Geriatricians and Hospitalists: Opportunities for Partnership

One of the most important recent changes in U.S. health care is the rise in the fraction of hospitalized patients cared for by hospitalists. At the inception of the hospitalist movement, leaders predicted a profound effect on academic medical centers. They also predicted that hospitalists would be able to deliver more-efficient, ‘‘high value’’ care, with value defined as the quality of care divided by its cost. The first prediction has come true, with growing hospitalist groups at most major academic medical centers and academic hospitalists becoming leaders in quality improvement. The question remains what the effect has been on the overall quality of care provided to older patients. One large retrospective cohort study of 76,926 patients aged 18 and older used multivariable models to compare length of stay (LOS), rate of death, and costs of patients cared for by hospitalists, family physicians, and general internists. Hospitalists in this study were defined according to physician specialty codes. Patients cared for by hospitalists had a slightly shorter hospital stay (adjusted difference of 0.4 days) than those cared for by general internists and family physicians. Costs were very modestly lower for those cared for by hospitalists than for those cared for by general internists, but there was no significant difference in costs between those cared for by hospitalists and family physicians. Rates of death and of 14-day readmission were similar. A plethora of small observational studies have largely had similar findings, with patients being cared for by hospitalists having modest but statistically significantly shorter LOS, although many of these are small, singleinstitution studies and had few hospitalists caring for all of the patients in the hospitalist arm. Data from the Multicenter Hospitalist (MCH) Trial, a prospective multicenter observational study of the effect of hospitalist care at academic medical centers, have not indicated differences in LOS between patients cared for by hospitalists and nonhospitalists. For example, a recent analysis of 450 patients with upper gastrointestinal hemorrhage from the MCH Trial showed similar mean LOS for patients cared for by hospitalists and nonhospitalists and higher costs for patients cared for by hospitalists. Similarly, data from the MCH Trial did not show any significant differences in LOS or costs between patients with decompensated heart failure cared for by hospitalists and nonhospitalists. Even if we accept that hospitalists reduce LOS modestly, is that a clinically significant finding, and what are the implications for elderly patients? Kuo and colleagues have previously reported on the growth in the care of older adults by hospitalists, but few studies have focused on outcomes of hospitalist care in the elderly population. One small observational study at a community teaching hospital showed statistically significantly shorter LOS and lower total costs that were most pronounced in patients aged 65 and older. There have been a few studies of the effect of hospitalist management or comanagement of elderly patients with hip fractures, with one historical cohort study showing significantly shorter LOS (10.6 vs 8.4 days) in patients with hip fractures comanaged by hospitalists, with no difference in inpatient deaths, 30-day readmission rates, or 1-year mortality. Why has there been so little research on the effect of hospitalists on elderly patients? Hospital medicine remains a popular career choice for young internists, for many reasons, including the ability to take care of acutely ill patients, the ability to engage in quality improvement projects, and work–life balance, but it is probably safe to say that few hospitalists specifically choose the field for the opportunity to care for older adults and target research and quality improvement initiatives toward that population. Few hospitalists have special training in geriatric medicine, and few hospitalist groups have programs addressing the needs of elderly patients, even though hospitalists care for many elderly patients and may even care for patients in skilled nursing facilities. Geriatricians, with a few notable exceptions, have been largely absent from the debate over the merits of the hospitalist system. In this issue of the Journal of the American Geriatrics Society, Kuo and Goodwin report results of an ambitious study to understand the health services implications of nationwide hospital care of Medicare-eligible persons by hospitalists and nonhospitalists. Because several studies have shown shorter LOS associated with hospitalist care, the authors further attempt to understand various patient and hospital characteristics that may or may not be associated with this shorter LOS and whether this phenomenon is changing over time. This is a retrospective cohort study using a 5% national sample of Medicare beneficiaries, winnowed down to approximately 300,000 subjects for the characteristics analysis and approximately 2 million for the trend analysis. The latter sample is approximately half of all hospitalizations in the 5% sample. They employ elaborate and appropriate multivariable methods to control for a large number of variables and interaction terms, using a very large sample size to do so. They found that the adjusted LOS was 0.36 days shorter in patients cared for by hospitalists, a finding similar to a previous study. Kuo and Goodwin also found a greater difference in LOS in the oldest patients, with a difference of 0.63 days (95% confidence DOI: 10.1111/j.1532-5415.2010. 03009.x