Original Research

Impact of Hospitalists on Care Outcomes in a Large Integrated Health System in British Columbia

Journal of Clinical Outcomes Management. 2020 March;27(2):59-72C

Author(s):

Vandad Yousefi, MD

Samar Hejazi, PhD

Andrew Lam

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References

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From the Fraser Health Authority, Surrey, British Columbia, Canada.

Abstract

Objective: To study care outcomes associated with a network of hospitalist services compared to traditional providers.
Design: Retrospective review of administrative data.
Setting and participants: Patients from a large integrated health care system in British Columbia in western Canada admitted and cared for by 3 provider groups between April 1, 2012, and March 31, 2018: hospitalists, family physicians (FP), and internal medicine (IM) physicians:
Measurements: Average total length of stay (LOS), 30-day readmission, in-hospital mortality, and hospital standardized mortality ratio (HSMR) were the study outcome measures. Multiple logistic regression or generalized regression were completed to determine the relationship between provider groups and outcomes.
Results: A total of 248,412 hospitalizations were included. Compared to patients admitted to hospitalists, patients admitted to other providers had higher odds of mortality (odds ratio [OR] for FP, 1.29; 95% confidence interval [CI], 1.21-1.37; OR for IM, 1.24; 95% CI, 1.15-1.33). Compared to hospitalist care, FP care was associated with higher readmission (OR, 1.27; 95% CI, 1.22-1.33), while IM care showed lower odds of readmission (OR, 0.83; 95% CI, 0.79-0.87). Patients admitted to the IM group had significantly lower total LOS (mean, 5.13 days; 95% CI, 5.04-5.21) compared to patients admitted to hospitalists (mean, 7.37 days; CI, 7.26-7.49) and FPs (mean, 7.30 days; 95% CI, 7.19-7.41). In a subgroup analysis of patients presenting with congestive heart failure, chronic obstructive pulmonary disease, and pneumonia, these general tendencies broadly persisted for mortality and LOS comparisons between FPs and hospitalists, but results were mixed for hospital readmissions.
Conclusion: Care provided by hospitalists was associated with lower mortality and readmission rates compared with care provided by FPs, despite similar LOS. These findings may reflect differences in volume of services delivered by individual physicians, on-site availability to address urgent medical issues, and evolving specialization of clinical and nonclinical care processes in the acute care setting.

Keywords: hospital medicine; length of stay; readmission; mortality.

The hospitalist model of care has undergone rapid growth globally in recent years.¹ The first hospitalist programs in Canada began around the same time as those in the United States and share many similarities in design and operations with their counterparts.^2-4 However, unlike in the United States, where the hospitalist model has successfully established itself as an emerging specialty, debates about the merits of the model and its value proposition continue among Canadian observers.^5-9

Historically, the type of physicians who acted as the most responsible provider (MRP) in Canadian hospitals depended on setting and geography.¹⁰ In large urban areas, groups of general internists or specialists have historically looked after general medicine patients as part of university-affiliated teaching services.^11,12 Patients admitted to community hospitals have traditionally been cared for by their own primary care providers, typically general practitioners or family physicians (FPs). In the mid-1990s, many primary care providers in urban centers began to withdraw from inpatient care and primarily focused their practices in the outpatient setting.^13-15Hospitalist programs emerged as health care administrators sought to fill the resulting gap in MRP coverage.^2,10

To date, attempts to understand the impact of hospitalist programs in Canada have been limited. A number of early studies aimed to describe¹⁶ the role of hospitalists in Canada and suggested improvements in length of stay (LOS) and staff satisfaction.¹⁷ However, these studies relied on unadjusted before-after comparisons and lacked methodological rigor to draw robust conclusions. More recently, a few studies have evaluated care outcomes associated with hospitalists using administrative databases, which attempted to control for potential confounding factors.^18-21

While these studies are beginning to shed some light on the impact of hospital medicine programs in Canada, there are a number of issues that limit their generalizability. For example, the majority of studies to date focus on hospital medicine programs in Canada’s largest province (Ontario), and most describe experiences from single institutions. Since each of the 13 provincial and territorial governments organizes its health care system differently,²² results from 1 province may not be generalizable to other parts of the country. Moreover, hospitalists in Ontario are more diverse in their training backgrounds, with a larger percentage having trained in general internal medicine (IM), as compared to other parts of Canada, where the majority of hospitalists are overwhelmingly trained as FPs.³

We aimed to study care outcomes associated with a network of hospitalist services compared to “traditional” providers (community-based FPs and IM specialists) in a large integrated health care system in the province of British Columbia in western Canada. The hospital medicine services in this network span a range of community and academic hospitals, and collectively constitute 1 of the largest regional programs in the country. This provides a unique opportunity to understand the impact of hospitalists on outcome measures across a range of acute care institutions.