Unfortunately, this was a small study that lacked sufficient power to detect modest differences between groups because the health maintenance organization sponsoring the critical care hospitalist group abandoned the program after 1 year. In addition, the differences in disease severity might have been significant in a larger sample. However, even after controlling for these differences statistically, we found no large differences for mortality, readmission, or returns to the emergency room.
Despite insufficient power to observe statistically significant differences in these relatively rare but important pneumonia outcomes, we did detect a substantial difference in adjusted hospital charges and a modest difference in length of stay. Subspecialist hospitalists had significantly higher adjusted charges than did primary care family physicians. Although the comparison across groups failed to show statistically significant differences, we did see a trend of increasing charges as the degree of hospitalization increased. These higher costs may be explained in part by primary care physicians advising shorter lengths of stay and the subspecialists’ increased use of multiple chest x-rays and trends toward greater use of other resources (eg, intensive care and blood and sputum cultures). Alternatively, some of the difference in charges may reflect differing levels of continuity; the critical care hospitalists had no outpatient continuity with their inpatients, whereas the family physician hospitalists had continuity relationships with some inpatients and the primary care physicians had relationships with all their inpatients. Thus the primary care physicians and, to a lesser extent, the family physician hospitalists may have had information about prior care. Hence, knowledge of previous antibiotic use might argue for the low yield of blood and sputum cultures, and having obtained an outpatient x-ray might obviate the need for another in the hospital. The critical care hospitalists’ increased length of stay and x-ray use, in conjunction with the trend toward greater use of cultures and intensive care, may in turn reflect different degrees of comfort with uncertainty between family physicians and subspecialists. Also, we examined only hospital charges rather than total costs to the system.
Interestingly, we found a trend showing that family physician hospitalists were more likely to document lifestyle modification counseling than were primary care physicians. This result should be interpreted with some caution. Our findings may indicate a true lack of performance by primary care physicians, or they may show a failure to document advice on the hospital chart, reflecting some aspect of the continuity relationship in which such discussions are relegated to the outpatient setting.We also were surprised to see the trend toward decreased end-of-life counseling by the primary care physicians. This could reflect some adverse effect of continuity, the time constraints imposed on nonhospitalists, or not documenting outpatient counseling on the inpatient record.
There were other potential sources of confounding in this study. All patients in the critical care hospitalist group were members of the same health maintenance organization, which may have introduced unmeasured bias despite our attempts to control for differences between groups. Even though we purposefully avoided differential use of house staff, its involvement in each case may have decreased any potential differences across practices.
We draw 2 important conclusions from our results. First, our findings of increased costs and length of stay for mandated hospitalists without significantly different outcomes support the assertion of the American Academy of Family Physicians, the American College of Physicians–American Society of Internal Medicine, the American Medical Association, and the National Association of Inpatient Physicians: the practice of mandating the use of hospitalists should be abandoned pending larger, more comprehensive contemporaneous trials. Second, if hospitalists are to be employed on a voluntary basis, the use of subspecialists rather than generalists may result in more costly care.
Acknowledgments
The authors thank Ralph B. D’Agonstino, Jr., PhD, of the Bowman Gray School of Medicine for his invaluable assistance in statistical methods and Cary Foster, MD, and Promoda Mahupatra, MD, for their collection of the data.