Study Suggests Use of Hospitalists May Reduce Lengths-of-Stay, Costs

A study recently published in the New England Journal of Medicine indicates that although hospitalist management of inpatients can reduce hospital lengths-of-stay, treatment costs associated with hospitalist care are only modestly lower than those of inpatients treated by general internists or family physicians. The researchers concluded that hospitalists offer "relatively modest improvements in efficiency as compared with traditional approaches to caring for hospitalized patients," and they urged further research into the best way to utilize these specialists.

Notably, the authors of the study, "Outcomes of Care by Hospitalists, General Internists, and Family Physicians," acknowledged that along with the hospitalist model comes a higher risk for medical errors and adverse events, as patients are handed off to a different care provider at hospital admission and discharge.

The researchers conducted a retrospective cohort study of 76,926 adult patients who were hospitalized for pneumonia, heart failure, chest pain, ischemic stroke, urinary tract infection, acute exacerbation of chronic obstructive pulmonary disease or acute myocardial infarction. Represented in the study were 284 hospitalists, 993 general internists and 971 family physicians.

Of the patients studied, 32 percent were cared for by hospitalists, 43 percent were cared for by general internists and 25 percent were cared for by family physicians. Slightly more than 4 percent of patients included in the study died during hospitalization, and 6.7 percent were readmitted within 14 days after discharge.

Multivariable analyses of the study's findings showed that, compared with patients treated by family physicians, patients treated by hospitalists had a hospital length-of-stay that was only 0.4 day shorter; costs, rates of death and readmission rates were similar for the two groups. Mean total costs per stay for patients treated by family physicians were $7,077; for hospitalists, they were $8,078.

Comparisons between patients treated by hospitalists and those cared for by general internists yielded similar results. Fourteen-day admission rates were 6.3 percent for patients cared for by hospitalists and 6.9 percent for those seen by general internists. Mean length-of-stay was 4.7 days for patients treated by hospitalists and 5.2 days for those who saw general internists.

"In this large observational study," the authors wrote, "we found that hospitalist care was associated with inpatient rates of death and 14-day readmission rates that were similar to the rates for care provided by general internists and family physicians. Furthermore, although we observed small differences in cost between the care provided by hospitalists and that provided by general internists, these findings were not consistent across statistical models, and the costs between hospitalists and family physicians were similar.

"Nevertheless, patients treated by hospitalists had a length-of-stay that was modestly shorter than that of patients treated by general internists or family physicians, and these differences persisted even after adjustment for physician caseload, suggesting that other proposed benefits of the hospitalist model, such as on-site availability or the alignment of incentives with the hospital, are more related to reductions in length-of-stay than is experience."

The researchers acknowledged several limitations of the study. First, they had to rely heavily on data that could have been confounded by any number of factors. For example, information about the age and years of practice of the physicians in the study was not available; both of these factors could influence resource use patterns. The researchers also had no information about the hospitalist services themselves, especially how long they had been in place, how patients were assigned to hospitalists or whether hospitalists were offered incentives to reduce patients' lengths-of-stay.

Perhaps most significantly, the researchers had no information on how long the various physicians had treated the study patients or whether the patients were the physicians' own patients, the patients of their partners or patients without primary care physicians who had been assigned to a physician. Also significant is the fact that the researchers only had access to information about in-hospital deaths and not about how many patients died after being discharged. They also were unable to assess patient costs after discharge.

Finally, because the researchers limited their study to seven conditions that make up a relatively small percentage of the annual caseload for physicians who treat patients in hospitals, the results may not be applicable to the full spectrum of inpatient medicine, they said.