Thursday, May 21, 2015

Rethinking the value of the hospitalist model

Here's an interesting study in the Journal of General Internal Medicine looking at the effect of availability of hospitalists on the productivity of primary care physicians (PCPs). From the paper:


We found that the use of hospitalists was significantly associated with a decreased number of hospital visits. The use of hospitalists was also associated with an increased number of office visits, but this was only significant for high users. Physicians who used hospitalists for more than three-quarters of their hospitalized patients had an extra 8.8 office visits per week on average (p = 0.05), which was equivalent to a 10 % increase in productivity over the predicted mean of 87 visits for physicians who did not use hospitalists. We did not find any significant differences in direct patient care time per visit.


Our study demonstrates that the increase in productivity for the one-third of PCPs who use hospitalists extensively may not be sufficient to offset the current loss of PCP workforce. However, our findings provide cautious optimism that if more PCPs effectively and efficiently used hospitalists, this could help mitigate a PCP shortage and improve access to primary care services.

This effect was more modest than I would have expected. An accompanying editorial estimates that only about one third of PCPs turn 75% or more of their inpatients over to hospitalists. That surprises me but if true means that penetration by hospitalists is far from complete, the niche will continue to expand, and the shortage of hospitalists will continue. The editorial is available as free full text here.

What interests me even more about the editorial is that the author, himself an academic hospitalist, gives a surprisingly objective assessment of the hospitalist model. For years hospitalist leaders have promoted the field with unsubstantiated claims and wishful thinking. These promotions range form statements that hospitalists increase the efficiency of resource utilization to more grandiose ideas about hospitalists being the grand integrators of health care. They have masterfully succeeded in turning this into a popular narrative despite a lack of evidence.

Dr. David Meltzer, the author of the editorial, acknowledges the lack of evidence. From the editorial:

However, there are still no randomized controlled trials (RCTs) that compare the outcomes of care by hospitalists to care by PCPs who care for their own patents in the inpatient and outpatient setting.

Meltzer goes further to say that the old model may even be better:

At one level, the absence of rigorous RCT data comparing the hospitalist model and the traditional model is unfortunate, as these data could inform a range of clinical and policy decisions. However, if the analysis by myself and Chung, as supported by the findings of Park and Jones, is correct, then the decline of PCPs that see patients both in clinic and the hospital may be a largely inevitable result of the time costs of trying to work in both settings, especially as ambulatory volumes increase relative to hospital volumes, so that a daily trip to the hospital has declining economic and clinical benefits relative to costs. Given the rich evidence to support the value of continuity in the doctor–patient relationship,6 – 9 it is plausible that patient benefits or health system savings would be large enough to overcome this economic pressure but it seems unlikely we will ever know this for certain.

Research comparing the hospitalist model with traditional care is beset with low level methodology, mixed results and publication bias. (The publication bias is illustrated by failure to publish this disappointing study, tossed down the memory hole after being presented at the SHM 2005 national meeting).

The piece concludes by suggesting another model:

One model that we have been examining is what we call the Comprehensive Care Physician (CCP) model.10 In this model, patients at increased risk of hospitalization receive care from the same physician in the inpatient and outpatient setting. The CCPs are able to care for these patients in both settings, because they focus their practice on a small panel of less than 200 patients at high risk of hospitalization, so that their clinic volumes are low enough that they can spend each morning seeing their own patients in the hospital, while the acuity of their panel is high enough that they consistently have enough hospitalized patients to justify their daily presence there even with their small panel size. We are currently evaluating the CCP model at the University of Chicago through a randomized trial funded by the Center for Medicare and Medicaid Innovation, with results expected within 2 years.

Those CCPs were the internists of a few decades ago. It's pretty much the old traditional model. The results, if favorable, could drive policy back in that direction. But in order to convince clinic internists to return to the hospital the system would have to provide them professional rewards and pay them handsomely. Given the emerging trends toward compensation for artificial performance metrics that seems unlikely to happen anytime soon.


Jame gaulte said...

What a thought. Not only were the old internists the CCPs but often they were the ER Docs as well.

Will the same economic forces that push internists our of hospital care make the "new model" of CCPs not viable?

R. W. Donnell said...

Maybe not the exact same economic forces. Today's policy makers are trying to replace the old production incentives with "quality" incentives. (I know you know what those quotation marks mean). Those incentives, unless there is a radical shift, have the potential to rob the clinician of much professional satisfaction and likely won't pay very well. So I do not see those CCPs (that is, the old style traditional internists) coming back to the hospital any time soon.