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1 August 1998 | Volume 129 Issue 3 | Pages 197-203
Background: Hospitalists are increasingly being used for inpatient care.
Objective: To investigate whether the use of hospitalists is beneficial.
Design: Retrospective cohort study.
Setting: Inpatient medical service of a 500-bed community teaching hospital.
Participants: 1620 patients in the study group, seen during the hospitalist year; 1679 patients from the same outpatient practice as the study group, seen during the previous year (prehospitalist year); an unselected comparison group of 3413 patients seen during the prehospitalist year and 3223 patients seen during the hospitalist year; and a subset of the unselected comparison group, cared for by outpatient practices, who had a prehospitalist length of stay similar to that of the study group (743 patients in the prehospitalist year and 786 in the hospitalist year).
Interventions: Full-time faculty hospitalists cared for the study group, were in the hospital during normal working hours, and made decisions throughout the day. In the prehospitalist year and in the comparison groups, primary care physicians managed their own hospitalized patients.
Measurements: Length of stay; cost of care; costs of hematology and chemistry evaluation, pharmacy, and radiology; and readmissions were determined for the prehospitalist and hospitalist years.
Results: In the study group, median length of stay decreased from 6.01 to 5.01 days (P < 0.001). Median cost of care decreased from $4139 to $3552 (P < 0.001), and the 14-day readmission rate decreased from 9.9 to 4.64 readmissions per 100 admissions (P < 0.001). In the comparison groups, length of stay decreased but both cost of care and readmission rates increased.
Conclusion: Hospitalists may improve the efficiency of inpatient care. Further study in various settings is needed to verify these findings.
Our study was conducted in a 542-bed, independent, urban community hospital in the northeastern United States. The hospital had approximately 19 000 admissions per year during the 2 years of the study. Of these admissions, approximately 5000 were admissions by primary care physicians. The hospital had its own independent residencies in internal medicine, family medicine, radiology, obstetrics and gynecology, and anesthesia. It is affiliated with a medical school and participates in university hospital-based training programs in emergency medicine and plastic surgery. Both the internal medicine and radiology residencies support subspecialty fellowships.
Study Patients
In the fall of 1995, a large primary care physician group whose practice was managed by our hospital's medical services organization agreed to have its inpatient admissions managed by hospitalists, who were members of the full-time faculty in the division of general internal medicine. The study group (hospitalist group) consisted of all patients who were admitted to the study hospital by these primary care physicians during the first 12 months in which hospitalists cared for patients admitted to this hospital. The group's major primary care office practice was in a hospital-owned physician practice building adjacent to the hospital. The group also had outlying offices and a large nursing home and personal care home practice. Approximately 50% of its admissions were to other hospitals, primarily those near its other practice sites. Patients admitted to these other hospitals were cared for by the primary care physicians in the primary care group, not hospitalists. All admissions to this hospital during the study years, including multiple admissions for the same patient, were counted as admissions in the study. Admissions to other hospitals were not included.
We compared all patients admitted to the study hospital by the hospitalist group in the first year of the hospitalist program (hospitalist year) with all patients admitted to the study hospital by the same physician group in the 12 months immediately preceding the study year (prehospitalist year) (comparison group 1).
Because many factors in our community influenced length of stay and cost of care during these 2 years, we used two additional comparison groups. To avoid selection bias, we also studied an unselected comparison group consisting of all patients admitted to the study hospital by all primary care internal medicine and family medicine private practice physicians (with the exception of the study group physicians and the full-time faculty group) during the prehospitalist year (comparison group 2) and the hospitalist year (comparison group 3).
Patients of these outpatient practices had a shorter length of stay during the prehospitalist year than the patients of the practice that adopted the hospitalist system. Because this difference could have influenced our results, we also identified subsets of comparison groups 2 and 3, composed of patients from the five primary care practices with the longest length of stay, as additional comparison groups (comparison group 2a for the prehospitalist year and comparison group 3a for the hospitalist year). Comparison groups 2a and 3a consisted of patients from outpatient practices whose prehospitalist lengths of stay were similar to that of the study patients. Physicians of patients in both comparison groups admitted patients to several other hospitals. Most admissions to other hospitals were to suburban hospitals and were based on the hospitals' geographic proximity to the patient.
At the study hospital, all patients in the hospitalist group and comparison groups were admitted to the same nursing units. For all groups, all patients admitted to the intensive care unit and the coronary care unit were assigned resident coverage. One housestaff team with a second-year resident and two first-year residents provided this coverage for patients not admitted to special care units. This team had a maximum capacity of 24 patients. When this capacity was exceeded, newly admitted patients were not assigned housestaff coverage. Approximately 75% of patients in comparison groups 2, 3, 2a, and 3a had resident coverage in both years. Patients in the comparison groups were also admitted without resident coverage when the capacity of the resident teams was exceeded. A few attending physicians preferred to write their own orders and did not have resident coverage on the general medicine floors. On resident-covered services, residents must write all orders. Coverage by a physician assistant was available for all patients who did not have resident coverage. Physician assistants did not care for patients covered by residents. In comparison group 1, patients not admitted to critical care units were covered by a physician assistant, but not a resident. We have previously reported that in our hospital, patients with and those without resident coverage had similar diagnosis-related group (DRG)-adjusted lengths of stay [5]. In all groups, the attending physician responsible for inpatient care was expected to see the patient at least once daily and to communicate with the medical resident or physician assistant.
Hospitalist System
The hospitalists were members of the full-time faculty in general internal medicine. Two hospitalists covered an average combined inpatient census of 28 study group patients. The hospitalists were in the hospital and available for patient care during regular working hours from Monday through Friday. Three hospitalists spent at least 50% of their time on inpatient care. One of the hospitalists functioned as a hospitalist throughout the year; the other two were hospitalists for approximately 6 months per year. Weekend and night call were rotated among all members of the general medicine faculty group. The primary care physicians could make "courtesy" visits to their patients on the hospitalist service. Hospitalists communicated discharge information to the patients' primary care physicians through telephone calls to the physicians' offices and copies of written discharge instructions and discharge summaries.
Before the hospitalist year, physicians in comparison group 1 had participated in inpatient rounds on a daily rotating schedule. Thus, patients infrequently saw their own primary care physician. One member of the group spent a large proportion of the time caring for inpatients. Most patients in comparison groups 2, 2a, 3, and 3a were cared for by their own primary care physician in both study years.
Because the hospitalists were present in the hospital throughout the day, they could evaluate patients and make decisions at any time; in contrast, other attending physicians usually evaluated patients only once per day. It was the attending physician's and the hospitalist's responsibility to inform patients of the hospitalist system. The hospitalists had no financial incentive to decrease length of stay or cost of care, but it was understood that these reductions would become a goal of the program. All attending physicians from all groups admitted their patients to the same nursing units and had access to the same clinical protocols, clinical pathways, utilization review, and discharge planning services.
Data Collection and Study Outcomes
The methods for data collection and analysis were identical for all groups for both study years. The number of admissions, patient age and other demographic data, insurance source, and length of stay were collected from the Clinical Cost Accounting System (Huff, Barrington, and Owen Co.). Patients were assigned to groups on the basis of the attending physician at discharge listed in this administrative database. Discharge diagnosis, DRG, and mortality data were also obtained from this database. We computed a DRG-adjusted Health Care Financing Administration (HCFA) expected length of stay for each group using HCFA expected length of stay adjusted for the DRG assigned to each admission. We also obtained the Medicare case-mix index.
We calculated cost of care using a relative value scale method developed by our hospital accounting system as the best approximation of actual hospital costs. Relative value units were developed for every billable patient service. Each unit includes labor, nonlabor, and overhead costs.
Readmissions to the study hospital within 14 and 30 days after discharge were collected prospectively by the hospital as part of its quality assurance program and were available from this data source. All readmissions to this hospital were counted and attributed to the original admitting group, even if the readmitted patient went to another service or department. Because these were private patients, readmission to primary care physicians was always attributed to the primary care group that had cared for the patient on the initial admission. We could not track readmissions to other institutions; thus, these are not included in the data.
Statistical Analysis
For continuous data, a t-test was used for between-group comparisons when the statistical assumptions were met. When the statistical assumptions were not met (because of between-group heterogeneity and non-normality), a Mann-Whitney test was used. For categorical outcome variables, a chi-square test or the Fisher exact test was used. Findings were considered statistically significant at a P value less than 0.05. Statistical analyses were done by using SAS software (SAS Institute, Cary, North Carolina).
The study group and comparison groups were similar in age, sex, distribution of types of insurance, and Medicare case-mix index (Table 1). Medicare admissions comprised almost two thirds of admissions in each group (Table 1). Less than 15% of patients in all three groups had managed care insurance coverage. Medicare managed care admissions during the study period were negligible. ARTICLE
The Effect of Full-Time Faculty Hospitalists on the Efficiency of Care at a Community Teaching Hospital
The term hospitalist has been introduced to describe physicians who specialize in inpatient medicine and who manage the care of hospitalized patients for primary care physicians [1]. As both hospital admissions and length of stay decline, the decreasing proportion of time that the average primary care physician spends on the inpatient service and the demand for efficiency in the practice of medicine have generated interest in hospitalists [2, 3]. Potential advantages of the use of hospitalists include the greater expertise and experience of the physicians providing inpatient care, availability of the inpatient physician to make decisions throughout the day, and greater efficiency in the use of time of the outpatient physician, who is freed from inpatient duty [1-4]. These advantages must be weighed against potential disadvantages resulting from the loss of continuity of care. The primary care physician loses the care of the hospitalized patient, and the inpatient physician loses follow-up care when the patient is discharged. The replacement of the familiar outpatient physician by an unfamiliar inpatient physician may decrease patient satisfaction. The relative merits of the hospitalist program can be determined only by studies that measure quality of care, patient satisfaction, and cost and efficiency of care in various settings [1]. We report here the experience of a community teaching hospital during the initial year of a hospitalist program.
Methods
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Study Setting
Results
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Demographic and Clinical Characteristics
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The 10 most frequent DRGs in the study group accounted for 40.5% of all discharges. In comparison group 1, the same 10 DRGs were the most frequent and accounted for 41.2% of discharges. These 10 DRGs represented 34.1% of discharges in comparison group 2 and 32.6% of discharges in comparison group 3. Nine and seven of these DRGs were among the 10 most frequent DRGs for comparison groups 2 and 3, respectively. For comparison groups 2a and 3a, these DRGs represented 34.1% and 32.6% of admissions, respectively. Seven and eight of these DRGs were among the 10 most frequent DRGs for comparison group 2a in the hospitalist year and for comparison group 3a, respectively.
Length of Stay
The median length of stay decreased by 17% (from 6.01 days in comparison group 1 to 5.01 days in the study group; P = 0.001) (Table 2). The median length of stay in comparison group 2 was shorter than that in the study group (5.01 days) and was decreased in comparison group 3 (4.00 days) (P = 0.0011). The median length of stay in comparison group 2a, which had been hypothesized to be similar to that of the study group, was 6.00 days. Comparison group 3a (seen during the hospitalist year) had a median length of stay of 5.00 days. The difference in length of stay between groups 2a and 3a was significant (P = 0.0022).
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The decrease in length of stay in the study group was disproportionately greater in the patients with the longest length of stay. The mean length of stay in the study group was 2.42 days shorter than that in comparison group 1. The mean decreases in length of stay were 0.45 days between comparison group 2 and comparison group 3 and 0.78 days between comparison group 2a and comparison group 3a (Table 2).
Cost of Care
The median cost of care was $4139 in comparison group 1 and $3552 in the study group (difference, 14.2%; P = 0.001) (Table 3). Cost of care was higher in comparison group 2 than in comparison group 3 (P < 0.001) and did not change significantly when comparison group 2a was compared with comparison group 3a. Among subcategories of cost of care, cost of chemistry and hematology evaluation was significantly lower in all three comparison groups between the prehospitalist and hospitalist years; pharmacy and radiology costs increased significantly.
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Other Study Outcomes
Mortality rates were similar (<4%) in all groups. Readmission rates were similar for the study group and comparison groups 1, 2, and 2a during the prehospitalist year. Both 14-day and 30-day readmission rates were lower in comparison group 1 than in the study group (P < 0.0011 for each comparison) and increased in comparison groups 3 and 3a (Table 4). Each of these comparisons was statistically significant, except for the increase in the 14-day readmission rate for comparison group 2a compared with group 3a.
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Discussion
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The most striking effect of our program was on cost of care. Cost of care for patients cared for by hospitalists was approximately $1000 lower per case than the cost of care for comparison patients, for a total of more than $1.5 million. Some of these savings were offset by additional faculty costs and other costs incurred in establishing the program, and some might have occurred in any case because length of stay also decreased in the comparison groups. However, costs in the comparison groups increased. We estimate an overall cost reduction in excess of $1 million. Although a similar decrease in median length of stay was seen in all patient groups, the decrease in mean length of stay was greater in the study group. Length of stay decreased by a mean of 2.42 days for 1620 admissions, for a total decrease of approximately 4000 patient-days.
The readmission rate decreased in the study group. However, we could not measure readmissions to other hospitals. Although physician admission patterns suggest that most readmissions were to the study hospital, we cannot exclude the possibility that rates of readmission to other hospitals were different in the study group and one or more of the comparison groups.
Our study has several limitations. It reports observations at a single institution and in a single period and used a single model of hospitalist care. Different results might be obtained at other institutions, in different settings, in different patient populations that have patients with more managed care insurance, or with physician groups of differing levels of skill and motivation in caring for an inpatient population. We were limited to retrospectively analyzing data that had been prospectively collected for administrative purposes. Given the rapidity of changes in the health care system in our community and the resulting changes in length of stay, cost of care, and readmission rates, comparison groups were necessary to compare the changes seen in our study population. Unfortunately, we could not randomly allocate patients to a control group or study group or provide a matched group of controls. Although we chose the patients of physician groups that cared for a patient population similar to the hospitalist-covered patient population, the comparison groups were not randomly selected; we cannot exclude the possibility that unrecognized differences may have affected our results. The HCFA case-mix index and DRG-adjusted length of stay were similar in the three groups. They were not identical, however, and our analysis does not correct for these differences. Other researchers have used DRG-adjusted length of stay to control for differences in severity of illness or cost of care when comparing patient groups. However, these measures have recognized limitations as measures of severity of illness [7]. Similarly, adjustments for HCFA case-mix index provide only a limited approximation of disease severity [8, 9].
The proportion of the patients in the study group who were on a housestaff-covered service increased in the hospitalist year. However, we previously reported that DRG-adjusted length of stay was similar on the teaching and nonteaching services in our hospital [5]. Although the hospitalists did not have any financial incentives to shorten length of stay or decrease cost of care, hospital pressures on all physicians to decrease length of stay may have been felt more intensely by these hospital-based, salaried physicians. The hospitalists also had no negative financial impact when length of stay was shortened for per diem-paying patients.
The average practicing primary care internist spends less than 20% of his or her time providing hospital care (as reported at the conference "The Emerging Role of Hospitalists in American Health Care" in San Francisco in December 1997). Our hospitalists spent at least 50% of their time providing inpatient care and therefore had greater experience with it. In patients with AIDS [10] and those undergoing surgery [11], greater experience has been found to correlate with better patient outcomes. Introducing internists on an intensive care unit and providing mandatory care by full-time intensivists have been found to improve outcomes and efficiency of care [12-14]. Our results are consistent with those cited in preliminary reports from other institutions (as presented at the conference "The Emerging Role of Hospitalists in American Health Care"). At this conference, Freese reported on cost savings from hospitalists at Park Nicollet Clinic Hospital Service. He found that almost all of the savings were in the most expensive DRGs. This result is consistent with our finding that most of the reduction in length of stay was seen with the patients whose length of stay was greater than the median length of stay for all patients. Freese also found no difference in inpatients' perception of the quality of care. At the same conference, Wachter reported that an academic medical service led by hospitalists had lower costs; shorter length of stay; and no change in clinical outcome, patient satisfaction, or housestaff satisfaction (Wachter RM. Outcome, Cost, and Satisfaction from Hospitalist Systems). We had no true quality outcome measures. No measured change in morbidity or mortality was seen. If a shortened length of stay can be attributed to the program and if this is considered a positive outcome for patients, it could represent a benefit. However, it is unknown whether patients perceive decreased length of stay as a benefit [15].
In summary, we found that the use of hospitalists was associated with shorter length of stay, lower cost of care, and a lower readmission rate. Each community hospital and clinical practice is different. No single study will provide a comprehensive view of the benefits and liabilities of the use of inpatient specialists for inpatient management. Nonetheless, we believe that formal studies are the best approach to determining the circumstances, if any, in which inpatient care specialists are valuable. It will be interesting to see whether other institutions employing hospitalists have results similar to ours.
Dr. Janosky: Department of Medicine and Clinical Epidemiology, Division of Biostatistics, University of Pittsburgh School of Medicine, 170 Lothrop Hall, Pittsburgh, PA 15261.
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References
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1. Wachter RM, Goldman L. The emerging role of "hospitalists" in the American health care system. N Engl J Med. 1996; 335:514-7.
2. Brandner J. Will hospital rounds go the way of the house call? Managed Care. 1995; July:19-28.
3. Moore JD Jr. The inpatient's best friend. "Hospitalists" specialize in managing care of the very ill. Mod Healthc. 1997; 27:54-6, 58-62.
4. Gipe B. A Pennsylvania model for in-house acute care physician services. Cost and Quality Quarterly Journal. 1996; 2:6.
5. Diamond HS, Fitzgerald LL, Day R. An analysis of the cost and revenue of an expanded medical residency. J Gen Intern Med. 1993; 8:614-8.
6. Nelson JR, Whitcomb WF. Introduction. The Hospitalist. 1997; 1:1.
7. Cameron JM. The increased costs of graduate medical education. N Engl J Med. 1985; 312:1233-8.
8. Horn SD. Measuring severity of illness: comparisons across institutions. Am J Public Health. 1983; 73:25-31.
9. Jencks SF, Dobson A. Defining case-mix adjustment. The research evidence. N Engl J Med. 1987; 317:679-86.
10. Kitahata MM, Koepsell TD, Deyo RA, Maxwell CL, Dodge WT, Wagner EH. Physicians' experience with the acquired immunodeficiency syndrome as a factor in patients' survival. N Engl J Med. 1996; 334:701-6.
11. Luft HS, Hunt SS, Maerki SC. The volume outcome relationship: practice-makes-perfect or selective-referral patterns? Health Serv Res. 1987; 22:157-82.
12. Carson SS, Stocking C, Podsadecki T, Christenson J, Pohlman A, Mac-Rae S, et al. Effects of organizational change in the medical intensive care unit of a teaching hospital: a comparison of "open" and "closed" formats. JAMA. 1996; 276:322-8.
13. Li TC, Phillips MC, Cook EF, Natanson C, Goldman L. On-site physician staffing in a community hospital intensive care unit. Impact on test and procedure use and patient outcome. JAMA. 1984; 252:2023-7.
14. Pollack MM, Katz RW, Ruttimann UE, Getson PR. Improving the outcome and efficiency of intensive care: the impact of an intensivist. Crit Care Med. 1988; 16:11-7.
15. Brook RH, Iezzoni LI, Jencks S, Knaus WA, Krakauer H, Lohr KN, et al. Symposium: case-mix measurement and assessing quality of hospital care. Health Care Finance Rev. 1987; Spec No:39-48.
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