Our study has a number of notable limitations. First, we used administrative data to conduct our evaluation and could only control for factors that are available in our data systems. As a result, some potential confounders may not have been taken into consideration. For example, our databases do not contain provider characteristics (eg, age, years of clinical experience) that have been deemed to be relevant by White and Glazier.26 Similarly, we did not have all the necessary information about the characteristics of the various MRP programs (eg, number of physicians involved in group practices, the schedule model of community FP call groups) and were not able to account for the potential impact of these on observed outcomes. Second, although our findings mirror prior studies from other parts of Canada, they may not be applicable to hospitalist programs in other jurisdictions or in health systems that are not regionalized or integrated. Third, our IM provider group is heterogeneous, with a number of different IM subspecialties (cardiologists, gastroenterologists, general internists) grouped under the IM category in our database. As a result, comparisons between the IM provider group and the other 2 provider groups, which are more homogenous, should be interpreted with caution.
Finally, we included only patients admitted to facilities in which a hospitalist service existed during the study period. As a result, a medium-size community hospital without a hospitalist service where patients are cared for exclusively by FPs and IM physicians was not included in the comparisons, and in 4 of the 10 facilities included, the number of FP patients was less than 10% of total hospitalized patients at the site (Appendix A). This may have resulted in an under-representation of FP patients.
Conclusion
Debates about the merits of the hospitalist model in Canada continue, and are in part fueled by a paucity of robust evidence about its impact on care outcomes compared to more traditional ways of providing inpatient care. In our evaluation, care provided by hospitalists is associated with lower mortality and readmission rates, despite similar LOS compared with FPs. Hospitalist care is also associated with lower mortality compared to IM providers. Hospitalists also demonstrated progressive improvement over time, with decreasing LOS and mortality rates and a stable readmission rate. Our results suggest that physicians with a focus on inpatient care can have positive contributions to quality and efficiency of care in Canada.
Corresponding author: Vandad Yousefi MD, CCFP, FHM, Fraser Health Authority, 400, 13450–102 Avenue, Surrey BC V3T 0H1, Canada.
