Colorectal cancer (CRC) is the second most common malignancy in the United States. In 2013, an estimated 142,820 men and women will be newly diagnosed, and 50,830 patients will die from colon or rectal cancer.[1] The majority of patients are aged 65 years or older at diagnosis, and with a growing elderly population, the CRC burden assumes increasing importance in this patient population.[1] Surgery remains the most important treatment option; however, surgical management of older CRC patients is often complicated because of the attendant comorbidities.[2, 3]

Recently, comanagement of surgical patients during their hospital stay has increased substantially in an effort to provide care to complex patients.[4, 5] Comanagement includes daily assessment of acute issues and comorbidities, and communication with surgeons by physicians including hospitalists and internists.[6] The presumed benefits of this comanaged approach to patient care include increased prescribing of evidence‐based treatments,[7] reduced time to surgery,[8] fewer transfers to an intensive care unit,[9] fewer postoperative complications,[9, 10, 11] shortened length of hospital stay,[12, 13] and lower readmission rates.[7] Information regarding detailed characteristics of patients receiving comanagement during hospitalization, specifically for CRC surgery, is lacking. This is an important consideration because comanagement may be particularly beneficial for CRC patients, who tend to be older at diagnosis and may have multiple comorbidities.[5] Hospitalists may be especially important for postoperative management of CRC patients, depending upon the complexity of the surgery and also the need for close medical and surgical monitoring in the perioperative setting, particularly among older CRC patients. Many CRC patients develop complications following surgery,[14] and it is possible that these patients may be rescued by comanagement with hospitalist physicians. Our aim was to assess the use of and characteristics associated with comanagement of patients undergoing surgical intervention for CRC.

METHODS

We obtained data from an existing linkage of 2000 to 2005 National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program data with 1999 to 2005 Medicare claim files from the Centers for Medicare and Medicaid Services (CMS).[15] In this study, data from 16 tumor registries and 1242 hospitals were included, covering approximately 28% of the US population. We selected patients aged 66 years or older with a first primary stage I to III colon or rectal cancer diagnosis between 2000 and 2005. Patients were eligible for inclusion when they had both Medicare parts A and B coverage and underwent surgical treatment for CRC. We excluded patients identified from autopsy or death certificate only, patients for whom the month of diagnosis was not available, and patients who were members of a Health Maintenance Organization and thereby lacking Medicare claims data. We excluded patients who were only eligible for Medicare because they were disabled or had end‐stage renal disease (ie, patients younger than 65 years of age). The age restriction of 66 years of age or older allowed for 1 year of Medicare claims data prior to CRC diagnosis to determine preexisting comorbidity. We used 1999 Medicare data to obtain information about comorbidity for CRC patients who were diagnosed in 2000. Definitive surgery for CRC was measured by searching inpatient, outpatient, and carrier claims using previously identified Healthcare Common Procedure Coding System and/or International Classification of Diseases, 9th Revision (ICD‐9). In the event of multiple surgical interventions in 1 patient record, the date on which the most invasive surgery was performed was used.[16]

RESULTS

There were 47,828 patients aged 66 years or older who were diagnosed with a first primary CRC between 2000 and 2005, had both Medicare parts A and B, and were not members of a Health Maintenance Organization during the study period. We excluded patients for whom we were unable to calculate complications (n = 2649), surgery or hospital volume (n = 6415), or who had missing data (n = 238). Finally, we excluded CRC patients with in situ, stage IV, or missing stage information, resulting in 37,065 patients in the study population. Patients in the study population were typically aged 75 to 84 years, were female, had 1 or more comorbid condition, lived in areas with the population poverty rate <10%, were diagnosed with AJCC stage II, had elective surgery, and were treated with partial colectomy (Table 1). During 2000 to 2005, 10,230 (27.6%) of 37,065 patients were comanaged during hospitalization for CRC surgery. In a model with no covariates, variability of comanagement across hospitals was significant (ICC = 0.382). All patient and hospital characteristics except for sex and race/ethnicity were significantly associated with comanagement use, when adjusted for clustering within hospitals. The most common characteristics associated with comanagement were emergency surgery (40.4%), complications (39.7%), and having 2 or more comorbid conditions (37.1%). Comanagement was less common among those with no comorbidity (21.0%), unknown tumor grade (21.9%), and other surgery (18.6%). Furthermore, comanagement increased from 24.8% in 2000 to 30.1% in 2005 (P for trend < 0.001; Table 1).

Table 2 shows the adjusted ORs of the covariates associated with comanagement. This model includes only variables independently associated with comanagement. Increasing age was associated with increased odds of receiving comanagement, with OR = 1.22 for patients aged between 75 and 84 years, and OR = 1.52 for patients aged 85 years and older. Comorbidity scores of 1 or 2 or more were associated with increased odds of comanagement use following CRC surgery compared to patients without comorbidities (OR = 1.39 and OR = 1.92, respectively). Patients who received Medicaid were more likely to receive comanagement (OR = 1.11) compared with patients without Medicaid insurance. Higher AJCC stage was associated with increased use of comanagement, as was poor tumor differentiation. Patients undergoing surgery for colon versus rectal cancer were more likely to be comanaged during their hospital stay (OR = 1.23). Surgery after emergency admission was associated with an increased use of comanagement (OR = 1.95). The odds of comanagement increased slightly with increasing length of hospital stay (OR = 1.03), but were higher for patients who developed 1 or more complications during hospitalization compared with patients without complications (OR = 1.38). Compared with CRC patients treated in small hospitals (<200 beds), patients treated in hospitals with 200 to 349 beds were more likely to receive comanaged care (OR = 1.51), whereas patients treated in high‐volume hospitals with 500 beds were less likely to receive comanaged care during hospitalization (OR = 0.65). While census‐tract poverty rate was associated with comanagement in univariable analysis, no significant association was observed when adjusting for other covariates in the multivariable model. In a model with all covariates listed (Table 2), variability of comanagement across hospitals was significant (ICC = 0.376), suggesting that extensive variability across hospitals remained. The adjusted value of CRC patients receiving comanaged care varied widely, from 1.9% to 83.2% across hospitals. Our sensitivity analysis showed that odds ratios and confidence intervals were generally unchanged when using different definitions of comanagement.

DISCUSSION

In all, 27.6% of CRC patients were comanaged during hospitalization, but large disparities existed across patient, hospital, and geographic characteristics. Our finding that more complex patients are more likely to receive comanaged care (eg, increasing age and comorbidity, higher tumor stage and grade, emergency presentation, and complications) are in line with other studies.[5] Importantly, there was a wide range in hospital use of comanagement; the variability across hospitals accounted for 37.6% of the total variability in comanagement use. In some hospitals, almost none of the patients received comanaged care, whereas in other hospitals 83.2% of patients received such care. One reason for the large variability across hospitals may be the lack of evidence about the effectiveness of comanagement. Although comanaged care may benefit orthopedic patients,[7, 8, 9, 10, 11] to our knowledge, no studies have shown benefit to CRC patients. Typically, procedures for which there is more ambiguity about its effectiveness show greater variability across hospitals and geographic areas.[22] Similar to a previous study,[5] we found that patients treated in midsize hospitals were more likely to receive comanagement, and patients treated at high‐volume hospitals were less likely to receive comanagement compared to smaller hospitals. However, because the variability was similar between the model without any variables and the full multivariable model, other variables not available in SEERMedicare data likely played a role in explaining this large interhospital variability. Quality of cancer care may be improved by reducing variation in underuse of effective and necessary care, variation that indicates misuse of preference‐sensitive care (ie, care that offers equivalent options to be chosen by the patient), and variation that indicates overuse of supply‐sensitive care (ie, care influenced by medical capacity).[23] Examining and reducing variability in medical care has been an important policy consideration for almost 30 years.[24, 25] Future studies should examine additional reasons for variability in comanagement across hospitals, including variables at the level of the patient, provider, and hospital. Cost‐effective interventions should subsequently target modifiable factors to reduce use of unnecessary care among patients unlikely to benefit from comanagement.

Our study benefits from using a population‐based SEERMedicare cohort of older CRC patients, representing the diversity of geographic areas and hospitals across the United States. Furthermore, we were able to include a variety of covariates available in the SEERMedicare data, including patient, hospital, and area characteristics. Whereas most studies examining the use or effectiveness of comanagement include single institutions or a variety of surgical patients,[5, 8, 11, 17] we examined the use of and characteristics associated with comanagement throughout the United States for a specific patient population.

We recognize several limitations in this study. Our study specifically assessed comanagement among hospitalized CRC patients aged 65 years and older without managed care insurance. Generalizabilty of our findings to other surgical patients, to younger CRC patients, and those with managed care insurance may therefore be limited. With regard to the definition of comanagement, we used a cutoff point of submitting a claim for management and evaluation on 70% or more of the days of hospitalization for CRC. This cutoff is somewhat arbitrary, but different cutoffs did not influence the results. However, in a prior study, changes in the cutoff used in this definition only affected the proportion of comanaged patients and did not change the observation of increasing trends in the use of comanagement.[5] In addition, we examined a CRC population diagnosed between 2000 and 2005. Because an increasing trend in use of comanagement was observed, it is possible that comanagement use has increased further in more recent years. Our findings of lower use of comanaged care in larger hospitals may be related to the increased use of hospitalists as consultants, whose care may not be accurately or completely captured in claims data. We do not report data regarding the use of physician extenders (nurse practitioners and physician assistants). Although their use is increasing in some contexts, in our data, if we counted patients comanaged by physician extenders, we would only add 79 additional CRC patients (0.6%) to our analyses, which is unlikely to influence our findings.

In conclusion, more complex patients are more likely to receive comanaged care following CRC surgery. Extensive variability existed across patients and hospitals likely due to the lack of evidence about the clinical effectiveness of comanagement for patients undergoing CRC surgery. Future studies should examine additional reasons for variability in comanagement across hospitals, including variables at the level of the patient, provider, and hospital.

Colorectal cancer (CRC) is the second most common malignancy in the United States. In 2013, an estimated 142,820 men and women will be newly diagnosed, and 50,830 patients will die from colon or rectal cancer.[1] The majority of patients are aged 65 years or older at diagnosis, and with a growing elderly population, the CRC burden assumes increasing importance in this patient population.[1] Surgery remains the most important treatment option; however, surgical management of older CRC patients is often complicated because of the attendant comorbidities.[2, 3]

Recently, comanagement of surgical patients during their hospital stay has increased substantially in an effort to provide care to complex patients.[4, 5] Comanagement includes daily assessment of acute issues and comorbidities, and communication with surgeons by physicians including hospitalists and internists.[6] The presumed benefits of this comanaged approach to patient care include increased prescribing of evidence‐based treatments,[7] reduced time to surgery,[8] fewer transfers to an intensive care unit,[9] fewer postoperative complications,[9, 10, 11] shortened length of hospital stay,[12, 13] and lower readmission rates.[7] Information regarding detailed characteristics of patients receiving comanagement during hospitalization, specifically for CRC surgery, is lacking. This is an important consideration because comanagement may be particularly beneficial for CRC patients, who tend to be older at diagnosis and may have multiple comorbidities.[5] Hospitalists may be especially important for postoperative management of CRC patients, depending upon the complexity of the surgery and also the need for close medical and surgical monitoring in the perioperative setting, particularly among older CRC patients. Many CRC patients develop complications following surgery,[14] and it is possible that these patients may be rescued by comanagement with hospitalist physicians. Our aim was to assess the use of and characteristics associated with comanagement of patients undergoing surgical intervention for CRC.

METHODS

We obtained data from an existing linkage of 2000 to 2005 National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program data with 1999 to 2005 Medicare claim files from the Centers for Medicare and Medicaid Services (CMS).[15] In this study, data from 16 tumor registries and 1242 hospitals were included, covering approximately 28% of the US population. We selected patients aged 66 years or older with a first primary stage I to III colon or rectal cancer diagnosis between 2000 and 2005. Patients were eligible for inclusion when they had both Medicare parts A and B coverage and underwent surgical treatment for CRC. We excluded patients identified from autopsy or death certificate only, patients for whom the month of diagnosis was not available, and patients who were members of a Health Maintenance Organization and thereby lacking Medicare claims data. We excluded patients who were only eligible for Medicare because they were disabled or had end‐stage renal disease (ie, patients younger than 65 years of age). The age restriction of 66 years of age or older allowed for 1 year of Medicare claims data prior to CRC diagnosis to determine preexisting comorbidity. We used 1999 Medicare data to obtain information about comorbidity for CRC patients who were diagnosed in 2000. Definitive surgery for CRC was measured by searching inpatient, outpatient, and carrier claims using previously identified Healthcare Common Procedure Coding System and/or International Classification of Diseases, 9th Revision (ICD‐9). In the event of multiple surgical interventions in 1 patient record, the date on which the most invasive surgery was performed was used.[16]

RESULTS

There were 47,828 patients aged 66 years or older who were diagnosed with a first primary CRC between 2000 and 2005, had both Medicare parts A and B, and were not members of a Health Maintenance Organization during the study period. We excluded patients for whom we were unable to calculate complications (n = 2649), surgery or hospital volume (n = 6415), or who had missing data (n = 238). Finally, we excluded CRC patients with in situ, stage IV, or missing stage information, resulting in 37,065 patients in the study population. Patients in the study population were typically aged 75 to 84 years, were female, had 1 or more comorbid condition, lived in areas with the population poverty rate <10%, were diagnosed with AJCC stage II, had elective surgery, and were treated with partial colectomy (Table 1). During 2000 to 2005, 10,230 (27.6%) of 37,065 patients were comanaged during hospitalization for CRC surgery. In a model with no covariates, variability of comanagement across hospitals was significant (ICC = 0.382). All patient and hospital characteristics except for sex and race/ethnicity were significantly associated with comanagement use, when adjusted for clustering within hospitals. The most common characteristics associated with comanagement were emergency surgery (40.4%), complications (39.7%), and having 2 or more comorbid conditions (37.1%). Comanagement was less common among those with no comorbidity (21.0%), unknown tumor grade (21.9%), and other surgery (18.6%). Furthermore, comanagement increased from 24.8% in 2000 to 30.1% in 2005 (P for trend < 0.001; Table 1).

Table 2 shows the adjusted ORs of the covariates associated with comanagement. This model includes only variables independently associated with comanagement. Increasing age was associated with increased odds of receiving comanagement, with OR = 1.22 for patients aged between 75 and 84 years, and OR = 1.52 for patients aged 85 years and older. Comorbidity scores of 1 or 2 or more were associated with increased odds of comanagement use following CRC surgery compared to patients without comorbidities (OR = 1.39 and OR = 1.92, respectively). Patients who received Medicaid were more likely to receive comanagement (OR = 1.11) compared with patients without Medicaid insurance. Higher AJCC stage was associated with increased use of comanagement, as was poor tumor differentiation. Patients undergoing surgery for colon versus rectal cancer were more likely to be comanaged during their hospital stay (OR = 1.23). Surgery after emergency admission was associated with an increased use of comanagement (OR = 1.95). The odds of comanagement increased slightly with increasing length of hospital stay (OR = 1.03), but were higher for patients who developed 1 or more complications during hospitalization compared with patients without complications (OR = 1.38). Compared with CRC patients treated in small hospitals (<200 beds), patients treated in hospitals with 200 to 349 beds were more likely to receive comanaged care (OR = 1.51), whereas patients treated in high‐volume hospitals with 500 beds were less likely to receive comanaged care during hospitalization (OR = 0.65). While census‐tract poverty rate was associated with comanagement in univariable analysis, no significant association was observed when adjusting for other covariates in the multivariable model. In a model with all covariates listed (Table 2), variability of comanagement across hospitals was significant (ICC = 0.376), suggesting that extensive variability across hospitals remained. The adjusted value of CRC patients receiving comanaged care varied widely, from 1.9% to 83.2% across hospitals. Our sensitivity analysis showed that odds ratios and confidence intervals were generally unchanged when using different definitions of comanagement.

DISCUSSION

In all, 27.6% of CRC patients were comanaged during hospitalization, but large disparities existed across patient, hospital, and geographic characteristics. Our finding that more complex patients are more likely to receive comanaged care (eg, increasing age and comorbidity, higher tumor stage and grade, emergency presentation, and complications) are in line with other studies.[5] Importantly, there was a wide range in hospital use of comanagement; the variability across hospitals accounted for 37.6% of the total variability in comanagement use. In some hospitals, almost none of the patients received comanaged care, whereas in other hospitals 83.2% of patients received such care. One reason for the large variability across hospitals may be the lack of evidence about the effectiveness of comanagement. Although comanaged care may benefit orthopedic patients,[7, 8, 9, 10, 11] to our knowledge, no studies have shown benefit to CRC patients. Typically, procedures for which there is more ambiguity about its effectiveness show greater variability across hospitals and geographic areas.[22] Similar to a previous study,[5] we found that patients treated in midsize hospitals were more likely to receive comanagement, and patients treated at high‐volume hospitals were less likely to receive comanagement compared to smaller hospitals. However, because the variability was similar between the model without any variables and the full multivariable model, other variables not available in SEERMedicare data likely played a role in explaining this large interhospital variability. Quality of cancer care may be improved by reducing variation in underuse of effective and necessary care, variation that indicates misuse of preference‐sensitive care (ie, care that offers equivalent options to be chosen by the patient), and variation that indicates overuse of supply‐sensitive care (ie, care influenced by medical capacity).[23] Examining and reducing variability in medical care has been an important policy consideration for almost 30 years.[24, 25] Future studies should examine additional reasons for variability in comanagement across hospitals, including variables at the level of the patient, provider, and hospital. Cost‐effective interventions should subsequently target modifiable factors to reduce use of unnecessary care among patients unlikely to benefit from comanagement.

Our study benefits from using a population‐based SEERMedicare cohort of older CRC patients, representing the diversity of geographic areas and hospitals across the United States. Furthermore, we were able to include a variety of covariates available in the SEERMedicare data, including patient, hospital, and area characteristics. Whereas most studies examining the use or effectiveness of comanagement include single institutions or a variety of surgical patients,[5, 8, 11, 17] we examined the use of and characteristics associated with comanagement throughout the United States for a specific patient population.

We recognize several limitations in this study. Our study specifically assessed comanagement among hospitalized CRC patients aged 65 years and older without managed care insurance. Generalizabilty of our findings to other surgical patients, to younger CRC patients, and those with managed care insurance may therefore be limited. With regard to the definition of comanagement, we used a cutoff point of submitting a claim for management and evaluation on 70% or more of the days of hospitalization for CRC. This cutoff is somewhat arbitrary, but different cutoffs did not influence the results. However, in a prior study, changes in the cutoff used in this definition only affected the proportion of comanaged patients and did not change the observation of increasing trends in the use of comanagement.[5] In addition, we examined a CRC population diagnosed between 2000 and 2005. Because an increasing trend in use of comanagement was observed, it is possible that comanagement use has increased further in more recent years. Our findings of lower use of comanaged care in larger hospitals may be related to the increased use of hospitalists as consultants, whose care may not be accurately or completely captured in claims data. We do not report data regarding the use of physician extenders (nurse practitioners and physician assistants). Although their use is increasing in some contexts, in our data, if we counted patients comanaged by physician extenders, we would only add 79 additional CRC patients (0.6%) to our analyses, which is unlikely to influence our findings.

In conclusion, more complex patients are more likely to receive comanaged care following CRC surgery. Extensive variability existed across patients and hospitals likely due to the lack of evidence about the clinical effectiveness of comanagement for patients undergoing CRC surgery. Future studies should examine additional reasons for variability in comanagement across hospitals, including variables at the level of the patient, provider, and hospital.

Colorectal cancer (CRC) is the second most common malignancy in the United States. In 2013, an estimated 142,820 men and women will be newly diagnosed, and 50,830 patients will die from colon or rectal cancer.[1] The majority of patients are aged 65 years or older at diagnosis, and with a growing elderly population, the CRC burden assumes increasing importance in this patient population.[1] Surgery remains the most important treatment option; however, surgical management of older CRC patients is often complicated because of the attendant comorbidities.[2, 3]

Recently, comanagement of surgical patients during their hospital stay has increased substantially in an effort to provide care to complex patients.[4, 5] Comanagement includes daily assessment of acute issues and comorbidities, and communication with surgeons by physicians including hospitalists and internists.[6] The presumed benefits of this comanaged approach to patient care include increased prescribing of evidence‐based treatments,[7] reduced time to surgery,[8] fewer transfers to an intensive care unit,[9] fewer postoperative complications,[9, 10, 11] shortened length of hospital stay,[12, 13] and lower readmission rates.[7] Information regarding detailed characteristics of patients receiving comanagement during hospitalization, specifically for CRC surgery, is lacking. This is an important consideration because comanagement may be particularly beneficial for CRC patients, who tend to be older at diagnosis and may have multiple comorbidities.[5] Hospitalists may be especially important for postoperative management of CRC patients, depending upon the complexity of the surgery and also the need for close medical and surgical monitoring in the perioperative setting, particularly among older CRC patients. Many CRC patients develop complications following surgery,[14] and it is possible that these patients may be rescued by comanagement with hospitalist physicians. Our aim was to assess the use of and characteristics associated with comanagement of patients undergoing surgical intervention for CRC.

METHODS

We obtained data from an existing linkage of 2000 to 2005 National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program data with 1999 to 2005 Medicare claim files from the Centers for Medicare and Medicaid Services (CMS).[15] In this study, data from 16 tumor registries and 1242 hospitals were included, covering approximately 28% of the US population. We selected patients aged 66 years or older with a first primary stage I to III colon or rectal cancer diagnosis between 2000 and 2005. Patients were eligible for inclusion when they had both Medicare parts A and B coverage and underwent surgical treatment for CRC. We excluded patients identified from autopsy or death certificate only, patients for whom the month of diagnosis was not available, and patients who were members of a Health Maintenance Organization and thereby lacking Medicare claims data. We excluded patients who were only eligible for Medicare because they were disabled or had end‐stage renal disease (ie, patients younger than 65 years of age). The age restriction of 66 years of age or older allowed for 1 year of Medicare claims data prior to CRC diagnosis to determine preexisting comorbidity. We used 1999 Medicare data to obtain information about comorbidity for CRC patients who were diagnosed in 2000. Definitive surgery for CRC was measured by searching inpatient, outpatient, and carrier claims using previously identified Healthcare Common Procedure Coding System and/or International Classification of Diseases, 9th Revision (ICD‐9). In the event of multiple surgical interventions in 1 patient record, the date on which the most invasive surgery was performed was used.[16]

RESULTS

There were 47,828 patients aged 66 years or older who were diagnosed with a first primary CRC between 2000 and 2005, had both Medicare parts A and B, and were not members of a Health Maintenance Organization during the study period. We excluded patients for whom we were unable to calculate complications (n = 2649), surgery or hospital volume (n = 6415), or who had missing data (n = 238). Finally, we excluded CRC patients with in situ, stage IV, or missing stage information, resulting in 37,065 patients in the study population. Patients in the study population were typically aged 75 to 84 years, were female, had 1 or more comorbid condition, lived in areas with the population poverty rate <10%, were diagnosed with AJCC stage II, had elective surgery, and were treated with partial colectomy (Table 1). During 2000 to 2005, 10,230 (27.6%) of 37,065 patients were comanaged during hospitalization for CRC surgery. In a model with no covariates, variability of comanagement across hospitals was significant (ICC = 0.382). All patient and hospital characteristics except for sex and race/ethnicity were significantly associated with comanagement use, when adjusted for clustering within hospitals. The most common characteristics associated with comanagement were emergency surgery (40.4%), complications (39.7%), and having 2 or more comorbid conditions (37.1%). Comanagement was less common among those with no comorbidity (21.0%), unknown tumor grade (21.9%), and other surgery (18.6%). Furthermore, comanagement increased from 24.8% in 2000 to 30.1% in 2005 (P for trend < 0.001; Table 1).

Table 2 shows the adjusted ORs of the covariates associated with comanagement. This model includes only variables independently associated with comanagement. Increasing age was associated with increased odds of receiving comanagement, with OR = 1.22 for patients aged between 75 and 84 years, and OR = 1.52 for patients aged 85 years and older. Comorbidity scores of 1 or 2 or more were associated with increased odds of comanagement use following CRC surgery compared to patients without comorbidities (OR = 1.39 and OR = 1.92, respectively). Patients who received Medicaid were more likely to receive comanagement (OR = 1.11) compared with patients without Medicaid insurance. Higher AJCC stage was associated with increased use of comanagement, as was poor tumor differentiation. Patients undergoing surgery for colon versus rectal cancer were more likely to be comanaged during their hospital stay (OR = 1.23). Surgery after emergency admission was associated with an increased use of comanagement (OR = 1.95). The odds of comanagement increased slightly with increasing length of hospital stay (OR = 1.03), but were higher for patients who developed 1 or more complications during hospitalization compared with patients without complications (OR = 1.38). Compared with CRC patients treated in small hospitals (<200 beds), patients treated in hospitals with 200 to 349 beds were more likely to receive comanaged care (OR = 1.51), whereas patients treated in high‐volume hospitals with 500 beds were less likely to receive comanaged care during hospitalization (OR = 0.65). While census‐tract poverty rate was associated with comanagement in univariable analysis, no significant association was observed when adjusting for other covariates in the multivariable model. In a model with all covariates listed (Table 2), variability of comanagement across hospitals was significant (ICC = 0.376), suggesting that extensive variability across hospitals remained. The adjusted value of CRC patients receiving comanaged care varied widely, from 1.9% to 83.2% across hospitals. Our sensitivity analysis showed that odds ratios and confidence intervals were generally unchanged when using different definitions of comanagement.

DISCUSSION

In all, 27.6% of CRC patients were comanaged during hospitalization, but large disparities existed across patient, hospital, and geographic characteristics. Our finding that more complex patients are more likely to receive comanaged care (eg, increasing age and comorbidity, higher tumor stage and grade, emergency presentation, and complications) are in line with other studies.[5] Importantly, there was a wide range in hospital use of comanagement; the variability across hospitals accounted for 37.6% of the total variability in comanagement use. In some hospitals, almost none of the patients received comanaged care, whereas in other hospitals 83.2% of patients received such care. One reason for the large variability across hospitals may be the lack of evidence about the effectiveness of comanagement. Although comanaged care may benefit orthopedic patients,[7, 8, 9, 10, 11] to our knowledge, no studies have shown benefit to CRC patients. Typically, procedures for which there is more ambiguity about its effectiveness show greater variability across hospitals and geographic areas.[22] Similar to a previous study,[5] we found that patients treated in midsize hospitals were more likely to receive comanagement, and patients treated at high‐volume hospitals were less likely to receive comanagement compared to smaller hospitals. However, because the variability was similar between the model without any variables and the full multivariable model, other variables not available in SEERMedicare data likely played a role in explaining this large interhospital variability. Quality of cancer care may be improved by reducing variation in underuse of effective and necessary care, variation that indicates misuse of preference‐sensitive care (ie, care that offers equivalent options to be chosen by the patient), and variation that indicates overuse of supply‐sensitive care (ie, care influenced by medical capacity).[23] Examining and reducing variability in medical care has been an important policy consideration for almost 30 years.[24, 25] Future studies should examine additional reasons for variability in comanagement across hospitals, including variables at the level of the patient, provider, and hospital. Cost‐effective interventions should subsequently target modifiable factors to reduce use of unnecessary care among patients unlikely to benefit from comanagement.

Our study benefits from using a population‐based SEERMedicare cohort of older CRC patients, representing the diversity of geographic areas and hospitals across the United States. Furthermore, we were able to include a variety of covariates available in the SEERMedicare data, including patient, hospital, and area characteristics. Whereas most studies examining the use or effectiveness of comanagement include single institutions or a variety of surgical patients,[5, 8, 11, 17] we examined the use of and characteristics associated with comanagement throughout the United States for a specific patient population.

We recognize several limitations in this study. Our study specifically assessed comanagement among hospitalized CRC patients aged 65 years and older without managed care insurance. Generalizabilty of our findings to other surgical patients, to younger CRC patients, and those with managed care insurance may therefore be limited. With regard to the definition of comanagement, we used a cutoff point of submitting a claim for management and evaluation on 70% or more of the days of hospitalization for CRC. This cutoff is somewhat arbitrary, but different cutoffs did not influence the results. However, in a prior study, changes in the cutoff used in this definition only affected the proportion of comanaged patients and did not change the observation of increasing trends in the use of comanagement.[5] In addition, we examined a CRC population diagnosed between 2000 and 2005. Because an increasing trend in use of comanagement was observed, it is possible that comanagement use has increased further in more recent years. Our findings of lower use of comanaged care in larger hospitals may be related to the increased use of hospitalists as consultants, whose care may not be accurately or completely captured in claims data. We do not report data regarding the use of physician extenders (nurse practitioners and physician assistants). Although their use is increasing in some contexts, in our data, if we counted patients comanaged by physician extenders, we would only add 79 additional CRC patients (0.6%) to our analyses, which is unlikely to influence our findings.

In conclusion, more complex patients are more likely to receive comanaged care following CRC surgery. Extensive variability existed across patients and hospitals likely due to the lack of evidence about the clinical effectiveness of comanagement for patients undergoing CRC surgery. Future studies should examine additional reasons for variability in comanagement across hospitals, including variables at the level of the patient, provider, and hospital.

In 1999, the Accreditation Council for Graduate Medical Education (ACGME) established the requirement for residency programs to assess trainees' competencies in 6 core domains: patient care, medical knowledge, practice‐based learning, systems‐based practice, interpersonal and communication skills, and professionalism.[1] With the rollout of the Next Accreditation System (NAS), and a focus of graduate medical education turning to the assessment of milestones within the ACGME core competencies, it is essential for clinician educators to reflect on how current educational activities meet the needs of our learners and enable compliance with the new recommendations.[1]

On internal medicine services in the inpatient setting, clinician educators routinely supervise and teach trainees during attending rounds. The long‐standing practice of rounding innately offers a forum for making patient care decisions and for sharing medical knowledge.[2] However, the rounding process may also afford clinician educators opportunities to teach material relevant to the other 4 ACGME core competencies.[3] Despite the ubiquitous presence of rounds on internal medicine services, rounding practices vary markedly among and within institutions.[4, 5] Furthermore, there is no consensus with respect to best practices for rounds in general, or more specifically as they pertain to graduate medical education and teaching within the 6 core competencies.

We have conducted a multicenter survey study of internal medicine rounding practices at academic institutions from all US regions. As part of a larger investigation of rounding practices, we surveyed attending physicians regarding the frequency with which they participated in different rounding models (card‐flipping rounds [CFR], hallway rounds [HR], or bedside rounds [BR]), and the perceived capacity of each of these models to promote teaching of material relevant to the 6 ACGME core competencies.

METHODS

RESULTS

Rounding Models and Core Competencies

Most attending physicians surveyed perceived CFR to perform well or very well for teaching medical knowledge (78%), practice‐based learning (59%), and systems‐based practice (53%). Conversely, a minority thought CFR performed well or very well with respect to teaching patient care (21%), professionalism (27%), or interpersonal skills and communication (16%).

The majority of respondents perceived HR to perform well or very well across all ACGME domains, including teaching patient care (91%), medical knowledge (87%), practice‐based learning (74%), systems‐based practice (69%), professionalism (87%), and interpersonal skills and communication (90%).

Most attending physicians surveyed felt BR performed well or very well with respect to teaching patient care (88%), medical knowledge (58%), professionalism (92%), and interpersonal skills and communication (95%). A minority of participants perceived BR to perform well or very well in teaching practice‐based learning (47%) or systems‐based practice (47%).

Compared with CFR, both HR and BR were perceived to be significantly more effective in teaching patient care, professionalism, and interpersonal skills and communication (Figure 1). Respondents rated BR as significantly inferior to both CFR and HR in teaching medical knowledge. In addition, BR was perceived to be inferior to HR with respect to teaching systems‐based practice and practice‐based learning.

Figure 1

DISCUSSION

In the inpatient setting, attending rounds may offer a primary means for attending physician teaching of trainees. Although all trainees are assessed by their knowledge and skills within the 6 ACGME core competencies, little attention has been paid as to how various rounding models support resident education across these domains.[4] To our knowledge, this is the first cross‐national, multicenter survey study that examines how well the 3 most commonly employed internal medicine rounding practices promote teaching of material relevant to the 6 ACGME core competencies. We found that significant heterogeneity exists in current rounding practices, and different models are perceived to perform variably in their promotion of teaching content within the educational competencies.

In general, with respect to teaching across ACGME domains, CFR were perceived to be less effective compared with HR or BR, and significantly less so in the teaching of patient care, professionalism, and interpersonal skills and communication. Yet, CFR remain widely employed and are used by 17% of attending physicians for new patients and more than 36% for old patients. The reason for their ongoing use was not assessed by our survey; however, this practice does not appear to be driven by educational objectives. The prevalence of CFR may be related to a perception of improved efficiency and a frequent preference among trainees and attending physicians to do this model of rounding. There may be other perceived benefits, including physical comfort of providers or access to the electronic health record, but these qualities were not captured in this study. To our knowledge, there are no prior studies specifically examining CFR as a rounding model.

HR was the most commonly utilized rounding method for the majority of respondents. Attending physicians considered HR particularly effective in teaching patient care, medical knowledge, professionalism, and interpersonal skills and communication. The perceived value of HR may be related to the bimodal nature of the encounter. The discussion of the patient and the care plan outside of the room may include, but is not limited to, formulating the care plan through the formal oral case presentation, focusing on the patient management component of patient care, and sharing medical knowledge without fear of provoking patient anxiety or causing confusion. Subsequently, the time spent in the room may allow for observation and instruction of the physical examination, observation and modeling of professionalism in the patient interaction, and observation and modeling of effective communication with the patient and family members.

We found it interesting that attending physicians also considered HR superior to BR in their capacity to teach practice‐based learning and systems‐based practice. This requires further exploration, as it would seem that increased patient involvement in care plans could offer advantages for the teaching of both of these competencies. Despite the popularity of this rounding structure, there is little prior evidence examining the pros and cons of HR.

Conversely, there is significant literature exploring BR as a rounding model. Prior research has elucidated the multiple benefits of bedside rounding including, but not limited to, teaching history taking, physical examination skills, and clinical ethics; modeling humanism and professionalism; and promoting effective communication.[3, 7, 8, 9, 10, 11] Furthermore, the majority of patients may prefer bedside presentations.[11, 12, 13] Despite their apparent merits, roughly half of attendings surveyed never conduct BR. This may reflect the trend reported in the literature of diminishing bedside teaching, and more specifically, reports that in the United States, less than 5% of time is spent on observing learners' clinical skills and correcting faulty exam techniques.[2, 14] The perception that HR and CFR were superior to BR in teaching medical knowledge suggests that attending physicians value the teaching that occurs away from the patient's bedside. Prior studies suggest that, of the core clinical skills taught on the wards, trainees may find teaching of differential diagnosis to be most challenged by BR, and residents may not appreciate the educational benefits of BR in general.[11, 13] Although time constraints were cited as a significant barrier to BR, recent studies have suggested that BR do not necessarily take more time overall.[15] The notion that patient psychosocial complexities may limit BR has been reflected in the literature,[16, 17, 18, 19, 20] but these situations may also afford unique bedside teaching opportunities.[21] Finally, faculty, and in particular more junior attendings, may be uncomfortable teaching in the presence of the patient.[13] This barrier may be overcome through faculty development efforts.[15]

As internal medicine training transitions to the NAS and a milestone‐based assessment framework,[1] residency programs will need to consider how rounding can be structured to help trainees achieve the required milestones, and to help programs meaningfully assess trainee performance. Our survey indicates that HR may be effective across all of the competencies and the potential for this should be further explored. Yet, HR may allow for a limited ability to observe learners with patients, as there may only be cursory data gathering from the patient, a brief physical exam, and limited communication with patients and/or family members. Furthermore, the patient‐centeredness of HR may be called into question, given restricted emphasis on shared decision making. Finally, as efficiency remains crucial in the wake of duty‐hour reform, HR may also prove to be more time consuming than BR, given that it often requires information shared outside of the patient's room to be repeated in the patient's presence. Ultimately, there may not be a 1 size fits all solution, and institutions should ensure the organization and structure of their rounding models are optimally designed to enable the achievement and assessment of ACGME milestones.

Our study has several limitations. Due to our employment of snowball sampling, we could not calculate a response rate. We also recruited a self‐selected sample of internal medicine attending physicians, raising the possibility of selection bias. However, we captured a wide range of experience and opinion, and do not have reason to believe that any particular viewpoints are over‐ or under‐represented. Further, our study may have been influenced by sampling bias, reaching primarily attending physicians at university‐affiliated medical centers, calling into question the generalizability of our results and making any comparisons between academic and community health centers less meaningful. Nonetheless, we received responses from both large and small medical centers, as well as quaternary care and community‐based hospitals. The reported benefits and barriers were respondents' personal perceptions, rather than measured outcomes. Moreover, we focused primarily on the effectiveness of teaching of the ACGME competencies and did not explore other outcomes that could be impacted by rounding structure (eg, patient satisfaction, trainee satisfaction, length of stay, time of discharge). Our study also did not address the variety of complex factors that influence the location and methods of attending rounds. For example, the various institutions surveyed have a variety of team sizes and compositions, admitting schedules, geographic layouts, and time allotted for attending rounds, all of which can influence choices for rounding practices. Finally, we did not assess resident perceptions, an area of future study that would allow us to corroborate the findings of our survey.

In conclusion, in this cross‐national, multicenter survey study of the 3 most prevalent internal medicine rounding practices, respondents utilized HR most commonly and believed this model was effective in teaching across the 6 ACGME core competencies. Those surveyed identified the benefits and barriers to BR, and a substantial number continue to use CFR despite recognizing its educational limitations. Future studies should explore factors that promote various rounding models and assess the relationship between rounding structure and educational outcomes for trainees.

Disclosure: Nothing to report.

In 1999, the Accreditation Council for Graduate Medical Education (ACGME) established the requirement for residency programs to assess trainees' competencies in 6 core domains: patient care, medical knowledge, practice‐based learning, systems‐based practice, interpersonal and communication skills, and professionalism.[1] With the rollout of the Next Accreditation System (NAS), and a focus of graduate medical education turning to the assessment of milestones within the ACGME core competencies, it is essential for clinician educators to reflect on how current educational activities meet the needs of our learners and enable compliance with the new recommendations.[1]

On internal medicine services in the inpatient setting, clinician educators routinely supervise and teach trainees during attending rounds. The long‐standing practice of rounding innately offers a forum for making patient care decisions and for sharing medical knowledge.[2] However, the rounding process may also afford clinician educators opportunities to teach material relevant to the other 4 ACGME core competencies.[3] Despite the ubiquitous presence of rounds on internal medicine services, rounding practices vary markedly among and within institutions.[4, 5] Furthermore, there is no consensus with respect to best practices for rounds in general, or more specifically as they pertain to graduate medical education and teaching within the 6 core competencies.

We have conducted a multicenter survey study of internal medicine rounding practices at academic institutions from all US regions. As part of a larger investigation of rounding practices, we surveyed attending physicians regarding the frequency with which they participated in different rounding models (card‐flipping rounds [CFR], hallway rounds [HR], or bedside rounds [BR]), and the perceived capacity of each of these models to promote teaching of material relevant to the 6 ACGME core competencies.

METHODS

RESULTS

Rounding Models and Core Competencies

Most attending physicians surveyed perceived CFR to perform well or very well for teaching medical knowledge (78%), practice‐based learning (59%), and systems‐based practice (53%). Conversely, a minority thought CFR performed well or very well with respect to teaching patient care (21%), professionalism (27%), or interpersonal skills and communication (16%).

The majority of respondents perceived HR to perform well or very well across all ACGME domains, including teaching patient care (91%), medical knowledge (87%), practice‐based learning (74%), systems‐based practice (69%), professionalism (87%), and interpersonal skills and communication (90%).

Most attending physicians surveyed felt BR performed well or very well with respect to teaching patient care (88%), medical knowledge (58%), professionalism (92%), and interpersonal skills and communication (95%). A minority of participants perceived BR to perform well or very well in teaching practice‐based learning (47%) or systems‐based practice (47%).

Compared with CFR, both HR and BR were perceived to be significantly more effective in teaching patient care, professionalism, and interpersonal skills and communication (Figure 1). Respondents rated BR as significantly inferior to both CFR and HR in teaching medical knowledge. In addition, BR was perceived to be inferior to HR with respect to teaching systems‐based practice and practice‐based learning.

Figure 1

DISCUSSION

In the inpatient setting, attending rounds may offer a primary means for attending physician teaching of trainees. Although all trainees are assessed by their knowledge and skills within the 6 ACGME core competencies, little attention has been paid as to how various rounding models support resident education across these domains.[4] To our knowledge, this is the first cross‐national, multicenter survey study that examines how well the 3 most commonly employed internal medicine rounding practices promote teaching of material relevant to the 6 ACGME core competencies. We found that significant heterogeneity exists in current rounding practices, and different models are perceived to perform variably in their promotion of teaching content within the educational competencies.

In general, with respect to teaching across ACGME domains, CFR were perceived to be less effective compared with HR or BR, and significantly less so in the teaching of patient care, professionalism, and interpersonal skills and communication. Yet, CFR remain widely employed and are used by 17% of attending physicians for new patients and more than 36% for old patients. The reason for their ongoing use was not assessed by our survey; however, this practice does not appear to be driven by educational objectives. The prevalence of CFR may be related to a perception of improved efficiency and a frequent preference among trainees and attending physicians to do this model of rounding. There may be other perceived benefits, including physical comfort of providers or access to the electronic health record, but these qualities were not captured in this study. To our knowledge, there are no prior studies specifically examining CFR as a rounding model.

HR was the most commonly utilized rounding method for the majority of respondents. Attending physicians considered HR particularly effective in teaching patient care, medical knowledge, professionalism, and interpersonal skills and communication. The perceived value of HR may be related to the bimodal nature of the encounter. The discussion of the patient and the care plan outside of the room may include, but is not limited to, formulating the care plan through the formal oral case presentation, focusing on the patient management component of patient care, and sharing medical knowledge without fear of provoking patient anxiety or causing confusion. Subsequently, the time spent in the room may allow for observation and instruction of the physical examination, observation and modeling of professionalism in the patient interaction, and observation and modeling of effective communication with the patient and family members.

We found it interesting that attending physicians also considered HR superior to BR in their capacity to teach practice‐based learning and systems‐based practice. This requires further exploration, as it would seem that increased patient involvement in care plans could offer advantages for the teaching of both of these competencies. Despite the popularity of this rounding structure, there is little prior evidence examining the pros and cons of HR.

Conversely, there is significant literature exploring BR as a rounding model. Prior research has elucidated the multiple benefits of bedside rounding including, but not limited to, teaching history taking, physical examination skills, and clinical ethics; modeling humanism and professionalism; and promoting effective communication.[3, 7, 8, 9, 10, 11] Furthermore, the majority of patients may prefer bedside presentations.[11, 12, 13] Despite their apparent merits, roughly half of attendings surveyed never conduct BR. This may reflect the trend reported in the literature of diminishing bedside teaching, and more specifically, reports that in the United States, less than 5% of time is spent on observing learners' clinical skills and correcting faulty exam techniques.[2, 14] The perception that HR and CFR were superior to BR in teaching medical knowledge suggests that attending physicians value the teaching that occurs away from the patient's bedside. Prior studies suggest that, of the core clinical skills taught on the wards, trainees may find teaching of differential diagnosis to be most challenged by BR, and residents may not appreciate the educational benefits of BR in general.[11, 13] Although time constraints were cited as a significant barrier to BR, recent studies have suggested that BR do not necessarily take more time overall.[15] The notion that patient psychosocial complexities may limit BR has been reflected in the literature,[16, 17, 18, 19, 20] but these situations may also afford unique bedside teaching opportunities.[21] Finally, faculty, and in particular more junior attendings, may be uncomfortable teaching in the presence of the patient.[13] This barrier may be overcome through faculty development efforts.[15]

As internal medicine training transitions to the NAS and a milestone‐based assessment framework,[1] residency programs will need to consider how rounding can be structured to help trainees achieve the required milestones, and to help programs meaningfully assess trainee performance. Our survey indicates that HR may be effective across all of the competencies and the potential for this should be further explored. Yet, HR may allow for a limited ability to observe learners with patients, as there may only be cursory data gathering from the patient, a brief physical exam, and limited communication with patients and/or family members. Furthermore, the patient‐centeredness of HR may be called into question, given restricted emphasis on shared decision making. Finally, as efficiency remains crucial in the wake of duty‐hour reform, HR may also prove to be more time consuming than BR, given that it often requires information shared outside of the patient's room to be repeated in the patient's presence. Ultimately, there may not be a 1 size fits all solution, and institutions should ensure the organization and structure of their rounding models are optimally designed to enable the achievement and assessment of ACGME milestones.

Our study has several limitations. Due to our employment of snowball sampling, we could not calculate a response rate. We also recruited a self‐selected sample of internal medicine attending physicians, raising the possibility of selection bias. However, we captured a wide range of experience and opinion, and do not have reason to believe that any particular viewpoints are over‐ or under‐represented. Further, our study may have been influenced by sampling bias, reaching primarily attending physicians at university‐affiliated medical centers, calling into question the generalizability of our results and making any comparisons between academic and community health centers less meaningful. Nonetheless, we received responses from both large and small medical centers, as well as quaternary care and community‐based hospitals. The reported benefits and barriers were respondents' personal perceptions, rather than measured outcomes. Moreover, we focused primarily on the effectiveness of teaching of the ACGME competencies and did not explore other outcomes that could be impacted by rounding structure (eg, patient satisfaction, trainee satisfaction, length of stay, time of discharge). Our study also did not address the variety of complex factors that influence the location and methods of attending rounds. For example, the various institutions surveyed have a variety of team sizes and compositions, admitting schedules, geographic layouts, and time allotted for attending rounds, all of which can influence choices for rounding practices. Finally, we did not assess resident perceptions, an area of future study that would allow us to corroborate the findings of our survey.

In conclusion, in this cross‐national, multicenter survey study of the 3 most prevalent internal medicine rounding practices, respondents utilized HR most commonly and believed this model was effective in teaching across the 6 ACGME core competencies. Those surveyed identified the benefits and barriers to BR, and a substantial number continue to use CFR despite recognizing its educational limitations. Future studies should explore factors that promote various rounding models and assess the relationship between rounding structure and educational outcomes for trainees.

Disclosure: Nothing to report.

In 1999, the Accreditation Council for Graduate Medical Education (ACGME) established the requirement for residency programs to assess trainees' competencies in 6 core domains: patient care, medical knowledge, practice‐based learning, systems‐based practice, interpersonal and communication skills, and professionalism.[1] With the rollout of the Next Accreditation System (NAS), and a focus of graduate medical education turning to the assessment of milestones within the ACGME core competencies, it is essential for clinician educators to reflect on how current educational activities meet the needs of our learners and enable compliance with the new recommendations.[1]

On internal medicine services in the inpatient setting, clinician educators routinely supervise and teach trainees during attending rounds. The long‐standing practice of rounding innately offers a forum for making patient care decisions and for sharing medical knowledge.[2] However, the rounding process may also afford clinician educators opportunities to teach material relevant to the other 4 ACGME core competencies.[3] Despite the ubiquitous presence of rounds on internal medicine services, rounding practices vary markedly among and within institutions.[4, 5] Furthermore, there is no consensus with respect to best practices for rounds in general, or more specifically as they pertain to graduate medical education and teaching within the 6 core competencies.

We have conducted a multicenter survey study of internal medicine rounding practices at academic institutions from all US regions. As part of a larger investigation of rounding practices, we surveyed attending physicians regarding the frequency with which they participated in different rounding models (card‐flipping rounds [CFR], hallway rounds [HR], or bedside rounds [BR]), and the perceived capacity of each of these models to promote teaching of material relevant to the 6 ACGME core competencies.

METHODS

RESULTS

Rounding Models and Core Competencies

Most attending physicians surveyed perceived CFR to perform well or very well for teaching medical knowledge (78%), practice‐based learning (59%), and systems‐based practice (53%). Conversely, a minority thought CFR performed well or very well with respect to teaching patient care (21%), professionalism (27%), or interpersonal skills and communication (16%).

The majority of respondents perceived HR to perform well or very well across all ACGME domains, including teaching patient care (91%), medical knowledge (87%), practice‐based learning (74%), systems‐based practice (69%), professionalism (87%), and interpersonal skills and communication (90%).

Most attending physicians surveyed felt BR performed well or very well with respect to teaching patient care (88%), medical knowledge (58%), professionalism (92%), and interpersonal skills and communication (95%). A minority of participants perceived BR to perform well or very well in teaching practice‐based learning (47%) or systems‐based practice (47%).

Compared with CFR, both HR and BR were perceived to be significantly more effective in teaching patient care, professionalism, and interpersonal skills and communication (Figure 1). Respondents rated BR as significantly inferior to both CFR and HR in teaching medical knowledge. In addition, BR was perceived to be inferior to HR with respect to teaching systems‐based practice and practice‐based learning.

Figure 1

DISCUSSION

In the inpatient setting, attending rounds may offer a primary means for attending physician teaching of trainees. Although all trainees are assessed by their knowledge and skills within the 6 ACGME core competencies, little attention has been paid as to how various rounding models support resident education across these domains.[4] To our knowledge, this is the first cross‐national, multicenter survey study that examines how well the 3 most commonly employed internal medicine rounding practices promote teaching of material relevant to the 6 ACGME core competencies. We found that significant heterogeneity exists in current rounding practices, and different models are perceived to perform variably in their promotion of teaching content within the educational competencies.

In general, with respect to teaching across ACGME domains, CFR were perceived to be less effective compared with HR or BR, and significantly less so in the teaching of patient care, professionalism, and interpersonal skills and communication. Yet, CFR remain widely employed and are used by 17% of attending physicians for new patients and more than 36% for old patients. The reason for their ongoing use was not assessed by our survey; however, this practice does not appear to be driven by educational objectives. The prevalence of CFR may be related to a perception of improved efficiency and a frequent preference among trainees and attending physicians to do this model of rounding. There may be other perceived benefits, including physical comfort of providers or access to the electronic health record, but these qualities were not captured in this study. To our knowledge, there are no prior studies specifically examining CFR as a rounding model.

HR was the most commonly utilized rounding method for the majority of respondents. Attending physicians considered HR particularly effective in teaching patient care, medical knowledge, professionalism, and interpersonal skills and communication. The perceived value of HR may be related to the bimodal nature of the encounter. The discussion of the patient and the care plan outside of the room may include, but is not limited to, formulating the care plan through the formal oral case presentation, focusing on the patient management component of patient care, and sharing medical knowledge without fear of provoking patient anxiety or causing confusion. Subsequently, the time spent in the room may allow for observation and instruction of the physical examination, observation and modeling of professionalism in the patient interaction, and observation and modeling of effective communication with the patient and family members.

We found it interesting that attending physicians also considered HR superior to BR in their capacity to teach practice‐based learning and systems‐based practice. This requires further exploration, as it would seem that increased patient involvement in care plans could offer advantages for the teaching of both of these competencies. Despite the popularity of this rounding structure, there is little prior evidence examining the pros and cons of HR.

Conversely, there is significant literature exploring BR as a rounding model. Prior research has elucidated the multiple benefits of bedside rounding including, but not limited to, teaching history taking, physical examination skills, and clinical ethics; modeling humanism and professionalism; and promoting effective communication.[3, 7, 8, 9, 10, 11] Furthermore, the majority of patients may prefer bedside presentations.[11, 12, 13] Despite their apparent merits, roughly half of attendings surveyed never conduct BR. This may reflect the trend reported in the literature of diminishing bedside teaching, and more specifically, reports that in the United States, less than 5% of time is spent on observing learners' clinical skills and correcting faulty exam techniques.[2, 14] The perception that HR and CFR were superior to BR in teaching medical knowledge suggests that attending physicians value the teaching that occurs away from the patient's bedside. Prior studies suggest that, of the core clinical skills taught on the wards, trainees may find teaching of differential diagnosis to be most challenged by BR, and residents may not appreciate the educational benefits of BR in general.[11, 13] Although time constraints were cited as a significant barrier to BR, recent studies have suggested that BR do not necessarily take more time overall.[15] The notion that patient psychosocial complexities may limit BR has been reflected in the literature,[16, 17, 18, 19, 20] but these situations may also afford unique bedside teaching opportunities.[21] Finally, faculty, and in particular more junior attendings, may be uncomfortable teaching in the presence of the patient.[13] This barrier may be overcome through faculty development efforts.[15]

As internal medicine training transitions to the NAS and a milestone‐based assessment framework,[1] residency programs will need to consider how rounding can be structured to help trainees achieve the required milestones, and to help programs meaningfully assess trainee performance. Our survey indicates that HR may be effective across all of the competencies and the potential for this should be further explored. Yet, HR may allow for a limited ability to observe learners with patients, as there may only be cursory data gathering from the patient, a brief physical exam, and limited communication with patients and/or family members. Furthermore, the patient‐centeredness of HR may be called into question, given restricted emphasis on shared decision making. Finally, as efficiency remains crucial in the wake of duty‐hour reform, HR may also prove to be more time consuming than BR, given that it often requires information shared outside of the patient's room to be repeated in the patient's presence. Ultimately, there may not be a 1 size fits all solution, and institutions should ensure the organization and structure of their rounding models are optimally designed to enable the achievement and assessment of ACGME milestones.

Our study has several limitations. Due to our employment of snowball sampling, we could not calculate a response rate. We also recruited a self‐selected sample of internal medicine attending physicians, raising the possibility of selection bias. However, we captured a wide range of experience and opinion, and do not have reason to believe that any particular viewpoints are over‐ or under‐represented. Further, our study may have been influenced by sampling bias, reaching primarily attending physicians at university‐affiliated medical centers, calling into question the generalizability of our results and making any comparisons between academic and community health centers less meaningful. Nonetheless, we received responses from both large and small medical centers, as well as quaternary care and community‐based hospitals. The reported benefits and barriers were respondents' personal perceptions, rather than measured outcomes. Moreover, we focused primarily on the effectiveness of teaching of the ACGME competencies and did not explore other outcomes that could be impacted by rounding structure (eg, patient satisfaction, trainee satisfaction, length of stay, time of discharge). Our study also did not address the variety of complex factors that influence the location and methods of attending rounds. For example, the various institutions surveyed have a variety of team sizes and compositions, admitting schedules, geographic layouts, and time allotted for attending rounds, all of which can influence choices for rounding practices. Finally, we did not assess resident perceptions, an area of future study that would allow us to corroborate the findings of our survey.

In conclusion, in this cross‐national, multicenter survey study of the 3 most prevalent internal medicine rounding practices, respondents utilized HR most commonly and believed this model was effective in teaching across the 6 ACGME core competencies. Those surveyed identified the benefits and barriers to BR, and a substantial number continue to use CFR despite recognizing its educational limitations. Future studies should explore factors that promote various rounding models and assess the relationship between rounding structure and educational outcomes for trainees.

Disclosure: Nothing to report.

Cirrhosis affects up to 3% of the population and is 1 of the 10 most common causes of death in the United States.[1, 2, 3, 4] Paracentesis procedures are frequently performed in patients with liver disease and ascites for diagnostic and/or therapeutic purposes. These procedures can be performed safely by trained clinicians at the bedside or referred to interventional radiology (IR).[2, 3, 4]

National practice patterns show that paracentesis procedures are increasingly referred to IR rather than performed at the bedside by internal medicine or gastroenterology clinicians.[5, 6, 7] In fact, a recent study of Medicare beneficiaries showed that inpatient and outpatient paracentesis procedures performed by radiologists increased by 964% from 1993 to 2008.[7] Reasons for the decline in bedside procedures include the increased availability of IR, lack of sufficient reimbursement, and the time required to perform paracentesis procedures.[5, 6, 7, 8] Surveys of internal medicine and family medicine residents and gastroenterology fellows show trainees often lack the confidence and experience needed to perform the procedure safely.[9, 10, 11] Additionally, many clinicians do not have expertise with ultrasound use and may not have access to necessary equipment.

Inconsistent certification requirements may also impact the competence and experience of physicians to perform paracentesis procedures. Internal medicine residents are no longer required by the American Board of Internal Medicine (ABIM) to demonstrate competency in procedures such as paracentesis for certification.[12] However, the Accreditation Council for Graduate Medical Education (ACGME) requirements state that internal medicine programs must offer residents the opportunity to demonstrate competence in the performance of procedures such as paracentesis, thoracentesis, and central venous catheter insertion.[13] The American Board of Family Medicine (ABFM) does not outline specific procedural competence for initial certification.[14] The ACGME states that family medicine residents must receive training to perform those clinical procedures required for their future practices but allows each program to determine which procedures to require.[15] Due to this uncertainty, practicing hospitalists are likely to have variable training and competence in bedside procedures such as paracentesis.

We previously showed that internal medicine residents rotating on the hepatology service of an academic medical center performed 59% of paracentesis procedures at the bedside.[16] These findings are in contrast to national data showing that 74% of paracentesis procedures performed on Medicare beneficiaries were performed by radiologists.[7] Practice patterns at university hospitals may not be reflected in this data because the study was limited to Medicare beneficiaries and included ambulatory patients.[7] In addition to uncertainty about who is performing this procedure in inpatient settings, little is known about the effect of specialty on postparacentesis clinical outcomes.[16, 17]

The current study had 3 aims: (1) evaluate which clinical specialties perform paracentesis procedures at university hospitals; (2) model patient characteristics associated with procedures performed at the bedside versus those referred to IR; and (3) among patients with a similar likelihood of IR referral, evaluate length of stay (LOS) and hospital costs of patients undergoing procedures performed by different specialties.

METHODS

We performed an observational administrative database review of patients who underwent paracentesis procedures in hospitals participating in the University HealthSystem Consortium (UHC) Clinical Database from January 2010 through December 2012. UHC is an alliance of 120 nonprofit academic medical centers and their 290 affiliated hospitals. UHC maintains databases containing clinical, operational, financial, and patient safety data from affiliated hospitals. Using the UHC database, we described the characteristics of all patients who underwent paracentesis procedures by clinical specialty performing the procedure. We then modeled the effects of patient characteristics on decision‐making about IR referral. Finally, among patients with a homogeneous predicted probability of IR referral, we compared LOS and direct costs by specialty performing the procedure. The Northwestern University institutional review board approved this study.

RESULTS

Predicted Probabilities of IR Referral

Figure 1 presents the distribution of predicted probabilities for IR referral. Predicted probabilities were low overall, with very few patients having an equal chance of referralthe standard often used in comparative effectiveness analyses from observational data. Figure 1 indicates that IR referral probabilities were clustered in an unusual bimodal distribution. The cluster on the left, which centers around a 15% predicted probability of IR referral, consists of discharges with patient characteristics that were associated with a very low chance of an IR paracentesis. We therefore used this distribution to conduct comparative analyses of admission outcomes between clinical specialty groups, choosing to examine patients with a 20% or greater chance of IR referral.

Figure 1

Post hoc analysis revealed that the biggest factor driving low predicted probability of IR referral was whether patients experienced an ICU stay at any time during hospitalization. Among the discharges with a predicted probability 0.2 (n=26,615 discharges), there were only 87 discharges with ICU stays (0.3%). For the discharges with predicted probability <0.2 (n=7676), 91.9% (n=7055) had an ICU admission. We therefore used a threshold of 0.2 or greater to present the most comparable LOS and direct cost differences.

DISCUSSION

This study showed that internal medicine‐ and family medicine‐trained clinicians perform approximately half of the inpatient paracentesis procedures at university hospitals and their affiliates. This confirms findings from our earlier single‐institution study[16] but contrasts with previously published reports involving Medicare data. The earlier report, using Medicare claims and including ambulatory procedures, revealed that primary care physicians and gastroenterologists only performed approximately 10% of US paracentesis procedures in 2008.[7] Our findings suggest that practices are different at university hospitals, where patients with severe liver disease often seek care. Because we used the UHC database, it was not possible to determine if the clinicians who performed paracentesis procedures in this study were internal medicine or family medicine residents, fellows, or attending physicians. However, findings from our own institution show that the vast majority of bedside paracentesis procedures are performed by internal medicine residents.[16]

Our findings have implications for certification of internal medicine and family medicine trainees. In 2008, the ABIM removed the requirement that internal medicine residents demonstrate competency in paracentesis.[12] This decision was informed by a lack of standardized methods to determine procedural competency and published surveys showing that internal medicine and hospitalist physicians rarely performed bedside procedures.[5, 6] Despite this policy change, our findings show that current clinical practice at university hospitals does not reflect national practice patterns or certification requirements, because many internal medicine‐ and family medicine‐trained clinicians still perform paracentesis procedures. This is concerning because internal medicine and family medicine trainees report variable confidence, experience, expertise, and supervision regarding performance of invasive procedures.[9, 10, 21, 22, 23, 24] Furthermore, earlier research also demonstrates that graduating residents and fellows are not able to competently perform common bedside procedures such as thoracentesis, temporary hemodialysis catheter insertion, and lumbar puncture.[25, 26, 27]

The American Association for the Study of Liver Diseases (AASLD) recommends that trained clinicians perform paracentesis procedures.[3, 4] However, the AASLD provides no definition for how training should occur. Because competency in this procedure is not specifically required by the ABIM, ABFM, or ACGME, a paradoxical situation occurs in which internal medicine and family medicine residents, and internal medicine‐trained fellows and faculty continue to perform paracentesis procedures on highly complex patients, but are no longer required to be competent to do so.

In earlier research we showed that simulation‐based mastery learning (SBML) was an effective method to boost internal medicine residents' paracentesis skills.[28] In SBML, all trainees must meet or exceed a minimum passing score on a simulated procedure before performing one on an actual patient.[29] This approach improves clinical care and outcomes in procedures such as central venous catheter insertion[30, 31] and advanced cardiac life support.[32] SBML‐trained residents also performed safe paracentesis procedures with shorter hospital LOS, fewer ICU transfers, and fewer blood product transfusions than IR procedures.[16] Based on the results of this study, AASLD guidelines regarding training, and our experience with SBML, we recommend that all clinicians complete paracentesis SBML training before performing procedures on patients.

Using our propensity model we identified patient characteristics that were associated with IR referral. Patients with a liver transplant were more likely to be cared for in IR. This may be due to a belief that postoperative procedures are anatomically more complex or because surgical trainees do not commonly perform this procedure. The current study confirms findings from earlier work that obese and female patients are more likely to be referred to IR.[16] IR referral of obese patients is likely to occur because paracentesis procedures are technically more difficult. We have no explanation why female patients were more likely to be referred to IR, because most decisions appear to be discretionary. Prospective studies are needed to determine evidence‐based recommendations regarding paracentesis procedure location. Patients with more comorbidities (eg, ICU stay, awaiting liver transplant, coagulation disorders) were more likely to undergo bedside procedures. The complexity of patients undergoing bedside paracentesis procedures reinforces the need for rigorous skill assessment for clinicians who perform them because complications such as intraperitoneal bleeding can be fatal.

Finally, we showed that LOS was similar but hospital direct costs were $800 to $1300 lower for patients whose paracentesis procedure was performed by medicine or gastroenterology/hepatology compared to IR. Medical subspecialties and surgery procedures were more expensive than IR, consistent with the higher LOS seen in these groups. IR procedures add costs due to facility charges for space, personnel, and equipment.[33] At our institution, the hospital cost of an IR paracentesis in 2012 was $361. If we use this figure, and assume costs are similar across university hospitals, the resultant cost savings would be $10,257,454 (for the procedure alone) if all procedures referred to IR in this 2‐year study were instead performed at the bedside. This estimate is approximate because it does not consider factors such as cost of clinician staffing models, which may differ across UHC hospitals. As hospitals look to reduce costs, potential savings due to appropriate use of bedside and IR procedures should be considered. This is especially important because there is no evidence that the extra expense of IR procedures is justified due to improved patient outcomes.

This study has several limitations. First, this was an observational study. Although the database was large, we were limited by coding accuracy and could not control for all potential confounding factors such as Model for End‐Stage Liver Disease score,[34, 35] other specific laboratory values, amount of ascites fluid removed, or bedside procedure failures later referred to IR. However, we do know that only a small number of second, third, or fourth procedures were subsequently referred to IR after earlier ones were performed at the bedside. Additionally the UHC database does not include patient‐specific data, and therefore we could not adjust for multiple visits or procedures by the same patient. Second, we were unable to determine the level of teaching involvement at each UHC affiliated hospital. Community hospitals where attendings managed most of the patients without trainees could not be differentiated from university hospitals where trainees were involved in most patients' care. Third, we did not have specialty information for 9434 (9.7%) procedures and had to exclude these cases. We also excluded a large number of paracentesis procedures in our final outcomes analysis. However, this was necessary because we needed to perform a patient‐level analysis to ensure the propensity and outcomes models were accurate. Finally, we did not evaluate inpatient mortality or 30‐day hospital readmission rates. Mortality and readmission from complications of a paracentesis procedure are rare events.[3, 4, 36] However, mortality and hospital readmission among patients with liver disease are relatively common.[37, 38] It was impossible to link these outcomes to a paracentesis procedure without the ability to perform medical records review.

In conclusion, paracentesis procedures are performed frequently by internal medicine‐ and family medicine‐trained clinicians in university hospitals. Because of these findings regarding current practice patterns, we believe the ACGME, ABIM, and ABFM should clarify their policies to require that residents are competent to perform paracentesis procedures before performing them on patients. This may improve supervision and training for paracentesis procedures that are already occurring and possibly encourage performance of additional, less costly bedside procedures.

Cirrhosis affects up to 3% of the population and is 1 of the 10 most common causes of death in the United States.[1, 2, 3, 4] Paracentesis procedures are frequently performed in patients with liver disease and ascites for diagnostic and/or therapeutic purposes. These procedures can be performed safely by trained clinicians at the bedside or referred to interventional radiology (IR).[2, 3, 4]

National practice patterns show that paracentesis procedures are increasingly referred to IR rather than performed at the bedside by internal medicine or gastroenterology clinicians.[5, 6, 7] In fact, a recent study of Medicare beneficiaries showed that inpatient and outpatient paracentesis procedures performed by radiologists increased by 964% from 1993 to 2008.[7] Reasons for the decline in bedside procedures include the increased availability of IR, lack of sufficient reimbursement, and the time required to perform paracentesis procedures.[5, 6, 7, 8] Surveys of internal medicine and family medicine residents and gastroenterology fellows show trainees often lack the confidence and experience needed to perform the procedure safely.[9, 10, 11] Additionally, many clinicians do not have expertise with ultrasound use and may not have access to necessary equipment.

Inconsistent certification requirements may also impact the competence and experience of physicians to perform paracentesis procedures. Internal medicine residents are no longer required by the American Board of Internal Medicine (ABIM) to demonstrate competency in procedures such as paracentesis for certification.[12] However, the Accreditation Council for Graduate Medical Education (ACGME) requirements state that internal medicine programs must offer residents the opportunity to demonstrate competence in the performance of procedures such as paracentesis, thoracentesis, and central venous catheter insertion.[13] The American Board of Family Medicine (ABFM) does not outline specific procedural competence for initial certification.[14] The ACGME states that family medicine residents must receive training to perform those clinical procedures required for their future practices but allows each program to determine which procedures to require.[15] Due to this uncertainty, practicing hospitalists are likely to have variable training and competence in bedside procedures such as paracentesis.

We previously showed that internal medicine residents rotating on the hepatology service of an academic medical center performed 59% of paracentesis procedures at the bedside.[16] These findings are in contrast to national data showing that 74% of paracentesis procedures performed on Medicare beneficiaries were performed by radiologists.[7] Practice patterns at university hospitals may not be reflected in this data because the study was limited to Medicare beneficiaries and included ambulatory patients.[7] In addition to uncertainty about who is performing this procedure in inpatient settings, little is known about the effect of specialty on postparacentesis clinical outcomes.[16, 17]

The current study had 3 aims: (1) evaluate which clinical specialties perform paracentesis procedures at university hospitals; (2) model patient characteristics associated with procedures performed at the bedside versus those referred to IR; and (3) among patients with a similar likelihood of IR referral, evaluate length of stay (LOS) and hospital costs of patients undergoing procedures performed by different specialties.

METHODS

We performed an observational administrative database review of patients who underwent paracentesis procedures in hospitals participating in the University HealthSystem Consortium (UHC) Clinical Database from January 2010 through December 2012. UHC is an alliance of 120 nonprofit academic medical centers and their 290 affiliated hospitals. UHC maintains databases containing clinical, operational, financial, and patient safety data from affiliated hospitals. Using the UHC database, we described the characteristics of all patients who underwent paracentesis procedures by clinical specialty performing the procedure. We then modeled the effects of patient characteristics on decision‐making about IR referral. Finally, among patients with a homogeneous predicted probability of IR referral, we compared LOS and direct costs by specialty performing the procedure. The Northwestern University institutional review board approved this study.

RESULTS

Predicted Probabilities of IR Referral

Figure 1 presents the distribution of predicted probabilities for IR referral. Predicted probabilities were low overall, with very few patients having an equal chance of referralthe standard often used in comparative effectiveness analyses from observational data. Figure 1 indicates that IR referral probabilities were clustered in an unusual bimodal distribution. The cluster on the left, which centers around a 15% predicted probability of IR referral, consists of discharges with patient characteristics that were associated with a very low chance of an IR paracentesis. We therefore used this distribution to conduct comparative analyses of admission outcomes between clinical specialty groups, choosing to examine patients with a 20% or greater chance of IR referral.

Figure 1

Post hoc analysis revealed that the biggest factor driving low predicted probability of IR referral was whether patients experienced an ICU stay at any time during hospitalization. Among the discharges with a predicted probability 0.2 (n=26,615 discharges), there were only 87 discharges with ICU stays (0.3%). For the discharges with predicted probability <0.2 (n=7676), 91.9% (n=7055) had an ICU admission. We therefore used a threshold of 0.2 or greater to present the most comparable LOS and direct cost differences.

DISCUSSION

This study showed that internal medicine‐ and family medicine‐trained clinicians perform approximately half of the inpatient paracentesis procedures at university hospitals and their affiliates. This confirms findings from our earlier single‐institution study[16] but contrasts with previously published reports involving Medicare data. The earlier report, using Medicare claims and including ambulatory procedures, revealed that primary care physicians and gastroenterologists only performed approximately 10% of US paracentesis procedures in 2008.[7] Our findings suggest that practices are different at university hospitals, where patients with severe liver disease often seek care. Because we used the UHC database, it was not possible to determine if the clinicians who performed paracentesis procedures in this study were internal medicine or family medicine residents, fellows, or attending physicians. However, findings from our own institution show that the vast majority of bedside paracentesis procedures are performed by internal medicine residents.[16]

Our findings have implications for certification of internal medicine and family medicine trainees. In 2008, the ABIM removed the requirement that internal medicine residents demonstrate competency in paracentesis.[12] This decision was informed by a lack of standardized methods to determine procedural competency and published surveys showing that internal medicine and hospitalist physicians rarely performed bedside procedures.[5, 6] Despite this policy change, our findings show that current clinical practice at university hospitals does not reflect national practice patterns or certification requirements, because many internal medicine‐ and family medicine‐trained clinicians still perform paracentesis procedures. This is concerning because internal medicine and family medicine trainees report variable confidence, experience, expertise, and supervision regarding performance of invasive procedures.[9, 10, 21, 22, 23, 24] Furthermore, earlier research also demonstrates that graduating residents and fellows are not able to competently perform common bedside procedures such as thoracentesis, temporary hemodialysis catheter insertion, and lumbar puncture.[25, 26, 27]

The American Association for the Study of Liver Diseases (AASLD) recommends that trained clinicians perform paracentesis procedures.[3, 4] However, the AASLD provides no definition for how training should occur. Because competency in this procedure is not specifically required by the ABIM, ABFM, or ACGME, a paradoxical situation occurs in which internal medicine and family medicine residents, and internal medicine‐trained fellows and faculty continue to perform paracentesis procedures on highly complex patients, but are no longer required to be competent to do so.

In earlier research we showed that simulation‐based mastery learning (SBML) was an effective method to boost internal medicine residents' paracentesis skills.[28] In SBML, all trainees must meet or exceed a minimum passing score on a simulated procedure before performing one on an actual patient.[29] This approach improves clinical care and outcomes in procedures such as central venous catheter insertion[30, 31] and advanced cardiac life support.[32] SBML‐trained residents also performed safe paracentesis procedures with shorter hospital LOS, fewer ICU transfers, and fewer blood product transfusions than IR procedures.[16] Based on the results of this study, AASLD guidelines regarding training, and our experience with SBML, we recommend that all clinicians complete paracentesis SBML training before performing procedures on patients.

Using our propensity model we identified patient characteristics that were associated with IR referral. Patients with a liver transplant were more likely to be cared for in IR. This may be due to a belief that postoperative procedures are anatomically more complex or because surgical trainees do not commonly perform this procedure. The current study confirms findings from earlier work that obese and female patients are more likely to be referred to IR.[16] IR referral of obese patients is likely to occur because paracentesis procedures are technically more difficult. We have no explanation why female patients were more likely to be referred to IR, because most decisions appear to be discretionary. Prospective studies are needed to determine evidence‐based recommendations regarding paracentesis procedure location. Patients with more comorbidities (eg, ICU stay, awaiting liver transplant, coagulation disorders) were more likely to undergo bedside procedures. The complexity of patients undergoing bedside paracentesis procedures reinforces the need for rigorous skill assessment for clinicians who perform them because complications such as intraperitoneal bleeding can be fatal.

Finally, we showed that LOS was similar but hospital direct costs were $800 to $1300 lower for patients whose paracentesis procedure was performed by medicine or gastroenterology/hepatology compared to IR. Medical subspecialties and surgery procedures were more expensive than IR, consistent with the higher LOS seen in these groups. IR procedures add costs due to facility charges for space, personnel, and equipment.[33] At our institution, the hospital cost of an IR paracentesis in 2012 was $361. If we use this figure, and assume costs are similar across university hospitals, the resultant cost savings would be $10,257,454 (for the procedure alone) if all procedures referred to IR in this 2‐year study were instead performed at the bedside. This estimate is approximate because it does not consider factors such as cost of clinician staffing models, which may differ across UHC hospitals. As hospitals look to reduce costs, potential savings due to appropriate use of bedside and IR procedures should be considered. This is especially important because there is no evidence that the extra expense of IR procedures is justified due to improved patient outcomes.

This study has several limitations. First, this was an observational study. Although the database was large, we were limited by coding accuracy and could not control for all potential confounding factors such as Model for End‐Stage Liver Disease score,[34, 35] other specific laboratory values, amount of ascites fluid removed, or bedside procedure failures later referred to IR. However, we do know that only a small number of second, third, or fourth procedures were subsequently referred to IR after earlier ones were performed at the bedside. Additionally the UHC database does not include patient‐specific data, and therefore we could not adjust for multiple visits or procedures by the same patient. Second, we were unable to determine the level of teaching involvement at each UHC affiliated hospital. Community hospitals where attendings managed most of the patients without trainees could not be differentiated from university hospitals where trainees were involved in most patients' care. Third, we did not have specialty information for 9434 (9.7%) procedures and had to exclude these cases. We also excluded a large number of paracentesis procedures in our final outcomes analysis. However, this was necessary because we needed to perform a patient‐level analysis to ensure the propensity and outcomes models were accurate. Finally, we did not evaluate inpatient mortality or 30‐day hospital readmission rates. Mortality and readmission from complications of a paracentesis procedure are rare events.[3, 4, 36] However, mortality and hospital readmission among patients with liver disease are relatively common.[37, 38] It was impossible to link these outcomes to a paracentesis procedure without the ability to perform medical records review.

In conclusion, paracentesis procedures are performed frequently by internal medicine‐ and family medicine‐trained clinicians in university hospitals. Because of these findings regarding current practice patterns, we believe the ACGME, ABIM, and ABFM should clarify their policies to require that residents are competent to perform paracentesis procedures before performing them on patients. This may improve supervision and training for paracentesis procedures that are already occurring and possibly encourage performance of additional, less costly bedside procedures.

Cirrhosis affects up to 3% of the population and is 1 of the 10 most common causes of death in the United States.[1, 2, 3, 4] Paracentesis procedures are frequently performed in patients with liver disease and ascites for diagnostic and/or therapeutic purposes. These procedures can be performed safely by trained clinicians at the bedside or referred to interventional radiology (IR).[2, 3, 4]

National practice patterns show that paracentesis procedures are increasingly referred to IR rather than performed at the bedside by internal medicine or gastroenterology clinicians.[5, 6, 7] In fact, a recent study of Medicare beneficiaries showed that inpatient and outpatient paracentesis procedures performed by radiologists increased by 964% from 1993 to 2008.[7] Reasons for the decline in bedside procedures include the increased availability of IR, lack of sufficient reimbursement, and the time required to perform paracentesis procedures.[5, 6, 7, 8] Surveys of internal medicine and family medicine residents and gastroenterology fellows show trainees often lack the confidence and experience needed to perform the procedure safely.[9, 10, 11] Additionally, many clinicians do not have expertise with ultrasound use and may not have access to necessary equipment.

Inconsistent certification requirements may also impact the competence and experience of physicians to perform paracentesis procedures. Internal medicine residents are no longer required by the American Board of Internal Medicine (ABIM) to demonstrate competency in procedures such as paracentesis for certification.[12] However, the Accreditation Council for Graduate Medical Education (ACGME) requirements state that internal medicine programs must offer residents the opportunity to demonstrate competence in the performance of procedures such as paracentesis, thoracentesis, and central venous catheter insertion.[13] The American Board of Family Medicine (ABFM) does not outline specific procedural competence for initial certification.[14] The ACGME states that family medicine residents must receive training to perform those clinical procedures required for their future practices but allows each program to determine which procedures to require.[15] Due to this uncertainty, practicing hospitalists are likely to have variable training and competence in bedside procedures such as paracentesis.

We previously showed that internal medicine residents rotating on the hepatology service of an academic medical center performed 59% of paracentesis procedures at the bedside.[16] These findings are in contrast to national data showing that 74% of paracentesis procedures performed on Medicare beneficiaries were performed by radiologists.[7] Practice patterns at university hospitals may not be reflected in this data because the study was limited to Medicare beneficiaries and included ambulatory patients.[7] In addition to uncertainty about who is performing this procedure in inpatient settings, little is known about the effect of specialty on postparacentesis clinical outcomes.[16, 17]

The current study had 3 aims: (1) evaluate which clinical specialties perform paracentesis procedures at university hospitals; (2) model patient characteristics associated with procedures performed at the bedside versus those referred to IR; and (3) among patients with a similar likelihood of IR referral, evaluate length of stay (LOS) and hospital costs of patients undergoing procedures performed by different specialties.

METHODS

We performed an observational administrative database review of patients who underwent paracentesis procedures in hospitals participating in the University HealthSystem Consortium (UHC) Clinical Database from January 2010 through December 2012. UHC is an alliance of 120 nonprofit academic medical centers and their 290 affiliated hospitals. UHC maintains databases containing clinical, operational, financial, and patient safety data from affiliated hospitals. Using the UHC database, we described the characteristics of all patients who underwent paracentesis procedures by clinical specialty performing the procedure. We then modeled the effects of patient characteristics on decision‐making about IR referral. Finally, among patients with a homogeneous predicted probability of IR referral, we compared LOS and direct costs by specialty performing the procedure. The Northwestern University institutional review board approved this study.

RESULTS

Predicted Probabilities of IR Referral

Figure 1 presents the distribution of predicted probabilities for IR referral. Predicted probabilities were low overall, with very few patients having an equal chance of referralthe standard often used in comparative effectiveness analyses from observational data. Figure 1 indicates that IR referral probabilities were clustered in an unusual bimodal distribution. The cluster on the left, which centers around a 15% predicted probability of IR referral, consists of discharges with patient characteristics that were associated with a very low chance of an IR paracentesis. We therefore used this distribution to conduct comparative analyses of admission outcomes between clinical specialty groups, choosing to examine patients with a 20% or greater chance of IR referral.

Figure 1

Post hoc analysis revealed that the biggest factor driving low predicted probability of IR referral was whether patients experienced an ICU stay at any time during hospitalization. Among the discharges with a predicted probability 0.2 (n=26,615 discharges), there were only 87 discharges with ICU stays (0.3%). For the discharges with predicted probability <0.2 (n=7676), 91.9% (n=7055) had an ICU admission. We therefore used a threshold of 0.2 or greater to present the most comparable LOS and direct cost differences.

DISCUSSION

This study showed that internal medicine‐ and family medicine‐trained clinicians perform approximately half of the inpatient paracentesis procedures at university hospitals and their affiliates. This confirms findings from our earlier single‐institution study[16] but contrasts with previously published reports involving Medicare data. The earlier report, using Medicare claims and including ambulatory procedures, revealed that primary care physicians and gastroenterologists only performed approximately 10% of US paracentesis procedures in 2008.[7] Our findings suggest that practices are different at university hospitals, where patients with severe liver disease often seek care. Because we used the UHC database, it was not possible to determine if the clinicians who performed paracentesis procedures in this study were internal medicine or family medicine residents, fellows, or attending physicians. However, findings from our own institution show that the vast majority of bedside paracentesis procedures are performed by internal medicine residents.[16]

Our findings have implications for certification of internal medicine and family medicine trainees. In 2008, the ABIM removed the requirement that internal medicine residents demonstrate competency in paracentesis.[12] This decision was informed by a lack of standardized methods to determine procedural competency and published surveys showing that internal medicine and hospitalist physicians rarely performed bedside procedures.[5, 6] Despite this policy change, our findings show that current clinical practice at university hospitals does not reflect national practice patterns or certification requirements, because many internal medicine‐ and family medicine‐trained clinicians still perform paracentesis procedures. This is concerning because internal medicine and family medicine trainees report variable confidence, experience, expertise, and supervision regarding performance of invasive procedures.[9, 10, 21, 22, 23, 24] Furthermore, earlier research also demonstrates that graduating residents and fellows are not able to competently perform common bedside procedures such as thoracentesis, temporary hemodialysis catheter insertion, and lumbar puncture.[25, 26, 27]

The American Association for the Study of Liver Diseases (AASLD) recommends that trained clinicians perform paracentesis procedures.[3, 4] However, the AASLD provides no definition for how training should occur. Because competency in this procedure is not specifically required by the ABIM, ABFM, or ACGME, a paradoxical situation occurs in which internal medicine and family medicine residents, and internal medicine‐trained fellows and faculty continue to perform paracentesis procedures on highly complex patients, but are no longer required to be competent to do so.

In earlier research we showed that simulation‐based mastery learning (SBML) was an effective method to boost internal medicine residents' paracentesis skills.[28] In SBML, all trainees must meet or exceed a minimum passing score on a simulated procedure before performing one on an actual patient.[29] This approach improves clinical care and outcomes in procedures such as central venous catheter insertion[30, 31] and advanced cardiac life support.[32] SBML‐trained residents also performed safe paracentesis procedures with shorter hospital LOS, fewer ICU transfers, and fewer blood product transfusions than IR procedures.[16] Based on the results of this study, AASLD guidelines regarding training, and our experience with SBML, we recommend that all clinicians complete paracentesis SBML training before performing procedures on patients.

Using our propensity model we identified patient characteristics that were associated with IR referral. Patients with a liver transplant were more likely to be cared for in IR. This may be due to a belief that postoperative procedures are anatomically more complex or because surgical trainees do not commonly perform this procedure. The current study confirms findings from earlier work that obese and female patients are more likely to be referred to IR.[16] IR referral of obese patients is likely to occur because paracentesis procedures are technically more difficult. We have no explanation why female patients were more likely to be referred to IR, because most decisions appear to be discretionary. Prospective studies are needed to determine evidence‐based recommendations regarding paracentesis procedure location. Patients with more comorbidities (eg, ICU stay, awaiting liver transplant, coagulation disorders) were more likely to undergo bedside procedures. The complexity of patients undergoing bedside paracentesis procedures reinforces the need for rigorous skill assessment for clinicians who perform them because complications such as intraperitoneal bleeding can be fatal.

Finally, we showed that LOS was similar but hospital direct costs were $800 to $1300 lower for patients whose paracentesis procedure was performed by medicine or gastroenterology/hepatology compared to IR. Medical subspecialties and surgery procedures were more expensive than IR, consistent with the higher LOS seen in these groups. IR procedures add costs due to facility charges for space, personnel, and equipment.[33] At our institution, the hospital cost of an IR paracentesis in 2012 was $361. If we use this figure, and assume costs are similar across university hospitals, the resultant cost savings would be $10,257,454 (for the procedure alone) if all procedures referred to IR in this 2‐year study were instead performed at the bedside. This estimate is approximate because it does not consider factors such as cost of clinician staffing models, which may differ across UHC hospitals. As hospitals look to reduce costs, potential savings due to appropriate use of bedside and IR procedures should be considered. This is especially important because there is no evidence that the extra expense of IR procedures is justified due to improved patient outcomes.

This study has several limitations. First, this was an observational study. Although the database was large, we were limited by coding accuracy and could not control for all potential confounding factors such as Model for End‐Stage Liver Disease score,[34, 35] other specific laboratory values, amount of ascites fluid removed, or bedside procedure failures later referred to IR. However, we do know that only a small number of second, third, or fourth procedures were subsequently referred to IR after earlier ones were performed at the bedside. Additionally the UHC database does not include patient‐specific data, and therefore we could not adjust for multiple visits or procedures by the same patient. Second, we were unable to determine the level of teaching involvement at each UHC affiliated hospital. Community hospitals where attendings managed most of the patients without trainees could not be differentiated from university hospitals where trainees were involved in most patients' care. Third, we did not have specialty information for 9434 (9.7%) procedures and had to exclude these cases. We also excluded a large number of paracentesis procedures in our final outcomes analysis. However, this was necessary because we needed to perform a patient‐level analysis to ensure the propensity and outcomes models were accurate. Finally, we did not evaluate inpatient mortality or 30‐day hospital readmission rates. Mortality and readmission from complications of a paracentesis procedure are rare events.[3, 4, 36] However, mortality and hospital readmission among patients with liver disease are relatively common.[37, 38] It was impossible to link these outcomes to a paracentesis procedure without the ability to perform medical records review.

In conclusion, paracentesis procedures are performed frequently by internal medicine‐ and family medicine‐trained clinicians in university hospitals. Because of these findings regarding current practice patterns, we believe the ACGME, ABIM, and ABFM should clarify their policies to require that residents are competent to perform paracentesis procedures before performing them on patients. This may improve supervision and training for paracentesis procedures that are already occurring and possibly encourage performance of additional, less costly bedside procedures.