Zero to 50,000 — The 20th Anniversary of the Hospitalist

Previous investigations of the effect of the hospitalist model on resource use and patient outcomes have focused on academic medical centers or have used short follow-up periods. To determine the effects of hospitalist care on resource use and patient outcomes and whether these effects change over time. Retrospective cohort study. Community-based, urban teaching hospital. 5308 patients cared for by community or hospitalist physicians in the 2 years after implementation of a voluntary hospitalist service. Length of stay, costs, 10-day readmission rates, use of consultative services, in-hospital mortality rate, and mortality rate at 30 and 60 days. Patients of hospitalists were younger than those of community physicians (65 years vs. 74 years; P < 0.001) and were more likely to be of black than of white ethnicity (33.3% vs. 17.9%; P < 0.001), have Medicaid insurance (25.1% vs. 10.2%; P < 0.001), and receive intensive care (19.9% vs. 15.8%; P < 0.001). After adjustment in multivariable models, length of stay and costs were not different in the first year of the study. In year 2, patients of hospitalists had shorter stays (0.61 day shorter; P = 0.002) and lower costs ($822 lower; P = 0.002). Over the 2 years of this study, patients of hospitalists had lower risk for death in the hospital (adjusted relative hazard, 0.71 [95% CI, 0.54 to 0.93]) and at 30 and 60 days of follow-up. A voluntary hospitalist service at a community-based teaching hospital produced reductions in length of stay and costs that became statistically significant in the second year of use. A mortality benefit extending beyond hospitalization was noted in both years. Future investigations are needed to understand the ways in which hospitalists increase clinical efficiency and appear to improve the quality of care. Show more

Shared management of surgical patients between surgeons and hospitalists (comanagement) is increasingly common, yet few studies have described its effects. Retrospective, interrupted time-series analysis of data collected from adults admitted to a neurosurgery service at our university-based teaching hospital between June 1, 2005, and December 31, 2008. Data regarding length of stay, costs, inpatient mortality rate, and 30-day readmission rate were collected from administrative sources; patient and caregiver satisfaction was assessed through surveys. We used multivariable models to estimate the effect of comanagement on key outcomes after adjusting for secular trends and patient-specific risk factors. During the study period, 7596 patients were admitted to the neurosurgery service: 4203 (55.3%) before July 1, 2007, and 3393 (44.7%) after comanagement began. Of those admitted during the postimplementation period, 988 (29.1%) were comanaged. After implementation of comanagement, no differences were found in patient mortality rate, readmission, or length of stay. No consistent improvements were seen in patient satisfaction, but strong perceived improvements occurred in care quality reported by nurses and nonnurse health care professionals. In addition, we observed a reduction in hospital costs of $1439 per admission. Implementation of a hospitalist comanagement service had little effect on patient outcomes or satisfaction but appeared to reduce hospital costs and improve health care professionals' perceptions of care quality. As comanagement models are adopted, more emphasis should be placed on developing systems that improve patient outcomes. Show more