Saturday, March 09, 2019

More uncritical praise for the hospitalist movement

This time it comes from The American Journal of Medicine.  From the recent narrative review article:
Multiple studies have shown that patients managed by a hospitalist have a shorter length of stay and lower hospital costs than those managed by other physicians.1, 3,6, 7

The reduced length of stay and reduced hospitalization costs are sufficient to strongly encourage community and teaching hospital directors to adopt and support the hospitalist model.

This is by no means proven.  Arguably the best and largest study examining this issue was negative.  It was presented at the hospitalist national meeting in 2005.  The researchers were leaders in the hospitalist movement.  The study was never published.  In fact, it was buried to such a degree that I had to go to the Internet Archive to find it.  You can access it at page 25 of this link.

Update: Since I composed this post, the link immediately above has gone bad. It’s been scrubbed from the Wayback Machine. I wasn’t aware that was possible but found out today that if you want something removed it’s easy enough to do, though requiring deliberate effort, as described here. Things don’t just disappear from the archive so I can only conclude that someone wanted it removed.

The study, though reported in The Hospitalist magazine, was never published in a Medline indexed journal, thus biasing every systemic review and meta-analysis on the hospitalist model published since then.

Fortunately the study received quite a bit of attention in the blogosphere at the time. Dr. Robert Centor, the author of DB’s Medical Rants, blogged about it and reproduced the study findings. Here they are, from his post:

Background: Several studies suggest that hospitalists can improve costs or outcomes in academic medical centers, but almost all of these studies have nonrandom assignment of patients to hospitalists, and no multi¬center studies exist. We studied patients assigned to hospitalist or non-hospitalist physicians based only on day of admission to determine the effects of hospitalists on outcomes and costs in 6 academic medical centers.

Methods: From July 2001 to June 2003, 31,891 general medicine inpatients were assigned to hospitalist or non-hospitalist physicians according to a predetermined daily call schedule. Patient interviews at admission and 1 month after discharge and administrative data were used to study effects on outcomes and costs.

Results: Twelve thousand and onepatients were cared for by hospitalists and 19,890 by non-hospitalists. There were no statistically significant differences in age, race, gender, Charlson Index, or distribution of primary diagnosis be¬tween the 2 groups. There were no statistically significant differences in in-hospital mortality, 30-day readmission and emergency room use, 30-day self-reported health status, or patient satisfaction. Mortality data up to 1 year after admission are pending. Average length of stay was 0.05 days shorter for hospitalist patients but this difference was not statistically significant. Costs were also similar between the groups. Individual center analyses had large confidence intervals on outcomes and costs and failed to show statistically significant effects on any measure of outcomes or costs except for 1 of the larger centers, which had lower length of stay and costs for hospitalists.

Conclusions: Hospitalists had small effects on selected outcome measures available to date, but did not produce the large resource savings that had been suggested by some earlier studies. The effectiveness of hospitalists appeared to vary by site, but was difficult to assess due to limited statistical power for site-specific analyses. Understanding the factors, such as physician experience, that may influence the effectiveness of hospitalists is important for maximizing the efficacy of hospitalist programs, because effects on outcomes may be small, vary by site, and be difficult to distinguish from chance in a specific clinical setting.

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