Article    Table of Contents                    Full Text of this article    PDF of this article (PDFs free after 6 months)    Summary for Patients    Summary for Patients (PDF)    Figures/Tables List    Related articles in Annals  Services    Send comment/rapid response letter    Notify a friend about this article    Alert me when this article is cited    Add to Personal Archive    Download to Citation Manager    ACP Search                            Get Permissions  Google Scholar    Search for Related Content  PubMed Articles in PubMed by Author:    Meltzer, D.    Levinson, W.    Related Articles in PubMed    PubMed Citation    PubMed

ARTICLE

Effects of Physician Experience on Costs and Outcomes on an Academic General Medicine Service: Results of a Trial of Hospitalists

David Meltzer, MD, PhD; Willard G. Manning, PhD; Jeanette Morrison, MD; Manish N. Shah, MD; Lei Jin, MA; Todd Guth, MD; and Wendy Levinson, MD

3 December 2002 | Volume 137 Issue 11 | Pages 866-874

Background: Hospitalists may decrease costs and improve outcomes in hospitalized patients, but existing evidence is limited and has not identified mechanisms for such effects.

Objective: To study the costs and outcomes for patients on an academic general medicine service assigned to teams led by hospitalists and nonhospitalists.

Design: Cohort study.

Setting: Academic general medicine service.

Patients: 6511 patients admitted to the hospital from July 1997 through June 1999.

Intervention: All patients admitted every fourth day were assigned to 1 of 2 hospitalists caring for inpatients 6 months each year or 1 of 58 nonhospitalists caring for inpatients 1 to 2 months each year.

Measurements: Length of stay; inpatient costs; and 30-, 60-, and 365-day mortality.

Results: Patients assigned to hospitalists (24.8%) and nonhospitalists (75.2%) did not differ in age, race, sex, diagnosis mix, or Charlson index score. In year 1, average adjusted length of stay was 0.29 day shorter for patients cared for by hospitalists than by nonhospitalists (95% CI, –0.66 to 0.06 day; P = 0.06); in year 2, average adjusted length of stay was 0.49 day shorter for patients cared for by hospitalists (CI, –0.79 to –0.15 day; P = 0.01). Average adjusted costs were not significantly reduced for hospitalists compared with nonhospitalists in year 1 but were reduced by $782 in year 2 (CI, –$1313 to –$187; P = 0.01). When years 1 and 2 were combined or when year 1 was analyzed alone, 30-day mortality was not significantly different for hospitalists and nonhospitalists; however, 30-day mortality was 4.2% for hospitalists compared with 6.0% for nonhospitalists in year 2 (CI for difference, 1.8 percentage points [–3.6 to –0.1 percentage points]; P = 0.04) and the adjusted relative risk was 0.65 (CI, 0.44 to 0.96; P = 0.03). In multivariate analyses, resource use decreased with the physician's cumulative experience in caring for a patient's primary diagnosis. Mortality showed a similar pattern.

Conclusions: Hospitalist care was associated with lower costs and short-term mortality in the second but not the first year of hospitalists' experience. Disease-specific physician experience may reduce resource use and improve patient outcomes; in addition, it may be an important determinant of the effectiveness of hospitalists.

Editors' Notes Context Despite the growing number of hospitalist physicians in the United States, evidence about their effect on outcomes of care is limited. Contribution This observational study suggests that patients cared for by hospitalists had shorter hospital stays, lower costs, and lower short-term mortality compared with patients cared for by nonhospitalists. These differences became evident only in the second year of the hospitalist program, suggesting that hospitalists' skills improve with additional clinical experience. Cautions Because the study included only two hospitalist physicians at one hospital, readers should be cautious about generalizing the findings to other settings. –The Editors

 

Author and Article Information

From the University of Chicago, Chicago, Illinois.

Acknowledgments: The authors thank Adriana Hernanadez, MA; Asif Dhar, BA; Corrinna Weckerle, BA; Catherine Humikowski, BA; Sharleen Suico, BA; and Johnny Lee, BA, for excellent research assistance. They also thank Dr. Scott Stern, Dr. Alex Lickerman, other attending physicians on the general medicine service, and the medicine housestaff.

Grant Support: By the University of Chicago Hospitals, Chicago, Illinois; the Charles E. Culpeper Foundation, New York, New York; the National Institute of Aging, Bethesda, Maryland; and the Robert Wood Johnson Foundation, Princeton, New Jersey.

Requests for Single Reprints: David Meltzer, MD, PhD, Section of General Internal Medicine, the University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637; e-mail, dmeltzer{at}medicine.bsd.uchicago.edu.

Current Author Addresses: Dr. Meltzer: The University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637.

Dr. Manning: The University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637.

Dr. Morrison: 6814 North Oriole Street, Chicago, IL 60631.

Dr. Shah: University of Rochester, 601 Elmwood Avenue, Box 655, Rochester, NY 14642.

Dr. Jin: University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637.

Dr. Guth: Naval Aero-medical Medical Institute, 220 Hovey Road, Pensacola, FL 32508.

Dr. Levinson: St. Michael's Hospital, 30 Bond Street, Queen Wing 4036, Toronto, Ontario M5B 1W8, Canada.

Author Contributions: Conception and design: D. Meltzer, W. Levinson.

Analysis and interpretation of the data: D. Meltzer, W.G. Manning, M. Shah, L. Jin, T. Guth, W. Levinson.

Drafting of the Article: D. Meltzer, W.G. Manning, M.N. Shah.

Critical revision of the article for important intellectual content: D. Meltzer, W.G. Manning, J. Morrison, M.N. Shah, L. Jin, W. Levinson.

Final approval of the article: D. Meltzer, W.G. Manning.

Provision of study materials or patients: D. Meltzer, J. Morrison, M.N. Shah.

Statistical expertise: D. Meltzer, W.G. Manning, L. Jin.

Obtaining of funding: D. Meltzer, J. Morrison, M.N. Shah, W. Levinson.

Administrative, technical, or logistic support: D. Meltzer, M.N. Shah, T. Guth.

Collection and assembly of data: D. Meltzer, J. Morrison, M.N. Shah, L. Jin, T. Guth.

Related articles in Annals:

Articles
Implementation of a Voluntary Hospitalist Service at a Community Teaching Hospital: Improved Clinical Efficiency and Patient Outcomes
Andrew D. Auerbach, Robert M. Wachter, Patricia Katz, Jonathan Showstack, Robert B. Baron, AND Lee Goldman

Annals 2002 137: 859-865. [ABSTRACT][SUMMARY][Full Text]  

Editorials
The Who, What, When, Where, Whom, and How of Hospitalist Care
The Editors

Annals 2002 137: 930-931. [Full Text]  

Summaries for Patients
Hospitalists and the Costs and Outcomes of Hospital Care

Annals 2002 137: I-25. [Full Text]  

Letters
Improved Outcomes in a Voluntary Hospitalist Model
David Neely

Annals 2003 139: 76. [Full Text]  

Letters
Improved Outcomes in a Voluntary Hospitalist Model
Andrew D. Auerbach, Robert M. Wachter, AND Lee Goldman

Annals 2003 139: 76. [Full Text]  

Letters
Improved Outcomes in a Voluntary Hospitalist Model
James P. Nolan

Annals 2003 139: W-69. [Full Text]  

Letters
Hospitalist Care
William Rifkin, Brad Flansbaum, AND Steven Walerstein

Annals 2003 139: 702. [Full Text]  

Letters
Hospitalist Care
Jonathan P. Whitney

Annals 2003 139: 702-703. [Full Text]  

Letters
Hospitalist Care
Tariq Shafi

Annals 2003 139: 703. [Full Text]  

Letters
Hospitalist Care
Jerome S. Tannenbaum

Annals 2003 139: 703-704. [Full Text]  

This article has been cited by other articles:

				D. Samoil Are inpatients' needs better served by hospitalists than by their family doctors: YES Can Fam Physician, August 1, 2008; 54(8): 1100 - 1101. [Full Text] [PDF]

				D. Samoil Les hospitaliers repondent-ils mieux aux besoins des patients hospitalises que leurs medecins de famille?: OUI Can Fam Physician, August 1, 2008; 54(8): 1104 - 1106. [Full Text] [PDF]

				M. V. Williams Hospitalists and the Hospital Medicine System of Care Are Good for Patient Care Arch Intern Med, June 23, 2008; 168(12): 1254 - 1256. [Full Text] [PDF]

				M. H. Al-Shaer, E. S. Suleiman, W. P. Jerome, E. S. Chu, R. K. Albert, M. Wei, D. van Amerongen, P. K. Lindenauer, M. B. Rothberg, and A. D. Auerbach Outcomes of Care by Hospitalists N. Engl. J. Med., April 17, 2008; 358(16): 1755 - 1758. [Full Text] [PDF]

				W. D. Freeman, G. Gronseth, and B. H. Eidelman Invited Article: Is it time for neurohospitalists? Neurology, April 8, 2008; 70(15): 1282 - 1288. [Abstract] [Full Text] [PDF]

				P. K. Lindenauer, M. B. Rothberg, P. S. Pekow, C. Kenwood, E. M. Benjamin, and A. D. Auerbach Outcomes of Care by Hospitalists, General Internists, and Family Physicians N. Engl. J. Med., December 20, 2007; 357(25): 2589 - 2600. [Abstract] [Full Text] [PDF]

				L. F. McMahon Jr. The Hospitalist Movement -- Time to Move On N. Engl. J. Med., December 20, 2007; 357(25): 2627 - 2629. [Full Text] [PDF]

				F. Lehmann, Y. Brunelle, M. Dawes, R. Boule, and R. Bergeron Les implications du phenomene des medecins hospitaliers Can Fam Physician, December 1, 2007; 53(12): 2131 - 2131. [Abstract] [Full Text] [PDF]

				W. N. Southern, M. A. Berger, E. Y. Bellin, S. M. Hailpern, and J. H. Arnsten Hospitalist Care and Length of Stay in Patients Requiring Complex Discharge Planning and Close Clinical Monitoring Arch Intern Med, September 24, 2007; 167(17): 1869 - 1874. [Abstract] [Full Text] [PDF]

				G. L. Freed, K. Brzoznowski, K. Neighbors, I. Lakhani, and American Board of Pediatrics, Research Advisory Co Characteristics of the Pediatric Hospitalist Workforce: Its Roles and Work Environment Pediatrics, July 1, 2007; 120(1): 33 - 39. [Abstract] [Full Text] [PDF]

				J. J. Glasheen, K. R. Epstein, E. Siegal, J. S. Kutner, and A. V. Prochazka The Spectrum of Community-Based Hospitalist Practice: A Call to Tailor Internal Medicine Residency Training Arch Intern Med, April 9, 2007; 167(7): 727 - 728. [Full Text] [PDF]

				M. Ong, A. Bostrom, A. Vidyarthi, C. McCulloch, and A. Auerbach House Staff Team Workload and Organization Effects on Patient Outcomes in an Academic General Internal Medicine Inpatient Service Arch Intern Med, January 8, 2007; 167(1): 47 - 52. [Abstract] [Full Text] [PDF]

				P. H. Conway, S. Edwards, E. R. Stucky, V. W. Chiang, M. C. Ottolini, and C. P. Landrigan Variations in Management of Common Inpatient Pediatric Illnesses: Hospitalists and Community Pediatricians Pediatrics, August 1, 2006; 118(2): 441 - 447. [Abstract] [Full Text] [PDF]

				C. P. Landrigan, P. H. Conway, S. Edwards, and R. Srivastava Pediatric Hospitalists: A Systematic Review of the Literature Pediatrics, May 1, 2006; 117(5): 1736 - 1744. [Abstract] [Full Text] [PDF]

				P. S. Lye, D. A. Rauch, M. C. Ottolini, C. P. Landrigan, V. W. Chiang, R. Srivastava, S. Muret-Wagstaff, and S. Ludwig Pediatric Hospitalists: Report of a Leadership Conference Pediatrics, April 1, 2006; 117(4): 1122 - 1130. [Abstract] [Full Text] [PDF]

				S. L. Ettner, J. Kotlerman, A. Afifi, S. Vazirani, R. D. Hays, M. Shapiro, and M. Cowan An Alternative Approach to Reducing the Costs of Patient Care? A Controlled Trial of the Multi-Disciplinary Doctor-Nurse Practitioner (MDNP) Model. Med Decis Making, January 1, 2006; 26(1): 9 - 17. [Abstract] [PDF]

				J. Coffman and T. G. Rundall The Impact of Hospitalists on the Cost and Quality of Inpatient Care in the United States: A Research Synthesis Med Care Res Rev, August 1, 2005; 62(4): 379 - 406. [Abstract] [PDF]

				C. L. Roy, E. G. Poon, A. S. Karson, Z. Ladak-Merchant, R. E. Johnson, S. M. Maviglia, and T. K. Gandhi Patient Safety Concerns Arising from Test Results That Return after Hospital Discharge Ann Intern Med, July 19, 2005; 143(2): 121 - 128. [Abstract] [Full Text] [PDF]

				M. P. Phy, D. J. Vanness, L. J. Melton III, K. H. Long, C. D. Schleck, D. R. Larson, P. M. Huddleston, and J. M. Huddleston Effects of a Hospitalist Model on Elderly Patients With Hip Fracture Arch Intern Med, April 11, 2005; 165(7): 796 - 801. [Abstract] [Full Text] [PDF]

				K. E. Hauer, R. M. Wachter, C. E. McCulloch, G. A. Woo, and A. D. Auerbach Effects of Hospitalist Attending Physicians on Trainee Satisfaction With Teaching and With Internal Medicine Rotations Arch Intern Med, September 27, 2004; 164(17): 1866 - 1871. [Abstract] [Full Text] [PDF]

				J. M. Huddleston, K. H. Long, J. M. Naessens, D. Vanness, D. Larson, R. Trousdale, M. Plevak, M. Cabanela, D. Ilstrup, R. M. Wachter, et al. Medical and Surgical Comanagement after Elective Hip and Knee Arthroplasty: A Randomized, Controlled Trial Ann Intern Med, July 6, 2004; 141(1): 28 - 38. [Abstract] [Full Text] [PDF]

				G. J. Merli The Hospitalist Joins the Surgical Team Ann Intern Med, July 6, 2004; 141(1): 67 - 69. [Full Text] [PDF]

				B. A. Sharpe Perceptions of Physician Shortages JAMA, April 14, 2004; 291(14): 1695 - 1696. [Full Text] [PDF]

				A. D. Auerbach and J. Kleinbart Update in Hospital Medicine Ann Intern Med, March 2, 2004; 140(5): 363 - 369. [Full Text] [PDF]

				T. Shafi Hospitalist Care Ann Intern Med, October 21, 2003; 139(8): 703 - 703. [Full Text] [PDF]

				W. Rifkin, B. Flansbaum, and S. Walerstein Hospitalist Care Ann Intern Med, October 21, 2003; 139(8): 702 - 702. [Full Text] [PDF]

				J. P. Whitney Hospitalist Care Ann Intern Med, October 21, 2003; 139(8): 702 - 703. [Full Text] [PDF]

				J. S. Tannenbaum Hospitalist Care Ann Intern Med, October 21, 2003; 139(8): 703 - 704. [Full Text] [PDF]

				J. P. Nolan Improved Outcomes in a Voluntary Hospitalist Model Ann Intern Med, September 2, 2003; 139(5_Part_1): W-69 - W-69. [Full Text] [PDF]

				D. Neely Improved Outcomes in a Voluntary Hospitalist Model Ann Intern Med, July 1, 2003; 139(1): 76 - 76. [Full Text] [PDF]

				A. D. Auerbach, R. M. Wachter, and L. Goldman Improved Outcomes in a Voluntary Hospitalist Model Ann Intern Med, July 1, 2003; 139(1): 76 - 76. [Full Text] [PDF]

				J. R. Dichter Teamwork and Hospital Medicine: A Vision for the Future Crit. Care Nurse, June 1, 2003; 23(3): 8 - 11. [Full Text] [PDF]

				Do Hospitalists Improve Patient Outcomes? Journal Watch Gastroenterology, February 25, 2003; 2003(225): 7 - 7. [Full Text]

				Do Hospitalists Improve Patient Outcomes? Journal Watch (General), January 14, 2003; 2003(114): 4 - 4. [Full Text]

				The Editors The Who, What, When, Where, Whom, and How of Hospitalist Care Ann Intern Med, December 3, 2002; 137(11): 930 - 931. [Full Text] [PDF]