Armed with a cup of coffee, with my dogs walked and fed and the sun rising into view, I eased into my home office chair and contentedly folded open the pages of The Wall Street Journal.
My ritual early-morning glance at the local and national papers usually provides little more than a glum outlook for my favorite sports teams, a glummer view of my financial investments, and a few seeds to cultivate into elevator small talk.
This morning, however, I was struck by this headline: “‘Hospitalists’ Are Seen as Help.”1 I happily noted the subheading, which referred to us as “specialists.” I reveled in the general tone of the article, which indicated that we reduce hospital length of stay and costs.
The article reported the findings of a New England Journal of Medicine paper by Lindenauer, et al., that showed a 0.4-day reduction in length of stay (LOS) and a net savings of $268 per patient compared with non-hospitalist general internist providers.2 Good news for the field, indeed.
Or was it? What was not highlighted in The Wall Street Journal was that while hospitalists also reduced LOS 0.4 days versus non-hospitalist family physicians, there was no statistically significant reduction in cost versus this cohort. Further, there was no difference in hospital mortality or 14-day readmission rate versus either non-hospitalist set of providers.
While not the greatest markers of quality, mortality and readmission rate are two of the easiest and most recognized markers of effective care. Dr. Lindenauer’s paper found no benefit from the hospitalist model.
Granted, other studies have shown a benefit of the hospitalist model in areas such as co-management of orthopedic patients. But these effects were modest and primarily limited to process measures, not quality-of-care outcomes.
Another recent paper by Auerbach, et al., reported that general medical consultation by hospitalists on surgical patients did not result in better glycemic control, use of perioperative beta blockade, or venous thromboembolism prophylaxis versus surgical care alone.
In a healthcare system that the Institute of Medicine claims is responsible for unfathomable rates of medication errors and upward of 100,000 avoidable inpatient deaths every year, it sounds as though hospitalists are missing the chance to fulfill their promise.
The promise of the hospital medicine movement is that hospitalists will do it better: cheaper, faster, and safer. If we accept this, then these new data appear to paint a picture of a movement that is chugging off course.
I don’t think it’s that simple. Rather, this speaks to two key elements in the maturation process of the hospitalist field.
First, changing the fundamentals of healthcare delivery is difficult work. This is especially true for a young group of providers, who struggle with overwhelming growth, constant understaffing, and a business model that favors patient encounters over process improvement.
On top of this, we are asked to change behavior in a complex system where instituting change often involves altering the practice of others outside your group, such as nurses or other physician groups.
Add to this significant undertraining in patient safety and process improvement, and a lack of time for quality improvement work or rewards to encourage it.