Tuesday, September 09, 2008

The debate on the hospitalist model

---between Dr. Mark Williams and Dr. Robert Centor just got some more coverage in an interview with Dr. Williams in the September issue of Today’s Hospitalist.

Dr. Williams believes it’s a slam dunk that the hospitalist model is better for patients. Concerning the debate, he said:

That has been settled, and the answer is an unequivocal “yes.” The question we should be debating is not whether to use hospitalists but how to best optimize their use.

Concerning the traditional internist, he believes it’s an anachronism:

I think the concept of a “complete internist” is an anachronism that may have applied 20-plus years ago. While there may be a few internists still like that in rural private practice, it’s clear that optimal care for hospitalized patients is having a hospitalist on-site who’s available to respond to emergencies.

I gave my take in a post I wrote shortly after the debate was published. I believe in the traditional internal medicine model. It’s not for everyone but there are many who can do it well provided the organizational structure is in place. If the debate about the hospitalist model of care is settled it’s not based on evidence. Although the idea of having a hospital based physician on site 24/7 make sense and is appealing the advantages are counterbalanced by the downsides of discontinuity of care, which is why studies have repeatedly failed to show that the hospitalist model improves outcomes for patients.

What has settled the debate is the reality of economics and other external factors, not patient outcome based evidence. The final finishing blow to the traditional model will come if, has been speculated, some version of the Kennedy-Gephardt bill is resurrected.

The Today’s Hospitalist piece, by the way, cited Dr. Centor with an interesting observation: we don’t know the long term outcomes of the hospitalist model. I’ve mentioned this fact a time or two before. One of the larger and more methodologically sound comparative studies, presented at SMH 2005, showed no difference in efficiency or outcomes. The study has not, as far as I’m aware, been published in a Medline indexed journal but the abstract of the SMH presentation, published in this issue of The Hospitalist, tells us that “mortality data up to one year after admission are pending.” That was 3 years ago. Have those data been published or presented anywhere?

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