At a time when managed care is forcing hospitals to cut costs, a new UC San Francisco study has found that increasing the involvement of faculty doctors who specialize in hospital care may be a key to shorter, less costly hospital stays that don't compromise quality or teaching.
The study, published in the May 20th edition of the Journal of the American Medical Association, found that patients spend less time in the hospital--and their care costs less as a result--when their cases are managed by doctors in the recently emerged specialty of hospital care, called hospitalists.
Traditionally, residents, who are medical school graduates in the late stages of training, manage inpatient care in teaching hospitals.
The role of the hospitalist is a departure from the way faculty doctors traditionally have functioned in academic hospitals. Under the traditional model, faculty members serve as advisors to the residents and rotate in that role infrequently, often just one month a year.
"What you have with the hospitalist model is more direct supervision by individuals who are more experienced in this attending role, more skilled in it and for whom this role is a larger part of their professional identity," said Robert M. Wachter, MD, UCSF associate professor of medicine and epidemiology.
Wachter is associate chairman of UCSF's Department of Medicine, chief of the Medical Service at UCSF Medical Center and the study's principal investigator. UCSF Medical Center is part of UCSF Stanford Health Care.
The year-long study, which involved 1,623 patients at UCSF Medical Center from July 1995 to June 1996, showed that patients stayed an average of 4.3 days, at a cost of $7,007, when their care was managed more closely, generally by a hospitalist. They spent 4.9 days, at $7,777, under a more traditional structure. Patients were randomly divided into the two groups.
There was no significant difference between how patients in both groups fared healthwise, or how satisfied they were with the care they received, Wachter said. That finding is based on a wide range of observations, including patient outcomes and hospital readmissions, as well as a patient survey.
The study also may ease concerns of residents that the increasing involvement of hospitalists could cost them their autonomy and compromise the quality of their education, Wachter said. A survey showed that a majority of residents who worked side-by-side with the hospitalists were highly satisfied with the experience. In fact, the majority preferred it to the traditional system.
Also allayed were the concerns of other specialists, who questioned whether they would get fewer referrals as a result of greater reliance on hospitalists, Wachter said.
The findings, Wachter said, further support the increasingly popular idea of using hospitalists to improve the efficiency, and possibly the quality, of inpatient care. The concept of the dedicated inpatient physician was first described by Wachter and co-author Lee Goldman, MD, UCSF professor of medicine and chair of the UCSF Department of Medicine, in a seminal 1996 New England Journal of Medicine article, in which the term "hospitalist" was coined.
While improving value may not have been a primary focus as little as five years ago, managed care now forces health care providers to look for ways to cut costs without harming quality or patient satisfaction, Wachter said.
"Nearly two years after the study, the practice of having attending physicians being involved sooner and more intensely makes up the majority of the way things work now," Wachter said. "Now these methods are standard procedure."
Co-investigators include Goldman; Patricia Katz, PhD, UCSF assistant professor of medicine; Jonathan Showstack, PhD, MPH, UCSF professor of medicine; and Andrew Bindman, MD, UCSF associate professor of medicine.
Journal
JAMA