Invited Article: Is it time for neurohospitalists?

What is a neurology hospitalist?

No standard definition for neurology hospitalists or neurohospitalists exists. We derive our definition for a neurology hospitalist or neurohospitalist from previous definitions for “hospitalist neurology”¹⁰ and internal medicine hospitalists.¹¹ Therefore, we define neurohospitalists as 1) hospital-based neurology specialists who devote at least 25% of their cumulative time to inpatient neurology practice; and 2) neurology specialists whose subspecialty interest is inpatient neurology. Therefore, not every attending physician who rotates on the hospital ward service qualifies as a neurohospitalist, lacking either sufficient cumulative time in the hospital or subspecialty interest in hospital neurology-specific diseases. Before this definition, neurohospitalists described themselves as “stroke neurologists,” “general neurologists,” or “hospital neurologists.” It is also important to note the distinction between hospitalists, which refers generally to inpatient-specific specialists such as pediatric or internal medicine hospitalists, whereas neurohospitalists are hospitalists who specifically manage inpatients with neurologic disease. Further, neurohospitalists are free of outpatient responsibilities during their inpatient time and are specialists who are “site specific,” similar to intensivists. Some neurohospitalists devote 75% to 100% of their time in the hospital and spend their remaining time in administrative, clinical, research, or educational pursuits. Like other medical hospitalists,¹² neurology hospitalists admit patients who are transferred from the clinic or directly from the ED and later dismiss them back to the care of their clinic physicians.

The specific details of a neurology hospitalist practice vary by location and institution. Some neurohospitalists act as the inpatient stroke neurologist, the inpatient neurology attending physician, or as the neurology consultant to the hospital services, intensive care unit, and ED. Others work as a dual-trained neurohospitalist–neurointensivist.

How many neurology hospitalists currently practice?

The precise number of neurohospitalists is unknown. However, the same health care issues that led to the explosive growth of medical and pediatric hospitalists are fueling the growth of neurology hospitalists.^7,10,11,13 The number of medical and pediatric hospitalists grew from 8,000 in 2004 to 10,000 in 2006 and is estimated to reach 25,000 in 2010^7,13,14 (figure). Medical and pediatric hospitalists formed the Society of Hospital Medicine,¹³ which has more than 15,000 members. Given the growth of medical and pediatric hospitalists, the future appears promising for neurology hospitalists; however, we found only limited data estimating the current number of neurology hospitalists. Dendrite, the American Academy of Neurology classified advertisement Web site, listed one neurology hospitalist position in 2005, three in 2006, and six in 2007.³⁹ Only one neurology hospitalist fellowship has been listed³⁹; it was started in 2003 and continues in 2007. Part of the difficulty of determining the true number of neurohospitalists is explained by differences in terminology; as detailed above, we found that many neurology hospitalists described themselves as “stroke neurologists” or “neurointensivists.” The absence of a central organizational affiliation also made it difficult to precisely determine the number of neurohospitalists.

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Figure Growth of hospital medicine in the United States

From the Society of Hospital Medicine (home page on the Internet) (cited May 22, 2007). Philadelphia: Society of Hospital Medicine; © 2007. Available at: http://www.hospitalmedicine.org/Content/NavigationMenu/Media/GrowthofHospitalMedicineNationwide/Growth_of_Hospital_M.htm. Used with permission.

What are potential advantages of neurology hospitalists?

The table lists the potential advantages and disadvantages of neurohospitalists; these were inferred from the medical or pediatric hospitalist literature. The most commonly cited value of a neurology hospitalist is improved efficiency of inpatient care. Neurologists in private practice often provide services to multiple hospitals, some of which may be distant from the primary office. Such a division of duties is inefficient because time must be spent traveling, and patient care may be compromised if travel delays are incurred in emergency situations. Furthermore, escalating fuel costs and multiple trips to the same hospital must be considered, and the office practice may be disrupted by the unpredictable demands of hospital practice.

A dedicated hospitalist addresses many of these problems. Travel time between the hospital and clinic is reduced and allows the hospitalist to be immediately available for emergency care and consultations. This allows the other office-based members of the group to concentrate on providing uninterrupted outpatient services and to perform procedures (e.g., electromyography, encephalography). Another benefit of the hospitalist is the ability to treat more neurology patients in the ED. The increased burden on the primary care physician, now charged by managed care providers as the outpatient “gatekeeper” of the health care process, has resulted in the increasing referral of patients to the ED.¹ Medicare and managed care strive to provide cost-effective care, minimize out-of-network services or medications, and provide acute care costs incurred by either ED or inpatient evaluations.⁴⁰ Assigning an inpatient neurologist to cover the ED allows expeditious consultations for urgent cases, especially tPA administration, and possibly results in more standardized care, decreased length of stay, and improved quality and patient safety. Most neurology hospitalists are trained in stroke and cerebrovascular events, critical care neurology (neurointensive care), and general neurology, whereas others are trained in internal medicine and neurology.⁷

Improved education of neurology residents is another potential benefit of the neurology hospitalist. Medical and pediatric hospitalist expertise is based on experience in acute care, ability to navigate inpatient resources and implement quality measures,⁴¹ and close work with case managers.^15–17 It is our experience that neurohospitalists provide similar expertise as medical and pediatric hospitalists in acute care and inpatient resource utilization. Training requirements and core competencies have been proposed for neurology,⁹ medicine,^17–19,21 and pediatric hospitalists^16,20 to fill training gaps of traditional residency programs. Neurohospitalist subspecialty fellowship education also has been proposed recently,^8,9 and one such program was established in 2003³⁹ and exists in 2007. Specific education competencies proposed by pediatric and medical hospitalists could be considered for neurohospitalists and include health economics, quality improvement, communication skills, continuity of care, palliative care, and end-of-life issues.^17,21,22 Although most neurology residency programs in the United States require several months of service in an inpatient neurology ward, many do not have dedicated neurology hospitalists. Instead, attending physicians who spend only part of their time at the hospital supervise residents.

Neurology hospitalists can conduct research on neurologic diseases that are specific to the inpatient population. Research topics include emergency and critical care neurology, cerebrovascular or stroke neurology, seizures and status epilepticus, outcomes research, neurologic complications of HIV infection, bone marrow, solid-organ transplantation, and general medical and surgical disease.¹⁰ Other areas of research include headache (e.g., intractable headache) and neuromuscular disease (e.g., myasthenic crisis and critical illness neuropathy/myopathy).¹⁰ Cerebrovascular or stroke neurology is the most active area of inpatient research; studies are conducted by stroke neurologists, ward (attending) physicians, general neurologists, neurohospitalists, and neurointensivists. Neurology hospitalists may also meet the growing need for quality improvement and patient safety research reported by general hospitalists.⁴²

Without hospitalists, physicians have increased risk of poor performance and burnout from stress, sleep deprivation, and lost family time if they simultaneously provide outpatient care, inpatient care, and emergency hospital consultations and have overnight on-call responsibilities.⁴³ Additionally, outpatient neurologists have no financial incentive to perform inpatient consultations. In fact, increased litigation risk may be associated with evaluation of patients with acute stroke and determining eligibility for therapy with tPA.^1,2,5 Increasing litigation and malpractice premiums and concurrent dwindling reimbursement rates for acute stroke care has caused many neurologists to cease providing hospital services. Others have demanded additional “stroke-call” reimbursement from hospitals.^1,2,5

What are the challenges of implementing a neurology hospitalist practice?

The biggest challenge of implementing a neurology hospitalist model is financial. Many patients who seek care in the inpatient and ED setting are uninsured. Who is responsible if the neurohospitalist’s revenue is insufficient to support the income and overhead costs? Considering the advantages of a dedicated hospitalist, some larger neurology practices (academic and nonacademic) and hospitals subsidize their neurohospitalists to ensure neurology coverage for the ED. Other institutions hire medical hospitalists to admit patients for neurologists, alleviate overburdened resident hospital staff, or reduce Accreditation Council for Graduate Medical Education resident duty hours.⁸ The median income for medicine hospitalists according to a 2005–2006 Society of Hospital Medicine executive survey was $160,000 to $180,000, depending on geographic region.⁴⁴ However, rather than being primary revenue generators, hospitalists decrease hospital costs by reducing length of stay. By minimizing distractions to the outpatient practice, the hospitalist allows the outpatient revenue stream to be uninterrupted.

Obviously, not all practices and institutions may be willing or able to afford a neurohospitalist because of the limited number of neurohospitalists or because of small hospital or ED call volumes. Solo, small, or rural neurology practices often try to provide outpatient and inpatient consultations by going to the hospital at the middle or end of the day.⁵ These small practices may not have enough inpatient volume (i.e., ED and hospital consultations) to justify support of a neurohospitalist’s salary and benefits.²³ However, practices in large cities may have several neurohospitalists providing continual hospital coverage (24 hours/day, 365 days/year) while maintaining a large neurology outpatient practice.⁷ For neurology practices that cover one hospital that is far away (or cover multiple hospitals simultaneously), the expenses (salary and benefits) associated with hiring a neurohospitalist may offset lost clinic revenue attributable to time spent driving to and from the hospital. For example, in the scenario described at the beginning of this report, the neurologist canceled his outpatient clinic patients to see one patient at the hospital and likely received less reimbursement than he would have received by doing several outpatient consultations. For detailed information about hiring costs,⁴⁴ hospitalist revenue, and hospitalist staffing logisitics,²³ the reader is referred to several useful references^{11,12,14,23,44}; data are also available for neurohospitalists.^7,39

Another challenge encountered by the internal medicine hospitalist model is the discontinuity of care and its effects on the primary care doctor–patient relationship.^24–27 This may be mitigated by the hospitalist’s experience managing inpatients⁴⁵ and by maximizing the amount of time that hospitalists may dedicate to their inpatients. Hospitalists can meet with other consultants, patients, and families, and they may respond to abnormal laboratory and radiographic findings or to changes in patient status more rapidly because they are located in the hospital.⁴⁶ However, communication may be poor between the hospitalist and the primary care physician.^28,29 Other concerns include patient satisfaction, cost-shifting between inpatient and outpatient practices, and decreased resident autonomy because of more supervision by a hospitalist.^7,16,30–33 These issues may also be encountered by neurohospitalists caring for patients with neurologic disease in the inpatient setting who later return to see their primary neurologist and internist in the clinic setting.

What effect does a neurology hospitalist have on patient outcomes?

Nationally, the momentum is growing for improved quality and pay for performance that is based on quality indicators.^42,47,48 Neurohospitalist expertise provides benefits similar to those reported by other hospitalists,^30,31,34 which include reducing length of stay and inpatient costs and improving clinical outcomes and patient satisfaction.

Although we found no studies that directly reported advantages of a neurology hospitalist, some advantages could be inferred from the medical literature. The strength of medical and pediatric hospitalists resides in the provision of efficient inpatient care (derived from considerable experience), unlike the intermittent care that may be provided by physicians who are primarily based in a clinic.^{10,30,35,36,49} Examples from the hospitalist literature include proficient use of hospital resources such as case managers,¹⁵ reduction of preventable complications such as deep vein thrombosis, and improved compliance with best practice standards (e.g., testing of lipid profile in stroke patients) by both stroke neurologists⁴¹ and hospitalists.³⁷ Several studies showed pediatric and internal medicine hospitalists reducing the total cost of care by 13.4% and reducing the length of stay by as much as 16.6%.^6,16,31 However, reduction in length of stay and reduced total cost of care only reached statistical significance during the hospitalists’ second year of service, which suggests that experience is crucial for efficient delivery of care.^30,36 Another study showed that hospitalists shorten the length of stay but accrue higher costs per day, which indicates that hospitalists may provide more intense treatment during the shorter stay.³⁸ Other studies suggest similar or improved patient outcomes when compared with those of patients managed by physicians who were not hospitalists.^30,36 There are no studies to date specifically about neurohospitalists and patient outcomes although the terms neurology hospitalist and neurohospitalist are relatively new. The area of research for neurology hospitalists appears to be ripe, based on the amount of other hospitalist research produced in the past decade.^{30,31,33,34,36,38}