Hospitalized elderly patients are receiving care from hospitalists more and more often, a study of Medicare beneficiaries has found.
“The odds that a hospitalized Medicare patient would receive care from a hospitalist increased by 29.2% per year from 1997 to 2006,” Yong-Fang Kuo, Ph.D., of the University of Texas at Galveston, and colleagues wrote (N. Engl. J. Med. 2009;360:1102–12). “Although the growth of care by hospitalists has been greater in large hospitals, teaching hospitals, and in certain geographic areas, substantial growth occurred in every area and type of hospital.”
The researchers looked at Medicare claims data from a 5% nationwide sample of beneficiaries for 1995, 1997, 1999, and 2001–2006. They defined hospitalists as general internal medicine physicians who had at least five evaluation and management billings in a given year and generated at least 90% of their total evaluation and management billings in that year from services to hospital inpatients.
The number of hospitalists increased greatly during this period; hospitalists identifying themselves as general internists, for example, grew from 2,770 in 1995 to 13,466 in 2006. Hospitalists' career stability has also increased over time; while 33% of those identified as hospitalists in 1995 met that definition 2 years later, that percentage rose to 66% for those identified as hospitalists in 2004.
The percentage of hospitals with at least three hospitalists increased as well, from 12% in 1995 to 47% in 2006. In major teaching and nonteaching hospitals, the median numbers of hospitalists were 11 and 3, respectively, in 2006. Use of hospitalists varied greatly by region, with Medicare patients in New England nearly four times more likely to receive care from a hospitalist as patients in the mid-Atlantic region in 2006.
Dr. Win Whitcomb, cofounder of the Society for Hospital Medicine, said the study provided a good qualitative snapshot of the increase in hospitalists overall.
“Their analysis is very detailed and as rigorous as any I've seen,” he said in an interview. “I think the numbers are going to continue to increase for an indefinite period of time.”
He said he was not surprised by the regional variation the authors found in hospitalist care. Nationally speaking, “Health care's hallmark is wide degrees in variation, so I'm not surprised by this.”
Not everyone is thrilled with the increase in hospitalist care. “Although hospitalists provide important benefits, their involvement disrupts the continuity of care provided by the patients' primary care physicians, resulting in potential adverse effects for both patients and doctors,” Dr. Arnold M. Epstein of the Harvard School of Public Health, Boston, and his colleagues wrote in an editorial. “With the increasing burden of chronic illness and complexity of medical care, coordinating care across settings and providers has become especially important. When primary care physicians are not at the bedside of their acutely ill patients, valuable opportunities to deepen the patient-doctor relationship are missed” (N. Engl. J. Med. 2009;360:1141–3).
Furthermore, “there is little to suggest that the hospitalist movement has increased the attractiveness of primary care as a career,” Dr. Epstein and colleagues continued. Hospitalists “may have reduced [primary care physicians'] own value in the eyes of their patients and, in some instances, decreased their job satisfaction.” Although the authors note that hospitalists have played an important role in the area of transitioning patients to outpatient or home care, they urged greater use, where possible, of a model in which members of a primary care group practice rotate as the practice's inpatient attending physician.
But Dr. Whitcomb said that he has seen “rotator” models of hospitalist practice come and go over the years. “In that model, as a primary care physician you're in the hospital 1 week out of every 8. You can't become involved in the hospital system or become a leader in hospital improvement” if you're there so infrequently. In addition, “if you have a busy practice and go away every 6–8 weeks for 1 week, you come back and are overwhelmed with office work and administrative responsibilities.”
And rather than detract from the attractiveness of primary care, “no primary care practice can effectively recruit without hospitalists,” said Dr. Whitcomb, vice president for quality improvement at Mercy Medical Center in Springfield, Mass. Although the hospitalist movement was driven by primary care in its early days, today primary care physicians coming out of training are going into practices that are covered by hospitalists, he said.
One coauthor of the study, Dr. Gulshan Sharma, reported receiving lecture fees from Pfizer Inc.; the other study authors and editorial authors reported no conflicts of interest.