Development of a novel hospitalist advanced practice provider assessment instrument: A pilot study.

Advanced practice providers (APPs) graduate from school with variable hospitalist experience. While hospitalist-specific onboarding is recommended for hospitalist APPs, no standard method currently exists to assess their readiness for practice. We created a 17-item instrument called the Cardin Hospitalist Advanced Practice Provider-Readiness Assessment (CHAPP-RA) to assess APPs'; readiness for practice using a milestones-based scale. We piloted CHAPP-RA at a single site where 11 APPs with varied experience were rated by 30 supervising physicians. Supervisors also provided global ratings for overall performance. We investigated the feasibility of CHAPP-RA and collected validity evidence for the interpretation of scores. The mean time to complete one CHAPP-RA was 10.5 min. Supervisors rated novice APPs lower than more experienced APPs, p ≤ .001. CHAPP-RA ratings also correlated strongly with global ratings. CHAPP-RA is feasible to implement and has initial validity evidence.

Effect of Heart Failure With Preserved Ejection Fraction on Perioperative Outcomes in Patients Undergoing Hip Fracture Surgery.

INTRODUCTION: Heart failure is a leading cause of morbidity and mortality in hip fracture surgery. The impact of heart failure with preserved ejection fraction (HFpEF) is poorly understood in this population. We designed a study to evaluate national perioperative outcomes in hip fracture for patients with HFpEF. METHODS: Patients with hip fracture undergoing total hip arthroplasty, hemiarthroplasty, or open/closed reduction with internal and external fixation from January 2005 to December 2013 were identified using the Nationwide Inpatient Sample. Inpatient outcomes during the index hospitalization were compared between patients without heart failure and with HFpEF. Heart failure with reduced ejection fraction was included as a secondary comparator. Perioperative major adverse cardiovascular and cerebrovascular events (MACCEs), defined as in-hospital all-cause death, acute myocardial infarction, and in-hospital cardiac arrest or acute ischemic stroke, were evaluated. RESULTS: Among 2,020,712 hospitalizations for hip fracture surgery, perioperative MACCE occurred in 67,554 hospitalizations (3.3%), corresponding to an annual incidence of approximately 7,506 events after applying sample weights. Compared with patients without heart failure, patients with HFpEF experienced increased odds of MACCE, adjusted odds ratio [aOR], 1.69; 95% confidence interval (CI), 1.51 to 1.89. In comparison, the aOR of experiencing a MACCE event in the heart failure with reduced ejection fraction group was 1.75 (95% CI, 1.57 to 1.96). HFpEF was also associated with increased odds of acute respiratory failure (aOR, 1.71; 95% CI, 1.53 to 1.91) and acute renal failure (aOR, 1.52; 95% CI, 1.41 to 1.64). CONCLUSION: HFpEF confers a significant perioperative risk of MACCE in patients undergoing hip fracture surgery.

Documentation of Clinical Reasoning in Admission Notes of Hospitalists: Validation of the CRANAPL Assessment Rubric.

BACKGROUND: High-quality documentation of clinical reasoning is a professional responsibility and is essential for patient safety. Accepted standards for assessing the documentation of clinical reasoning do not exist. OBJECTIVE: To establish a metric for evaluating hospitalists' documentation of clinical reasoning in admission notes. STUDY DESIGN: Retrospective study. SETTING: Admissions from 2014 to 2017 at three hospitals in Maryland. PARTICIPANTS: Hospitalist physicians. MEASUREMENTS: A subset of patients admitted with fever, syncope/dizziness, or abdominal pain were randomly selected. The nine-item Clinical Reasoning in Admission Note Assessment & Plan (CRANAPL) tool was developed to assess the comprehensiveness of clinical reasoning documented in the assessment and plans (A&Ps) of admission notes. Two authors scored all A&Ps by using this tool. A&Ps with global clinical reasoning and global readability/clarity measures were also scored. All data were deidentified prior to scoring. RESULTS: The 285 admission notes that were evaluated were authored by 120 hospitalists. The mean total CRANAPL score given by both raters was 6.4 (SD 2.2). The intraclass correlation measuring interrater reliability for the total CRANAPL score was 0.83 (95% CI, 0.76-0.87). Associations between the CRANAPL total score and global clinical reasoning score and global readability/clarity measures were statistically significant (P < .001). Notes from academic hospitals had higher CRANAPL scores (7.4 [SD 2.0] and 6.6 [SD 2.1]) than those from the community hospital (5.2 [SD 1.9]), P < .001. CONCLUSIONS: This study represents the first step to characterizing clinical reasoning documentation in hospital medicine. With some validity evidence established for the CRANAPL tool, it may be possible to assess the documentation of clinical reasoning by hospitalists.

The Current State of Advanced Practice Provider Fellowships in Hospital Medicine: A Survey of Program Directors.

BACKGROUND: Postgraduate training for advanced practice providers (APPs) is a growing field in hospital medicine. As hospital programs continue to benefit from highly trained physician assistants (PAs) and nurse practitioners (NPs), fellowship programs have become more prevalent. However, little is known about the number of active programs or how they prepare trainees. OBJECTIVES: To describe the existing APP fellowships in hospital medicine, with a focus on program characteristics, rationale, curricula, and learner assessment. METHODS: An electronic survey was distributed by e-mail to hospital medicine program directors in May 2018. The survey consisted of 25 multiple choice and short answer questions. Descriptive statistics were calculated utilizing Stata 13 for data analysis. RESULTS: Of the 11 fellowships identified, 10 (91%) of directors responded to the survey. Eighty percent of programs accept both NPs and PAs and 80% are between 12 and 13 months long. All programs cite "training and retaining" as the main driver for their creation and 90% were founded in institutions with existing physician residencies. Ninety percent of program curricula are informed by Society of Hospital Medicine resources. Despite these similarities, there was wide variation in both curricular content and APP fellow assessment. CONCLUSION: APP fellowships in hospital medicine are quickly growing as a means to train and retain nonphysician hospitalists. While most programs accept similar types of applicants and share a common rationale for program development, there is little standardization in terms of curriculum or assessment. Further research may be valuable to characterize the best practices to guide the future of these fellowships.