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Proof Positive


 

Many studies have been published in recent years about the effect of hospitalists on outcomes, efficiency, and cost-effectiveness of care (see also “In the Literature,” p. 30). While the studies have demonstrated varying results, the majority suggest that hospitalists contribute positively to care. And the tremendous growth of hospitalist programs nationwide indicates that hospital administrators and others agree.

Does this mean that there have been enough studies about the cost-effectiveness and efficiency of hospitalists, and about outcomes relating to hospitalists? Also, where should hospitalist research go next?

Looking Back

To date, the results of studies regarding hospitalists and their effect on outcomes and cost-effectiveness have varied. Most suggest positive correlations:

  • Diamond, Goldberg, and Janosky demonstrated a 54% decrease in hospital readmission rates and shorter LOS when a community teaching hospital implemented full-time faculty hospitalists.1
  • Auerbach, Wachter, and colleagues studied 5,308 patients cared for by hospitalists and community physicians at a community teaching hospital. They found that the voluntary hospitalist service reduced lengths of stay and costs that were statistically significant in the second year the services were used.2
  • Bellet and Whitaker compared traditional ward service with a hospitalist system of care at a pediatric teaching hospital and found that the average LOS was a day shorter for the patients care for by hospitalists.3
  • A review of five years of evidence-based hospitalist studies showed an average 13.4% cost reduction, as well as a 16.6% LOS reduction.4
  • Rifkin, et al, compared treatment provided by hospitalist and primary care physicians among patients with community-acquired pneumonia. The authors found that hospitalists’ patients had shorter LOS and reduced costs.5
  • Wachter reviewed the data to date in 2002 and concluded that it supported the hypothesis that hospitalists can lead to improved efficiency without compromising patient outcomes or satisfaction.6
  • Meltzer, et al, studied costs and outcomes associated with patients on an academic general medical service cared for by hospitalists and non-hospitalists. They found that the average adjusted costs were similar for hospitalists and non-hospitalists in the first year. However, hospitalist costs were reduced by $782 in year two. The authors also concluded that short-term mortality was lower for hospitalists as well, but, again, only in the second year.7
  • Auerbach and Pantilat assessed the effects of hospitalists’ care on communication, care patterns, and outcomes of end-of-life patients. They found that hospitalists documented “substantial efforts” to communicate with their dying patients and their families; and this may have resulted in better care.8
  • Hauer, et al, analyzed house staff and student evaluations of their attending physicians and internal medicine ward rotations at two university-affiliated teaching hospitals over a two-year period. They found that trainees reported they received more effective teaching and more satisfying inpatient rotations when supervised by hospitalists.9
Studies that “go under the hood and answer questions about the mechanisms by which hospitalists improve outcomes” also will be useful. “Hospitals need to realize that hospitalists aren’t a magic bullet. It’s not as simple as implementing a hospitalist model of care and costs go down.”

—Peter Lindenauer, MD, MSc

A few studies have indicated that hospitalists may have less impact on costs and outcomes. Among them:

  • Smith, Westfall, and Nicholas performed a retrospective chart review of HMO critical care patients and found that the mean charge by primary care physicians ($5,680) was significantly lower than that of the hospitalists ($7,699). The authors suggested that “claims of better and cheaper care by hospitalists need further investigation” and that HMOs should not mandate the use of hospitalists.10
  • Kearns, et al, compared clinical outcomes and care costs for patients treated by hospital- and clinic-based attending physicians. The researchers detected no difference in costs or clinical outcomes associated with either type of physician.11

Clearly, the majority of the studies suggest that hospitalists have a positive effect on outcomes, effectiveness, and/or costs. But can the research take credit for the growing popularity of hospitalists?

“The studies have gone a long way toward proving the value of hospitalist care. But the experiences of physicians and hospitals also have been very positive,” says Robert Wachter, MD, FACP, professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. He adds that the studies wouldn’t mean much if the experiences of hospitals didn’t back up their findings.

So what has been learned from hospitalist studies on costs and outcomes to date? The data “suggest that hospitalists have the greatest impact on efficiency,” says Dr. Wachter, in part because “it is much easier to measure lengths of stay than improvements in outcomes.” He states that data are “strong on cost-effectiveness and reducing lengths of stay.”

Dr. Wachter says that the greatest effect of hospitalist studies to date has been “the presence of a very large number of energetic, enthusiastic physicians who ‘live’ in the hospital and have embraced the notion that they are there not only to improve care but to benefit the hospital and contribute to making it a better place. We have seen hospitalists emerge as leaders on virtually every committee aimed at improving care.”

Peter Lindenauer, MD, MSc, a hospitalist at Baystate Medical Center in Springfield, Mass., and assistant professor of medicine at Tufts University School of Medical School, Boston, agrees.

“What’s been most astounding has been the growth of the field,” he says. “And one of the more interesting facets has been the extent to which hospitalists have fully integrated themselves into every aspect of hospital operations and care in a short period of time.

“It is now rare to find hospitals that do not have hospitalists,” continues Dr. Lindenauer. “It also is uncommon to see quality improvement, patient safety, patient satisfaction, and other activities at the hospital that don’t have a hospitalist as a key member.”

Nonetheless, there is always room for improvement. While the data “are quite clear that efficiency improves without harming quality, they are not strong enough to show definitively that hospitalists improve quality and safety,” cautions Dr. Wachter. “We need more data on this.”

He cautions that data involving mature hospitalist programs may not show the same increases in efficiency as studies about new or young programs. He refers to a study coming out next year that looks at six academic medical centers and mature hospitalists programs and doesn’t show the same increase in efficiency as earlier studies.

“It may be natural that some efficiency may wash away. As hospitalists become more dominant, they set the practice style and standards for their hospitals,” he says. “We need to continue to look for ways to improve.” However, he stresses that none of this takes away from the original argument that hospitalists improve efficiency.

I don’t know what future studies will look like. I think we’ll see more studies about hospitalists in the community environment, more studies on mechanisms, and more hospitalists doing research on hospital care.

—David Meltzer, MD, PhD

The Next Generation of Hospitalist Studies

Dr. Wachter suggests that the next generation of hospitalist research will have greater impact and importance if it goes beyond examining efficiency and cost-effectiveness.

“I don’t think the studies we began years ago are very interesting anymore, and I don’t think the system is looking for more of them,” he says. Now, research needs to look at the role of hospitalists—the role of hospitalists in teaching hospitals, what physicians make the best hospitalists, and so on.

Dr. Lindenauer would like to see more studies about hospitalists’ impact on quality of care. “There remains a relative paucity of information on this,” he says. “To date, there have been mostly small observational studies on this.” There is a need “to learn more about the impact of hospitalists, especially on more clinical outcomes and quality.”

Studies that “go under the hood and answer questions about the mechanisms by which hospitalists improve outcomes” also will be useful predicts Dr. Lindenauer. “Hospitals need to realize that hospitalists aren’t a magic bullet. It’s not as simple as implementing a hospitalist model of care and costs go down.”

Results of such studies need to be shared with hospitals nationwide so they can make the best and most effective use of hospitalists.

Studies addressing hospitalists working in specialty areas also are likely to become more common in the future, says Michael Phy, DO, MSC, associate program director and assistant professor at Texas Tech University Health Sciences Center in Austin, Texas. Earlier this year, he and his colleagues published a study looking at the hospitalist’s impact on geriatric surgical patients.12 During a two-year period, Dr. Phy and his team studied 466 elderly patients admitted to a hospital for surgical repair of a hip fracture. They found that a hospitalist model decreased the time to surgery, as well as the time from surgery to discharge, without adversely affecting mortality.

Dr. Phy’s study has interested other hospitals around the country. “We’ve been invited to speak on the model. People want to know how we did it, what the flaws were,” he explains. “The say that they are interested in using this kind of model, and they want to learn how to do it.

“I would like to see more studies about patient satisfaction and hospitalists,” says Dr. Phy. He also thinks that more studies about the impact of hospitalists on resident education will be useful. “There are a lot of studies about hospitalist involvement with residents; I am more interested in hospitalist’s indirect impact on residents. Does resident education improve when they are not so overworked because they have hospitalists who help provide patient care?”

In contrast, David Meltzer, MD, PhD, a hospitalist and an associate professor of medicine, General Internal Medicine, at the University of Chicago, doesn’t see patient satisfaction as a priority for the future. “Patient satisfaction isn’t an unreasonable thing to study,” he asserts. “But I personally don’t think that this is the most important issue.

“I don’t know what future studies will look like. I would like to say that we will see more and bigger studies,” continues Dr. Meltzer. “I also think we’ll see more studies about hospitalists in the community environment, more studies on mechanisms, and more hospitalists doing research on hospital care.”

To date, “hospitalist studies have been messy and ask the wrong questions,” says Robert Centor, MD, director of the Division of Internal Medicine, professor of internal medicine, and associate dean at the Huntsville Regional Medical Center in Alabama. He suggests that future studies should “look at hospitalists as a function of years of experience—first-year hospitalists compared to second, third, and forth.” Another useful focus would be to compare hospitalists with non-hospitalists, looking at “volume and lengths of stay and where the curve straightens out.”

Hurdling the Barriers

Especially as they get larger and involve more facilities, hospitalist studies will face some challenges. “Different people define hospitalists in different ways. It’s hard to tell what definitions studies are using; so in looking at two studies or trying to compare a study to what is happening at your facility, you don’t know if you’re comparing apples to apples or apples to oranges,” says Dr. Centor.

The nature of studies addressing hospitalist quality also poses some challenges. “Quality improvement interventions are harder to measure and are more institutionally dependent. Results can’t necessarily be translated from one institution to another,” explains Dr. Lindenauer.

He suggests that identifying funding sources for hospitalist studies will be an ongoing challenge. Researchers will be competing for an already shrinking number of dollars.

“The funding base for producing knowledge is limited, especially for studies that are not intrinsically disease-focused,” agrees Dr. Meltzer.

There is some organizational support for hospitalist researchers. For example, Dr. Phy notes that the SHM Web site will soon have a page where “you can list yourself and your clinical research interests, with the goal of hooking up with collaborators or mentors.”

The Third Generation

“At a certain point, we will turn our attention away from ‘navel gazing’—constantly assessing our impact—and accept that the hospitalist model is here to stay. Then hospitalists will begin to conduct research about the management of common conditions we take care of on a day-to-day basis—asthma, pneumonia, heart failure, COPD, and so on,” says Dr. Lindenauer. This is the third generation of hospitalist research, he suggests, adding, “This is where I would like to see the field evolve.” TH

Contributing Writer Joanne Kaldy wrote about psychiatric hospitalists in the October 2005 issue.

References

  1. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1999;130:338-342.
  2. Auerbach AD, Wachter RM, Katz P, et al. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002:137;859-865.
  3. Bellet PS, Whitaker RC. Evaluation of a pediatric hospitalist service: impact on length of stay and hospital charges. Pediatrics. 2000;105(3):478-484.
  4. No author listed. Hospitalist prove their worth for capitated providers, plans. Capitation Manag Rep. 2002;Apr;9(4):62-64, 49.
  5. Rifkin WD, Conner D, Silver A, et al. Comparison of processes and outcomes of pneumonia care between hospitalists and community-based primary care physicians. Mayo Clin Proc. 2002;77(10):1053-1058.
  6. Wachter RM. The evolution of the hospitalist model in the United States. Med Clin North Am. 2002;86(4):687-706.
  7. Meltzer D, Manning WG, Morrison J, et al. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874.
  8. Auerbach AD, Pantilat SZ. End-of-life care in a voluntary hospitalist model: effects on communication, processes of care, and patient symptoms. Am J Med. 2004;116(10):669-675.
  9. Hauer KE, Wachter RM, McCulloch CE, et al. Effects of hospitalist attending physicians on trainee satisfaction with teaching and with internal medicine rotations. Arch Intern Med. 2004;164(17):1866-1871.
  10. Smith PC, Westfall JM, Nicholas RA. Primary care family physicians and two hospitalist models: comparison of outcomes, processes, and costs. J Fam Pract. 2002;51:1021-1027.
  11. Kearns PJ, Wang CC, Morris WJ, et al. Hospital care by hospital-based and clinic-based faculty: a prospective, controlled trial. Arch Intern Med. 2001;161:235-241.

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