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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