The Effect of Full-Time Faculty Hospitalists on the Efficiency of Care at a Community Teaching Hospital

The term hospitalist has been introduced to describe physicians who specialize in inpatient medicine and who manage the care of hospitalized patients for primary care physicians [1]. As both hospital admissions and length of stay decline, the decreasing proportion of time that the average primary care physician spends on the inpatient service and the demand for efficiency in the practice of medicine have generated interest in hospitalists [2, 3]. Potential advantages of the use of hospitalists include the greater expertise and experience of the physicians providing inpatient care, availability of the inpatient physician to make decisions throughout the day, and greater efficiency in the use of time of the outpatient physician, who is freed from inpatient duty [1-4]. These advantages must be weighed against potential disadvantages resulting from the loss of continuity of care. The primary care physician loses the care of the hospitalized patient, and the inpatient physician loses follow-up care when the patient is discharged. The replacement of the familiar outpatient physician by an unfamiliar inpatient physician may decrease patient satisfaction. The relative merits of the hospitalist program can be determined only by studies that measure quality of care, patient satisfaction, and cost and efficiency of care in various settings [1]. We report here the experience of a community teaching hospital during the initial year of a hospitalist program. Methods Study Setting Our study was conducted in a 542-bed, independent, urban community hospital in the northeastern United States. The hospital had approximately 19 000 admissions per year during the 2 years of the study. Of these admissions, approximately 5000 were admissions by primary care physicians. The hospital had its own independent residencies in internal medicine, family medicine, radiology, obstetrics and gynecology, and anesthesia. It is affiliated with a medical school and participates in university hospital-based training programs in emergency medicine and plastic surgery. Both the internal medicine and radiology residencies support subspecialty fellowships. Study Patients In the fall of 1995, a large primary care physician group whose practice was managed by our hospital's medical services organization agreed to have its inpatient admissions managed by hospitalists, who were members of the full-time faculty in the division of general internal medicine. The study group (hospitalist group) consisted of all patients who were admitted to the study hospital by these primary care physicians during the first 12 months in which hospitalists cared for patients admitted to this hospital. The group's major primary care office practice was in a hospital-owned physician practice building adjacent to the hospital. The group also had outlying offices and a large nursing home and personal care home practice. Approximately 50% of its admissions were to other hospitals, primarily those near its other practice sites. Patients admitted to these other hospitals were cared for by the primary care physicians in the primary care group, not hospitalists. All admissions to this hospital during the study years, including multiple admissions for the same patient, were counted as admissions in the study. Admissions to other hospitals were not included. We compared all patients admitted to the study hospital by the hospitalist group in the first year of the hospitalist program (hospitalist year) with all patients admitted to the study hospital by the same physician group in the 12 months immediately preceding the study year (prehospitalist year) (comparison group 1). Because many factors in our community influenced length of stay and cost of care during these 2 years, we used two additional comparison groups. To avoid selection bias, we also studied an unselected comparison group consisting of all patients admitted to the study hospital by all primary care internal medicine and family medicine private practice physicians (with the exception of the study group physicians and the full-time faculty group) during the prehospitalist year (comparison group 2) and the hospitalist year (comparison group 3). Patients of these outpatient practices had a shorter length of stay during the prehospitalist year than the patients of the practice that adopted the hospitalist system. Because this difference could have influenced our results, we also identified subsets of comparison groups 2 and 3, composed of patients from the five primary care practices with the longest length of stay, as additional comparison groups (comparison group 2a for the prehospitalist year and comparison group 3a for the hospitalist year). Comparison groups 2a and 3a consisted of patients from outpatient practices whose prehospitalist lengths of stay were similar to that of the study patients. Physicians of patients in both comparison groups admitted patients to several other hospitals. Most admissions to other hospitals were to suburban hospitals and were based on the hospitals' geographic proximity to the patient. At the study hospital, all patients in the hospitalist group and comparison groups were admitted to the same nursing units. For all groups, all patients admitted to the intensive care unit and the coronary care unit were assigned resident coverage. One housestaff team with a second-year resident and two first-year residents provided this coverage for patients not admitted to special care units. This team had a maximum capacity of 24 patients. When this capacity was exceeded, newly admitted patients were not assigned housestaff coverage. Approximately 75% of patients in comparison groups 2, 3, 2a, and 3a had resident coverage in both years. Patients in the comparison groups were also admitted without resident coverage when the capacity of the resident teams was exceeded. A few attending physicians preferred to write their own orders and did not have resident coverage on the general medicine floors. On resident-covered services, residents must write all orders. Coverage by a physician assistant was available for all patients who did not have resident coverage. Physician assistants did not care for patients covered by residents. In comparison group 1, patients not admitted to critical care units were covered by a physician assistant, but not a resident. We have previously reported that in our hospital, patients with and those without resident coverage had similar diagnosis-related group (DRG)-adjusted lengths of stay [5]. In all groups, the attending physician responsible for inpatient care was expected to see the patient at least once daily and to communicate with the medical resident or physician assistant. Hospitalist System The hospitalists were members of the full-time faculty in general internal medicine. Two hospitalists covered an average combined inpatient census of 28 study group patients. The hospitalists were in the hospital and available for patient care during regular working hours from Monday through Friday. Three hospitalists spent at least 50% of their time on inpatient care. One of the hospitalists functioned as a hospitalist throughout the year; the other two were hospitalists for approximately 6 months per year. Weekend and night call were rotated among all members of the general medicine faculty group. The primary care physicians could make courtesy visits to their patients on the hospitalist service. Hospitalists communicated discharge information to the patients' primary care physicians through telephone calls to the physicians' offices and copies of written discharge instructions and discharge summaries. Before the hospitalist year, physicians in comparison group 1 had participated in inpatient rounds on a daily rotating schedule. Thus, patients infrequently saw their own primary care physician. One member of the group spent a large proportion of the time caring for inpatients. Most patients in comparison groups 2, 2a, 3, and 3a were cared for by their own primary care physician in both study years. Because the hospitalists were present in the hospital throughout the day, they could evaluate patients and make decisions at any time; in contrast, other attending physicians usually evaluated patients only once per day. It was the attending physician's and the hospitalist's responsibility to inform patients of the hospitalist system. The hospitalists had no financial incentive to decrease length of stay or cost of care, but it was understood that these reductions would become a goal of the program. All attending physicians from all groups admitted their patients to the same nursing units and had access to the same clinical protocols, clinical pathways, utilization review, and discharge planning services. Data Collection and Study Outcomes The methods for data collection and analysis were identical for all groups for both study years. The number of admissions, patient age and other demographic data, insurance source, and length of stay were collected from the Clinical Cost Accounting System (Huff, Barrington, and Owen Co.). Patients were assigned to groups on the basis of the attending physician at discharge listed in this administrative database. Discharge diagnosis, DRG, and mortality data were also obtained from this database. We computed a DRG-adjusted Health Care Financing Administration (HCFA) expected length of stay for each group using HCFA expected length of stay adjusted for the DRG assigned to each admission. We also obtained the Medicare case-mix index. We calculated cost of care using a relative value scale method developed by our hospital accounting system as the best approximation of actual hospital costs. Relative value units were developed for every billable patient service. Each unit includes labor, nonlabor, and overhead costs. Readmissions to the study hospital within 14 and 30 days after discharge were collected prospectively by the hospital as part of its quality assurance