13
This article was downloaded by: [Lulea University of Technology] On: 15 September 2013, At: 10:06 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Gerontology & Geriatrics Education Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wgge20 “Geriatricizing” Hospitalists: Identifying Educational Opportunities Susan M. Friedman a , Suzanne M. Gillespie a , Annette M. Medina- Walpole a , Thomas V. Caprio a , Jurgis Karuza a & Robert M. McCann a a Division of Geriatrics/Aging, Department of Medicine , University of Rochester School of Medicine and Dentistry , Rochester , New York , USA Accepted author version posted online: 03 Jul 2013.Published online: 25 Aug 2013. To cite this article: Susan M. Friedman , Suzanne M. Gillespie , Annette M. Medina-Walpole , Thomas V. Caprio , Jurgis Karuza & Robert M. McCann , Gerontology & Geriatrics Education (2013): “Geriatricizing” Hospitalists: Identifying Educational Opportunities, Gerontology & Geriatrics Education, DOI: 10.1080/02701960.2013.819802 To link to this article: http://dx.doi.org/10.1080/02701960.2013.819802 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms- and-conditions

“Geriatricizing” Hospitalists: Identifying Educational Opportunities

Embed Size (px)

Citation preview

This article was downloaded by: [Lulea University of Technology]On: 15 September 2013, At: 10:06Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Gerontology & Geriatrics EducationPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/wgge20

“Geriatricizing” Hospitalists: IdentifyingEducational OpportunitiesSusan M. Friedman a , Suzanne M. Gillespie a , Annette M. Medina-Walpole a , Thomas V. Caprio a , Jurgis Karuza a & Robert M. McCanna

a Division of Geriatrics/Aging, Department of Medicine , Universityof Rochester School of Medicine and Dentistry , Rochester , NewYork , USAAccepted author version posted online: 03 Jul 2013.Publishedonline: 25 Aug 2013.

To cite this article: Susan M. Friedman , Suzanne M. Gillespie , Annette M. Medina-Walpole ,Thomas V. Caprio , Jurgis Karuza & Robert M. McCann , Gerontology & Geriatrics Education (2013):“Geriatricizing” Hospitalists: Identifying Educational Opportunities, Gerontology & GeriatricsEducation, DOI: 10.1080/02701960.2013.819802

To link to this article: http://dx.doi.org/10.1080/02701960.2013.819802

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Gerontology & Geriatrics Education, 00:1–12, 2013Copyright © Taylor & Francis Group, LLCISSN: 0270-1960 print/1545-3847 onlineDOI: 10.1080/02701960.2013.819802

“Geriatricizing” Hospitalists: IdentifyingEducational Opportunities

SUSAN M. FRIEDMAN, SUZANNE M. GILLESPIE, ANNETTE M.MEDINA-WALPOLE, THOMAS V. CAPRIO, JURGIS KARUZA, and

ROBERT M. McCANNDivision of Geriatrics/Aging, Department of Medicine, University of Rochester School of

Medicine and Dentistry, Rochester, New York, USA

The objective of this study was to identify differences betweengeriatricians and hospitalists in caring for hospitalized olderadults, so as to inform faculty development programs that havethe goal of improving older patient care. Eleven hospitalists and13 geriatricians were surveyed regarding knowledge, confidence,and practice patterns in caring for hospitalized older adults,targeting areas previously defined as central to taking care ofolder hospitalized patients. Overall, geriatricians had more confi-dence and more knowledge in caring for older hospitalized adults.The areas in which hospitalists expressed the least confidencewere in caring for patients with dementia, self-care issues, andcare planning. Geriatricians reported more routine medicationreviews, functional and cognitive assessments, and fall evalua-tions. Geriatricians and hospitalists differ in their approach to olderadults. Where these differences reflect lack of knowledge or experi-ence, they set the stage for developing curricula to help narrow thesegaps.

KEYWORDS curriculum, faculty development, older adults

The authors would like to thank Julie Hutchison for her help and expertise inadministering and collating the survey.

Address correspondence to Susan M. Friedman, Division of Geriatrics/Aging, Departmentof Medicine, University of Rochester School of Medicine and Dentistry, 1000 South Avenue,Box 58, Rochester, NY 14620, USA. E-mail: [email protected]

1

Dow

nloa

ded

by [

Lul

ea U

nive

rsity

of

Tec

hnol

ogy]

at 1

0:06

15

Sept

embe

r 20

13

2 S. M. Friedman et al.

INTRODUCTION

Although adults older than age 65 represent 13% of the population in theUnited States (Werner, 2011), they account for 43% of hospital days (Hall,DeFrances, Williams, Golosinskiy, & Schwartzman, 2010). Older patientsoften have longer lengths of stay (Hall et al., 2010) and poorer outcomes(Gillick, Serrell, & Gillick, 1982; Thomas & Brennan, 2000) at higher coststhan their younger counterparts. Vulnerable older adults are at risk formany adverse consequences of hospitalization, such as functional decline(Covinsky et al., 2003; Inouye et al., 1993b), delirium (Inouye, 1998; Inouye,Viscoli, Horwitz, Hurst, & Tinetti, 1993a), iatrogenic events including adversedrug events (Gray, Sager, Lestico, & Jalaluddin, 1998), and readmissions(Jencks, Williams, & Coleman, 2009).

Increasingly, hospitalized patients are being cared for by hospitalists,rather than by primary care physicians. Currently, it is estimated that31,000 hospitalists are practicing in the United States, and that number israpidly growing. Hospitalists practice in 3,300 hospitals nationwide and in80% of hospitals with more than 200 beds (Shank, 2010). The majority ofhospitalists are trained in internal medicine. Understanding how hospitalistsapproach the care of older adults is therefore a critical step in optimizingquality of care. Hospitalists’ knowledge, attitudes, and behaviors related tothe care of older adults are also important to their role as educators of healthprofessional trainees, patients and caregivers. Tanner et al. (2006) describedfrustration and low levels of comfort among nongeriatricians compared togeriatricians in caring for older adults.

Geriatricians focus their practice on the care of older adults. Of thosewho complete a fellowship, 82% previously completed an internal medicineresidency, and 17% previously completed family medicine training. Eightypercent of fellowship-trained geriatricians obtain a Certificate of AddedQualifications in Geriatrics (Medina-Walpole et al., 2002).

It has been demonstrated that adherence to quality hospital indica-tors for general medical care is better than for geriatric-specific care (Aroraet al., 2007). It has also been shown that geriatricians have different practicepatterns than generalists with respect to prescribing habits and assess-ment of geriatric syndromes in an outpatient setting (Phelan, Genshaft,Williams, LoGerfo, & Wagner, 2008). What is less clear is whether, and how,geriatricians and hospitalists differ in their approach to care of hospitalizedolder adults. The purpose of the study is to survey practicing geriatricians andhospitalists to identify self-reported specific gaps in knowledge, confidence,and practice. This data will be useful in informing faculty developmentprograms such as have been developed at other sites (Christmas, Park,Schmaltz, Gozu, & Durso, 2008; Mazotti et al., 2010; Podrazik et al.,2008).

Dow

nloa

ded

by [

Lul

ea U

nive

rsity

of

Tec

hnol

ogy]

at 1

0:06

15

Sept

embe

r 20

13

“Geriatricizing” Hospitalists 3

METHOD

The Donald W. Reynolds Foundation and Highland Hospital providedfunding to develop a comprehensive, evidence-based educational programintegrating elements of high-quality geriatric hospital care into the daily prac-tice of the hospitalist group at Highland Hospital in Rochester, New York.In preparation for that effort, a baseline survey was developed to assess dif-ferences between geriatricians and hospitalists with respect to confidence,knowledge, and self-reported practice of geriatric skills.

Development of the Survey

The survey was developed by faculty of the Division of Geriatrics/Agingat the University of Rochester, based on a framework of assessing knowl-edge, confidence, and skills related to the care of hospitalized older adults.Care domains included were identified by geriatrics faculty input, publishedminimum geriatric competencies for internal medicine and family medicineresidents, and a review of the literature on geriatric education for hospital-based physicians (Podrazik et al., 2008). A modified Delphi approach wasused to develop questions regarding attitudes and practice patterns. Six of theReynolds faculty participated in this process, including five content expertsand one methodology expert.

Fourteen questions targeted physician confidence in key areas relatedto care of the hospitalized older adult: identifying frail and vulnerable olderadults, preventing hazards of hospitalization, addressing palliative care needsand end-of-life issues, and improving transitions of care, as these domainswere consistent with those previously described as central learning needsin the Care of the Hospitalized Aging Medical Patient (CHAMP) curriculum(Podrazik et al., 2008). Physicians rated their confidence on a 7-point unipo-lar scale, anchored by 1 (not at all confident) and 7 (very confident) (Table 1,Cronbach’s alpha = 0.98).

The 17 multiple-choice knowledge questions were used with permissionfrom the CHAMP program knowledge test for hospitalists. Questions targetedissues faced by hospitalists and incorporated the domains of focus in theCHAMP curriculum (Table 2, Cronbach’s alpha = .28).

Twelve questions queried self-report of geriatrics practice patterns andattitudes, using a 7-point Likert-type scale, ranging from 1 (completely dis-agree) to 7 (completely agree) (Table 3). Some questions were adapted froma previously published scale (Reuben, et al., 1998).

Survey Participants

Highland Hospital is a 261-bed community hospital affiliated with theUniversity of Rochester. The hospital employs 11 full-time hospitalists who

Dow

nloa

ded

by [

Lul

ea U

nive

rsity

of

Tec

hnol

ogy]

at 1

0:06

15

Sept

embe

r 20

13

4 S. M. Friedman et al.

TABLE 1 Percent With High Level of Confidence in Specific Competencies in Caring ForHospitalized Older Adultsa

Question Hospitalists Geriatricians Significance

Identifying frail and vulnerable older adultsConducting family meetings 45.5 92.3 ∗

Prioritizing medical care in frail patientswith multiple comorbidities

45.5 92.3 ∗

Determining who is at risk for functionaldecline

36.4 92.3 ∗∗

Preventing hazards of hospitalizationIdentifying meds to be avoided in older

adults54.5 76.9

Perform initial delirium workup 36.4 84.6 ∗

Identify factors which increase a patient’sfall risk

27.3 69.2 ∗

Differentiate delirium, dementia anddepression

27.3 84.6 ∗

Assessing/managing pain in dementia 18.2 84.6 ∗∗

Develop treatment plan for patients withdementia and agitation

18.2 76.9 ∗∗

Addressing palliative care and end-of-life issuesIdentifying patients appropriate for hospice 63.6 92.3Discussing goals of care based on

prognosis/function45.5 92.3 ∗

Improving transitions of careDevelop care plan with interdisciplinary

team40.0 84.6 ∗

Assess patients’ ability to care forthemselves

27.3 53.8

Assessing adequacy of social support /living arrangements for dischargeplanning

18.2 69.2 ∗

aRated 6 or 7 on a Likert-type scale (1–7), with 1 (not at all confident) and 7 (very confident). Hospitalists:n = 11 (n = 10 for question re developing a care plan with an interdisciplinary team due to one notanswering this question); Geriatricians: n = 13.Groups are compared via chi-squared and Fisher’s exact where appropriate, df = 1.∗p < .05, ∗∗p < .01.

provide care to more than 3,300 patients a year who are older than age 70.These hospitalists also provide clinical teaching to 93 internal medicine and28 family medicine residents, and approximately 104 medical students.

The hospitalists have all completed internal medicine residencies(Table 4). Six of the hospitalists were age 30 to 39, two were 40 to 49, andthree were 50 to 59. Seventy-three percent were men. Experience rangedfrom 1 to 26 years of practice, with a median of 8 years. Two had addi-tional board certification in palliative care. One had fellowship training inpulmonary medicine.

Thirteen University of Rochester faculty members from the Division ofGeriatrics and Aging whose clinical practice included care of the hospitalized

Dow

nloa

ded

by [

Lul

ea U

nive

rsity

of

Tec

hnol

ogy]

at 1

0:06

15

Sept

embe

r 20

13

“Geriatricizing” Hospitalists 5

TABLE 2 Knowledge of Specific Geriatric Topics

Topic of question Hospitalists Geriatricians Significance

Systems approaches to delirium prevention 100.0 100.0 −Age-related physiologic changes and

medications100.0 100.0 −

Pain management 100.0 92.3Dementia and feeding tubes 90.9 92.3Decision making capacity 90.9 100.0Pain assessment in older adults with

dementia81.8 92.3

Analgesic dosing 81.8 92.3Diagnosing dementia 81.8 84.6Pressure wound management 72.7 84.6Gait, assistive devices 72.7 69.2Predictors of hospitalization 72.7 69.2Sites of rehabilitation 45.5 92.3 ∗

Instrumental activities of daily living 45.5 76.9Outcomes of bed rest 45.5 76.9Predictors of falls 45.5 53.8Diagnosing delirium 36.4 92.3 ∗∗

Cardiopulmonary resuscitation survival 27.3 53.8

Hospitalists: n = 11; Geriatricians: n = 13.Groups are compared via chi-squared and Fisher’s exact where appropriate, df = 1.— Unable to calculate due to each variable not having two levels.∗p < .05, ∗∗p < .01.

older adult were asked to serve as the comparison group. The geriatricsfaculty all serve as teachers for the Reynolds Foundation initiative. They hadbeen in practice a median of 12 years. One completed a family medicineresidency, and the rest were trained in internal medicine. Two thirds weregeriatrics fellowship trained, and 84.6% were board certified in geriatrics.Seven of the 13 had board certification in palliative care, although nonecompleted a fellowship. There is substantial variability in the amount of timethat the geriatrics faculty spends in hospital care, but none provides hospitalcare full time. Fewer than one half had outpatient practices.

Analysis

Comparisons were made between geriatricians and hospitalists. For thequestions addressing confidence and practice patterns, the percent with aconfidence level of 6 or 7 (i.e., a high level of confidence) and the percentwith a level of agreement of 6 or 7 (i.e., a high level of agreement withpractice patterns or values) was reported. Chi-squared and Fisher’s exacttests (df = 1) were used to compare the groups where appropriate. For theknowledge questions, mean percent correct was calculated for each group,with significance between the two groups determined via t test. The per-cent correct for each question was assessed for the hospitalists and thegeriatricians separately, as well as the group overall. Differences between

Dow

nloa

ded

by [

Lul

ea U

nive

rsity

of

Tec

hnol

ogy]

at 1

0:06

15

Sept

embe

r 20

13

6 S. M. Friedman et al.

TABLE 3 Percent of Geriatricians and Hospitalists With a High Level of Agreement WithSelf-Reported Values and Practicesa

Item Hospitalists Geriatricians Significance

I feel comfortable speaking with patients/familiesabout comfort care options.

81.8 92.3

I regularly review advance directives with patientsand families.

81.8 84.6

I routinely discuss prognosis with patients andfamilies.

54.5 92.3

Older patients tend to be more appreciative ofmedical care.

36.4 69.2

Most of my patients at the end of life have goodsymptom control and are comfortable.

36.4 76.9

I routinely review medications to identify thosethat might be dangerous or should be used withcaution.

27.3 100 ∗∗∗

I routinely evaluate patients who have fallen, tomake changes in their treatment plan.

27.3 76.9 ∗

Treatment of chronically ill old patients is a timeburden.

18.2 15.4

I routinely identify functional deficits and developa preliminary plan.

18.2 76.9 ∗∗

I routinely perform/interpret cognitive assessmentin patients with confusion.

9.1 76.9 ∗∗

I tend to pay more attention and have moresympathy toward my older patients.

9.1 30.8

I recommend feeding tubes in advanced dementiaand dysphagia.

0 7.7

aRated 6 or 7 on a Likert-type scale (1–7), with 1 (completely disagree) and 7 (completely agree).Hospitalists: n = 11; Geriatricians: n = 13.Groups are compared via chi-squared and Fisher’s exact where appropriate, df = 1.∗p < .05, ∗∗p < .01, ∗∗∗p < .001.

the groups for each question were determined via Fisher’s exact and chi-squared tests where appropriate. A mean confidence score was calculatedfor all survey respondents, and a correlation coefficient was calculated toassess the correlation between confidence and knowledge and between con-fidence and years in practice. The correlation between number of years inpractice and knowledge was also calculated. Similarly, correlations betweeneach practice pattern item and years in practice was assessed. Cronbach’salphas were calculated for the knowledge and confidence scales. Statisticalanalyses were conducted using Statview 5 software for Windows (ver. 5, SASInstitute, 1999) for all calculations other than Cronbach’s alpha, which wascompleted using MedCalc for Windows (ver. 12.5, MedCalc Software, 2013).

RESULTS

All hospitalists and geriatrician faculty completed the survey. Overall,geriatricians and hospitalists expressed a fairly high level of confidence in

Dow

nloa

ded

by [

Lul

ea U

nive

rsity

of

Tec

hnol

ogy]

at 1

0:06

15

Sept

embe

r 20

13

“Geriatricizing” Hospitalists 7

TABLE 4 Survey Participants

Characteristic Hospitalists Geriatricians Significance

Gender, % male 72.7 61.5Years in practice, median (range) 8 (1–26) 12 (3.5–30)

Age, % in range30–39 54.5 23.140–49 18.2 53.850–59 27.3 15.460+ 0 7.7

Residency training, %Internal medicine 100.0 92.3Family practice 0 7.7

Fellowship training, %Geriatrics 0 69.2 ∗∗∗

Other 9.1 0

Board certificationGeriatrics 0 84.6 ∗∗∗

Palliative care 18.2 53.8Other 0 7.7

Hospitalists: n = 11; Geriatricians: n = 13. Years in practice are compared via t-test; allother comparisons are via chi-squared and Fisher’s exact where appropriate, df = 1 forgender, residency, fellowship and board certification; df = 3 for age.∗∗∗p < .001.

specific geriatric competencies. However, geriatricians were more likely toexpress a high level of confidence than the hospitalists in all competenciesother than identifying patients appropriate for hospice, identifying medica-tions to be avoided in older adults, and assessing patients’ ability to care forthemselves (Table 1). Three of the areas of lowest confidence among thehospitalists involved caring for patients with dementia, including differenti-ating delirium, dementia, and depression; assessing and managing pain indementia; and developing a treatment plan for patients with dementia andagitation (with fewer than one third expressing high levels of confidence).The other area in which hospitalists expressed lower confidence was withinthe realm of transitions of care, with fewer than one third expressing ahigh level of confidence for assessing the adequacy of social support, orin assessing patients’ ability to care for themselves. There was no signifi-cant correlation between overall confidence and number of years in practice(r = –0.009, p = .97, df = 21).

Overall, the geriatricians scored 83.7% (±7.7), and the hospitalistsscored 70.1% (±10.0) on the 17-question knowledge test (p = .001). 92.3%of the geriatricians versus 36.4% of hospitalists achieved a score of 75%or more. Question topics not reaching a threshold of 60% of hospitalistrespondents answering correctly were delirium, comprehensive geriatricassessment, rehabilitation, deconditioning, cardiopulmonary resuscitation(CPR) outcomes, and falls (Table 2). For the group overall, there was amodest correlation between confidence and percent of knowledge questions

Dow

nloa

ded

by [

Lul

ea U

nive

rsity

of

Tec

hnol

ogy]

at 1

0:06

15

Sept

embe

r 20

13

8 S. M. Friedman et al.

answered correctly (r = .48, p = .02, df = 21). There was no significantcorrelation between years in practice and percent of knowledge questionsanswered correctly (r = .06, p = .77, df = 22).

Reported values and practices were similar for geriatricians andhospitalists (Table 3). Areas of significant difference in self-reported practicepatterns between the geriatricians and hospitalists included routine review ofmedications, identification of functional deficits, performing and interpretingcognitive assessment, and falls evaluation. Practice patterns and values werenot significantly correlated with number of years in practice.

DISCUSSION

Older adults who are hospitalized are at high risk of functional decline(Covinsky et al., 2003; Inouye et al., 1993b; Sager et al., 1996), compli-cations (Creditor, 1993; Gillick et al., 1982), and mortality (Levine, Sachs,Jin, & Meltzer, 2007), when compared to their younger counterparts.Hospitalization of the older adult may represent a sentinel event or transitionin health status (Walter et al., 2001). As a result, it is imperative to optimizethe care that is provided during this time period, to improve outcomes aswell as to provide guidance to patients and their families with respect tocare planning.

A survey comparing the confidence, knowledge, and self-reported prac-tice patterns of hospitalists and geriatricians identified multiple areas oflower confidence, knowledge deficits, and less frequent self-reported prac-tice behaviors in the hospitalist group. Specifically, issues related to cognitionand function, which are central to the care of hospitalized older adults, werefound to be gaps in all three of these realms.

These gaps also dovetail with the core competencies developed bythe Society of Hospital Medicine, whose goal was to characterize hospitalmedicine to “guide medical educators in developing curricula that incor-porate these competencies into the training and evaluation of students,clinicians-in-training, and practicing hospitalists” (Dressler, Pistoria, Budnitz,McKean, & Amin, 2006, p. 48). These core competencies include care of theelderly patient, care of vulnerable populations, drug safety, multidisciplinarycare, transitions of care, and palliative care.

These findings provide guidance in the development of a curriculumtargeted to geriatrics training of hospitalists. This is particularly importantas the rate of trainees entering hospitalist medicine far exceeds the rate ofthose entering geriatrics. In fact, in a recent survey of geriatric care inno-vation in hospitals, one half of programs were staffed by hospitalists withgeneral medical training, not geriatric specialty training (Wald, Huddleston,& Kramer, 2006).

Dow

nloa

ded

by [

Lul

ea U

nive

rsity

of

Tec

hnol

ogy]

at 1

0:06

15

Sept

embe

r 20

13

“Geriatricizing” Hospitalists 9

It is anticipated that development of a curriculum that is directed towardareas of self-identified low confidence and knowledge will increase knowl-edge and skills. This, in turn, will allow hospitalists to incorporate geriatricevaluation and management into their routine practice and will also improveconfidence in these measures, with the goal of improving quality of careprovided to older adults (Podrazik et al., 2008).

The findings from this evaluation have served as the basis of geriatricscurriculum development for hospitalists at Highland Hospital. This multi-component initiative incorporates weekly case-based discussions; quarterlyretreats involving lectures and case discussion; monthly noon conferences formedical students and residents, taught by hospitalists; videotaping of tran-sitions of care; development of peer review instruments; newsletters; andteaching tools. Changes in measures of knowledge, confidence, and practicebehaviors will be assessed following these teaching efforts.

It should be noted that, despite differences between the hospitalistsand geriatricians, the hospitalists demonstrated a good overall knowledgeof geriatrics. Scores in the 17-question knowledge component of the surveyaveraged 70%. This compares favorably with a survey of hospitalists and gen-eral internists completed as part of the CHAMP curriculum, with an averagescore of 62% prior to instruction and 68% following instruction (Podraziket al., 2008). Highland Hospital has a strong geriatric hospitalist presence,with geriatric fellowship-trained hospitalists who work on the same units asthe hospitalists who are being evaluated. These two groups also work withthe same house staff and students. It might be that some of the “culture” ofthe hospital has already changed the hospitalists’ approach to care.

This study offers valuable information about hospitalist values, confi-dence, and self-reported practice of geriatrics and compares them to a localstandard for geriatric practice. This study, however, also has several limita-tions. First, these results are based on self-report, rather than actual measure-ment of practice patterns. Although it has previously been demonstrated thatphysicians are limited in their ability to self-assess capabilities (Davis et al.,2006), these self-assessments do provide an impetus for ongoing learningefforts. Some of the self-reported differences seen in practice patterns in thisstudy have been reported in other settings, namely, screening for inappropri-ate medications, and screening of geriatric syndromes (Phelan et al., 2008).Furthermore, for the group overall, there was a modest correlation betweenlevel of confidence and percent correct on the knowledge component.Whether and how this translates to practice will be important to assess.

Second, this study was limited to one center, located in a community-based teaching hospital, with a strong geriatrics presence. Generalizabilityto other settings may be limited. However, in the hospitalist group studied,more than one half were younger than age 40, 73% were men, and mediantime in practice was 8 years. All had residency training in internal medicine.These findings are similar to a recent national survey, where average age

Dow

nloa

ded

by [

Lul

ea U

nive

rsity

of

Tec

hnol

ogy]

at 1

0:06

15

Sept

embe

r 20

13

10 S. M. Friedman et al.

of hospitalists was 43, and 61% of hospitalists were men, with an averagetime practicing as a hospitalist of 6.1 years. Seventy-five percent had generalinternal medicine training (Today’s Hospitalist, 2012).

The care provided by hospitalists has previously been shown to com-pare favorably with that provided by general internists, leading to lowerlength of stay and lower costs, without an increase in readmission or mor-tality (Lindenauer et al., 2007). Our analysis did not look at issues of generalmedical care but focused on geriatric-specific issues. It might certainly bethe case that the hospitalists surveyed had more confidence and knowledgeabout more general medical practices than the geriatricians.

CONCLUSIONS

This study compares the confidence, knowledge, and self-reported prac-tice behaviors of generalist hospitalists and geriatricians, in their care ofgeriatric patients. It demonstrates significant differences in these two groups’approach to older adults. Where these differences are a function of lack ofknowledge or experience, they set the stage for developing curricula to helpnarrow these gaps.

REFERENCES

Arora, V. M., Johnson, M., Olson, J., Podrazik, P. M., Levine, S., Dubeau, C. E.,.. . . Meltzer, D. O. (2007). Using assessing care of vulnerable elders qualityindicators to measure quality of hospital care for vulnerable elders. Journal ofthe American Geriatrics Society, 55, 1705–1711.

Christmas, C., Park, E., Schmaltz, H., Gozu, A., & Durso, S. C. (2008). A modelintensive course in geriatric teaching for non-geriatrician educators. Journal ofGeneral Internal Medicine, 23, 1048–1052.

Covinsky, K. E., Palmer, R. M., Fortinsky, R. H., Counsell, S. R., Stewart, A. L.,Kresevic, D.,. . . . Landefeld, C. S. (2003). Loss of independence in activitiesof daily living in older adults hospitalized with medical illnesses: Increasedvulnerability with age. Journal of the American Geriatrics Society, 51, 451–458.

Creditor, M. C. (1993). Hazards of hospitalization of the elderly. Annals of InternalMedicine, 118, 219–223.

Davis, D. A., Mazmanian, P. E., Fordis, M., Van Harrison, R., Thorpe, K. E., & Perrier,L. (2006). Accuracy of physician self-assessment compared with observed mea-sures of competence: A systematic review. Journal of the American MedicalAssociation, 296 , 1094–1102.

Dressler, D. D., Pistoria, M. J., Budnitz, T. L., McKean, S. C., & Amin, A. N. (2006).Core competencies in hospital medicine: Development and methodology.Journal of Hospital Medicine, 1(Suppl. 1), 48–56.

Dow

nloa

ded

by [

Lul

ea U

nive

rsity

of

Tec

hnol

ogy]

at 1

0:06

15

Sept

embe

r 20

13

“Geriatricizing” Hospitalists 11

Gillick, M. R., Serrell, N. A., & Gillick, L. S. (1982). Adverse consequences ofhospitalization in the elderly. Social Science & Medicine, 16 , 1033–1038.

Gray, S. L., Sager, M., Lestico, M. R., & Jalaluddin, M. (1998). Adverse drug eventsin hospitalized elderly. Journals of Gerontology Series A: Biological Sciences andMedical Sciences, 53(1), M59–63.

Hall, M. J., DeFrances, C. J., Williams, S. N., Golosinskiy, A., & Schwartzman, A.(2010). National Hospital Discharge Survey: 2007 summary. National HealthStatistics Reports, 29, 1–20, 24.

Inouye, S. K. (1998). Delirium in hospitalized older patients. Clinics in GeriatricMedicine, 14, 745–764.

Inouye, S. K., Viscoli, C. M., Horwitz, R. I., Hurst, L. D., & Tinetti, M. E. (1993a). Apredictive model for delirium in hospitalized elderly medical patients based onadmission characteristics. Annals of Internal Medicine, 119, 474–481.

Inouye, S. K., Wagner, D. R., Acampora, D., Horwitz, R. I., Cooney, L. M., Jr., Hurst,L. D., & Tinetti, M. E. (1993b). A predictive index for functional decline inhospitalized elderly medical patients. Journal of General Internal Medicine, 8,645–652.

Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalizations amongpatients in the Medicare fee-for-service program. New England Journal ofMedicine, 360, 1418–1428.

Levine, S. K., Sachs, G. A., Jin, L., & Meltzer, D. (2007). A prognostic model for 1-yearmortality in older adults after hospital discharge. American Journal of Medicine,120, 455–460.

Lindenauer, P. K., Rothberg, M. B., Pekow, P. S., Kenwood, C., Benjamin, E. M., &Auerbach, A. D. (2007). Outcomes of care by hospitalists, general internists, andfamily physicians. New England Journal of Medicine, 357 , 2589–2600.

Mazotti, L., Moylan, A., Murphy, E., Harper, G. M., Johnston, C. B., & Hauer, K. E.(2010). Advancing geriatrics education: An efficient faculty development pro-gram for academic hospitalists increases geriatric teaching. Journal of HospitalMedicine, 5, 541–546.

Medina-Walpole, A., Barker, W. H., Katz, P. R., Karuza, J., Williams, T. F., & Hall, W. J.(2002). The current state of geriatric medicine: A national survey of fellowship-trained geriatricians, 1990 to 1998. Journal of the American Geriatrics Society,50, 949–955.

Phelan, E. A., Genshaft, S., Williams, B., LoGerfo, J. P., & Wagner, E. H. (2008).A comparison of how generalists and fellowship-trained geriatricians provide“geriatric” care. Journal of the American Geriatrics Society, 56 , 1807–1811.

Podrazik, P. M., Levine, S., Smith, S., Scott, D., Dubeau, C. E., Baron, A.,. . . . Sachs,G. (2008). The Curriculum for the Hospitalized Aging Medical Patient program:A collaborative faculty development program for hospitalists, general internists,and geriatricians. Journal of Hospital Medicine, 3, 384–393.

Reuben, D. B., Lee, M., Davis, J. W., Jr., Eslami, M. S., Osterweil, D. G., Melchiore, S.,& Weintraub, N. T. (1998). Development and validation of a geriatrics attitudesscale for primary care residents. Journal of the American Geriatrics Society,46 ,1425–1430.

Sager, M. A., Rudberg, M. A., Jalaluddin, M., Franke, T., Inouye, S. K., Landefeld,C. S.,. . . . Winograd, C. H. (1996). Hospital Admission Risk Profile (HARP):

Dow

nloa

ded

by [

Lul

ea U

nive

rsity

of

Tec

hnol

ogy]

at 1

0:06

15

Sept

embe

r 20

13

12 S. M. Friedman et al.

Identifying older patients at risk for functional decline following acute medi-cal illness and hospitalization. Journal of the American Geriatrics Society, 44,251–257.

Shank, B. (June 2010). Hospitalists, transforming health care, revolutionizingpatient care: 2011 media kit. Retrieved from http://www.hospitalmedicine.org/Content/NavigationMenu/Media/MediaKit/SHM_MediaKit1213.pdf

Tanner, C. E., Eckstrom, E., Desai, S. S., Joseph, C. L., Ririe, M. R., & Bowen, J.L. (2006). Uncovering frustrations. A qualitative needs assessment of academicgeneral internists as geriatric care providers and teachers. Journal of GeneralInternal Medicine, 21(1), 51–55.

Thomas, E. J., & Brennan, T. A. (2000). Incidence and types of preventable adverseevents in elderly patients: Population based review of medical records. BritishMedical Journal, 320(7237), 741–744.

Today’s Hospitalist. (2012). Hospitalist demographics. Retrieved from http://www.todayshospitalist.com/survey/11_salary_survey/index.php

Wald, H., Huddleston, J., & Kramer, A. (2006). Is there a geriatrician in the house?Geriatric care approaches in hospitalist programs. Journal of Hospital Medicine,1(1), 29–35.

Walter, L. C., Brand, R. J., Counsell, S. R., Palmer, R. M., Landefeld, C. S., Fortinsky,R. H., & Covinsky, K. E. (2001). Development and validation of a prognosticindex for 1-year mortality in older adults after hospitalization. Journal of theAmerican Medical Association, 285, 2987–2994.

Werner, C. A. (2011). The older population: 2010. 2010 census briefs. Retrieved fromhttp://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf

Dow

nloa

ded

by [

Lul

ea U

nive

rsity

of

Tec

hnol

ogy]

at 1

0:06

15

Sept

embe

r 20

13