Hospitalist Care Study Looks Back, Not Ahead

Leading hospitalists are calling a recent study that links hospitalist care with higher post-discharge medical utilization and costs a glimpse at the past, rather than a snapshot of today’s practices.

In the study, inpatients managed by hospitalists had, on average, 0.64 fewer days of hospitalization and $282 less in hospital costs as compared with inpatients managed by their primary care physician. In the first 30 days after discharge, however, Medicare costs were $332 higher in patients who received care from hospitalists. Additionally, patients cared for by hospitalists were less likely to be discharged home (odds ratio 0.82). Further, these patients were more likely in the 30-day period to have emergency department visits (OR 1.18) and to be readmitted to the hospital (OR 1.08).

The study, conducted by Yong-Fang Kuo, Ph.D., and Dr. James S. Goodwin of the department of internal medicine at the University of Texas Medical Branch, Galveston, drew its findings from a 5% national sample of Medicare patients, which consisted of 58,125 admissions at 454 hospitals between 2001 and 2006 (Ann. Intern Med. 2011;155:152-9).

Dr. Michael J. Pistoria

Dr. Alpesh Amin, professor and chair of the department of medicine and executive director of the hospitalist program at the University of California, Irvine, called patient encounters between 2001 and 2006 "early in the course of the hospitalist movement ... I wonder [if] the findings would be the same if the researchers had looked at 2008-2011, for example."

The researchers also acknowledged limitations of the study and wrote "our results may not be applicable to patients without an identified PCP," as the study selectively compared care by hospitalists and care by identified primary care physicians who personally provided care for their hospitalized patients. "In addition, the study included only patients admitted with medical diagnoses. Hospitalists have a smaller effect on length of stay with surgical patients, so the results may differ. Also, we did not include patients cared for by medical subspecialists who were hospitalists. Another limitation is that we studied patients with fee-for-service Medicare coverage."

Dr. Michael J. Pistoria, president of the medical staff and associate chief of the division of general internal medicine at Lehigh Valley Health Network, Allentown, Pa., contrasted the environment at the time of study with ongoing initiatives in hospitalist practice.

"If you look at hospital medicine’s growth, our first several years in the ‘limelight’ were focused on demonstrating that we provide efficient and high-quality care in the hospital. As we have evolved as a specialty, our focus has shifted to the impact of our care (and its built-in discontinuity) outside of the hospital. Specifically, we have seen new research and major projects [like the Better Outcomes for Older Adults Through Safe Transitions, or BOOST] that now examine and evaluate our transitions of care," Dr. Pistoria said in an interview.

While it remains unclear what kind of impact the findings will have on hospital medicine going forward, the study "is good for our patients and good for hospital medicine in that it reinforces our need to improve care along the inpatient-outpatient continuum," he said.

Dr. Amir K. Jaffer, division chief of hospital medicine at the University of Miami, similarly lauded the progress of nationwide quality improvement projects, such as BOOST and Project RED (Re-Engineered Discharge), designed to bolster efforts to lower readmission rates and post-discharge costs.

"The innovative bundling of payments that is planned by CMS also should help," Dr. Jaffer said. "Increasing costs of care after discharge could be addressed by [creating incentives for] physicians to focus on the patients’ whole episode of care rather than just focusing on the hospitalization," he said.

"Clearly, we have work to do to improve care transitions, as do our primary care physician colleagues," Dr. Pistoria said. "This paper will spur further research into care transitions and efforts to improve the flow of information between various care settings."

The study was funded by the National Institute on Aging and the National Cancer Institute.

Dr. Kuo and Dr. Goodwin stated that they had no relevant financial conflicts to disclose.