THE PRACTICE OF oncology has migrated out of hospitals and into outpatient clinics where just about all chemotherapy and immunotherapy are delivered. As a result, according to a recent study in the Journal of Hospital Medicine (JHM) on the benefits of hospitalist comanagement of oncology patients, “Hospitalists are increasingly the attendings of record for solid tumor inpatients.”
Large cancer hospitals—including the MD Anderson Cancer Center in Houston and New York’s Memorial Sloan Kettering—have for years implemented dedicated hospitalist teams; patients benefit from hospitalists having no outpatient responsibilities and from their expertise with complex inpatient care. But what impact does that comanagement have on quality metrics like length of stay and readmission rates?
Hospitalist Jensa Morris, MD, is director of the hospitalist service at Smilow Cancer Center, which occupies a tower in Yale New Haven Hospital in New Haven, Conn., and lead author of that JHM study.
As Dr. Morris points out, her center’s decision to implement dedicated hospitalist comanagement in July 2021 makes it “fairly late to the game” in getting such a service off the ground. But for six months, she and her colleagues were able to run two parallel services— one a traditional service led by an oncologist, the other a hospitalist-led service that used oncologists only as consultants—to compare outcomes.
“We see greater hospice and palliative care use as a positive development we’re able to make.”
Jensa Morris, MD Smilow Cancer Center
“What is so unique about our study,” says Dr. Morris, “is that we were able to isolate the impact of hospitalists on quality outcomes because we had two identical inpatient services caring for similar patients.” The results: The hospitalist service reduced patients’ average length of stay by 0.76 days (4.71 days vs. 5.47). That reduction opened up 1.64 beds per day and saved the hospital 304 bed days over six months.
Hospitalists also had a higher adjusted early discharge rate (6.22% vs. 2.06%), and their mean discharge time was a half hour earlier than the oncologists’ (3:45 p.m. vs. 4:16 p.m.). Readmission rates for both services were the same.
“As you may expect,” points out Dr. Morris, who is also co-director of hospital medicine at Yale New Haven, “those outcomes were very well-received, largely because—like every other hospital in the nation—ours is packed.”
Researchers also surveyed the center’s oncologists for their experience of having hospitalists manage their inpatients. According to those surveys, oncologists reported having lower stress and a better ability to juggle competing responsibilities, including those of their outpatient clinics. Moreover, oncologists reported no difference in their perception of quality of care between the two service lines.
Read about a successful example of what’s become a major focus of many hospitalist groups: how to improve comanagement. Crafting the best comanagement agreements
Given those benefits, Dr. Morris has been able to expand the service beyond the four hospitalists she initially hired.
“We’re now up to 10 in addition to me, and I’m hoping to hire an eleventh,” she says. The comanagement line has also expanded to staff an inpatient hematology service. And beginning this July, solid tumor patients who overflow to beds in Yale New Haven Hospital will be cohorted in one unit and covered by the Smilow hospitalist service.
“We will have oncology hospitalists for all our solid tumor patients within Yale New Haven,” says Dr. Morris. “We’re expanding our service to cover all the hospital’s sickle cell patients as well.”
In terms of recruiting, she now has many more hospitalist applicants than positions. But when the service was first launched, she had to rely on the center’s oncologists to work their colleague networks to find possible hospitalist recruits.
One of the four original hires had prior experience as a hematology hospitalist, while the other three— who were straight out of residency—were general internists with a strong interest in oncology. One of those four, Dr. Morris says, has since gone on to an oncology fellowship.
General vs. specialty training
As the comanagement service continues to expand, “we wrestle with whether we should hire hospitalists with fellowships in hematology/oncology or stick with a model that’s internist-based,” Dr. Morris notes. “I’m an internist so I’m biased, but there are merits to general medicine physicians and merits to specialty trained physicians who want to work only in the hospital. We may be best served by having both.”
That debate—over whether to staff such a dedicated service with doctors board-certified in hem/onc— won’t be taken up by community hospitals that may be considering hospitalist comanagement of oncology patients. According to Dr. Morris, hospitalists with general training can certainly staff such a service line.
“If you have one or two doctors with an interest in oncology, they should be the ones to primarily staff the service during the day,” she points out. “That way, they’ll build the rapport with oncologists that facilitates trust and communication.” Allowing physicians to immerse themselves in such specialized comanagement “certainly makes them better at it.”
Hospice and palliative care
During the study period, Dr. Morris and her research team measured other outcomes between the two service lines: the percentage of patients discharged to hospice and the amount of time patients stayed on the inpatient service before being discharged to hospice. Those data make up another study currently being reviewed for publication.
The results: Hospitalists posted “dramatically” better numbers for both metrics than oncologists.
“That leaves a lot of questions,” she adds. “Do hospitalists just do better recognizing end of life? Is it because we’re here all day and we have a better sense of patients’ wants and needs? Or are oncologists just more treatment-oriented?”
With the service line only two years old, Dr. Morris says it remains to be seen whether working exclusively with critically ill cancer patients in the hospital will prove to be traumatizing for the doctors staffing the service. As she explains, the ability to have end-of-life discussions and to help guide patients toward hospice and palliative care can be rewarding. “We see greater hospice and palliative care use as a positive development we’re able to make, and that helps prevent burnout,” she says. “It also contributes to having a sense of meaning in our practice, and we have a great team of nurses around us. That buoys our spirits every day.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Published in the July/August 2023 issue of Today’s Hospitalist