'Modest' benefits seen with use of hospitalists

No significant improvement in patient outcomes

As the use of hospitalists continues to grow, the ability to demonstrate the benefits of having these professionals on staff also grows in importance. Accordingly, the findings of a new study in the New England Journal of Medicine1 should be of particular interest to quality managers.

The study does not demonstrate the dramatic benefits many would have hoped. Compared with patients who were cared for by general internists, patients in the study had what the authors called "modestly" shorter hospital stays — specifically, about 0.4 fewer days per patient — as well as lower costs (an average of $268 per patient).

While it's true that both of these figures appear "modest," there were 76,926 patients in the study, so a benefit of $268 per patient would result in total savings of more than $20 million. In addition, avoiding the cost of nearly a half-day stay in the hospital for this many patients would also save a considerable amount of money.

When compared with patients cared for by family physicians, those treated by hospitalists had a similar shorter length of stay (LOS) of 0.4 days, but the cost of savings per patient was only $125. In addition, the study showed similar mortality rates and readmission rates for all patients.

A mixed bag?

While noting the many potential advantages of using hospitalists (i.e., all-day availability, greater familiarity with the hospital environment, greater clinical expertise through greater experience, greater incentives to reduce LOS, and freeing up the time of primary care physicians), the authors also noted a potential downside. "The hospitalist model introduces handoffs at the time of admission and at discharge, transitions during which the risk of errors and adverse events are high," they wrote. "These discontinuities, coupled with a lack of previous knowledge of a patient's care, may lead hospitalists to order excessive diagnostic tests, resulting in higher costs with no benefit to hospitalized patients."

Still, Peter K. Lindenauer, MD, Msc, FACP, of the Center for Quality and Safety Research, Baystate Medical Center in Springfield, MA, and lead author of the article, is supportive of the model.

"I think the major findings are that compared to traditional approaches for hospitalized patients, the hospitalist model appears to be a more efficient model, and we find their care associated with a small reduction in LOS — and potentially small cost reductions as well," he notes.

He adds that "this efficiency does not come at the expense of higher mortality or readmissions."

The differences the researchers observed were not explained by the annual number of cases, he says. "There seems to be something intrinsic to being a hospitalist that is associated with greater efficiency," he asserts. "Even internists with similar numbers of patients [have LOS and cost figures] more in keeping with other physicians in the hospital."

Lindenauer says that the greatest benefit in LOS that hospitalists provide lies in improving throughput. "If you shave half a day off LOS you can open up the hospital for many, many admissions each year with the same number of nurses and beds," he explains. This improved throughput, he adds, would be particularly beneficial for the ED and elective surgical procedures.

"In our hospital they care for 15,000 patients a year," he notes. "So, 0.4 days shorter LOS represents 6,000 bed days, or 1,200 more cases a year. That is even more significant than the cost savings."

Other benefits seen

Lindenauer says you must look beyond his study's findings to assess the true value of the hospitalist. "The LOS differences are not too far off from what some meta-analyses have shown, but we looked at a limited set of outcomes [pneumonia, heart failure, chest pain, ischemic stroke, urinary tract infection, acute exacerbation of chronic obstructive pulmonary disease, and acute myocardial infarction]," he says. "Many facilities turn to hospitalists to solve lots of other problems; they increasingly look to them as the glue that holds the hospital together everywhere between the ED and the ICU."

For QI personnel, he continues, they have a special value. "They are often the key clinical champion for addressing Joint Commission core measures, CMS Hospital Compare, and so forth," Lindenauer explains. "I worked with quality officers for many years and we struggled at finding physician champions."

The typical primary care provider, he explains, spends a limited amount of time each day in the hospital, "and is less willing to make the time and intellectual commitment to improve, say, immunization procedures. Thus, it is vital for the facility to provide a group of physicians to come to the hospital every day and have an investment in making things better."

More research needed

The authors concluded by calling for more research into how hospitalists function. "Given the large and growing presence of hospitalists, there remains a need to understand how hospitalist systems should be structured in order to improve the quality and outcomes of care," they wrote.

"While our study is interesting, ultimately it's sort of a very inward-looking kind of study," Lindenauer concedes. "It's probably more important to begin turning our attention to the fact that now that they are such a large and growing presence, how programs should be structured to achieve the best outcomes."

If you look at the 45 hospitals in the study, he notes, there was a wide range of income. "We need to ask questions such as, 'What are the structural changes required for rounding? What are the best performance models? How can hospitalists best collaborate with nurses and others? How can they best use IT to achieve improvements in care?'" Lindenauer asserts. "That's what I get excited about in looking at future research — how to structure the system and collaborate with other caregivers to be successful."

Reference

  1. Lindenauer PK, Rothberg MB, Pekow PS, Kenwood C, Benjamin EM, and Auerbach AD. Outcomes of Care by Hospitalists, General Internists, and Family Physicians. Ann Intern Med 2007 Dec 4; 147(11): 803-805.

[For more information, contact:

Peter K. Lindenauer, MD, Msc, FACP, The Center for Quality and Safety Research, Baystate Medical Center, 759 Chestnut St., P-5928, Springfield, MA 01199. Phone: (413) 794-5987. E-mail: peter.lindenauer@bhs.org.]