Hospitalists and the Costs and Outcomes of Hospital Care

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The summary below is from the full report titled "Implementation of a Voluntary Hospitalist Service at a Community Teaching Hospital: Improved Clinical Efficiency and Patient Outcomes." It is in the 3 December 2002 issue of Annals of Internal Medicine (volume 137, pages 859-865). The authors are AD Auerbach, RM Wachter, P Katz, J Showstack, RB Baron, and L Goldman.

What is the problem and what is known about it so far?

American doctors have traditionally spent part of their days seeing patients in their offices and part seeing patients in the hospital. More severe and complicated illnesses in hospitalized patients and the specialized nature of hospital care make it difficult for doctors to split their time between the outpatient office and the hospital. It is difficult to keep up with the huge amount of information relevant to both settings. Furthermore, doctors are unavailable to hospitalized patients for much of the day if they are seeing patients in the office. For these reasons, many hospitals have begun to use doctors called hospitalists. Hospitalists spend their entire day taking care of hospitalized patients. They aim to improve quality of hospital care and reduce costs. But do hospitalists actually benefit patients?

Why did the researchers do this particular study?

To compare outcomes and costs for patients cared for by hospitalists and patients cared for by nonhospitalists.

Who was studied?

The researchers studied 5710 adult medical patients admitted to a community-based teaching hospital between July 1997 and June 1999. The hospitalists were five academic faculty based at the hospital, and the nonhospitalist doctors were 113 physicians based in the community.

How was the study done?

All patients were admitted to a housestaff team that included doctors in training (residents and interns) and medical students. Housestaff wrote all patient orders and provided 24-hour coverage for the patients. Hospitalists supervised the care of 1615 patients. Community physicians supervised care for 3693 patients whom they had also cared for as outpatients. The researchers compared lengths and costs of hospital stays, as well as the proportions of patients who died who had received care supervised by hospitalists and nonhospitalists.

What did the researchers find?

In the first year of the study, hospitalists' and nonhospitalists' patients stayed in the hospital for similar lengths of time. By year 2, hospitalists' patients stayed in the hospital an average of about half a day less than nonhospitalists' patients. Average hospital costs were similar for nonhospitalists and hospitalists in the first year but were $822 lower for hospitalists in the second year. In both years of the study, the proportions of patients who died in the hospital and within 1 to 2 months after discharge were lower among hospitalists' patients than nonhospitalists' patients.

What were the limitations of the study?

The study involved only five hospitalists and a single teaching hospital. The findings could be explained by differences in the levels of sickness or other patient factors or by differences in how housestaff interacted with hospitalists and nonhospitalists rather than by hospitalist care.

What are the implications of the study?

Hospitalists' patients appear to have shorter and less costly hospital stays and may be less likely to die in the hospital or within 1 to 2 months of leaving the hospital than nonhospitalists' patients. Hospitalists may have "learning curves," and some of benefits of their care may not be clear until they have been practicing hospital medicine for more than a year.