Neurology -- Correspondence for Freeman et al., 70 (15) 1282-1288

Correspondence published:

Invited Article: Is it time for neurohospitalists?: Gregory Y Chang, Alpesh Amin (26 June 2008)

Reply from the Authors: William D. Freeman, Gary Gronseth, and Benjamin H. Eidelman (26 June 2008)

Invited Article: Is it time for neurohospitalists?: David J. Likosky (19 June 2008)

Reply from the authors: William D. Freeman, Bruce L. Mitchell, Gary Gronseth, BH Eidelman (19 June 2008)

Invited Article: Is it time for neurohospitalists? 26 June 2008

Gregory Y Chang,
UC Irvine Medical Center
UCI Hospitalist Program, 101 The City Drive South, Building 26 Suite 1001, Orange CA, 92868,
Alpesh Amin
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Re: Invited Article: Is it time for neurohospitalists?

gychang{at}uci.edu Gregory Y Chang, et al.

We read the article by Freeman et al. regarding the advantages of neurohospitalists which represents an emerging field of neurology serving cost-effective, high-quality medical care to the inpatient population. [1] The authors postulated potential advantages of improved logistical efficiency leading to improved patient outcome but how this is achieved was not explained.
In our 400-bed academic medical center at the University of California, Irvine (UCI), the Hospitalist Program consists of 16 board certified hospitalists physicians from nine medical specialties: Internal Medicine, Family Medicine, Pediatrics, Neurology, Geriatrics, Palliative Care, Adult Infectious Disease, Pediatric Infectious Disease and Critical Care.
One of us (GYC) joined the UCI Hospitalist Program as the first full-time neurohospitalist more than 2 years ago. Although no previous comparable data is available, our experience in forming a true multidisciplinary Hospitalist Program with specialists from various medical disciplines located in the same office and attending required hospitalist faculty meetings and hospitalist-oriented weekly conferences has enhanced inpatient based communication and facilitated a more collaborative approach to patient care and education.
We also instituted daily critical care hospitalist-neurohospitalist �handshake rounds� in which the two hospitalist teams (neurohospitalist attending plus housestaff and critical care hospitalist attendings plus housestaff) meet briefly during morning rounds to discuss clinical data as well as medical-legal, and ethical aspects of patient care. This is more difficult to accomplish in the traditional approach.
We agree with the authors that neurohospitalist model will continue to expand and grow. Our experience of adding a neurohospitalist to our multidisciplinary Hospitalist Program has been advantageous for patient care, education of our trainees, and developing collaborative, progressive models of multidisciplinary inpatient care processes.
Reference
1. Freeman WD, Gronseth G, Eidelman BH. Invited Article: Is it time for neurohospitalists? Neurology, 2008;70:1282�1288.
Disclosure: The authors report no disclosures.

Reply from the Authors 26 June 2008

William D. Freeman,
Mayo Clinic
Jacksonville, FL,
Gary Gronseth, and Benjamin H. Eidelman
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Re: Reply from the Authors

freeman.william1{at}mayo.edu William D. Freeman, et al.

Dr. Chang et al. inquire about the method by which neurohospitalists provide improved outcomes in health care delivery to medicine or pediatric hospitalists.
We suggest neurohospitalists provide similar if not equal outcomes as other hospitalists by standardizing quality measures (i.e., deep vein thrombosis prevention), providing improved emergency department coverage, and reducing length of hospitalization. [2-4]
We note the authors� review of their experience at UC Irvine hospitalist practice. We acknowledge there are different and diverse hospitalist systems that can achieve similar patient outcomes and quality results in the current US Health care system.
References
2. Auerbach AD, Wachter RM, Katz P et al. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med 2002;137:859-865.
3. Coffman J, Rundall TG. The impact of hospitalists on the cost and quality of inpatient care in the United States: a research synthesis. Med Care Res Rev 2005; 62:379-406.
4. Davis KM, Koch KE, Harvey JK, Wilson R, Englert J, Gerard PD. Effects of hospitalists on cost, outcomes, and patient satisfaction in a rural health system. Am J Med 2000;108:621-626.
Disclosure: Drs. Freeman and Eidelman report no conflicts of interest. Dr. Gronseth is a member of Boehringer Ingelheim Pharmaceutical�s speaker�s bureau.

Invited Article: Is it time for neurohospitalists? 19 June 2008

David J. Likosky,
Evergreen Hospital Medical Center
12040 NE 128th St, Kirkland, WA, 98034
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Re: Invited Article: Is it time for neurohospitalists?

dalikosky{at}evergreenhealthcare.org David J. Likosky

As a hospitalist and neurohospitalist, I read the article by Freeman et al. with interest. [1] Adult medicine hospitalists are asking for help with inpatient neurologic care, and neurohospitalists have the greatest potential to answer this call. [2]
While many perceive neurology as an internal medicine subspecialty and therefore expect hospitalists to assume that role, the reality is that the neurologic experience in internal medicine training programs is often minimal and is no substitute for a neurology residency. When surveyed on their medicine residency experience, many hospitalists felt more neurology training would be helpful in their practice of hospital medicine. [3] Unfortunately, neurologic consultation is not available to many or is underutilized due to many of the factors the authors list.
The presence of a neurologist (who wants to be) in the hospital will greatly improve US neurologic care. Many patients who would not be seen on either an inpatient or outpatient basis by a neurologist may now be seen by a neurohospitalist who is both available and affable�without the pull of multiple sites of practice. The cost of this service may be defrayed by increased source of patients, medical directorships, and pay�for-call which is becoming more common.
There may be conflict for the neurohospitalist who continues in an outpatient practice, but may see patients for other neurologists when they are inpatients. This is largely avoided in the more traditional hospitalist model in which outpatient office practice is uncommon. [4]
If a hospital has insufficient neurohospitalists to cover all hours, a partnership with local neurologists for call coverage may help obviate this concern and help foster good relations. A successful neurohospitalist should help an outpatient neurologist improve their income, but this remains to be proven.
References
1. Freeman WD, Gronseth G, Eidelman BH. Invited Article: Is it time for neurohospitalists? Neurology 2008;70;1282-1288.
2. Likosky DJ, Amin AN. Who will care for our hospitalized patients? Stroke 2005;36:1113.
3. Plauth WH 3rd, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists� perceptions of their residency training needs: results of a national survey. Am J Med 2001;111:247-254.
4. Society of Hospital Medicine 2005-2006 SHM Survey: State of the Hospital Medicine Movement, 2006.
Disclosure: The author reports no disclosures.

Reply from the authors 19 June 2008

William D. Freeman,
Mayo Clinic
4500 San Pablo Rd, Cannaday 2 East,
Bruce L. Mitchell, Gary Gronseth, BH Eidelman
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Re: Reply from the authors

freeman.william1{at}mayo.edu William D. Freeman, et al.

We thank Dr Likosky for his response. We agree and emphasize that the presence of a neurohospitalist has potential for improving neurologic care. [1,2]
We echo his sentiments about the dearth of neurology training in medicine residencies, despite a predominance of neurologic diseases of the aging population. More communication is needed between the Internal Medicine and Neurology Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committees (RRC) to potentially change Internal Medicine core curriculum, as expressed in the survey. [3]
Dr. Likosky also outlines the benefits of having a neurologist on site at the hospital. [2] This is often poorly understood by physicians and administrators trying to pay for neurohospitalists. The value of a neurohospitalist resides in �sheltering� the outpatient practice from emergent department (ED) consultations that lead to lost outpatient revenue, providing timely consultations to emergent and inpatient consultations, and improved patient care by improved efficiency as there are no outpatient distractions. In addition, there are improved inpatient metrics (e.g., length of stay, and compliance with Joint Commission quality indicators) as well as the billing revenue they provide. After implementation of a neurohospitalist system, hospital and ED neurologic consultations often increase with time due to increased referrals from ED and other inpatient services.
Hospitals with sufficient volume and resources (neurohospitalists and hospitalists) to provide 24/7/365 �stroke call coverage� remain to be determined by each location and practice. Collaboration between neurohospitalists and medicine hospitalists occurs at our institution (WDF, BHE, BLM) and works well for ED triage by presenting problem. [4]
We find no conflicts between neurohospitalists and the referring outpatient neurologists when adequate communication exists between them. We find such communication actually facilitates disposition and discharge planning including outpatient follow-up.
Disclosure: Drs. Freeman, Mitchell, Eidelman report no disclosures. Dr. Gronseth is a member of Boehringer Ingelheim Pharmaceutical�s speaker�s bureau.