAUTI patients, but more importantly would help reduce CAUTI incidence as well as catheter‐related, noninfectious complications.[13, 14] We hope that our tool will greatly assist hospitals in promoting their CAUTI prevention efforts and improve the overall safety of hospitalized patients.

Healthcare‐associated infections affect 5% to 10% of all hospitalized patients each year in the United States, account for nearly $45 billion in direct hospital costs, and cause nearly 100,000 deaths annually.[1, 2] Because catheter‐associated urinary tract infection (CAUTI) is one of the most common healthcare‐associated infections in the United States and is reasonably preventable, the Centers for Medicare and Medicaid Services stopped reimbursing hospitals in 2008 for the additional costs of caring for patients who develop CAUTI during hospitalization.[3] Still, strategies for reducing inappropriate urinary catheterization are infrequently implemented in practice; this is despite a consensus that such strategies are effective.[4]

To help motivate hospitals to reduce inappropriate urinary catheter use, we present a tool for estimating costs of CAUTI for individual hospitals. Although other tools for estimating the excess costs of healthcare‐associated infections are available (eg, the APIC Cost of Healthcare‐Associated Infections Model available at http://www.apic.org/Resources/Cost‐calculators), they do not provide estimates of potential cost savings. Our approach adds to the literature by providing estimates of a hospital's current costs based on a few simple inputs (eg, annual admissions and catheterization rate), and also yields projected costs after a hypothetical intervention to prevent infections. Results are derived by combining appropriate cost and risk estimates from the literature. Importantly, an online implementation of our approach is available that can be easily used by clinicians, hospital administrators, and national policymakers. Our implementation nicely complements efforts like the Society of Hospital Medicine's Choosing Wisely campaign, which highlights avoiding inappropriate urinary catheter use first on its list of Five Things Physicians and Patients Should Question, and aims to increase awareness about issues that could improve patient outcomes and reduce healthcare costs.[5] Although accounting for the full spectrum of institution‐specific costs (eg, actual intervention costs, opportunity costs) was beyond the scope of this work, the simple tool we present helps meet the primary goal of generating an awareness of the potential cost savings stemming from CAUTI prevention efforts.

METHODS

General Setup

We consider 4 possible events after urinary catheter placement: bacteriuria, symptomatic urinary tract infection (SUTI), bloodstream infection (BSI), and catheter removal. Conservatively, assuming that bacteriuria must precede SUTI and BSI, there are 5 possible trajectories for any hospitalized patient (Figure 1): (1) no infection, (2) only bacteriuria, (3) bacteriuria and SUTI, (4) bacteriuria and BSI, or (5) bacteriuria, SUTI, and BSI. The cost of CAUTI for a particular hospital is therefore the per‐patient cost of each trajectory multiplied by the number of patients experiencing each trajectory. Our approach for estimating hospital costs is based on factorizing the number of patients experiencing each trajectory into a product of terms for which estimates are available from the literature (see the Supporting Information, Appendix, in the online version of this article for all technical details).

Figure 1

RESULTS

Figure 2 shows the projected savings in hospital costs due to CAUTI across a range of interventions defined by percent decreases in placement and duration, for a hypothetical hospital with 3000 total patients, 15% with urinary catheters preintervention, and with all other default values listed in Table 1. The current costs for this hospital (ie, the costs when the percent reduction in placement and duration is zero) are estimated to be $37,868 (95% confidence interval [CI]: $9159‐$156,564). After an intervention resulting in 40% reductions in both urinary catheter placement and duration, this hospital would be expected to save $22,653 (95% CI: $5479‐$93,656). A less effective intervention yielding a 10% reduction in both urinary catheter placement and duration would result in more modest savings of $6376 (95% CI: $1542‐$26,360).

Figure 2

After an intervention resulting in 29% and 37% reductions in placement and duration, respectively, reflecting reductions seen in practice,[10, 11] our hypothetical hospital is estimated to save $19,126 (95% CI: $4626‐$79,074). This reflects an estimated savings of nearly 50%.

DISCUSSION

We have presented a tool for estimating customized hospital costs of CAUTI, both before and after a hypothetical intervention to reduce risk of infection. Our approach relies on mostly conservative assumptions, incorporates published risk estimates (properly accounting for their associated variability), and has easy‐to‐use online implementation. We believe this can play an important role in motivating hospitals to reduce inappropriate urinary catheter use.

The methodology employed here does have a few limitations. First and foremost, our results depend on the reliability of the input values, which are either provided by users or are based on estimates from the literature (see Table 1 for a complete list of suggested defaults). New information could potentially be incorporated if and when available. For example, substitution of more precise risk estimates could help reduce confidence interval length. Second, our approach essentially averages over hospital quality; we do not directly take into account quality of care or variation in underlying infection risk across hospitals in computing estimated costs. Finally, we only compute direct costs due to infection; other costs (eg, intervention costs) would typically also need to be considered for decision making.

Despite these limitations, we believe that our tool can help infection control professionals demonstrate the values of CAUTI prevention efforts to key administrators, particularly at a time where it has become increasingly necessary to develop a business case to initiate new interventions or justify the continued support for ongoing programs.[12] Additionally, we believe the proposed approach can be an important supplement to initiatives like the Society of Hospital Medicine's Choosing Wisely campaign, which aims to help reduce inappropriate urinary catheter use. Reducing catheter utilization has the potential to reduce costs associated with caring for CAUTI patients, but more importantly would help reduce CAUTI incidence as well as catheter‐related, noninfectious complications.[13, 14] We hope that our tool will greatly assist hospitals in promoting their CAUTI prevention efforts and improve the overall safety of hospitalized patients.

Peripherally inserted central catheters (PICCs) have become among the most common central venous catheters (CVCs) used in contemporary medical practice.[1] Although they were originally developed for delivery of parenteral nutrition, the use of PICCs has expanded to include chemotherapy administration, long‐term intravenous (IV) antibiotic treatment, and venous access when obtaining peripheral veins is difficult (eg, occluded peripheral veins, unusual venous anatomies).[2] Despite these roles, little is known about PICC use in hospitalized patients. This knowledge gap is important, as PICCs are placed in inpatient settings for a variety of reasons. Some of these reasons may not be appropriate, and inappropriate PICC use may worsen outcomes and increase healthcare costs.[3] In addition, PICCs are not innocuous and are frequently associated with important complications including thrombophlebitis, central‐lineassociated bloodstream infection and venous thromboembolism.[4, 5, 6] Therefore, understanding patterns and knowledge associated with PICC use is also an important patient safety concern.

As the main providers of inpatient care, hospitalists frequently order the insertion of PICCs and treat PICC‐related complications. Unfortunately, to date, no study has surveyed hospitalists regarding management or use of PICCs. Understanding hospitalist experiences, practice, opinions, and knowledge related to PICCs is therefore of significant interest when examining present‐day PICC use. To bridge this important knowledge gap and better understand these practices, we conducted a Web‐based survey of hospitalists in 5 healthcare systems in the state of Michigan.

METHODS

A convenience sample of hospitalists (N=227) was assembled from 5 large healthcare systems (representing 10 hospitals) that participate in the Hospital Medicine Safety (HMS) Consortium, a Blue Cross/Blue Shield of Michiganfunded statewide collaborative quality initiative. Individuals engaged in research, quality improvement, or leadership at HMS sites were invited to serve as site principal investigators (site PIs). Site PIs were responsible for obtaining regulatory approval at their parent facilities and disseminating the survey to providers in their group. Participation in the survey was solicited via e‐mail invitations from site PIs to hospitalists within their provider group. To encourage participation, a $10 electronic gift card was offered to respondents who successfully completed the survey. Reminder e‐mails were also sent each week by site PIs to augment participation. To enhance study recruitment, all responses were collected anonymously. The survey was administered between August 2012 and September 2012; data collection occurred for 5 weeks during this interval.

Survey questions were derived from our published, evidence‐based conceptual framework of PICC‐related complications. Briefly, this model identifies complications related to PICCs as arising from domains related to patient‐, provider‐, and device‐related characteristics based on existing evidence.[2] For our survey, questions were sourced from each of these domains so as to improve understanding of hospitalist experience, practice, opinions, and knowledge regarding PICC use. To ensure clarity of the survey questions, all questions were first pilot‐tested with a group of randomly selected hospitalist respondents at the University of Michigan Health System. Direct feedback obtained from these respondents was then used to iteratively improve each question. In order to generate holistic responses, questions were designed to generate a response reflective of the participants typical PICC use/subenario. We used SurveyMonkey to collect and manage survey data.

RESULTS

A total of 227 surveys were administered and 144 responses collected, for a survey response rate of 63%. Each participating site had unique characteristics including size, number of hospitalists, and modality of PICC insertion (Table 1). Of the hospitalists who completed the survey, 81% held full‐time clinical positions and had been in practice an average of 5.6 years. Surveyed hospitalists reported caring for an average of 40.6 patients per week and ordering a mean of 2.9 (range, 015) PICCs per week of clinical service. Among survey respondents, 36% provided direct patient care, 34% provided care either directly or through mid‐level providers and housestaff, and 9% delivered care exclusively through mid‐level providers or housestaff (Table 2). As our survey was conducted anonymously, potential identifying information such as age, race, and sex of those responding was not collected.

DISCUSSION

In this survey of hospitalists practicing at 5 large healthcare systems in Michigan, we observed significant variation in experience, reported practice, opinions, and knowledge related to PICCs. Our findings highlight important concerns related to inpatient PICC use and suggest a need for greater scrutiny related to these devices in these settings.

The use of PICCs in hospitalized patients has risen dramatically over the past decade. Though such growth is multifactorial and relates in part to increasing inpatient volume and complexity, hospitalists have increasingly turned to PICCs as a convenient and reliable tool to obtain venous access.[7] Indeed, in our survey, PICCs that were only used during hospitalization were most likely to be placed for this very reason. Because PICCs are safer to insert than CVCs and the original evidence regarding PICC‐related VTE or bloodstream infection suggested low rates of these events,[8, 9, 10, 11, 12, 13, 14] many hospitalists may not perceive these devices as being associated with significant risks. In fact, some have suggested that hospitalists be specifically trained to insert these devices, given their safety compared with traditional CVCs.[7]

However, accumulating evidence suggests that PICCs are associated with important complications.[5, 15, 16] In studies examining risk of bloodstream infection, PICCs were associated with significant risk of this outcome.[6, 17, 18] Recently, the presence of a PICC was identified as an independent predictor of VTE in hospitalized patients.[19] Several studies and systematic reviews have repeatedly demonstrated these findings.[19, 20, 21, 22] A recent systematic review examining nonpharmacologic methods to prevent catheter‐related thrombosis specifically called for avoidance of PICC insertion to prevent thrombosis in hospitalized patients.[23] Despite this growing evidence base, the use of PICCs in the inpatient setting is likely to rise, and our survey highlights several practices that may contribute to adverse outcomes. For instance, hospitalists in our survey were unlikely to remove a PICC until a patient was discharged, irrespective of the need for this device. As each day with a PICC increases the risk of complications, such practice poses potential patient safety concerns. Similarly, many hospitalists believe that PICCs are safer than CVCs, a viewpoint that does not stand up to increasing scrutiny and highlights important knowledge gaps. The risk of PICC‐related complications appears not to be a stationary target, but rather a dynamic balance that is influenced by patient‐, provider‐, and device‐specific characteristics.[2] Increasing discretionary use (especially for patients with poor peripheral venous access), forgetting at times that a patient has a PICC, and the finding that up to 25% of PICCs placed in their hospitals may be unnecessary underscore concerns regarding the safety of current practice trends. Interestingly, the viewpoints of hospitalists in practice <5 years and those providing direct patient care were more likely to reflect concerns regarding inappropriate placement, influence of vascular nurses, and use of PICCs for blood culture. This finding may reflect that these nuances are more recent phenomena or perhaps most apparent when care is delivered directly.

Our study must be interpreted in the context of several limitations. First, as this was a survey‐based study of a small, convenience sample of hospitalists in a single state, recall, respondent, and systematic biases remain threats to our findings. However, all site PIs encouraged survey participation and (through local dialogue) none were aware of material differences between those who did or did not participate in the study. Similarly, Michigan is a diverse and relatively large state, and our results should be generalizable to other settings; however, national studies are necessary to confirm our findings. Second, our response rate may be perceived as low; however, our rates are in accordance with, and, in fact, superior to those of many existing physician surveys.[24] Finally, only 1 federal facility was included in this study; thus, this care‐delivery model is underrepresented, limiting generalization of findings to other such sites.

However, our study also has important strengths. First, this is the only survey that specifically examines hospitalist viewpoints when it comes to PICCs. As hospitalists frequently order and/or insert these devices, their perspectives are highly pertinent to discussions regarding current PICC use. Second, our survey highlights several instances that may be associated with preventable patient harm and identifies areas where interventions may be valuable. For example, forgetting the presence of a device, keeping PICCs in place throughout hospitalization, and rendering treatment for PICC‐related VTE not in accordance with accepted guidelines are remediable practices that may lead to poor outcomes. Interventions such as device‐reminder alerts, provider education regarding complications from PICCs, and systematic efforts to identify and remove unnecessary PICCs may mitigate these problems. Finally, our findings highlight the need for data repositories that track PICC use and hospitalist practice on a national scale. Given the risk and significance of the complications associated with these devices, understanding the epidemiology, use, and potential misuse of PICCs are important areas for hospitalist research.

In conclusion, our study of hospitalist experience, practice, opinions, and knowledge related to PICCs suggests important gaps between available evidence and current practice. There is growing need for the development of appropriateness criteria to guide vascular access in inpatient settings.[25, 26] Such criteria should consider not only type of venous access device, but granular details including rationale for venous access, nature of the infusate, optimal number of lumens, and safest gauge when recommending devices. Until such criteria and comparative studies become available, hospitals should consider instituting policies to monitor PICC use with specific attention to indication for insertion, duration of placement, and complications. These interventions represent a first and necessary step in improving patient safety when it comes to preventing PICC‐related complications.

Disclosures

The Blue Cross/Blue Shield of Michigan Foundation in Detroit funded this study through an investigator‐initiated research proposal (1931‐PIRAP). The funding source, however, played no role in study design, acquisition of data, data analysis, or reporting of these results. The authors report no conflicts of interest.

Peripherally inserted central catheters (PICCs) have become among the most common central venous catheters (CVCs) used in contemporary medical practice.[1] Although they were originally developed for delivery of parenteral nutrition, the use of PICCs has expanded to include chemotherapy administration, long‐term intravenous (IV) antibiotic treatment, and venous access when obtaining peripheral veins is difficult (eg, occluded peripheral veins, unusual venous anatomies).[2] Despite these roles, little is known about PICC use in hospitalized patients. This knowledge gap is important, as PICCs are placed in inpatient settings for a variety of reasons. Some of these reasons may not be appropriate, and inappropriate PICC use may worsen outcomes and increase healthcare costs.[3] In addition, PICCs are not innocuous and are frequently associated with important complications including thrombophlebitis, central‐lineassociated bloodstream infection and venous thromboembolism.[4, 5, 6] Therefore, understanding patterns and knowledge associated with PICC use is also an important patient safety concern.

As the main providers of inpatient care, hospitalists frequently order the insertion of PICCs and treat PICC‐related complications. Unfortunately, to date, no study has surveyed hospitalists regarding management or use of PICCs. Understanding hospitalist experiences, practice, opinions, and knowledge related to PICCs is therefore of significant interest when examining present‐day PICC use. To bridge this important knowledge gap and better understand these practices, we conducted a Web‐based survey of hospitalists in 5 healthcare systems in the state of Michigan.

METHODS

A convenience sample of hospitalists (N=227) was assembled from 5 large healthcare systems (representing 10 hospitals) that participate in the Hospital Medicine Safety (HMS) Consortium, a Blue Cross/Blue Shield of Michiganfunded statewide collaborative quality initiative. Individuals engaged in research, quality improvement, or leadership at HMS sites were invited to serve as site principal investigators (site PIs). Site PIs were responsible for obtaining regulatory approval at their parent facilities and disseminating the survey to providers in their group. Participation in the survey was solicited via e‐mail invitations from site PIs to hospitalists within their provider group. To encourage participation, a $10 electronic gift card was offered to respondents who successfully completed the survey. Reminder e‐mails were also sent each week by site PIs to augment participation. To enhance study recruitment, all responses were collected anonymously. The survey was administered between August 2012 and September 2012; data collection occurred for 5 weeks during this interval.

Survey questions were derived from our published, evidence‐based conceptual framework of PICC‐related complications. Briefly, this model identifies complications related to PICCs as arising from domains related to patient‐, provider‐, and device‐related characteristics based on existing evidence.[2] For our survey, questions were sourced from each of these domains so as to improve understanding of hospitalist experience, practice, opinions, and knowledge regarding PICC use. To ensure clarity of the survey questions, all questions were first pilot‐tested with a group of randomly selected hospitalist respondents at the University of Michigan Health System. Direct feedback obtained from these respondents was then used to iteratively improve each question. In order to generate holistic responses, questions were designed to generate a response reflective of the participants typical PICC use/subenario. We used SurveyMonkey to collect and manage survey data.

RESULTS

A total of 227 surveys were administered and 144 responses collected, for a survey response rate of 63%. Each participating site had unique characteristics including size, number of hospitalists, and modality of PICC insertion (Table 1). Of the hospitalists who completed the survey, 81% held full‐time clinical positions and had been in practice an average of 5.6 years. Surveyed hospitalists reported caring for an average of 40.6 patients per week and ordering a mean of 2.9 (range, 015) PICCs per week of clinical service. Among survey respondents, 36% provided direct patient care, 34% provided care either directly or through mid‐level providers and housestaff, and 9% delivered care exclusively through mid‐level providers or housestaff (Table 2). As our survey was conducted anonymously, potential identifying information such as age, race, and sex of those responding was not collected.

DISCUSSION

In this survey of hospitalists practicing at 5 large healthcare systems in Michigan, we observed significant variation in experience, reported practice, opinions, and knowledge related to PICCs. Our findings highlight important concerns related to inpatient PICC use and suggest a need for greater scrutiny related to these devices in these settings.

The use of PICCs in hospitalized patients has risen dramatically over the past decade. Though such growth is multifactorial and relates in part to increasing inpatient volume and complexity, hospitalists have increasingly turned to PICCs as a convenient and reliable tool to obtain venous access.[7] Indeed, in our survey, PICCs that were only used during hospitalization were most likely to be placed for this very reason. Because PICCs are safer to insert than CVCs and the original evidence regarding PICC‐related VTE or bloodstream infection suggested low rates of these events,[8, 9, 10, 11, 12, 13, 14] many hospitalists may not perceive these devices as being associated with significant risks. In fact, some have suggested that hospitalists be specifically trained to insert these devices, given their safety compared with traditional CVCs.[7]

However, accumulating evidence suggests that PICCs are associated with important complications.[5, 15, 16] In studies examining risk of bloodstream infection, PICCs were associated with significant risk of this outcome.[6, 17, 18] Recently, the presence of a PICC was identified as an independent predictor of VTE in hospitalized patients.[19] Several studies and systematic reviews have repeatedly demonstrated these findings.[19, 20, 21, 22] A recent systematic review examining nonpharmacologic methods to prevent catheter‐related thrombosis specifically called for avoidance of PICC insertion to prevent thrombosis in hospitalized patients.[23] Despite this growing evidence base, the use of PICCs in the inpatient setting is likely to rise, and our survey highlights several practices that may contribute to adverse outcomes. For instance, hospitalists in our survey were unlikely to remove a PICC until a patient was discharged, irrespective of the need for this device. As each day with a PICC increases the risk of complications, such practice poses potential patient safety concerns. Similarly, many hospitalists believe that PICCs are safer than CVCs, a viewpoint that does not stand up to increasing scrutiny and highlights important knowledge gaps. The risk of PICC‐related complications appears not to be a stationary target, but rather a dynamic balance that is influenced by patient‐, provider‐, and device‐specific characteristics.[2] Increasing discretionary use (especially for patients with poor peripheral venous access), forgetting at times that a patient has a PICC, and the finding that up to 25% of PICCs placed in their hospitals may be unnecessary underscore concerns regarding the safety of current practice trends. Interestingly, the viewpoints of hospitalists in practice <5 years and those providing direct patient care were more likely to reflect concerns regarding inappropriate placement, influence of vascular nurses, and use of PICCs for blood culture. This finding may reflect that these nuances are more recent phenomena or perhaps most apparent when care is delivered directly.

Our study must be interpreted in the context of several limitations. First, as this was a survey‐based study of a small, convenience sample of hospitalists in a single state, recall, respondent, and systematic biases remain threats to our findings. However, all site PIs encouraged survey participation and (through local dialogue) none were aware of material differences between those who did or did not participate in the study. Similarly, Michigan is a diverse and relatively large state, and our results should be generalizable to other settings; however, national studies are necessary to confirm our findings. Second, our response rate may be perceived as low; however, our rates are in accordance with, and, in fact, superior to those of many existing physician surveys.[24] Finally, only 1 federal facility was included in this study; thus, this care‐delivery model is underrepresented, limiting generalization of findings to other such sites.

However, our study also has important strengths. First, this is the only survey that specifically examines hospitalist viewpoints when it comes to PICCs. As hospitalists frequently order and/or insert these devices, their perspectives are highly pertinent to discussions regarding current PICC use. Second, our survey highlights several instances that may be associated with preventable patient harm and identifies areas where interventions may be valuable. For example, forgetting the presence of a device, keeping PICCs in place throughout hospitalization, and rendering treatment for PICC‐related VTE not in accordance with accepted guidelines are remediable practices that may lead to poor outcomes. Interventions such as device‐reminder alerts, provider education regarding complications from PICCs, and systematic efforts to identify and remove unnecessary PICCs may mitigate these problems. Finally, our findings highlight the need for data repositories that track PICC use and hospitalist practice on a national scale. Given the risk and significance of the complications associated with these devices, understanding the epidemiology, use, and potential misuse of PICCs are important areas for hospitalist research.

In conclusion, our study of hospitalist experience, practice, opinions, and knowledge related to PICCs suggests important gaps between available evidence and current practice. There is growing need for the development of appropriateness criteria to guide vascular access in inpatient settings.[25, 26] Such criteria should consider not only type of venous access device, but granular details including rationale for venous access, nature of the infusate, optimal number of lumens, and safest gauge when recommending devices. Until such criteria and comparative studies become available, hospitals should consider instituting policies to monitor PICC use with specific attention to indication for insertion, duration of placement, and complications. These interventions represent a first and necessary step in improving patient safety when it comes to preventing PICC‐related complications.

Disclosures

The Blue Cross/Blue Shield of Michigan Foundation in Detroit funded this study through an investigator‐initiated research proposal (1931‐PIRAP). The funding source, however, played no role in study design, acquisition of data, data analysis, or reporting of these results. The authors report no conflicts of interest.

Peripherally inserted central catheters (PICCs) have become among the most common central venous catheters (CVCs) used in contemporary medical practice.[1] Although they were originally developed for delivery of parenteral nutrition, the use of PICCs has expanded to include chemotherapy administration, long‐term intravenous (IV) antibiotic treatment, and venous access when obtaining peripheral veins is difficult (eg, occluded peripheral veins, unusual venous anatomies).[2] Despite these roles, little is known about PICC use in hospitalized patients. This knowledge gap is important, as PICCs are placed in inpatient settings for a variety of reasons. Some of these reasons may not be appropriate, and inappropriate PICC use may worsen outcomes and increase healthcare costs.[3] In addition, PICCs are not innocuous and are frequently associated with important complications including thrombophlebitis, central‐lineassociated bloodstream infection and venous thromboembolism.[4, 5, 6] Therefore, understanding patterns and knowledge associated with PICC use is also an important patient safety concern.

As the main providers of inpatient care, hospitalists frequently order the insertion of PICCs and treat PICC‐related complications. Unfortunately, to date, no study has surveyed hospitalists regarding management or use of PICCs. Understanding hospitalist experiences, practice, opinions, and knowledge related to PICCs is therefore of significant interest when examining present‐day PICC use. To bridge this important knowledge gap and better understand these practices, we conducted a Web‐based survey of hospitalists in 5 healthcare systems in the state of Michigan.

METHODS

A convenience sample of hospitalists (N=227) was assembled from 5 large healthcare systems (representing 10 hospitals) that participate in the Hospital Medicine Safety (HMS) Consortium, a Blue Cross/Blue Shield of Michiganfunded statewide collaborative quality initiative. Individuals engaged in research, quality improvement, or leadership at HMS sites were invited to serve as site principal investigators (site PIs). Site PIs were responsible for obtaining regulatory approval at their parent facilities and disseminating the survey to providers in their group. Participation in the survey was solicited via e‐mail invitations from site PIs to hospitalists within their provider group. To encourage participation, a $10 electronic gift card was offered to respondents who successfully completed the survey. Reminder e‐mails were also sent each week by site PIs to augment participation. To enhance study recruitment, all responses were collected anonymously. The survey was administered between August 2012 and September 2012; data collection occurred for 5 weeks during this interval.

Survey questions were derived from our published, evidence‐based conceptual framework of PICC‐related complications. Briefly, this model identifies complications related to PICCs as arising from domains related to patient‐, provider‐, and device‐related characteristics based on existing evidence.[2] For our survey, questions were sourced from each of these domains so as to improve understanding of hospitalist experience, practice, opinions, and knowledge regarding PICC use. To ensure clarity of the survey questions, all questions were first pilot‐tested with a group of randomly selected hospitalist respondents at the University of Michigan Health System. Direct feedback obtained from these respondents was then used to iteratively improve each question. In order to generate holistic responses, questions were designed to generate a response reflective of the participants typical PICC use/subenario. We used SurveyMonkey to collect and manage survey data.

RESULTS

A total of 227 surveys were administered and 144 responses collected, for a survey response rate of 63%. Each participating site had unique characteristics including size, number of hospitalists, and modality of PICC insertion (Table 1). Of the hospitalists who completed the survey, 81% held full‐time clinical positions and had been in practice an average of 5.6 years. Surveyed hospitalists reported caring for an average of 40.6 patients per week and ordering a mean of 2.9 (range, 015) PICCs per week of clinical service. Among survey respondents, 36% provided direct patient care, 34% provided care either directly or through mid‐level providers and housestaff, and 9% delivered care exclusively through mid‐level providers or housestaff (Table 2). As our survey was conducted anonymously, potential identifying information such as age, race, and sex of those responding was not collected.

DISCUSSION

In this survey of hospitalists practicing at 5 large healthcare systems in Michigan, we observed significant variation in experience, reported practice, opinions, and knowledge related to PICCs. Our findings highlight important concerns related to inpatient PICC use and suggest a need for greater scrutiny related to these devices in these settings.

The use of PICCs in hospitalized patients has risen dramatically over the past decade. Though such growth is multifactorial and relates in part to increasing inpatient volume and complexity, hospitalists have increasingly turned to PICCs as a convenient and reliable tool to obtain venous access.[7] Indeed, in our survey, PICCs that were only used during hospitalization were most likely to be placed for this very reason. Because PICCs are safer to insert than CVCs and the original evidence regarding PICC‐related VTE or bloodstream infection suggested low rates of these events,[8, 9, 10, 11, 12, 13, 14] many hospitalists may not perceive these devices as being associated with significant risks. In fact, some have suggested that hospitalists be specifically trained to insert these devices, given their safety compared with traditional CVCs.[7]

However, accumulating evidence suggests that PICCs are associated with important complications.[5, 15, 16] In studies examining risk of bloodstream infection, PICCs were associated with significant risk of this outcome.[6, 17, 18] Recently, the presence of a PICC was identified as an independent predictor of VTE in hospitalized patients.[19] Several studies and systematic reviews have repeatedly demonstrated these findings.[19, 20, 21, 22] A recent systematic review examining nonpharmacologic methods to prevent catheter‐related thrombosis specifically called for avoidance of PICC insertion to prevent thrombosis in hospitalized patients.[23] Despite this growing evidence base, the use of PICCs in the inpatient setting is likely to rise, and our survey highlights several practices that may contribute to adverse outcomes. For instance, hospitalists in our survey were unlikely to remove a PICC until a patient was discharged, irrespective of the need for this device. As each day with a PICC increases the risk of complications, such practice poses potential patient safety concerns. Similarly, many hospitalists believe that PICCs are safer than CVCs, a viewpoint that does not stand up to increasing scrutiny and highlights important knowledge gaps. The risk of PICC‐related complications appears not to be a stationary target, but rather a dynamic balance that is influenced by patient‐, provider‐, and device‐specific characteristics.[2] Increasing discretionary use (especially for patients with poor peripheral venous access), forgetting at times that a patient has a PICC, and the finding that up to 25% of PICCs placed in their hospitals may be unnecessary underscore concerns regarding the safety of current practice trends. Interestingly, the viewpoints of hospitalists in practice <5 years and those providing direct patient care were more likely to reflect concerns regarding inappropriate placement, influence of vascular nurses, and use of PICCs for blood culture. This finding may reflect that these nuances are more recent phenomena or perhaps most apparent when care is delivered directly.

Our study must be interpreted in the context of several limitations. First, as this was a survey‐based study of a small, convenience sample of hospitalists in a single state, recall, respondent, and systematic biases remain threats to our findings. However, all site PIs encouraged survey participation and (through local dialogue) none were aware of material differences between those who did or did not participate in the study. Similarly, Michigan is a diverse and relatively large state, and our results should be generalizable to other settings; however, national studies are necessary to confirm our findings. Second, our response rate may be perceived as low; however, our rates are in accordance with, and, in fact, superior to those of many existing physician surveys.[24] Finally, only 1 federal facility was included in this study; thus, this care‐delivery model is underrepresented, limiting generalization of findings to other such sites.

However, our study also has important strengths. First, this is the only survey that specifically examines hospitalist viewpoints when it comes to PICCs. As hospitalists frequently order and/or insert these devices, their perspectives are highly pertinent to discussions regarding current PICC use. Second, our survey highlights several instances that may be associated with preventable patient harm and identifies areas where interventions may be valuable. For example, forgetting the presence of a device, keeping PICCs in place throughout hospitalization, and rendering treatment for PICC‐related VTE not in accordance with accepted guidelines are remediable practices that may lead to poor outcomes. Interventions such as device‐reminder alerts, provider education regarding complications from PICCs, and systematic efforts to identify and remove unnecessary PICCs may mitigate these problems. Finally, our findings highlight the need for data repositories that track PICC use and hospitalist practice on a national scale. Given the risk and significance of the complications associated with these devices, understanding the epidemiology, use, and potential misuse of PICCs are important areas for hospitalist research.

In conclusion, our study of hospitalist experience, practice, opinions, and knowledge related to PICCs suggests important gaps between available evidence and current practice. There is growing need for the development of appropriateness criteria to guide vascular access in inpatient settings.[25, 26] Such criteria should consider not only type of venous access device, but granular details including rationale for venous access, nature of the infusate, optimal number of lumens, and safest gauge when recommending devices. Until such criteria and comparative studies become available, hospitals should consider instituting policies to monitor PICC use with specific attention to indication for insertion, duration of placement, and complications. These interventions represent a first and necessary step in improving patient safety when it comes to preventing PICC‐related complications.

Disclosures

The Blue Cross/Blue Shield of Michigan Foundation in Detroit funded this study through an investigator‐initiated research proposal (1931‐PIRAP). The funding source, however, played no role in study design, acquisition of data, data analysis, or reporting of these results. The authors report no conflicts of interest.

Payers and policymakers are increasingly holding hospitals accountable for patients' experiences with their care. Since 2006, the Centers for Medicare and Medicaid Services (CMS) have collected data on patients' experiences with inpatient care using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a well‐validated and widely used tool. In 2008, these data on patient experience began to be publicly reported, and CMS now plans to base part of its payments to hospitals on HCAHPS performance scores. In this context, hospitals are looking for ways to improve patient satisfaction.

The effort to hold hospitals accountable for patient experience may conflict with another major trend in US hospitals: the increasing use of hospitalists.[1] Although hospitalists may have greater expertise in the day‐to‐day care of the hospitalized patient, they generally do not know the patient and cannot cater to patients' preferences in ways that the primary‐care provider might. Therefore, given that patients may prefer to be seen by their primary‐care provider,[2] greater use of hospitalists may actually lead to a decrease in patient satisfaction. Unfortunately, we are unaware of any national examination of the relationship between hospitalist use in an institution and that entity's performance on patient‐experience scores.

To better understand the relationship between greater hospitalist staffing and patient‐centered care, we examined the association between hospitalist staffing and patient satisfaction with both overall care and specific domains of patient‐centered care. We hypothesized that hospitals that used a high proportion of hospitalists would generally have lower patient‐experience scores. Further, we expected that the relationship would be monotonic (greater use of hospitalists associated with lower scores) and particularly pronounced in 2 domains: patient experience with discharge planning and patient experience with physician communication.

METHODS

RESULTS

Among all hospitals, the median proportion of general‐medicine admissions cared for by hospitalists was 41.2% (interquartile range [IQR], 11.5%67.4%). However, US hospitals varied widely in the proportion of general‐medicine patients cared for by hospitalists (Figure 1). Whereas 3.5% of hospitals had all of their general‐medicine patients cared for by hospitalists, 16.6% had none of their general‐medicine patients seen by hospitalists. For hospitals with at least some hospitalist care, the proportion of patients cared for by hospitalists was distributed fairly evenly across the range of possibilities (Figure 1).

Figure 1

Because hospitalist care varied widely among hospitals, we categorized hospitals into 3 groups (non‐hospitalist, mixed, and hospitalist). The median proportion of patients cared for by hospitalists in the 3 groups was 0%, 39.5%, and 76.5%, respectively (Table 1). The non‐hospitalist hospitals, when compared with mixed and hospitalist hospitals, were more likely to be small, nonteaching, for‐profit institutions located in the Midwestern United States. They also were less likely to have an ICU and had lower nurse‐to‐bed ratios.

The types of patients cared for at all 3 hospital types (non‐hospitalist, mixed, and hospitalist) were similar in age and day of admission (Table 2). Patients cared for at non‐hospitalist hospitals were slightly more likely to be female and non‐White, and less likely to be admitted from the emergency department or another hospital or healthcare facility.

When we examined unadjusted relationships between type of hospital and patient experience, we found that patients at hospitalist vs non‐hospitalist hospitals were more likely to recommend the hospital (69.4% vs 65.1%: P < 0.001), and report higher overall satisfaction (65.9% vs 63.6%: P < 0.001) ((see Supporting Information, Appendix, Table A1, in the online version of this article)). Care at hospitalist hospitals was associated with higher satisfaction with discharge, but lower satisfaction with room cleanliness and communication with doctors. These differences were statistically significant at the P < 0.05 level.

When we examined the relationship between having more hospitalists and patient experience using multivariable models that accounted for differences in hospital characteristics, we found largely similar results: The proportion of patients who were satisfied with their overall care was still higher at hospitalist compared with non‐hospitalist hospitals (65.6% vs 63.9%: P < 0.001) (Figure 2). Similarly, patients were more likely to definitely recommend their hospital if they had been cared for at a hospitalist vs non‐hospitalist hospital (66.0% vs 63.4%: P < 0.001).

Figure 2

To better understand which domains of care might be contributing to greater overall satisfaction, we also examined patient satisfaction with specific domains of care at hospitalist vs non‐hospitalist hospitals (Table 3) in our adjusted analyses. Among 8 domains, the largest difference in satisfaction between patients cared for at hospitalist vs non‐hospitalist hospitals occurred with discharge. At hospitalist hospitals, 80.3% of patients said they were satisfied with the quality of the discharge planning compared with 78.1% at non‐hospitalist hospitals (P < 0.001). Patients at hospitalist hospitals were more satisfied with most other domains of care as well. Patients cared for at hospitalist hospitals were slightly less likely to be satisfied with communication with doctors, but this difference was not statistically significant (P = 0.45). Results were qualitatively similar in propensity‐score analyses (see Supporting Information, Appendix, Table A2, in the online version of this article).

DISCUSSION

We found that in 2009, US hospitals varied widely in the proportion of general medicine patients cared for by hospitalists. Hospitals with higher levels of hospitalist care did better on most measures of patient satisfaction. Differences were largest in overall satisfaction and for discharge planning. In 5 other domains of care, differences were smaller, but hospitals with more hospitalist care consistently performed better than non‐hospitalist hospitals. Hospitalist care was not associated with patient satisfaction in 2 domains: communication with doctors and cleanliness of room.

Our findings of modestly higher patient satisfaction at hospitalist hospitals along most dimensions of care are surprising and reassuring. Indeed, when hospitalists first began caring for inpatients, some expressed concerns that hospitalist care would decrease patient satisfaction.[8, 9] Though this has been an ongoing concern, we found no evidence to support this contention. It may be that as a response to the concern, hospitals with hospitalists have paid particular attention to issues such as effective handoffs to primary‐care providers.[10, 11, 12, 13] Whether due to these efforts or other factors such as the 24/7 inpatient presence of hospitalists, we found that patients at hospitalist hospitals were more likely to be satisfied with their inpatient care, including their experience at discharge. In contrast, one area that may offer room for improvement for hospitalist hospitals is communication with physicians. It may be that patients cared for by hospitalists do not know their physicians as well as patients whose care is being orchestrated by their primary‐care provider, and thus the benefits of having an ever‐present hospitalist are diminished.

The magnitude of the associations that we found should also be placed in the context of existing research on patient satisfaction. Prior work has described baseline hospital performance, changes over time, and factors associated with greater inpatient satisfaction.[5, 14, 15] The associations that we found between hospitalist care and satisfaction with care at discharge were larger than those found for teaching (vs non‐teaching) hospitals.[5] However, compared with other hospital characteristics such as nurse staffing or profit status, hospitalist care was associated with smaller differences in patient satisfaction. In one study, hospitals in the highest quartile of nurse staffing had HCAHPS scores (ie, willingness to recommend measure) that were 6.7 points higher than those in the lowest quartile of nurse staffing, and similar differences existed between not‐for‐profit, public hospitals vs for‐profit hospitals.[5]

Taken together, our findings address an important gap in knowledge about hospitalist care. Prior research has documented growth in the use of hospitalist care[1] and described the association of hospitalist care with outcomes such as mortality and resource use, and receipt of recommended care.[16, 17, 18, 19] However, we are unaware of any national study that has examined the association of hospitalist care with patient satisfaction. One study surveyed patients in a single health system and found that patients were similarly satisfied with care provided by hospitalists and primary‐care physicians.[20] Our findings should be reassuring to clinical leaders and policymakers who have advocated greater use of hospitalists: the results suggest that there need be no tradeoff between greater use of hospitalist services and patient satisfaction. Indeed, patients appear to be even more satisfied in hospitals that have greater use of hospitalist physicians.

Our study has several limitations. First, it was a cross‐sectional study, and thus we cannot make any conclusions about causality. Although we adjusted for several potential confounders (eg, teaching status, advanced care capabilities, nurse staffing), it is possible that hospitalist care is a surrogate marker for features of hospitals that we could not measure but that directly influence patient experience. In addition, it is possible that patients cared for at hospitalist hospitals differ in unmeasured ways from patients cared for at other types of hospitals. Second, we constructed our primary predictor and outcome from different cohorts. Our primary predictor was derived from the proportion of general‐medicine patients cared for by hospitalists in Medicare claims data. In contrast, our primary outcome was based on HCAHPS responses from a random sampling of all hospital admissions. This misclassification likely would have biased us towards finding small or no associations. Therefore, we are likely underestimating the true association between hospitalist use and patient experience. Third, our findings may not be generalizable to hospitals that serve younger patients or have a large number of specialist hospitalists (who were not included in our definition of hospitalists). For example, compared with older patients with multiple comorbidities, relatively healthy younger patients may derive less benefit from an ever‐present hospitalist who can explain discharge plans or an attentive nurse.

In summary, we found that US hospitals varied widely in their use of hospitalist physicians, and those which a greater proportion of care was delivered by hospitalists generally had better scores on patient experience, especially on the global assessment of satisfaction and in discharge care. Our findings suggest that adoption of the hospitalist modelone of the strategies employed by US hospitals in the past 2 decades to provide efficient careshould not detract from achieving the goal of more patient‐centered care.

Disclosures

Dr. Chen's work is supported in part by the National Institutes of Health/National Institute on Aging (AG024824, University of Michigan Claude D. Pepper Older Americans Independence Center), and the National Institutes of Health/National Center for Research Resources (UL1‐RR024986, Michigan Institute for Clinical and Health Research). Dr. Chen is also supported by a Career Development Grant Award (K08HS020671) from the Agency for Healthcare Research and Quality.

Payers and policymakers are increasingly holding hospitals accountable for patients' experiences with their care. Since 2006, the Centers for Medicare and Medicaid Services (CMS) have collected data on patients' experiences with inpatient care using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a well‐validated and widely used tool. In 2008, these data on patient experience began to be publicly reported, and CMS now plans to base part of its payments to hospitals on HCAHPS performance scores. In this context, hospitals are looking for ways to improve patient satisfaction.

The effort to hold hospitals accountable for patient experience may conflict with another major trend in US hospitals: the increasing use of hospitalists.[1] Although hospitalists may have greater expertise in the day‐to‐day care of the hospitalized patient, they generally do not know the patient and cannot cater to patients' preferences in ways that the primary‐care provider might. Therefore, given that patients may prefer to be seen by their primary‐care provider,[2] greater use of hospitalists may actually lead to a decrease in patient satisfaction. Unfortunately, we are unaware of any national examination of the relationship between hospitalist use in an institution and that entity's performance on patient‐experience scores.

To better understand the relationship between greater hospitalist staffing and patient‐centered care, we examined the association between hospitalist staffing and patient satisfaction with both overall care and specific domains of patient‐centered care. We hypothesized that hospitals that used a high proportion of hospitalists would generally have lower patient‐experience scores. Further, we expected that the relationship would be monotonic (greater use of hospitalists associated with lower scores) and particularly pronounced in 2 domains: patient experience with discharge planning and patient experience with physician communication.

METHODS

RESULTS

Among all hospitals, the median proportion of general‐medicine admissions cared for by hospitalists was 41.2% (interquartile range [IQR], 11.5%67.4%). However, US hospitals varied widely in the proportion of general‐medicine patients cared for by hospitalists (Figure 1). Whereas 3.5% of hospitals had all of their general‐medicine patients cared for by hospitalists, 16.6% had none of their general‐medicine patients seen by hospitalists. For hospitals with at least some hospitalist care, the proportion of patients cared for by hospitalists was distributed fairly evenly across the range of possibilities (Figure 1).

Figure 1

Because hospitalist care varied widely among hospitals, we categorized hospitals into 3 groups (non‐hospitalist, mixed, and hospitalist). The median proportion of patients cared for by hospitalists in the 3 groups was 0%, 39.5%, and 76.5%, respectively (Table 1). The non‐hospitalist hospitals, when compared with mixed and hospitalist hospitals, were more likely to be small, nonteaching, for‐profit institutions located in the Midwestern United States. They also were less likely to have an ICU and had lower nurse‐to‐bed ratios.

The types of patients cared for at all 3 hospital types (non‐hospitalist, mixed, and hospitalist) were similar in age and day of admission (Table 2). Patients cared for at non‐hospitalist hospitals were slightly more likely to be female and non‐White, and less likely to be admitted from the emergency department or another hospital or healthcare facility.

When we examined unadjusted relationships between type of hospital and patient experience, we found that patients at hospitalist vs non‐hospitalist hospitals were more likely to recommend the hospital (69.4% vs 65.1%: P < 0.001), and report higher overall satisfaction (65.9% vs 63.6%: P < 0.001) ((see Supporting Information, Appendix, Table A1, in the online version of this article)). Care at hospitalist hospitals was associated with higher satisfaction with discharge, but lower satisfaction with room cleanliness and communication with doctors. These differences were statistically significant at the P < 0.05 level.

When we examined the relationship between having more hospitalists and patient experience using multivariable models that accounted for differences in hospital characteristics, we found largely similar results: The proportion of patients who were satisfied with their overall care was still higher at hospitalist compared with non‐hospitalist hospitals (65.6% vs 63.9%: P < 0.001) (Figure 2). Similarly, patients were more likely to definitely recommend their hospital if they had been cared for at a hospitalist vs non‐hospitalist hospital (66.0% vs 63.4%: P < 0.001).

Figure 2

To better understand which domains of care might be contributing to greater overall satisfaction, we also examined patient satisfaction with specific domains of care at hospitalist vs non‐hospitalist hospitals (Table 3) in our adjusted analyses. Among 8 domains, the largest difference in satisfaction between patients cared for at hospitalist vs non‐hospitalist hospitals occurred with discharge. At hospitalist hospitals, 80.3% of patients said they were satisfied with the quality of the discharge planning compared with 78.1% at non‐hospitalist hospitals (P < 0.001). Patients at hospitalist hospitals were more satisfied with most other domains of care as well. Patients cared for at hospitalist hospitals were slightly less likely to be satisfied with communication with doctors, but this difference was not statistically significant (P = 0.45). Results were qualitatively similar in propensity‐score analyses (see Supporting Information, Appendix, Table A2, in the online version of this article).

DISCUSSION

We found that in 2009, US hospitals varied widely in the proportion of general medicine patients cared for by hospitalists. Hospitals with higher levels of hospitalist care did better on most measures of patient satisfaction. Differences were largest in overall satisfaction and for discharge planning. In 5 other domains of care, differences were smaller, but hospitals with more hospitalist care consistently performed better than non‐hospitalist hospitals. Hospitalist care was not associated with patient satisfaction in 2 domains: communication with doctors and cleanliness of room.

Our findings of modestly higher patient satisfaction at hospitalist hospitals along most dimensions of care are surprising and reassuring. Indeed, when hospitalists first began caring for inpatients, some expressed concerns that hospitalist care would decrease patient satisfaction.[8, 9] Though this has been an ongoing concern, we found no evidence to support this contention. It may be that as a response to the concern, hospitals with hospitalists have paid particular attention to issues such as effective handoffs to primary‐care providers.[10, 11, 12, 13] Whether due to these efforts or other factors such as the 24/7 inpatient presence of hospitalists, we found that patients at hospitalist hospitals were more likely to be satisfied with their inpatient care, including their experience at discharge. In contrast, one area that may offer room for improvement for hospitalist hospitals is communication with physicians. It may be that patients cared for by hospitalists do not know their physicians as well as patients whose care is being orchestrated by their primary‐care provider, and thus the benefits of having an ever‐present hospitalist are diminished.

The magnitude of the associations that we found should also be placed in the context of existing research on patient satisfaction. Prior work has described baseline hospital performance, changes over time, and factors associated with greater inpatient satisfaction.[5, 14, 15] The associations that we found between hospitalist care and satisfaction with care at discharge were larger than those found for teaching (vs non‐teaching) hospitals.[5] However, compared with other hospital characteristics such as nurse staffing or profit status, hospitalist care was associated with smaller differences in patient satisfaction. In one study, hospitals in the highest quartile of nurse staffing had HCAHPS scores (ie, willingness to recommend measure) that were 6.7 points higher than those in the lowest quartile of nurse staffing, and similar differences existed between not‐for‐profit, public hospitals vs for‐profit hospitals.[5]

Taken together, our findings address an important gap in knowledge about hospitalist care. Prior research has documented growth in the use of hospitalist care[1] and described the association of hospitalist care with outcomes such as mortality and resource use, and receipt of recommended care.[16, 17, 18, 19] However, we are unaware of any national study that has examined the association of hospitalist care with patient satisfaction. One study surveyed patients in a single health system and found that patients were similarly satisfied with care provided by hospitalists and primary‐care physicians.[20] Our findings should be reassuring to clinical leaders and policymakers who have advocated greater use of hospitalists: the results suggest that there need be no tradeoff between greater use of hospitalist services and patient satisfaction. Indeed, patients appear to be even more satisfied in hospitals that have greater use of hospitalist physicians.

Our study has several limitations. First, it was a cross‐sectional study, and thus we cannot make any conclusions about causality. Although we adjusted for several potential confounders (eg, teaching status, advanced care capabilities, nurse staffing), it is possible that hospitalist care is a surrogate marker for features of hospitals that we could not measure but that directly influence patient experience. In addition, it is possible that patients cared for at hospitalist hospitals differ in unmeasured ways from patients cared for at other types of hospitals. Second, we constructed our primary predictor and outcome from different cohorts. Our primary predictor was derived from the proportion of general‐medicine patients cared for by hospitalists in Medicare claims data. In contrast, our primary outcome was based on HCAHPS responses from a random sampling of all hospital admissions. This misclassification likely would have biased us towards finding small or no associations. Therefore, we are likely underestimating the true association between hospitalist use and patient experience. Third, our findings may not be generalizable to hospitals that serve younger patients or have a large number of specialist hospitalists (who were not included in our definition of hospitalists). For example, compared with older patients with multiple comorbidities, relatively healthy younger patients may derive less benefit from an ever‐present hospitalist who can explain discharge plans or an attentive nurse.

In summary, we found that US hospitals varied widely in their use of hospitalist physicians, and those which a greater proportion of care was delivered by hospitalists generally had better scores on patient experience, especially on the global assessment of satisfaction and in discharge care. Our findings suggest that adoption of the hospitalist modelone of the strategies employed by US hospitals in the past 2 decades to provide efficient careshould not detract from achieving the goal of more patient‐centered care.

Disclosures

Dr. Chen's work is supported in part by the National Institutes of Health/National Institute on Aging (AG024824, University of Michigan Claude D. Pepper Older Americans Independence Center), and the National Institutes of Health/National Center for Research Resources (UL1‐RR024986, Michigan Institute for Clinical and Health Research). Dr. Chen is also supported by a Career Development Grant Award (K08HS020671) from the Agency for Healthcare Research and Quality.

Payers and policymakers are increasingly holding hospitals accountable for patients' experiences with their care. Since 2006, the Centers for Medicare and Medicaid Services (CMS) have collected data on patients' experiences with inpatient care using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a well‐validated and widely used tool. In 2008, these data on patient experience began to be publicly reported, and CMS now plans to base part of its payments to hospitals on HCAHPS performance scores. In this context, hospitals are looking for ways to improve patient satisfaction.

The effort to hold hospitals accountable for patient experience may conflict with another major trend in US hospitals: the increasing use of hospitalists.[1] Although hospitalists may have greater expertise in the day‐to‐day care of the hospitalized patient, they generally do not know the patient and cannot cater to patients' preferences in ways that the primary‐care provider might. Therefore, given that patients may prefer to be seen by their primary‐care provider,[2] greater use of hospitalists may actually lead to a decrease in patient satisfaction. Unfortunately, we are unaware of any national examination of the relationship between hospitalist use in an institution and that entity's performance on patient‐experience scores.

To better understand the relationship between greater hospitalist staffing and patient‐centered care, we examined the association between hospitalist staffing and patient satisfaction with both overall care and specific domains of patient‐centered care. We hypothesized that hospitals that used a high proportion of hospitalists would generally have lower patient‐experience scores. Further, we expected that the relationship would be monotonic (greater use of hospitalists associated with lower scores) and particularly pronounced in 2 domains: patient experience with discharge planning and patient experience with physician communication.

METHODS

RESULTS

Among all hospitals, the median proportion of general‐medicine admissions cared for by hospitalists was 41.2% (interquartile range [IQR], 11.5%67.4%). However, US hospitals varied widely in the proportion of general‐medicine patients cared for by hospitalists (Figure 1). Whereas 3.5% of hospitals had all of their general‐medicine patients cared for by hospitalists, 16.6% had none of their general‐medicine patients seen by hospitalists. For hospitals with at least some hospitalist care, the proportion of patients cared for by hospitalists was distributed fairly evenly across the range of possibilities (Figure 1).

Figure 1

Because hospitalist care varied widely among hospitals, we categorized hospitals into 3 groups (non‐hospitalist, mixed, and hospitalist). The median proportion of patients cared for by hospitalists in the 3 groups was 0%, 39.5%, and 76.5%, respectively (Table 1). The non‐hospitalist hospitals, when compared with mixed and hospitalist hospitals, were more likely to be small, nonteaching, for‐profit institutions located in the Midwestern United States. They also were less likely to have an ICU and had lower nurse‐to‐bed ratios.

The types of patients cared for at all 3 hospital types (non‐hospitalist, mixed, and hospitalist) were similar in age and day of admission (Table 2). Patients cared for at non‐hospitalist hospitals were slightly more likely to be female and non‐White, and less likely to be admitted from the emergency department or another hospital or healthcare facility.

When we examined unadjusted relationships between type of hospital and patient experience, we found that patients at hospitalist vs non‐hospitalist hospitals were more likely to recommend the hospital (69.4% vs 65.1%: P < 0.001), and report higher overall satisfaction (65.9% vs 63.6%: P < 0.001) ((see Supporting Information, Appendix, Table A1, in the online version of this article)). Care at hospitalist hospitals was associated with higher satisfaction with discharge, but lower satisfaction with room cleanliness and communication with doctors. These differences were statistically significant at the P < 0.05 level.

When we examined the relationship between having more hospitalists and patient experience using multivariable models that accounted for differences in hospital characteristics, we found largely similar results: The proportion of patients who were satisfied with their overall care was still higher at hospitalist compared with non‐hospitalist hospitals (65.6% vs 63.9%: P < 0.001) (Figure 2). Similarly, patients were more likely to definitely recommend their hospital if they had been cared for at a hospitalist vs non‐hospitalist hospital (66.0% vs 63.4%: P < 0.001).

Figure 2

To better understand which domains of care might be contributing to greater overall satisfaction, we also examined patient satisfaction with specific domains of care at hospitalist vs non‐hospitalist hospitals (Table 3) in our adjusted analyses. Among 8 domains, the largest difference in satisfaction between patients cared for at hospitalist vs non‐hospitalist hospitals occurred with discharge. At hospitalist hospitals, 80.3% of patients said they were satisfied with the quality of the discharge planning compared with 78.1% at non‐hospitalist hospitals (P < 0.001). Patients at hospitalist hospitals were more satisfied with most other domains of care as well. Patients cared for at hospitalist hospitals were slightly less likely to be satisfied with communication with doctors, but this difference was not statistically significant (P = 0.45). Results were qualitatively similar in propensity‐score analyses (see Supporting Information, Appendix, Table A2, in the online version of this article).

DISCUSSION

We found that in 2009, US hospitals varied widely in the proportion of general medicine patients cared for by hospitalists. Hospitals with higher levels of hospitalist care did better on most measures of patient satisfaction. Differences were largest in overall satisfaction and for discharge planning. In 5 other domains of care, differences were smaller, but hospitals with more hospitalist care consistently performed better than non‐hospitalist hospitals. Hospitalist care was not associated with patient satisfaction in 2 domains: communication with doctors and cleanliness of room.

Our findings of modestly higher patient satisfaction at hospitalist hospitals along most dimensions of care are surprising and reassuring. Indeed, when hospitalists first began caring for inpatients, some expressed concerns that hospitalist care would decrease patient satisfaction.[8, 9] Though this has been an ongoing concern, we found no evidence to support this contention. It may be that as a response to the concern, hospitals with hospitalists have paid particular attention to issues such as effective handoffs to primary‐care providers.[10, 11, 12, 13] Whether due to these efforts or other factors such as the 24/7 inpatient presence of hospitalists, we found that patients at hospitalist hospitals were more likely to be satisfied with their inpatient care, including their experience at discharge. In contrast, one area that may offer room for improvement for hospitalist hospitals is communication with physicians. It may be that patients cared for by hospitalists do not know their physicians as well as patients whose care is being orchestrated by their primary‐care provider, and thus the benefits of having an ever‐present hospitalist are diminished.

The magnitude of the associations that we found should also be placed in the context of existing research on patient satisfaction. Prior work has described baseline hospital performance, changes over time, and factors associated with greater inpatient satisfaction.[5, 14, 15] The associations that we found between hospitalist care and satisfaction with care at discharge were larger than those found for teaching (vs non‐teaching) hospitals.[5] However, compared with other hospital characteristics such as nurse staffing or profit status, hospitalist care was associated with smaller differences in patient satisfaction. In one study, hospitals in the highest quartile of nurse staffing had HCAHPS scores (ie, willingness to recommend measure) that were 6.7 points higher than those in the lowest quartile of nurse staffing, and similar differences existed between not‐for‐profit, public hospitals vs for‐profit hospitals.[5]

Taken together, our findings address an important gap in knowledge about hospitalist care. Prior research has documented growth in the use of hospitalist care[1] and described the association of hospitalist care with outcomes such as mortality and resource use, and receipt of recommended care.[16, 17, 18, 19] However, we are unaware of any national study that has examined the association of hospitalist care with patient satisfaction. One study surveyed patients in a single health system and found that patients were similarly satisfied with care provided by hospitalists and primary‐care physicians.[20] Our findings should be reassuring to clinical leaders and policymakers who have advocated greater use of hospitalists: the results suggest that there need be no tradeoff between greater use of hospitalist services and patient satisfaction. Indeed, patients appear to be even more satisfied in hospitals that have greater use of hospitalist physicians.

Our study has several limitations. First, it was a cross‐sectional study, and thus we cannot make any conclusions about causality. Although we adjusted for several potential confounders (eg, teaching status, advanced care capabilities, nurse staffing), it is possible that hospitalist care is a surrogate marker for features of hospitals that we could not measure but that directly influence patient experience. In addition, it is possible that patients cared for at hospitalist hospitals differ in unmeasured ways from patients cared for at other types of hospitals. Second, we constructed our primary predictor and outcome from different cohorts. Our primary predictor was derived from the proportion of general‐medicine patients cared for by hospitalists in Medicare claims data. In contrast, our primary outcome was based on HCAHPS responses from a random sampling of all hospital admissions. This misclassification likely would have biased us towards finding small or no associations. Therefore, we are likely underestimating the true association between hospitalist use and patient experience. Third, our findings may not be generalizable to hospitals that serve younger patients or have a large number of specialist hospitalists (who were not included in our definition of hospitalists). For example, compared with older patients with multiple comorbidities, relatively healthy younger patients may derive less benefit from an ever‐present hospitalist who can explain discharge plans or an attentive nurse.

In summary, we found that US hospitals varied widely in their use of hospitalist physicians, and those which a greater proportion of care was delivered by hospitalists generally had better scores on patient experience, especially on the global assessment of satisfaction and in discharge care. Our findings suggest that adoption of the hospitalist modelone of the strategies employed by US hospitals in the past 2 decades to provide efficient careshould not detract from achieving the goal of more patient‐centered care.

Disclosures

Dr. Chen's work is supported in part by the National Institutes of Health/National Institute on Aging (AG024824, University of Michigan Claude D. Pepper Older Americans Independence Center), and the National Institutes of Health/National Center for Research Resources (UL1‐RR024986, Michigan Institute for Clinical and Health Research). Dr. Chen is also supported by a Career Development Grant Award (K08HS020671) from the Agency for Healthcare Research and Quality.