HM@15 – Are You Living Up to High Expectations of Efficiency?

In 2002, a summary article in the Journal of the American Medical Association helped put the relatively small but rapidly growing HM profession on the map. Reviewing the available data, Robert Wachter, MD, MHM, and Lee Goldman, MD, MPH, of the University of California at San Francisco (UCSF) concluded that implementing a hospitalist program yielded an average savings of 13.4% in hospital costs and a 16.6% reduction in the length of stay (LOS).¹

A decade later, the idea of efficiency has become so intertwined with hospitalists that SHM has included the concept in its definition of a profession that now comprises more than 30,000 doctors, nurses, and other care providers. HM practitioners work to enhance hospital and healthcare performance, in part, through “efficient use of hospital and healthcare resources,” according to SHM.

The growth of any profession can create exceptions and outliers, and observers point out that HM programs have become as varied as the hospitals in which they reside, complicating any attempt at broad generalizations. As a core part of the job description, though, efficiency and its implied benefit on costs have been widely promoted as arguments for expanding HM’s reach.

So are hospitalists meeting the lofty expectations?

A Look at the Evidence

A large retrospective study that examined outcomes of care for nearly 77,000 patients in 45 hospitals found that those cared for by hospitalists had a “modestly shorter” stay (by 0.4 days) in the hospital than those cared for by either general internists or family physicians.² Hospitalists saved about $270 per hospitalization compared with general internists but only about $125 per stay compared with family physicians, the latter of which was not deemed statistically significant.

Reversing Hospital Medicine’s Gains? The Effects of Care Fragmentation

Just as well-coordinated hospitalist programs can help reduce inpatient length of stay, other studies have found that the gains can be easily reversed by models that lead to more fragmentation of care.

A recent study by Kenneth Epstein, MD, MBA, FHM, FACP, found that such fragmentation, defined as the percentage of care provided by hospitalists other than the one who sees a specific patient the most, can significantly prolong LOS. The study linked a 10% increase in fragmentation to an increase of 0.39 days and 0.30 days in the LOS among pneumonia patients and heart failure patients, respectively.¹²

Arranging physician schedules to increase continuity, he says, can help avoid excessive fragmentation, as can ensuring efficient communication so that providers coming onto service understand the previous provider’s plan. Although Dr. Epstein’s study looked specifically at a hospitalist model, he stresses that other models could have as many, if not more, discontinuities of care.

“Hospitalist groups are more structured and aligned to try to resolve these issues—trying to reduce fragmentation of care and length of stay—whereas nonhospitalist groups may have as much fragmentation but may not be as motivated to try to resolve these issues,” he says.

Hospitalists are, in fact, leading efforts to address fragmentation-of-care concerns. At the 335-bed Johns Hopkins Bayview Medical Center in Baltimore, the hospitalist-instituted CICLE (Creating Incentives and Continuity Leading to Efficiency) model led to a 13% decline in unique providers and a 16% decrease in LOS, to 3.60 days from 4.31.¹³

Even more significantly, the average total hospital charge per admitted patient dropped roughly 20%, to about $8,000 from nearly $10,000. The study’s authors documented the most significant savings in medications, laboratory charges, and radiology charges

A more recent review of 33 studies found general agreement that hospitalist care led to reduced costs and length of stay but revealed less uniformity in the impacts on quality and patient outcomes.³