Study casts doubt on effectiveness of hospitalist care

The proportion of inpatient care provided by hospitalists has more than quadrupled since 1995, and many studies have found that patients cared for by hospitalists go home sooner than those who receive hospital care from their primary care physicians.

Shorter lengths of stay save hospitals money and could be a sign of higher-quality care, but a new study of nearly 60,000 Medicare patients over five years sheds light on how hospitalist-treated patients fare after they are discharged.

The patients cared for by hospitalists were discharged more than half a day earlier than patients treated by their primary care physicians, and their hospital charges were $282 lower on average. But the hospitalists' patients were 18% more likely to visit the emergency department within 30 days of leaving the hospital and 8% likelier to be rehospitalized within a month.

For the 30 days following discharge, the hospitalists' patients averaged $332 more in Medicare charges than patients treated by primary care physicians, meaning that hospitalist-provided care was costlier over a month despite the earlier discharges. The results were published in the Aug. 2 Annals of Internal Medicine (link).

"There could be discontinuity of care with hospitalists," said Yong-Fang Kuo, PhD, the study's lead author. "There may be post-discharge problems with communication that are causing hospitalists' patients to visit the emergency room and to be readmitted more often."

Thirty-seven percent of the patients in the study were treated by hospitalists, and today nearly half of inpatients are cared for by hospitalists, said Kuo, associate professor in the Dept. of Internal Medicine's Division of Geriatrics at the University of Texas Medical Branch in Galveston. Hospitalists specialize in treating inpatients and save primary care physicians the time it takes to care for their patients when they are hospitalized.

Cost only half of picture

Researchers did a good job of analyzing Medicare claims data, but the study does not examine patients' health outcomes, said Joseph Ming Wah Li, MD, president of the Society of Hospital Medicine, the organized medicine group that represents hospitalists.

"Cost information is hard to interpret without quality information," said Dr. Li, director of the hospitalist program at Beth Israel Deaconess Medical Center in Boston. "If the patient outcomes were the same, you could make a very robust argument that the hospitalists were providing higher-quality care by appropriately discharging patients sooner. We just don't know, based on this study."

Kuo argued that the readmission rate could be used as a proxy for care quality, noting that a new Medicare payment policy to penalize "excess readmissions" will take effect in October 2012 under the Patient Protection and Affordable Care Act.

Dr. Li disagreed. "We know the readmission rate will never be zero, but we want a system where patients who are sick enough to come back to the hospital are able to come back," he said. "And the ones who shouldn't return, or who can avoid rehospitalization through appropriate transitioning, those are unnecessary readmissions. The correct proxy for quality would be the unnecessary readmission rate, and that's not what we have in this study."

Kuo said she and her colleagues plan to study how hospitals' performance on quality indicators is correlated to how much of their inpatient care is provided by hospitalists.

"We are also going to study individual hospitalists," she said. "Some hospitalists have more experience than others; maybe their outcomes are better. We will be doing more detailed analysis."