Study ties hospitalist care to shorter patient stays

Organized medicine leaders acknowledge the findings but stress the importance of continuity of care.

By Myrle Croasdale — Posted Jan. 28, 2008

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Hospitalists trimmed 12% from the average hospital patient's stay, the equivalent of about a half-day off an average four-day visit.

That is the conclusion of a study published in the Dec. 20, 2007, New England Journal of Medicine.

"On first glance, this might appear to be a small difference," said Peter Lindenauer, MD, the study's lead author. "But multiply it out by 6,000 acute care hospitals, and you can see a dramatic impact on hospital efficiencies."

The study, the largest of its kind regarding hospitalists, also found that patients cared for by hospitalists had slightly lower costs per stay than those treated by a general internist or family physician. Patient outcomes were similar regardless of whether they were treated by a hospitalist, internist or family physician.

Dr. Lindenauer, who practices at Baystate Medical Center in Springfield, Mass., and is an associate professor of internal medicine at Tufts University School of Medicine in Boston, said the study's overall results should give hospitalists better bargaining power.

"Most hospitalist programs are not able to support themselves entirely through professional fees," Dr. Lindenauer said. "These kinds of demonstrated savings should help hospitalist programs during their negotiation with hospitals around program support."

Laurence McMahon Jr., MD, MPH, internal medicine division chief at the University of Michigan Health System in Ann Arbor, wrote a New England Journal of Medicine editorial in response to the study. He said the findings ought to end the debate regarding hospitalists' value. Now he would like to see researchers pursue topics like hospitalists' impact on quality improvement or patient safety.

"The fact is that hospitalist care is being placed in the hands of specialized doctors, hospitalists, and that's not going to change," Dr. McMahon said. "The next steps are to change the focus of the research to one where we take advantage of these physicians."

Joseph Miller, senior vice president of the Society of Hospital Medicine, said the study is good news. "It reinforces, on a much broader perspective than previous studies, the point that hospitalists are more efficient without any sacrifice in quality."

He said future efforts should focus on such issues as improving communication between hospitalists and community physicians when patients are discharged.

Ensuring continuity of care

James King, MD, president of the American Academy of Family Physicians and a family physician in Selmer, Tenn., agreed that improving communication between hospitalists and patients' primary care physicians was important.

"The hospitalist program is another way the patient gets fragmented, divided up," Dr. King said. "Continuity of care is a significant issue."

Dr. King also noted that the hospitalist model does not fit for small, rural hospitals that do not have enough beds to support a full-time hospitalist. Here, family physicians are often the ones handling inpatient care.

Steven Weinberger, MD, American College of Physicians' senior vice president of medical education and publishing, said that although the hospitalist model is here to stay, it is not necessarily the best model for every hospital or every patient.

"This study shows a hospitalist model works, but it may not be any better or worse than your own primary care physician," Dr. Weinberger said.

The American Medical Association holds that patients' participation in hospitalist care should be voluntary, and that patients and their primary care physician should not be penalized if they choose to opt out of hospitalist care.

Rapid growth

Dr. Lindenauer said hospitalists' rapid growth made a large-scale study important. "Hospitalists appear to be on the path to become the predominate method of providing in-hospital care for patients," Dr. Lindenauer said. "We felt there was an unmet need for a large, comprehensive study examining the practice of hospital medicine across a broad range of settings."

The "hospitalist" concept emerged a decade ago, and now 22,000 physicians consider themselves hospitalists, according to the Society of Hospital Medicine.

Past studies on hospitalists' care were small, he said, and typically carried out at academic medical centers. The latest study included community hospitals.

The study examined 76,926 patients from 45 hospitals between 2002 and 2005. Seven common conditions were tracked. Patient care outcomes by 284 hospitalists, 993 general internists and 971 family physicians were compared.

"The data are in," Dr. Lindenauer said. "Now let's turn our attention to the challenges and opportunities of addressing payment reform and developing a cadre of hospitalist researchers to advance the field."

Such advances might include research into new care models, better use of information technology and how to improve hospitalists' collaboration with other physicians and health care professionals, Dr. Lindenauer said.

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Comparing outcomes

A study of 76,926 hospital patients treated by either a hospitalist, general internist or family physician found that hospitalists' patients typically stayed in the hospital about a half-day less, though the costs of care did not vary much.

Hospitalist Internist Family physician
Total adjusted costs per patient $5,129 $5,397 $5,254
Length of stay in days 2.9 3.3 3.3

Source: "Outcomes of Care by Hospitalists, General Internists and Family Physicians," New England Journal of Medicine, Dec. 20, 2007

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