• When nothing seems to work: Hospitalists Edition

    There has been a recent push to use hospitalists, or full-time hospital-based physicians, to care for people in, well, hospitals. A number of studies have shown that patients cared for by hospitalists had shorter lengths of stay, which translates into reduced costs. That’s a good thing.

    In the “old days”, your regular doctor might also be responsible for you when you were hospitalized. Some have argued that this kind of arrangement is better because it leads to better continuity of care. This way, your regular doctor knows what happened to you in the hospital, and can be a better doctor for you afterwards. This argument seemed to be losing out, though, because spending less is important.

    Enter a new study from Annals of Internal Medicine:

    Background: Hospitalist care has grown rapidly, in part because it is associated with decreased length of stay and hospital costs. No national studies examining the effect of hospitalist care on hospital costs or on medical utilization and costs after discharge have been done.

    Objective: To assess the relationship of hospitalist care with hospital length of stay, hospital charges, and medical utilization and Medicare costs after discharge.

    Design: Population-based national cohort study.

    Setting: Hospital care of Medicare patients.

    Patients: A 5% national sample of enrollees in Medicare parts A and B with a primary care physician who were cared for by their primary care physician or a hospitalist during medical hospitalizations from 2001 to 2006.

    Measurements: Length of stay, hospital charges, discharge location and physician visits, emergency department visits, rehospitalization, and Medicare spending within 30 days after discharge.

    Researchers wanted to compare what happened to patients in Medicare cared for in the hospital by either a hospitalist or their primary care physician. What did they find?

    Patients cared for by hospitalists spent, on average, more than half a day less in the hospital for a savings of $282 per patient. That’s good! But, the costs to Medicare in the month after discharge were higher, to the tune of $332. That’s bad! Adding to the bad is the fact that patients who were cared for by hospitalists were, after discharge, significantly more likely not to be discharged to home, significantly more likely to have a visit to the emergency room, significantly more likely to be readmitted to the hospital, significantly more likely to have visits to nursing facilities, and significantly less likely to visit their primary care physician.

    Now this isn’t an RCT, and it’s not perfect, but it’s a fair amount of evidence that the savings seen by using hospitalists for patients in Medicare may be more problematic than we thought.

    This is a topic that needs more debate. I look forward to your thoughts.

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    • Its a well done study, and as a long time hospitalist, I gave it a good read. I believe the findings.

      Residual confounding, Yes, probably some. As some who have already appraised study point out, docs who care for folks long term and provide in and outpt care for them, will likely be different than docs caring for patients with disjointed care, from facilities, etc. There is SES and other unmeasured factors in these two cohorts. However, it does not nullify findings.

      My sense is that hospital medicine has grown so fast and quickly, that the current 30K practitioner database contains disproportionate numbers of hobbyists and junior faculty; pockets of excellence (and medicority) abound.

      When done right (good handoffs, communication, transitions, and supportive hospital), the model hits a home run. Conversely, if botched, it reduces system value.

      The million dollar question is what is the ramp up time to develop consistent models, and are the bodies there to do it well? I cant answer, but I sense with time, we will see more success. At this time, there is too much variation, and the aggregate, we get results such as those seen above.

      If folks want to learn more: http://www.hospitalmedicine,org (shameless plug). SHM is working diligently to create the models of care that will I hope, lead healthcare systems into the next phase of reform.

      Brad

    • I agree with Brad’s comment above. I’ve seen studies around health IT that have results showing no improvement in care yet some organizations swear by their med, lab and health record systems. In my opinion, the variable of interest should not solely be a hospitalist presence but should look at an established, supported and integrated hospitalist service. The best designed policy or organizational initiatives can fail to produce results with an inept or ill-prepared manager. I would like to see results stratified by different characteristics of the programs themselves as opposed to the hospital to look for effect modification.

      Calvin

    • I was a bit surprised that there was not a difference in utilization charges between the two groups. Before we had hospitalists, the internists just ordered everything they could (or so it seemed) so they could have results to look at when they rounded later in the day. From my POV, it has been a major boon in caring for very sick patients. The hospitalist is the go to guy for info.

      Steve

      • Steve
        This is not a new finding. Speculation as to why usually elicits similar answers: hospitalists on site tend to compress more in a shorter LOS. Also, they test on site, as opposed to in the office, where ambulists can consolidate their data, and more importantly, bill.

        This of course is theory, but I believe it.

        Brad

    • I wonder about use rates. It seems to me that any cost savings that might be achieved by superior hospitalist efficiency is likely to be more than offset by supply and convenience induced increase in admissions. I take it that was not addressed?

    • It would be interesting to look a bit deeper into the statistical aggregates at the heart of this study.

      In particular, it would be interesting to take a look at the controls for socioeconomic variables within this study. That is – are people from impoverished communities are less likely to have a PCP, and more likely to have a hospitalist look after them when…hospitalized.

      The PCP/specialist ratio tends to be higher in areas where families are intact and poverty is low in the first place. Consequently, the mere fact that you have a PCP that knows that you are in the hospital, much less supervising your care their probably means that you are more likely to have an intact family, be educated, have higher than average wealth, a broader and deeper network of people who look after you in and out of the hospital, and who do a gazillion things for free (like drive you to your follow up appointments, make sure you take your meds, etc) that poor people either have to have paid assistants do or that don’t get done at all.

      Did the original study even attempt to control for these factors?

    • Well done study. The significant observation may not be about the slight difference in costs but the fact that hospitalists also practice “incident” medicine. The incident just happens to be a hospital admission. Hand offs and communications are still a problem.

      Most PCPs practice incident based medicine. Medical practice in general seems to be incident-based and as long as physicians’ reimbursement is incident (fee-for-service) based physicians will be “piece workers” motivated to produce more units.

      Perhaps patient centered medical home will have a positive impact on medical practice (both the cost and quality of care delivered).

      Roger H Strube, MD (retired)
      Author – Discovering the Cause and the Cure for America’s Health Care Crisis