Literature suggesting improved patient outcomes and patient satisfaction with the hospitalist model of inpatient medical care coupled with the desire to improve provider satisfaction led to the introduction of the laborist in obstetrics. This represents a significant change in the way obstetrics has been experienced and practiced from both a patient and provider perspective. The laborist was designed as a plausible model of obstetric care delivery where hospitals employ physicians to provide continuous coverage of labor and delivery units without other competing clinical duties. Anecdotal use of the laborist model in the provision of obstetric care is growing rapidly, despite the lack of research regarding its impact on maternal outcomes, neonatal outcomes, patient and provider satisfaction, and graduate medical education. We provide an overview of both the positive and negative attributes of this model of obstetric care delivery, discuss the current state of research addressing these attributes, and propose a research strategy to improve understanding of the impact of this model of care delivery.
More than 4 million women give birth each year, the majority of which occur in the hospital setting. Obstetric care is characterized by the general expectation of good outcomes coupled with the unpredictability of poor outcomes. Additionally, the widespread utilization of continuous fetal heart rate monitoring requires continuous observation and interpretation by a skilled care provider.
These expectations have resulted in the development of new care models that address the need for more continuous monitoring of patients, a focus on reducing practice variation, and developing patient safety initiatives. One such model is the laborist model of obstetric care. However, there is little research about the current state of laborist models, and the research base for this model is lacking.
In this commentary, we provide an overview of both the positive and negative attributes of this model of obstetric care delivery, discuss the current state of research addressing these attributes, and propose a research strategy to improve understanding of the impact of this model of care delivery.
Learning from a prior movement: hospitalists in the provision of inpatient medical care
The concept of the hospitalist, a term coined in 1996 by Wachter and Goldman, refers to a physician whose primary focus is in the care of hospitalized patients. Hospitalists, or physicians who spend more than 25% of their time caring for inpatients, are a model of inpatient care whose use by hospital systems has grown over the past decade. A recent paper found that market pressures, such as rising health care costs and medicolegal pressures, are associated with the use of hospitalists in the inpatient system. Nonetheless, the number of hospitalists has increased over the last 15 years with currently more than 20,000 practicing hospitalists.
Hospitalists are found in a variety of settings, including intensive care units, but largely work in general medicine and pediatric inpatient settings. To understand the rationale for the development of laborist models of obstetric care, it is important to understand the overall impact of hospitalists on patient outcomes, patient and provider satisfaction, and medical education.
Hospitalists: efficiency, outcomes, and processes
Evaluation of the efficiency of hospital care by hospitalists demonstrates the greatest improvement when compared with more traditional models of inpatient care delivery. The 2 most widely studied metrics of efficiency are length of stay and total hospital costs, both of which have been improved with hospitalists.
In a recent review, the majority of more than 50 studies evaluating these 2 metrics demonstrate an improvement with hospitalists plausibly caused by on-site availability leading to increased efficiency. However, despite improved efficiency, there is conflicting literature about whether the hospitalist model of inpatient care is associated with improved patient outcomes. A decrease in readmissions and inpatient mortality have been observed with hospitalists in some studies. However, these improvements have been less reproducible, with several studies finding no change in inpatient mortality or readmission rates. A few studies have also demonstrated worse outcomes with this model of inpatient care delivery.
Using the Donabedian framework of the structure-process-outcome relationship to understand how hospitalists may improve quality, several more recent studies attempted to look at clinical process improvement. The literature in this area is conflicting as well. Improvement in the administration of deep vein thrombosis prophylaxis, pneumococcal vaccination, and documentation of discussions regarding end-of-life care has been observed with hospitalists. However, several other studies demonstrate no difference in processes of care. Rifkin et al demonstrated no difference in the appropriateness of antibiotic usage or in door-to-antibiotic administration time. Another study found no difference in adherence to evidence-based guidelines for cardiac care. Additional studies also found no difference in utilization of radiologic imaging, adherence to evidence-based practice guidelines, pain control, or patient understanding regarding the need for hospitalization.
In addition to potential clinical process and outcome effects, the purposeful discontinuity of care from the primary care patient setting with the hospitalist model raises concern about the impact on quality of care through lack of maintenance of care across inpatient and outpatient services and/or a lack of communication, particularly at discharge. Only a small number of studies have evaluated the communication patterns between outpatient and inpatient providers and have found no difference in means of communication.
Hospitalists: patient and provider satisfaction
Patient satisfaction was an initial concern with the hospital model of inpatient care. However, satisfaction levels appear no lower than satisfaction of similar patients cared for by their own primary care physician or a traditional academic ward attending.
Provider satisfaction is also important in evaluating the future of this medical specialty. Hospitalists represent a unique area of medicine, with the majority of time being spent in an acute, inpatient setting. A study by Glasheen et al reported on a national survey of more than 250 hospitalists. The majority were academicians and general internists. Although 75% reported general job satisfaction, 67% also reported a high level of stress and almost 25% reported some degree of burnout.
Hospitalists: evaluating medical education
The impact of the hospitalist model on education has not been widely studied. However, this is an important area, because models of care delivery in the inpatient setting greatly influence residency training and future workforce competence. One recent survey of department chairs and residency program directors reported an overwhelming majority of hospitalists participate in the education of students and house staff. A few published studies demonstrated an increase in availability of hospitalist attending to trainees and a general improvement in perception of education. However, a concern over reduction in senior resident autonomy has been raised in a survey of residency program directors.
In conclusion, the majority of the hospitalist literature to date involves teaching hospitals and single institutions, raising questions regarding the generalizability of this literature. Overall, the hospitalist literature demonstrates some efficiency improvements. These early studies demonstrating savings were used to justify financial support for hospitalist programs. This conflicting literature regarding outcomes and processes and limited studies evaluating patient and provider satisfaction and the impact on medical education underlies the assumptions made regarding the possible benefits of the laborist model in obstetric care.
Extrapolation of the hospitalist to labor and delivery: the laborist
The potential improvement in inpatient outcomes with the development of hospitalist medicine coupled with the desire to improve patient outcomes, reduce medical liability, and enhance provider satisfaction in the field of obstetrics and gynecology led to the introduction and evolution of the laborist model in the field of obstetrics. The laborist is traditionally an obstetrics and gynecology physician who is employed by the hospital to manage laboring patients and obstetric emergencies.
Laborists were first proposed by Dr Louis Weinstein in 2003 to offer an alternative career option within the field of obstetrics and gynecology to improve lifestyle and provider satisfaction and reduce burnout. It was subsequently extrapolated from the hospitalist literature that this new model in obstetrics could improve obstetric care delivery and, perhaps, reduce liability. Weinstein noted that “the reasons for development of the hospitalist [laborist] model included an increase in the serious nature of disease in hospitalized patients, the need for physicians to spend more time in their offices with increasing outpatient volume, the decrease in inpatient admissions, the difficulty for most practitioners to stay at the cutting edge of medical care, and the documented fact that those who do something repetitively do it better and with less expense.”
There have been a variety of opinions voiced on the positive and negative attributes of this model ( Table ). Without any direct evidence, the bias that individuals have in support of or against this model is based on anecdote, theoretic plausibility, large extrapolations from the hospitalist experience, and a desire to find a concrete method that may improve safety and decrease litigation.
| Suggested positive attributes | Suggested negative attributes |
|---|---|
|
|
Extrapolation of the hospitalist to labor and delivery: the laborist
The potential improvement in inpatient outcomes with the development of hospitalist medicine coupled with the desire to improve patient outcomes, reduce medical liability, and enhance provider satisfaction in the field of obstetrics and gynecology led to the introduction and evolution of the laborist model in the field of obstetrics. The laborist is traditionally an obstetrics and gynecology physician who is employed by the hospital to manage laboring patients and obstetric emergencies.
Laborists were first proposed by Dr Louis Weinstein in 2003 to offer an alternative career option within the field of obstetrics and gynecology to improve lifestyle and provider satisfaction and reduce burnout. It was subsequently extrapolated from the hospitalist literature that this new model in obstetrics could improve obstetric care delivery and, perhaps, reduce liability. Weinstein noted that “the reasons for development of the hospitalist [laborist] model included an increase in the serious nature of disease in hospitalized patients, the need for physicians to spend more time in their offices with increasing outpatient volume, the decrease in inpatient admissions, the difficulty for most practitioners to stay at the cutting edge of medical care, and the documented fact that those who do something repetitively do it better and with less expense.”
There have been a variety of opinions voiced on the positive and negative attributes of this model ( Table ). Without any direct evidence, the bias that individuals have in support of or against this model is based on anecdote, theoretic plausibility, large extrapolations from the hospitalist experience, and a desire to find a concrete method that may improve safety and decrease litigation.
| Suggested positive attributes | Suggested negative attributes |
|---|---|
|
|
Where are we right now: the current state of the laborist model
Although there are reportedly more than 20,000 hospitalists nationwide, based on the American Hospital Association’s most recent survey in 2007, the current state of the laborist model in the delivery of obstetric care is unknown. A recent American College of Obstetricians and Gynecologists (ACOG) committee opinion affirmed ACOG’s support for the continued development of the obstetrics and gynecology hospitalist because of the various demands of the specialty. Despite this support, the prevalence of laborist models in hospitals has never been evaluated or documented. In collaboration with the National Perinatal Information Center/Quality Analytic Services (NPIC/QAS), we assessed the use of this model of care delivery and evaluated hospital characteristics that were associated with the implementation of this model of care delivery. Of the 74 NPIC/QAS member hospitals, 93% (n = 69) responded to the survey and 37.7% reported utilization of laborists.
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