Promise or Insanity?
Insanity is doing the same thing over and over again and expecting different results.—Albert Einstein
A hospitalist is defined as a provider whose primary professional focus is the general medical care of hospitalized patients.1
While this allows a concise, usable characterization of a hospitalist, it’s not the whole story. If it were, medical residents, nurses, and inpatient pharmacists all would be hospitalists.
Indeed, a traditional internist with a large hospital practice could reasonably deem him or herself a hospitalist. What defines what a hospitalist does, or should be doing—and how, if at all, is that different than what a traditional internist does in the hospital?
Education Deficiencies
Early data suggested a stark difference between outcomes attributed to hospitalists and general internists who rotated between the clinic and the hospital.
An early experience from the academic environment showed a hospitalist teaching model, when compared with a traditional teaching service, resulted in a 0.6-day length-of-stay (LOS) reduction and a cost savings of $700 per patient with no decrement in the quality of care, clinical outcomes, or satisfaction of provider, housestaff, or patient.2
Similar findings were revealed when community teaching and non-teaching hospitals transitioned to the hospitalist model.3-5 A 2002 review of 19 hospitalist studies revealed an average decreased LOS of 17% coupled with a 1% reduction in hospital costs per case.6
The year 2002 also saw, for the first time, published data that the hospitalist model could reduce in-hospital and 30-day mortality rates.7,8 Together with a 2004 paper showing reductions in minor post-operative complications with hospitalist comanagement of orthopedic patients, these studies suggested hospitalists’ care transcended mere cost savings, improving quality measures as well.9
As one of Albert Einstein’s most famous maxims warns, hospitalists on a mission to improve quality of care will be poorly served by repeating training patterns of dubious value.
More recently, however, Lindenauer, et al., found important but less robust differences between hospitalists and non-hospitalists.10 As compared with traditional internists, hospitalists reduced LOS 0.4 days and cost per patient by $268.
While these moderate reductions in LOS and cost versus traditional internists are statistically and clinically significant, they are less vigorous than previous findings. Despite some methodological concerns, this largest investigation—in terms of hospital sites (45), patients (76,926) and hospitalists (284)—revealed no demonstrable improvements in the quality outcomes measured.
Similarly, another recent publication found consultation, provided by medical subspecialists or hospitalists, did not improve glycemic control, rate of appropriate venous thromboembolism (VTE) prophylaxis or perioperative beta-blocker use compared with patients cared for by surgeons alone.11,12
While it is tempting to think hospitalists have re-engineered the systems of care to the point that any provider can fluently and adroitly care for patients, continued reports of less-than-optimal hospital outcomes do not support this hypothesis. More likely, the variance in the early and recent studies relates to the egress from the hospital of less capable or engaged non-hospitalist providers such that more recent findings reflect a comparator group that more closely approximates, in terms of clinical volume, hospitalists.
It’s time to reconsider how we document the merit of hospitalists. Continuing to benchmark hospitalists against non-hospitalists will not tell us if inpatient care is becoming safer, only how one group is doing compared with another. Nor will it necessarily lead to improvements in the quality of care.
