Hospitalist Model May Reduce Costs Without Adversely Affecting Outcomes

Laurie Barclay, MD

May 25, 2007

May 25, 2007 (Dallas) — For patients with common inpatient diagnoses, the hospitalist model reduces length of stay and costs without adversely affecting mortality or readmission, according to a presentation by Peter K. Lindenauer, MD, MSc, medical director of clinical and quality informatics at Baystate Health and associate professor of medicine at Tufts University School of Medicine, in Springfield, Massachusetts, at Hospital Medicine 2007, the Society for Hospital Medicine annual meeting.

The hospitalist model, or designating specified physicians as hospitalists available to admit patients, was put forth a decade ago by Robert M. Wachter, MD, now a professor and associate chairman of medicine at the University of California, San Francisco (UCSF). Dr. Wachter was not involved with Dr. Lindenauer’s study, but was asked by Medscape to provide independent comment.

"Since I first described the hospitalist model in a 1996 New England Journal of Medicine article [335(7):514-7], the field has grown from a few hundred physicians to more than 20,000 today," said Dr. Wachter, who is also chief of the medical service at UCSF Medical Center. "This makes it the fastest growing physician specialty in the history of medicine. This remarkable growth has been fueled by studies that have shown that the model markedly improves efficiency without harming (and quite possibly improving) quality and medical education."

However, Dr. Wachter noted that previous studies were criticized for being relatively small, mostly involving only a few hospitalists, with short follow-up and limited generalizability.

"The study by Lindenauer and colleagues is by far the largest study to date testing the following critical hypothesis: Do hospitalists improve value or quality/cost when compared with care delivered by nonhospitalist generalists?" Dr. Wachter said. "The strongly positive result is likely to further increase the diffusion of hospitalist programs. Importantly, despite impressive cost and length-of-stay savings, there was no evidence that there was any harm in quality, [with] stable mortality and readmission rates."

Dr. Lindenauer’s group performed a retrospective cohort study of 76,296 patients 18 years and older who were hospitalized at 1 of 45 US hospitals that used an expanded set of physician specialty codes, which included an option to categorize attending physicians as hospitalists.

The investigators reviewed the hospital records of patients discharged between September 1, 2002 and June 30, 2005 who had a primary diagnosis of pneumonia, heart failure, chest pain, ischemic stroke, urinary tract infection, acute exacerbation of chronic obstructive pulmonary disease, or acute myocardial infarction, and who were attended by a hospitalist, general internist, or family physician.

A series of multivariable models evaluated the independent effect of physician specialty on length of stay, cost, inpatient mortality, and readmission, after adjustment for patient age, sex, ethnicity, insurance, principal diagnosis, and comorbid conditions; hospital characteristics, including size, teaching status, location, and urban or rural setting; and physician’s annual case volume. Generalized estimating equation models accounted for a clustering of patients with physicians and a clustering of physicians within hospitals, and all models included an interaction term of physician specialty with principal diagnosis.

By specialty, the average number of patients with 1 of the 7 selected diagnoses cared for each year was 20 patients for the 971 family physicians, 30 patients for the 993 general internists, and 75 patients for the 284 hospitalists.

Compared with patients cared for by general internists, those cared for by hospitalists had a shorter length of stay (adjusted difference, -0.6 days; 95% confidence interval [CI], -0.7 to -0.5 days) and lower costs (adjusted difference, -$417; 95% CI, -$704 to -$131). However, inpatient mortality was similar in both groups (odds ratio [OR], 0.95; 95% CI, 0.85 to 1.05), as was 14-day readmission risk (OR, 0.98; 95% CI, 0.91 to 1.05).

Compared with patients cared for by family physicians, those cared for by hospitalists had a shorter length of stay (adjusted difference, -0.4 days; 95% CI, -0.6 to -0.3 days). However, both groups had similar costs (adjusted difference, $8; 95% CI, -$296 to $311), mortality (OR, 0.95; 95% CI, 0.83 to 1.07), and readmissions (OR, 0.95; 95% CI, 0.87 to 1.04).

"For 7 of the most common conditions seen on an inpatient medical service, when compared with care provided by general internists, the hospitalist model was associated with reductions in length of stay (0.6 days) and costs (~$400) without adversely affecting mortality or readmission," Dr. Lindenauer told Medscape. "When compared with care provided by family physicians, the hospitalist model was associated with reductions in length of stay (0.4 days), but similar costs, mortality, and readmission."

"The improved efficiency was observed at both teaching and nonteaching institutions," said Dr. Lindenauer. "These efficiency gains were only partially explained by the higher inpatient volumes of hospitalists compared with the 2 other physician groups. This suggests that the other aspects of the hospitalist model — such as their on-site and often 24-hour presence and the alignment of their incentives with those of the hospital — can result in greater efficiency."

According to Dr. Wachter, the major strengths of this study include size (many times larger than earlier studies), rigorous methodology, and multivariate analysis accounting for all the key variables. Limitations include lack of information concerning the way some physicians came to be coded as hospitalists, and difficulty in determining whether the source of the information was administrative data or clinical chart reviews.

"Overall, though, the methodology seems appropriate and strong, especially since the length-of-stay differences are so robust (approximately half a day) that they are unlikely to be explained by any subtle methodologic flaws," Dr. Wachter said. "Thousands of hospitals have chosen to provide financial support for hospitalists, in part because they believe that there will be a positive return on investment. This study provides the strongest evidence to date that this investment, which is more than $1.5 billion in the United States alone, is a wise one."

Recommendations for future research proposed by Dr. Wachter include determining the impact of hospitalists on process and outcome measures of quality, on patient satisfaction, and on trainee education. Factors making individual hospitalists, or groups of hospitalists, more or less effective in meeting their quality and efficiency goals should also be explored, as should outcomes associated with hospitalist comanagement of surgical patients.

"Based on these results, we believe that hospitalist programs will continue to be attractive to hospitals seeking ways of improving efficiency," Dr. Lindenauer concluded. "While our study provides valuable data on differences in costs and length of stay, future research is required to evaluate the impact of hospitalists on quality of care and patient satisfaction."

No external funding source supported this project. None of the authors reported any relevant financial relationships, except Dr. Auerbach, who is supported by a K-08 award from HRQ, and Michael Rothberg, who is supported by a Doris Duke training award. Dr. Wachter is on the board of directors of the American Board of Internal Medicine and on the Healthcare Advisory Board for Google.

Hospital Medicine 2007: Abstract 40. Presented May 23-25, 2007.

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