Data show hospitalists can improve quality

Standardized care, best practices achieved

Hospitalists are gaining ground in health care, proving that they can improve quality of care while simultaneously reducing costs for the provider. Quality and peer review professionals should consider spearheading the adoption of a hospitalist program as a means of seeking better patient care, some advocates say.

Hospitalists are physicians who specialize in the care of hospitalized patients. Unlike most other physicians, they can care for a wide range of patients within the hospital and continue with a patient for long periods. By being available around the clock, hospitalists are able to attend to changes in a patient’s condition as they occur, proponents say, rather than having care delayed until the primary care physician can arrive from his or her practice. Advocates of a hospitalist system say the critical-care skills of these specialists are important factors in helping more critically ill hospital patients get the level of care they need. By delivering more efficient and timely care, hospitalists can reduce the time a patient spends in the hospital and the associated cost of care.

Providers are adopting the hospitalist model at a rapid pace; quality improvement is the primary motivator, says Ron Greeno, MD, chief medical officer and senior vice president of physician services at Cogent Healthcare in Laguna Hills, CA, one of several companies that provides hospitalist services to hospitals across the country. The system of hospitalists is very different from the traditional model of primary care physicians coming to the hospital to care for individual patients.

"Every hospital I’ve ever worked in has had the goal of trying to standardize care given by physicians within the walls of the hospital," Greeno says. "The first big obstacle is the sheer numbers. With 400 physicians giving care, and most only spending small parts of the day in the hospital, they’re much more concerned with their private practice than your hospital goals. The second obstacle is the way physicians are paid."

Physicians are paid under a system that Greeno calls "a reverse incentive" because they receive more money when the patient stays in the hospital longer and more treatment is provided. Hospitals, of course, are paid a flat rate based on diagnosis, so they are motivated to get the patient out as quickly as possible (in addition to the fact that a shorter stay usually means the patient is doing better).

"So the hospital and physician incentives are disparate. That negatively influences a hospital’s ability to standardize care to a best practices level," Greeno says. "A hospitalist program, if structured right, can overcome both obstacles. You can have a hospitalist program that handles a very large percentage of hospital admissions with a small group of doctors."

The pay structure for hospitalists can be designed so that they have the same incentives and measure quality the same way as hospitals, he says. A well-designed program can produce a cadre of physicians who are eager to work within the hospital processes.

"That’s how you do quality control and improve outcomes," Greeno says. "It’s very difficult to measure outcomes sometimes, but you absolutely are capable of measuring adherence to process. You can determine whether your physicians adhered
to certain best practices that you know have been shown to result in better quality care."

LOS reduced 31% at one hospital

One recent study found that hospitalists have
a significant effect on the quality of patient care. Robert M. Wachter, MD, and Lee Goldman, MD, MPH, originally described the hospitalist model of inpatient care in 1996, and they recently reported on the clinical, financial, educational, and policy implications of the trend (JAMA 2002; 287:487-494).

They reviewed data regarding the effect of hospitalists on resource use, quality of care, satisfaction, and teaching; and analyzed the impact of hospitalists on the health care system.

Wachter and Goldman searched medical data-bases from 1996 to September 2001 for studies comparing hospitalist care with an appropriate control group in terms of resource use, quality, or satisfaction outcomes. They found most studies indicated that implementation of hospitalist programs was associated with significant reductions in resource use, usually measured as hospital costs (average decrease, 13.4%) or average length of stay (average decrease, 16.6%).

"The few studies that failed to demonstrate reductions usually used atypical control groups," they write. "Although several studies found improved outcomes, such as inpatient mortality and readmission rates, these results were inconsistent. Patient satisfaction was generally preserved, while limited data supported positive effects on teaching. Although concerns about inpatient-outpatient information transfer remain, recent physician surveys indicate general acceptance of the model."

Wachter and Goldman conclude that "empirical research supports the premise that hospitalists improve inpatient efficiency without harmful effects on quality or patient satisfaction."

Partly as a result of such data, the clinical use of hospitalists is growing rapidly, and hospitalists also are assuming prominent roles as teachers, researchers, and quality leaders, they say.

Even better results can be realized, says Craig Miller, MD, senior vice president of medical affairs at Baptist Health Care in Pensacola, FL. Miller tells Hospital Peer Review that the health care network has seen encouraging results from a hospitalist inpatient program put in place recently at its Baptist Hospital in Pensacola. The hospital implemented a hospitalist program in January 2001 and has seen a dramatic decrease in length
of stay and associated costs.

"Our encouraging results demonstrate that a hospitalist program can improve quality of care and patient satisfaction levels while reducing the cost of hospital services for patients covered under a variety of reimbursement programs," Miller says. "Since beginning our hospitalist program in January of last year, we have reduced costs and length of stay, but more importantly, readmissions have been lowered and patient satisfaction surveys are at our highest ever."

In addition to saving Baptist Hospital $1.76
million in its first year, the hospitalist program decreased the average length of stay 1.9 days or 31%, and decreased the average cost of a hospital case by $990, a 33% reduction. Satisfaction ratings by both patients and primary care physicians
were more than 99%.

Thirty-day readmission rate, another indication of quality care, was 6% for hospitalist-managed patients vs. an overall 11%. Miller notes that the Baptist Hospital results surpassed those found in Wachter and Goldman’s study.

Baptist’s decision to start its hospitalist program was prompted by a number of factors. Miller and other leaders at the hospital thought that such a program would improve quality of care, and support from local physicians, and they wanted to find better ways to manage care for all patients, especially those who were uninsured or who had no assigned physician.

Once they decided to start a hospitalist program, the next question was how. They could hire the hospitalists themselves and construct a program from scratch, or they could contract with an outside company to provide the hospitalists and manage the program. After looking at the work involved with starting a program on their own, they opted for the latter.

The result has been a dramatic change in how the hospital works with physicians, Miller says. The attitude of hospitalist physicians often is very different from what peer review professionals are used to seeing in a hospital, Miller says. For one thing, they agree upfront that they will work with the hospital’s quality and peer review leaders to meet certain goals. There usually is little debate on that general issue; to be a hospitalist is to work with the hospital for mutual goals.

"Right now, hospitals are at the mercy of the medical staff. Hospitals don’t pick the medical staff; the medical staff picks the hospital," Greeno says. "With a hospitalist program, you can pick the hospitalists, so you can have a common vision and common set of values, which is standardizing care to a best practices level."

Contracting with an outside hospitalist provider can be a good choice for some hospitals, but of course, it comes with a hefty price tag. But if you decide that an outside company can spare you some of the hassle involved with getting a hospitalist program off the ground and managing it every month, the expense might be worth it.

The hospital or the outside company most likely will contract with an existing physicians group in the community that will be the leader of the hospitalist program in that community. Because the group already is in the community, it understands the politics among local physicians and has relationships that will prove useful. The physicians group probably will have to add more physicians because of the large volume of patients it will be taking on, Greeno says.

The hospital will need to provide an infrastructure for the hospitalists that allows them to provide the expected high level of care. That means nursing support, communications systems, and sometimes additional training.

"You can expect to see decreased readmission rates and an incredibly high patient satisfaction rating. There is a real opportunity for hospitals to see a significant return on investment," Greeno says. "But the program has to be managed. This is much more than just dropping a lot of doctors in the place and telling them to go to work. The way that it’s set up from the start and the way it’s managed on a daily basis are two major keys to success."

[For more information, contact:

  • Ron Greeno, MD, Chief Medical Officer and Senior Vice President of Physician Services, Cogent Healthcare, 23282 Mill Creek Road #300, Laguna Hills, CA 92653. Telephone: (949) 699-6000.
  • Craig Miller, MD, Baptist Health Care, 1000 West Moreno St., P.O. Box 17500, Pensacola, FL 32501-7500. Telephone: (850) 434-4011.]

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