Jensa C. Morris, MD: Oncology Hospitalist Co-Management May Be Linked to Efficient, High-Quality Care and Education
2022 ASCO Quality Care Symposium
Jensa C. Morris, MD, of the Yale School of Medicine, Smilow Hospitalist Service, discusses her findings on the benefits of hospitalist co-management of patients with cancer: It reduced the length of hospital stay by 1 day, increased early discharge (before 11:00 AM) by threefold; raised the educational rankings of house staff, and lowered oncologists’ stress level, improving their ability to manage competing responsibilities (Abstract 1).
Disclaimer: This video transcript has not been proofread or edited and may contain errors.
The Smilow Hospitalist program was born out of necessity at Yale New Haven Hospital on the Smilow inpatient cancer units. We had a problem. We had very long lengths of stay. We had high readmission rates, and most importantly, we had really high rates of burnout among our clinicians. There was a lot of dissatisfaction and distress among the oncology nurses and physicians. It seems that the problem was that our oncologists were stretched in way too many different directions. Our oncologists were responsible for teaching the fellows, the residents. They were responsible for clinics. They had huge ambulatory practices that demanded their attention. Administrative tasks, labs, research. Inpatient practice was really only a very small part of what our oncologists do in a day. The oncologists do really only four weeks a year of inpatient time, and during that time, they have no reprieve from their other responsibilities.
Now we know that hospitalists, hospitalists are the experts in inpatient care. Hospitalists are hired for that one single reason, is to take care of inpatients. We built a business model to incorporate hospitalists into our inpatient oncology units at Smilow. The business plan was approved in a stepwise fashion, meaning that in the first year of the business plan, we could only incorporate hospitalists in one of two of our oncology services. Actually, that set up a natural experiment. We were able to compare the outcomes from the traditional service, the oncologist-led service, with the hospitalist-led service. We were able to look at quality outcomes and efficiency of care outcomes between the two groups. On the hospitalist side, the hospitalist was the attending, was in the hospital 7:00 AM to 7:00 PM seven days a week, the team was staffed by house staff with overflow to advanced practice providers. On the traditional service, the oncologist was the attendee of record, rounded in the morning, and then attended to all their other responsibilities during the day. The staffing was the same. House staff and advanced practice providers and patients were randomly distributed to the two teams.
After six months of the program, we assessed our results. What we found was that length of stay on the hospitalist model was a full day shorter than on the traditional model. Length of stay was 5.4 days on the hospitalist service as compared to 6.4 days on the traditional service. Furthermore, we saw that efficiency of care was improved on the hospitalist service with about 6% of patients getting discharged before 11:00 AM as compared to 2% on the traditional model. We looked at volume of patients seen.
There was a statistically significant increase in the number of patients seen by the hospitalist service as compared to the traditional service, 400 versus 313 patients seen in the same time period and no difference in readmissions. We also looked at what was the impact on education for the residents. What was the impact on the oncologist experience? Overall, both the residents and the oncologists were very pleased with the program. The next step is that the business plan has now been approved to expand, to integrate hospitalists into both services as of July, 2022. Our only concern at this point is to be sure that we are mentoring the next generation of oncologists. We hope that we are inspiring and role modeling so that our current residents will choose oncology as a specialty in the future.
Joannie M. Ivory, MD, MSPH, of The University of North Carolina at Chapel Hill, discusses ways to raise the number of Black patients with cancer who take part in clinical trials. More successful accrual may be linked to conducting trials where Black patients live and designing studies to recruit a concrete target percentage of marginalized populations.
Dawn L. Hershman, MD, of Columbia University College of Physicians and Surgeons, discusses findings that showed substantial variability in clinicians’ adherence to prescribing primary prophylactic colony stimulating factors in a pragmatic trial. Although the ability to opt out of the intervention is a feature of pragmatic trials, careful prestudy planning to estimate nonadherence is critical to ensure adequate power to detect an effect. Understanding reasons for intervention opt-outs may also inform future pragmatic studies aimed at improving adherence to practice guidelines.
Changchuan Jiang, MD, MPH, of Roswell Park Comprehensive Cancer Center, discusses the lack of transportation as a potentially modifiable barrier to care for patients with cancer. Timely intervention may reduce visits to hospital emergency departments, lower costs, and improve outcomes (Abstract 70).
Sandra L. Wong, MD, of the Dartmouth-Hitchcock Medical Center, discusses her study findings showing that when patients with cancer who have had surgery reported severe symptoms via an electronic patient-reported outcomes questionnaire at six cancer centers, it appeared to be beneficial without overtaxing clinicians. There were few strong predictors of severe symptoms, which suggests population surveillance may be preferable to targeted surveillance (Abstract 243).
S. M. Qasim Hussaini, MD, of the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, discusses findings from a nationwide study of the association between living in areas with discriminatory mortgage practices from the 1930s with present-day access to quality colon cancer care. The study underscores the importance of state- and federal-level practices on mortgage lending regulation and fair housing practices in determining equitable cancer risk, access to care, and outcomes (Abstract 69).