|January 22, 2002
Care Destined to Become Dominant Model of Inpatient Care in the U.S., Say UCSF Researchers
The rapidly growing
hospitalist model of inpatient care has now achieved many of the attributes of other
medical specialties and seems destined to become the dominant model of hospital care in
the United States, according to a study published in the January 23, 2002 issue of the
Journal of the American Medical Association (JAMA).
"The Hospitalist Movement Five Years Later," by researchers at UCSF Medical
Center, says that the hospitalist field appears to be living up to its promise to improve
the efficiency and perhaps the quality of hospital care.
"Even skeptics now concede that it is here to stay," said Robert Wachter, MD,
associate chairman of the UCSF department of medicine, lead author of the JAMA article,
and the physician who first coined the term "hospitalist" in a 1996 issue of The
New England Journal of Medicine (NEJM).
According to the UCSF study, hospital care provided by physicians (typically
internists), who focus exclusively on hospitalized patients and are available throughout
the day is less costly. In addition, "hospitalists may provide a higher quality of
inpatient care than that provided by many primary care physicians who have few
hospitalized patients and can generally see patients only briefly once a day," said
"The model appears to have achieved its minimum goal of improving efficiency
without adverse effects on quality, teaching, or patient satisfaction," said Lee
Goldman, MD, chairman of the UCSF department of medicine and co-author of the article.
Fifteen of the 19 studies reviewed by UCSF researchers found significant decreases in
both hospital costs (average decrease 13.4 %) and lengths of stay (average decrease
16.6%). Two other studies demonstrated lower lengths of stay, but no decreases in costs.
The researchers noted that if the average American hospitalist cares for 600 inpatients
yearly and generates a 10% savings over the average medical inpatient cost of $8,000, the
nation's 5,000 hospitalists are safely reducing inpatient costs by approximately $2.4
billion per year.
"Thus far, there is little to suggest that hospitalist-generated savings come at
the expense of quality," said Wachter. He explained that most studies found no change
in quality measures. Two larger studies (averaging 1600 hospitalist
patients per study) found significant decreases in inpatient and short-term mortality
associated with hospitalist care.
The researchers noted that these results are insufficient to support an unqualified
statement that hospitalists improve quality. They suggest that future studies must use
more refined measures of quality.
Despite initial concerns regarding patient acceptance of hospitalists, surveys of
patients show high levels of satisfaction, equivalent to that of similar patients cared
for by their own primary care physicians or by traditional academic ward attendings.
"Patients appear to be willing to trade off the familiarity of their regular doctor
for the availability and acute care expertise of hospitalists," said Wachter.
"Most hospitalists are at the hospital at all times and thus accessible to the
patient and family, while primary care physicians spend most of their day at their offices
with outpatients, and are therefore less available."
Recent physician surveys also indicate acceptance of the model. "As primary care
physicians get used to the system, many are choosing to partner with hospitalists to care
for their inpatients," said Wachter. "Concerns about discontinuity have
diminished as hospitalists have found ways to communicate effectively with primary care
physicians and coordinate all aspects of care. At a time when hospital patients are more
acutely ill than ever before, more doctors appear to believe that it makes sense to have
these patients managed by physicians specializing in hospital care."
Moreover, some medical staffs see hospitalists as a solution to the long-standing
struggle to find physicians to care for patients admitted from the emergency department
who have no primary care provider, explained Wachter.
A recent analysis projected that the hospitalist workforce in the United States will
grow by the end of this decade to about 19,000, up from 5,000 presently, making it
comparable in size to cardiology. "Physicians are drawn to the hospitalist field
because it allows them to be generalists and still have the excitement and gratification
of acute care medicine," Wachter said.
Currently, there are hospitalist programs in 12 of America's top 15 hospitals (as
ranked by US News and World Report) as well as early training, residency track and
fellowship programs at major universities nationwide. At UCSF, 15 faculty hospitalists now
staff about two-thirds of the inpatient general medical service and all medical consult
months. Preliminary evidence indicates that resident teaching evaluations of hospitalists
are significantly higher than those of traditional ward attendings. In addition to their
clinical and teaching roles, academic hospitalists are also making important research
contributions in reducing medical errors, improving end-of-life care, and finding new ways
to care for patients with common inpatient diseases.
Wachter is also chief of medical service at UCSF Medical Center and was the first
elected president of the National Association of Inpatient Physicians (NAIP), the premier
professional organization representing nearly 2,500 hospitalists nationwide.
Goldman is a Julius R. Krevans professor of medicine and also associate dean of
clinical affairs in the UCSF School of Medicine.
Source: Maureen McInaney (UCSF) & Lisa Freeman (Kevin Ross Public Relations)