Friday, December 28, 2007

Top ten issues in hospital medicine for 2007, issue 3: does the hospitalist model of care improve efficiency and outcomes?

Two papers in 2007 weighed in on this debate. First was this study from the Archives of Internal Medicine showing a statistically significant reduction in length of stay (5.01 vs 5.87 days) associated with an academic hospitalist model in comparison with non-hospitalist care at Albert Einstein College of Medicine.

Just out is this paper from NEJM comparing hospitalitalist care with that of non-hospitalist internists and family practitioners. Hospitalist care was associated with a shorter length of stay than traditional care by internists and FPs (0.4 days for both comparisons), a reduction in cost per case of $268 compared with traditional internal medicine care and no significant difference with family practice care. (Maybe that means family practitioners order fewer or less expensive tests than internists).

How can we interpret these results in light of what was already known? There have been too many papers for me to link here, so I’ll offer an oversimplified timeline. Early in the movement, small studies suggested that the hospitalist care model was associated with reduced charges and length of stay. A study presented at the 2005 meeting of the Society of Hospital Medicine, however, burst the bubble. That largest to date study showed no superiority of hospitalist care in terms of outcomes or efficiency. To my knowledge that was the largest study conducted until the NEJM study linked above. Bob Wachter, commenting on the Archives paper, said there were more than 20 studies with results favoring the hospitalist model. (I didn’t know there were that many!).

From the varied blog reactions to the NEJM paper it seems there are a gazillion ways to interpret the evidence. Dr. Wes is skeptical of the results, seems to question the meaning of $268 per case and laments the discontinuity of care that is built into the hospitalist model. The Happy Hospitalist has a happier spin, doing a little math to suggest how $268 per case translates into real money over multiple admissions and comments on some intangible benefits of hospitalist care. Retired Doc offers a nice summary of the blog reactions here and concludes with perhaps the only statement we can all agree on: the hospitalist movement is here to stay. Bob Wachter weighed in here (did I miss anybody?).

Wachter has some interesting observations on how the fallout from this study may affect the hospitalist looking for a job or jockeying for better compensation. As I see it, it could play out in any number of ways. Wachter suggests that this study, which shows a smaller resource saving than some older studies, could prompt hospital administrators to tighten their budgets for hospitalist compensation:

Since most hospitalist groups get (and require) hospital support, and much of that support has been predicated on a Return-on-Investment drawn from earlier findings of 15 percent LOS and cost reductions, expect some skirmishes at budget time, with hospitals trying to tighten the screws on their hospitalist groups (“why should we raise your support – you only save us $200 per patient!”).

But I could see it play out another way. Given that the economic value of the hospitalist model was in dispute at least in the minds of some, administrators who look at this paper as having settled the issue once and for all may now say “Hospitalist care is supposed to save money. Why aren’t you doing better than your non-hospitalist peers?”

No matter how you slice it, you’re better off if you can convince folks that there are non-economic and intangible benefits of hospitalist care. As Wachter said,

The hospitalist group that has not convinced its CFO that the true ROI doesn’t hinge on pure cost reduction – but rather on systems improvement, QI, patient safety, and more – may be in for a bumpy ride.

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