Economic and healthcare forces of hospitalist movement

Association of hospitalist presence and hospital-level outcome measures among Medicare patients

BACKGROUND

Hospitalists have been shown to lower patient costs through better resource utilization and decreased length of stay, but it is unclear whether hospitalists are associated with quality of care. We examined the association between the presence of hospitalists and 30-day predicted excess all-cause hospital mortality and readmissions among Medicare patients admitted to a hospital with any of 3 conditions: heart failure, acute myocardial infarction, and pneumonia.

METHODS

Using national hospital-level, case mix-adjusted, risk-standardized, 30-day all-cause excess mortality and readmission data from the Centers for Medicare and Medicaid Services, we used descriptive and bivariate statistics to illustrate trends across hospitals. Using multivariable ordinary least squares regression to control for hospital-level characteristics, we then estimated the association between the presence of hospitalists and predicted hospital mortality and readmission.

RESULTS

After multivariable adjustment, the presence of hospitalists was associated with lower probability of readmission for all 3 target conditions. No significant associations for any of the target conditions were found in all-cause mortality models.

CONCLUSIONS

Hospitalists are already integral to the delivery of inpatient care at most institutions. This study, however, showed an association at the national level of the presence of hospitalists with an important and timely quality measure: reduction of readmission rates. Future research is indicated to explore specific causation pathways for the impact of hospitalists on quality of care.

The ethics of the hospitalist model

The hospitalist model was founded on the premise that it could improve the quality and reduce the cost of hospital care. Many randomized studies have all but definitively proven this original assertion. Nevertheless, the hospitalist specialty raises lingering classical ethical issues: protecting the patient-physician relationship in an environment of increasing specialization and discontinuity of care, preserving patient autonomy and choice when structural changes are made in the provision of care, and ensuring that a model founded on efficiency and cost-effectiveness does not erode the public trust in hospitalists to always serve their patients' best interests. This work aims to serve as an update of these initial criticisms, showing how some questions have been answered, while some have not.