Hospital-care specialists improve outcomes, reduce costs

December 2, 2002

Physicians who concentrate on hospital care produce better results than the general internists who have traditionally managed hospital stays, reveals a study by researchers at the University of Chicago. The study, published in the Dec. 3 issue of the Annals of Internal Medicine, found that "hospitalists" can reduce short-term mortality, decrease hospital stays and cut costs. The benefits, though modest at first, increased as the hospitalists--a relatively new specialty--gained experience.

In the first half of the two-year study, patients cared for by hospitalists stayed in the hospital about one-third of a day less than those cared for by internists. By the second year, the difference increased to half a day, which reduced costs by an average of $782 per patient.

More important, in the second year, short-term mortality fell by 37 percent. Six percent of the patients cared for by internists died within 30 days, but only 4.2 percent of the hospitalists' patients died within 30 days.

"Study after study has demonstrated a close relationship between volume and outcome for surgical procedures," said David Meltzer, M.D., Ph.D., associate professor in the departments of medicine and economics and in the Harris School of Public Policy at the University of Chicago and lead author of this study. "Our findings, for the first time, extend this phenomenon to hospitalized patients with common medical conditions, those usually cared for by general internists."

The study involved 6,511 patients admitted to the general medical service at the University of Chicago Hospitals between July 1, 1997, and June 30, 1999. Every fourth day, new patients were assigned to the care of one of two hospitalists. A pool of 58 general internists cared for patients admitted on the other three days. Patients in both groups were similar.

The two hospitalists, part of a new service at the Hospitals in 1997, rapidly accumulated experience caring for the specific needs of hospitalized patients. They alternated with each other every month, spending six months a year devoted to the care of hospitalized patients. Each of the 58 general internists, on the other hand, devoted a much smaller percentage of his or her time to hospital care. They continued to see other patients in the outpatient setting and spent two months or less each year caring for patients in the hospital.

The differences between the two groups slowly emerged over the course of the study. The average length of stay for all patients during this period fell by nearly half a day, from 5 to about 4.5 days, but inpatient stays decreased faster for patients cared for by hospitalists. In the second year of the study, patients cared for by internists stayed for an average of 4.59 days while those cared for by hospitalists left after an average stay of 4.1 days.

Hospitalists also reduced costs. While average adjusted costs per patient increased by $100 (from $8,701 to $8,801) for the generalists from year one to year two, it fell by $629 for the hospitalists (from $8,648 to $8,019), for a total difference in year two of $782 per patient. Even in this small trial, this produced savings of more than $600,000.

In year two, hospitalists produced significantly better survival rates. At 30 days, six percent of the internists' patients had died versus only 4.2 percent of those cared for by hospitalists. At 60 days most of the difference persisted: 8.8 percent of the internists' patients had died but only 6.8 percent of the hospitalists' patients.

Hospitalists also had slightly lower rates for in-hospital mortality (1.9% vs. 2.2 %), 30-day emergency department visits (7.6% vs. 8.2%) and 30-day readmission rates (10.8% vs. 12.2%).

The researchers attribute most of these gains, which continued to mount even during the second year of the study, to the increased experience of the hospitalists in handling the hospital care of patients with specific diseases.

"It shows," they note, "that even experienced clinicians can benefit from greater experience treating conditions that they regularly encounter."

"We need to be cautious," Meltzer added, "because this study examined only two hospitalists at a single institution." A larger, multi-center study is now underway.

Additional authors of the paper include Willard Manning, Jeannette Morrison, Manish Shah, Lei Jin, Todd Guth and Wendy Levinson. The University of Chicago Hospitals, the Charles E. Culpeper Foundation, the National Institute of Aging and the Robert Wood Johnson Foundation funded the study.

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