One hospitalist-led pilot project produced a 61% decrease in heart failure readmission rates. Another resulted in a 33% drop in all-cause readmissions. The numbers might be impressive, but what do they really say about how hospitalists have influenced healthcare quality?
When HM emerged 15 years ago, advocates pitched the fledgling physician specialty as a model of efficient inpatient care, and subsequent findings that the concept led to reductions in length of stay encouraged more hospitals to bolster their staff with the newcomers. With a rising emphasis on quality and patient safety over the past decade, and the new era of pay-for-performance, the hospitalist model of care has expanded to embrace improved quality of care as a chief selling point.
Measuring quality is no easy task, however, and researchers still debate the relative merits of metrics like 30-day readmission rates and inpatient mortality. “Without question, quality measurement is an imperfect science, and all measures will contain some level of imprecision and bias,” concluded a recent commentary in Health Affairs.1
Against that backdrop, relatively few studies have looked broadly at the contributions of hospital medicine. Most interventions have been individually tailored to a hospital or instituted at only a few sites, precluding large-scale, head-to-head comparisons.
And so the question remains: Has hospital medicine lived up to its promise on quality?
The Evidence
In one of the few national surveys of HM’s impact on patient care, a yearlong comparison of more than 3,600 hospitals found that the roughly 40% that employed hospitalists scored better on multiple Hospital Quality Alliance indicators. The 2009 Archives of Internal Medicine study suggested that hospitals with hospitalists outperformed their counterparts in quality metrics for acute myocardial infarction, pneumonia, overall disease treatment and diagnosis, and counseling and prevention. Congestive heart failure was the only category of the five reviewed that lacked a statistically significant difference.2
A separate editorial, however, argued that the study’s data were not persuasive enough to support the conclusion that hospitalists bring a higher quality of care to the table.3 And even less can be said about the national impact of HM on newly elevated metrics, such as readmission rates. The obligation to gather evidence, in fact, is largely falling upon hospitalists themselves, and the multitude of research abstracts from SHM’s annual meeting in May suggests that plenty of physician scientists are taking the responsibility seriously. Among the presentations, a study led by David Boyte, MD, assistant professor of medicine at Duke University and a hospitalist at Durham Regional Hospital, found that a multidisciplinary approach greatly improved one hospital unit’s 30-day readmission rates for heart failure patients. After a three-month pilot in the cardiac nursing unit, readmission rates fell to 10.7% from 27.6%.4
Although the multidisciplinary effort has included doctors, nurses, nutritionists, pharmacists, unit managers, and other personnel, Dr. Boyte says the involvement of hospitalists has been key to the project’s success. “We feel like we were the main participants who could see the whole picture from a patient-centered perspective,” he says. “We were the glue; we were the center node of all the healthcare providers.” Based on that dramatic improvement, Dr. Boyte says, the same interventional protocol has been rolled out in three other medical surgical units, and the hospital is using a similar approach to address AMI readmission rates.
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SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions5