Primary care family physicians and 2 hospitalist models: Comparison of outcomes, processes, and costs

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Original Research

Primary care family physicians and 2 hospitalist models: Comparison of outcomes, processes, and costs

J Fam Pract. 2002 December;51(12):1021-1027

By

Peter C. Smith, MD

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References

1. Wachter RM. An introduction to the hospitalist model. Ann Intern Med 1999;130:338-42.

2. Auerbach AD, Nelson EA, Lindenauer PK, et al. Physician attitudes toward and prevalence of the hospitalist model of care: results of a national survey. Am J Med 2000;109:648-53.

3. Stein MD, Hanson S, Tammaro D, Hanna L, Most AS. Economic effects of community vs hospital-based pneumonia care. J Gen Intern Med 1998;13:774-7.

4. Wachter RM, Katz P, Showstack J, Bindman AB, Goldman L. Reorganizing an academic medical service: impact on cost, quality, patient satisfaction, and education. JAMA 1998;279:1560-5.

5. Palmer HC, Armistead NS, Elnicki D, et al. The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. Am J Med 2001;111:627-32.

6. Davis KM, Koch KE, Harvey JK, et al. Effects of hospitalists on cost, outcomes, and patient satisfaction in a rural health system. Am J Med 2000;108:621-6.

7. Hackner D, Tu G, Braunstein GD, et al. The value of a hospitalist service: efficient care for the aging population? Chest 2001;119:580-9.

8. Molinari C, Short R. The effects of an HMO-hospitalist program on inpatient utilization. Am J Manag Care 2001;7:1051-17.

9. Wachter RM. An introduction to the hospitalist model. Ann Intern Med 1999;130:338-42.

10. Boschert S. “Hospitalists” may be an emerging specialty. Am Med News July 15, 1997;67.

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KEY POINTS FOR CLINICIANS

Family practice primary care physicians, rotating family practice faculty hospitalists, and full-time specialist hospitalists provide comparable care for inpatients with pneumonia.
Subspecialist hospitalists have higher hospital charges and longer lengths of stay and use more resources.
The use of hospitalists by hospital systems or insurers should be not be mandated.
Hospitalists and primary care physicians can better counsel inpatients about lifestyle modification and end-of-life issues.

ABSTRACT

OBJECTIVES: To compare the care provided by family practice primary care physicians with that provided by 2 hospitalist models: critical care hospitalists and rotating residency faculty family physician hospitalists.
STUDY DESIGN: Retrospective chart review. A health maintenance organization mandated that all patients be admitted to a critical care hospitalist team. The family physician hospitalists admitted all other residency patients and patients of some community family physicians. The primary care physicians admitted all their other patients. We adjusted for disease severity by using the Pneumonia Severity Index, age, sex, and comorbidities.
POPULATION: Adults admitted with pneumonia to our private urban community hospital. Exclusions included patients with nosocomial pneumonia, human immunodeficiency virus, and acquired immunodeficiency syndrome.
OUTCOMES MEASURED: Primary (adjusted for age, sex, comorbidities, and disease severity): hospital charges, length of stay, in-hospital mortality, readmissions, and returns to the emergency room. Secondary: chest radiographs, intensive care use, blood and sputum cultures, compliance with American Thoracic Society guidelines, lifestyle and end-of-life counseling.
RESULTS: Of 97 patients, 21 were admitted to the critical care hospitalists, 53 to the family physician hospitalists, and 23 to primary care physicians. The mean charge ($5680) by the primary care physicians was significantly lower than that of the critical care hospitalists ($10,231; P = .005) and trended toward being lower than that of the family physician hospitalists ($7699; P = .08). The patients of critical care and family physician hospitalists had longer mean lengths of stay (critical care hospitalists, 3.8 days; family physician hospitalists, 3.9 days) than did those of the primary care physicians (2.6 days; P = .04 and .01, respectively). Compared with the primary care physicians, the critical care hospitalists were more likely to obtain at least 2 chest x-rays (odds ratio, 4.1; 95% confidence interval, 1.1–15.5) and trended toward increased odds of lengthy stay in the intensive care unit (odd ratio, 2.9; 95% confidence interval, 0.6–14.6). We found no other significant differences in primary or secondary outcomes.
CONCLUSIONS: Claims of better and cheaper care by hospitalists need further investigation. Meanwhile, the use of hospitalists should not be mandated, and the use of family physicians as hospitalists should be considered a good alternative to the use of subspecialists.

The hospitalist movement has promised to improve the quality of inpatient care, increase patient satisfaction, and decrease costs.¹ Many hospitals, practices, and managed care corporations have adopted this model of care,² but whether this model has fulfilled its promises is unknown. Those who favor hospitalists have argued that hospitalists offer more efficient care by increasing quality and decreasing costs. Detractors are concerned about potential substandard quality through aggressive discharge policies and loss of continuity of care. Unfortunately, both positions are based largely on untested assumptions. We identified 6 peer-reviewed articles directly comparing hospitalists and primary care physicians.^3-8 Another 314 were descriptive studies, editorials, letters, and news pieces arguing about the potential risks and benefits of the hospitalist movement.

Hospitalists have been described as physicians who spend over one fourth of their time exclusively in the hospital caring for other physicians’ patients only during that admission.⁹ Others believe the hospitalist movement more accurately encompasses a broad spectrum of how inpatient care is organized,¹⁰ including primary care physicians managing their own inpatients and seeing clinic patients, primary care physicians sharing week- or month-long periods of exclusive hospital care with partners, or excluding the primary care physician from inpatient care by using dedicated inpatient-only physicians who may be family physicians, internists, or specialists.

The scant literature comparing care provided by hospitalists and primary care physicians has several methodologic constraints including before and after designs that may have time-effect bias,^11-15 inappropriately assigning subspecialists to the primary care group,³ restricting efficiency tools such as nurse managers and discharge planners to the intervention group,^4-6 failing to account for differential involvement of house staff,^7,11 using possibly unreliable outcomes,⁸ and relying exclusively on claims data.^11,14 Two recent studies avoided many of these pitfalls and found no differences between different types of hospitalists, but did not compare them with primary care physicians.^16,17 We designed our study to address multiple methodologic concerns and determine whether differences in outcomes, processes of care, and costs exist between these multiple models of inpatient care.