A separate report by David Meltzer, MD, PhD, and colleagues at the University of Chicago found that an HM program in an academic general medicine service led to a 30% reduction in 30-day mortality rates during its second year of operation.7 And a 2004 study led by Jeanne Huddleston, MD, at the Mayo Clinic College of Medicine in Rochester, Minn., found that a hospitalist-orthopedic co-management model (versus care by orthopedic surgeons with medical consultation) led to more patients being discharged with no complications after elective hip or knee surgery.8 Hospitalist co-management also reduced the rate of minor complications, but had no effect on actual length of stay or cost.
A subsequent study by the same group, however, documented improved efficiency of care through the HM model, but no effect on the mortality of hip fracture patients up to one year after discharge.9 Multiple studies of hospitalist programs, in fact, have seen increased efficiency but little or no impact on inpatient mortality, leading researchers to broadly conclude that such programs can decrease resource use without compromising quality.
In 2007, a retrospective study of nearly 77,000 patients admitted to 45 hospitals with one of seven common diagnoses compared the care delivered by hospitalists, general internists, and family physicians.10 Although the study authors found that hospitalist care yielded a small drop in length of stay, they saw no difference in the inpatient mortality rates or 14-day readmission rates. More recently, mortality has become ensnared in controversy over its reliability as an accurate indicator of quality.
When we sit on committees, people often look to us for answers and directions because they know we’re on the front lines and we’ve interfaced with all of the services in the hospital. You have a good view of the whole hospital operation from A to Z, and I think that’s pretty unique to hospitalists.
-Shai Gavi, DO, MPH, chief, section of hospital medicine, assistant professor, Stony Brook University School of Medicine, Brookhaven, N.Y.
Half of the Equation
Despite a lack of ideal metrics, another promising sign for HM might be the model’s exportability. Lee Kheng Hock, MMed, senior consultant and head of the Department of Family Medicine and Continuing Care at Singapore General Hospital, says the 1,600-bed hospital began experimenting with the hospitalist model when officials realized the existing care system wasn’t sustainable. Amid an aging population and increasingly complex and fragmented care, Hock views the hospitalist movement as a natural evolution of the healthcare system to meet the needs of a changing environment.
In a recent study, Hock and his colleagues used the hospital’s administrative database to examine the resource use and outcomes of patients cared for in 2008 by family medicine hospitalists or by specialists.11 The comparison, based on several standard metrics, found no significant improvements in quality, with similar inpatient mortality rates and 30-day, all-cause, unscheduled readmission rates regardless of the care delivery method. The study, though, revealed a significantly shorter hospital stay (4.4 days vs. 5.3 days) and lower costs per patient for those cared for by hospitalists ($2,250 vs. $2,500).11
Hock points out that, like his study, most analyses of hospitalist programs have shown an improvement in length of stay and cost of care without any increase in mortality and morbidity. If value equals quality divided by cost, he says, it stands to reason that quality must increase as overall value remains the same but costs decrease.
“The main difference is that the patients received undivided attention from a well-rounded generalist physician who is focused on providing holistic general medical care,” Hock says, adding that “it is really a no-brainer that the outcome would be different.”