The value of hospitalist?


Category : General, Medical Rants

Background: Several studies suggest that hospitalists can improve costs or outcomes in academic medical centers, but almost all of these studies have nonrandom assignment of patients to hospitalists, and no multi¬center studies exist. We studied patients assigned to hospitalist or non-hospitalist physicians based only on day of admission to determine the effects of hospitalists on outcomes and costs in 6 academic medical centers.
Methods: From July 2001 to June 2003, 31,891 general medicine inpatients were assigned to hospitalist or non-hospitalist physicians according to a predetermined daily call schedule. Patient interviews at admission and 1 month after discharge and administrative data were used to study effects on outcomes and costs.
Results: Twelve thousand and onepatients were cared for by hospitalists and 19,890 by non-hospitalists. There were no statistically significant differences in age, race, gender, Charlson Index, or distribution of primary diagnosis be¬tween the 2 groups. There were no statistically significant differences in in-hospital mortality, 30-day readmission and emergency room use, 30-day self-reported health status, or patient satisfaction. Mortality data up to 1 year after admission are pending. Average length of stay was 0.05 days shorter for hospitalist patients but this difference was not statistically significant. Costs were also similar between the groups. Individual center analyses had large confidence intervals on outcomes and costs and failed to show statistically significant effects on any measure of outcomes or costs except for 1 of the larger centers, which had lower length of stay and costs for hospitalists.
Conclusions: Hospitalists had small effects on selected outcome measures available to date, but did not produce the large resource savings that had been suggested by some earlier studies. The effectiveness of hospitalists appeared to vary by site, but was difficult to assess due to limited statistical power for site-specific analyses. Understanding the factors, such as physician experience, that may influence the effectiveness of hospitalists is important for maximizing the efficacy of hospitalist programs, because effects on outcomes may be small, vary by site, and be difficult to distinguish from chance in a specific clinical setting.

From the July/August 2005 issue of The Hospitalist.

Much of the fire behind the rapid growth of the hospitalist movement comes early studies which suggested that hospitalists made a large difference in cost and quality of care. This study suggests that we must be careful in attributing benefits. I do believe that there is a valid volume efficacy curve, but the big question is how we determine it. Having the title does not make one a better inpatient doctor. As the hospitalist movement grows rapidly, insuring consistent quality will become more difficult.

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Comments (3)

I doubt anyone who chooses to be a hospitalist does it because of outcome data.

Hospitalists prorgrams are full of physicians exiting the frustrations primary care. The residents becoming hospitalists choose for mainly the much better hours, better pay.

I agree with pj’s premise. In our institution, the initial hospitalists were internists (and FPs) who were either tired of office-based practice or, quite frankly, not very efficient at running an office practice. They turned out to be, not surprisingly, not very efficient at being hospitalists and quickly tired of being hospitalists! They stay because of [1] guaranteed salary [2] guaranteed work hours and [3] a very generous amount of time off.

Outside of academia, there are many good hospitalist programs, but I suspect it will take many years before that becomes the norm everywhere.

Just like any endeavor, people will go into it if it seems
personally and financially rewarding.

what’s unique about the hospitalist field is that it directly competes with outpatient primary care. Students and practitioners who once did outpatient primary care are rapidly choosing hospitalist work. why? that’s where the incentives are.

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