Published in the September 2004 issue of Today’s Hospitalist
When it comes to working as a hospitalist, several studies have examined the role of experience in affecting measures like length of stay and mortality. New research, however, finds that while experience in the inpatient setting is important, so is specialty.
Several studies have indicated that hospitalists really start to make a dent in these areas after a year or two. While those studies tend to examine how new hospitalist programs “typically one- and two-physician hospitalist teams “affect length of stay and other measures, the new research examined inpatient care provided by a large group of physicians at the University of Michigan Medical Center.
In an article published in the May 2004 issue of the Journal of General Internal Medicine, researchers looked closely at how 40 physicians cared for more than 2,500 inpatients. Most of the physicians were general internists, and seven were defined as hospitalists.
The group, however, also included rheumatologists, nephrologists, endocrinologists and other subspecialists. The rheumatology and nephrology services were folded into the general medical service in 2001, the year the study was conducted, giving researchers a unique opportunity to examine how specialty affects care for inpatients in a general medicine ward.
“We wanted to take a look at a broad swath of people and ask whether hospitalists make a difference because of the general model, or whether it’s because you hire two people and charge them with decreasing mortality and length of stay,” explains Vikas Parekh, MD, the study’s lead author and director of the nonhousestaff hospitalist service at the University of Michigan Hospital.
The overall results will come as no surprise to hospitalists. Physicians who had spent at least three months on an inpatient service in the study year “defined by researchers as hospitalists “significantly reduced adjusted mean length of stay (4.33 days) compared to rheumatologists (4.99 days) and endocrinologists (4.79 days).
Researchers in this study found no significant differences in adjusted in-hospital mortality or same-hospital readmission rates between hospitalists and nonhospitalists. Dr. Parekh notes that this result contradicts some recent studies, which showed that hospitalists did produce a benefit.)
Because only 18 percent of physicians in the study had three months of inpatient experience in the study year, however, researchers wanted to examine other broader definitions of inpatient experience. That’s where they encountered interesting results about the role of not only experience, but specialty.
The role of experience
To examine how inpatient experience affects a larger group of physicians, researchers focused on how much time doctors had spent in inpatient care in the two years before the study. They included time that nephrologists and rheumatologists had spent in the renal and rheumatology services before those areas were folded into general internal medicine.
Based on inpatient experience, researchers created two groups of physicians. Those who had spent five months on inpatient care in the two years before the study were placed in the top 10 percent of all physicians. Those who had spent less time “at least 4.5 months on inpatient care “were put in the top 20 percent.
When researchers recalculated the data, they found that physicians in the top 10% had a significantly lower length of stay than all other physicians (4.26 days vs. 4.65 days). Physicians in top 20%, however, showed no significant difference when compared to other physicians in the group.
Dr. Parekh notes these results came as something of a surprise because the total inpatient care experience between the two groups wasn’t significantly different.
Researchers recalculated the top 10th and 20th percentiles again, this time counting only general medical inpatient experience. Not surprisingly,
When the data were cut this way, physicians in the top 10th and 20th percentile outperformed all other physicians in terms of length of stay. The top 10 percent had an average length of stay of 4.26 days, compared to 4.31 days for the top 20 percent, and 4.66 days for everyone else.
Subspecialist effect?
Researchers concluded that working as a general internist was correlated with improved used of resources, and that working as a specialist is associated with greater use of resources.
Dr. Parekh acknowledges that the numbers of subspecialists in the study was relatively small, a factor he admits may have influenced the results. Even so, he thinks that experience with general medical patients is a key to developing efficient practice patterns critical to hospital medicine.
“We can’t exclude that there may be an independent negative effect of being a specialist,” he says. “It may be that you need a wide range of experience treating a broad range of patients to be efficient, as opposed to some specialists who have a narrow scope of experience in our study.”
The commentary in the study notes that subspecialists naturally lack experience treating the wide range of diagnoses seen by general medical teams. In the general medical service, no single diagnosis accounts for more than 10% of all admissions, giving those physicians experience with a wide range of patients.
The study also hypothesizes that the nature of subspecialties like rheumatology and endocrinology may lead to a more cost intensive, outpatient style of practice when those physicians conduct outpatient type of evaluations in the hospital.
Simple volume may also be a factor in the experience differential. Nephrologists and rheumatologists in the old services, for example, admitted far fewer patients per month than the general medical teams.
The study’s results may raise questions about the economic effectiveness of using subspecialists in a hospitalist service. Dr. Parekh, however, says that’s not an issue at his institution.
“If we’re looking purely at efficiency and cost, there may be a downside to having specialists on our general medical wards,” he acknowledges. “But the flip side is that at an academic medical center, there is an upside in terms of a diversity of experience and perspectives for our housestaff. We are not purely wed to our financial obligations.”
Looking ahead
When the study was conducted, University of Michigan had no formal hospitalist program. Physicians who were defined as hospitalists had limited outpatient duties.
Since the article was published, the program has hired dedicated hospitalists on the academic side, faculty that do six months of ward attending. While Dr. Parekh hasn’t formally looked at the data yet, he says that preliminary analysis seems to indicate that these “dedicated” hospitalists are doing better in areas like reducing length of stay.
He is quick to add, however, that his program’s goal of using hospitalists goes beyond just lowering costs and length of stay. “Quality of care and processes of care are the next focus for us as we move forward and expand our hospital program in our group,” he says. “Reducing length of stay and costs is nice, but to keep ourselves valuable to the institution, we have to show that we’re doing other things as well.”
“Length of stay can only go so low, and many programs have come to the same realization, that after about two years you’re not going to push that number any lower because of an inherent floor,” he notes. “In institutions where you’re pressured to show continual improvement, you have to expand your focus beyond those things.”
