Halasyamani L, Valenstein P, Friedlander M. et al. A comparison of two hospitalist models with traditional care in a community teaching hospital. Am J Med. 2005;118:536-543.
Background: A growing body of literature has demonstrated the effects of hospitalists on reducing inpatient length of stay and cost of care, with some literature showing a decreased in-hospital and 30-day mortality. However, most prior studies were conducted in academic medical centers or health maintenance organizations where one group of hospitalists, employed by the institution within which they worked, was compared with traditional primary care physicians. Direct comparisons between different hospitalist models practicing within a single institution have not been published. As a result, the impact of different hospitalist characteristics, including employment status and reimbursement incentives, on inpatient resource utilization and patient care outcomes is unknown.
Methods: Halasyamani and colleagues conducted a retrospective cohort study of 10,595 patients in a tertiary care community-based teaching hospital in which private hospitalists, academic hospitalists, and community physicians all practice. They measured risk-adjusted length of stay, variable costs, 30-day readmission rates, and in-hospital and 30-day mortality for patients treated by each of these three groups, controlling for potentially confounding variables. Community physicians belonged to 21 rounding groups, most of which were private or solo. Two of the community physicians groups were hospital-owned practices reimbursed by a relative value unit system. The private hospitalist group was self-employed with no financial relationship to the hospital and worked an average of 40 weeks per year. Community physicians and private hospitalists worked Monday-Friday and covered weekends or holidays about 25% of the time. Academic hospitalists worked with internal medicine residents and students on a teaching service. They were employed by the hospital using a relative value unit system. They worked an average of 14 weeks per year as an inpatient attending in half-month rotations, which included weekend coverage.
Results: There was a 20% reduction (-0.72 days absolute difference) in length of stay on the academic hospitalist service (P<0.0001) and 8% (-0.28 days absolute difference) on the private hospitalist service (P=0.049) compared with community physicians. Case-mix adjusted relative total costs were 10% less ($173 absolute difference) on the academic (P<0.0001) and 6% less ($109 absolute difference) on the private hospitalist services (P=0.02) compared with community physicians. There were no differences in 30-day readmission, in-hospital and 30-day mortality between the three groups.
Discussion: This study is the first to look at the effects of two separate hospitalist models on resource utilization and patient outcomes within the same institution. Although both the academic and private hospitalist groups demonstrated improved resource utilization as compared with the community physicians, the magnitude of benefit was much greater for the academic hospitalist group.
As the authors point out, one major difference between the two groups was employment status, with the academic hospitalists employed directly by the hospital and the private hospitalists receiving all payment directly from payers. Previous studies have also focused on hospitalists, which were employed by the institution at which they worked, raising the question of whether alignment of employee and employer incentives is an important factor affecting resource utilization outcomes.
Results of this study highlight the need for more studies which seek to clarify specific physician-level, group-level, and organization-level characteristics of hospitalists that result in improved resource utilization and patient care outcomes.
The Last Few Hours
Bailey FA, Burgio KL, Woodby LL, et al. Improving the processes of hospital care during the last hours of life. Arch Int Med. 2005;165(15):1722-1727.