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ARTICLE

Effects of Physician Experience on Costs and Outcomes on an Academic General Medicine Service: Results of a Trial of Hospitalists

David Meltzer, MD, PhD; Willard G. Manning, PhD; Jeanette Morrison, MD; Manish N. Shah, MD; Lei Jin, MA; Todd Guth, MD; and Wendy Levinson, MD

3 December 2002 | Volume 137 Issue 11 | Pages 866-874

Background: Hospitalists may decrease costs and improve outcomes in hospitalized patients, but existing evidence is limited and has not identified mechanisms for such effects.

Objective: To study the costs and outcomes for patients on an academic general medicine service assigned to teams led by hospitalists and nonhospitalists.

Design: Cohort study.

Setting: Academic general medicine service.

Patients: 6511 patients admitted to the hospital from July 1997 through June 1999.

Intervention: All patients admitted every fourth day were assigned to 1 of 2 hospitalists caring for inpatients 6 months each year or 1 of 58 nonhospitalists caring for inpatients 1 to 2 months each year.

Measurements: Length of stay; inpatient costs; and 30-, 60-, and 365-day mortality.

Results: Patients assigned to hospitalists (24.8%) and nonhospitalists (75.2%) did not differ in age, race, sex, diagnosis mix, or Charlson index score. In year 1, average adjusted length of stay was 0.29 day shorter for patients cared for by hospitalists than by nonhospitalists (95% CI, –0.66 to 0.06 day; P = 0.06); in year 2, average adjusted length of stay was 0.49 day shorter for patients cared for by hospitalists (CI, –0.79 to –0.15 day; P = 0.01). Average adjusted costs were not significantly reduced for hospitalists compared with nonhospitalists in year 1 but were reduced by $782 in year 2 (CI, –$1313 to –$187; P = 0.01). When years 1 and 2 were combined or when year 1 was analyzed alone, 30-day mortality was not significantly different for hospitalists and nonhospitalists; however, 30-day mortality was 4.2% for hospitalists compared with 6.0% for nonhospitalists in year 2 (CI for difference, 1.8 percentage points [–3.6 to –0.1 percentage points]; P = 0.04) and the adjusted relative risk was 0.65 (CI, 0.44 to 0.96; P = 0.03). In multivariate analyses, resource use decreased with the physician's cumulative experience in caring for a patient's primary diagnosis. Mortality showed a similar pattern.

Conclusions: Hospitalist care was associated with lower costs and short-term mortality in the second but not the first year of hospitalists' experience. Disease-specific physician experience may reduce resource use and improve patient outcomes; in addition, it may be an important determinant of the effectiveness of hospitalists.

Editors' Notes Context Despite the growing number of hospitalist physicians in the United States, evidence about their effect on outcomes of care is limited. Contribution This observational study suggests that patients cared for by hospitalists had shorter hospital stays, lower costs, and lower short-term mortality compared with patients cared for by nonhospitalists. These differences became evident only in the second year of the hospitalist program, suggesting that hospitalists' skills improve with additional clinical experience. Cautions Because the study included only two hospitalist physicians at one hospital, readers should be cautious about generalizing the findings to other settings. –The Editors

 

Author and Article Information

From the University of Chicago, Chicago, Illinois.

Acknowledgments: The authors thank Adriana Hernanadez, MA; Asif Dhar, BA; Corrinna Weckerle, BA; Catherine Humikowski, BA; Sharleen Suico, BA; and Johnny Lee, BA, for excellent research assistance. They also thank Dr. Scott Stern, Dr. Alex Lickerman, other attending physicians on the general medicine service, and the medicine housestaff.

Grant Support: By the University of Chicago Hospitals, Chicago, Illinois; the Charles E. Culpeper Foundation, New York, New York; the National Institute of Aging, Bethesda, Maryland; and the Robert Wood Johnson Foundation, Princeton, New Jersey.

Requests for Single Reprints: David Meltzer, MD, PhD, Section of General Internal Medicine, the University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637; e-mail, dmeltzer{at}medicine.bsd.uchicago.edu.

Current Author Addresses: Dr. Meltzer: The University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637.

Dr. Manning: The University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637.

Dr. Morrison: 6814 North Oriole Street, Chicago, IL 60631.

Dr. Shah: University of Rochester, 601 Elmwood Avenue, Box 655, Rochester, NY 14642.

Dr. Jin: University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637.

Dr. Guth: Naval Aero-medical Medical Institute, 220 Hovey Road, Pensacola, FL 32508.

Dr. Levinson: St. Michael's Hospital, 30 Bond Street, Queen Wing 4036, Toronto, Ontario M5B 1W8, Canada.

Author Contributions: Conception and design: D. Meltzer, W. Levinson.

Analysis and interpretation of the data: D. Meltzer, W.G. Manning, M. Shah, L. Jin, T. Guth, W. Levinson.

Drafting of the Article: D. Meltzer, W.G. Manning, M.N. Shah.

Critical revision of the article for important intellectual content: D. Meltzer, W.G. Manning, J. Morrison, M.N. Shah, L. Jin, W. Levinson.

Final approval of the article: D. Meltzer, W.G. Manning.

Provision of study materials or patients: D. Meltzer, J. Morrison, M.N. Shah.

Statistical expertise: D. Meltzer, W.G. Manning, L. Jin.

Obtaining of funding: D. Meltzer, J. Morrison, M.N. Shah, W. Levinson.

Administrative, technical, or logistic support: D. Meltzer, M.N. Shah, T. Guth.

Collection and assembly of data: D. Meltzer, J. Morrison, M.N. Shah, L. Jin, T. Guth.

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