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Hospitalists home
and abroad
What's a hospitalist? These
medical generalists take charge of individual
patients and oversee their care throughout their
hospital stay, monitoring their condition, liaising
with specialists, arranging complex discharges.
In the US, apart from the profit
motive for speeding discharges, the growth of
the hospitalist movement has been seen as a way
to streamline and improve the hospital's interaction
with patients.
Here in Canada, the hospitalist
movement is far less developed, having grown largely
as a reaction to the increasing number of "orphan
patients" and to the increasing number of family
doctors who refuse to follow their patients into
hospital.
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The average patient would probably
be a little shocked if they knew how much priority hospitals
attach to getting them discharged as quickly as possible.
But hospitals and the doctors who work there know that
time and money saved on one patient may be devoted to
another. And one of the most effective ways to reduce
time to discharge, according to a study in the September
24 Archives of Internal Medicine, is to use hospitalists.
Numerous recent studies have shown
that hospitalists get patients to discharge faster.
The Archives study goes a bit deeper, showing which
patients are most likely to see their stay curtailed.
Researchers from the University
Hospital for Albert Einstein College of Medicine, New
York, reviewed data on all patients discharged from
their 381-bed teaching hospital over a two-year period
beginning July 2002. That gave them 9,037 discharges.
Of these patient stays, just under a third had been
managed by hospitalist teams, while the rest had been
in the hands of non-hospitalist teams.
As expected, the hospitalists'
patients had shorter overall stays, remaining in hospital
for an average 5.01 days, versus 5.87 days for the other
patients. The reduction in length of stay was greatest
in patients requiring close clinical monitoring and
for those requiring complex discharge planning, the
researchers found.
STROKE
OF GENIUS
The most marked and important reduction was undoubtedly
that seen in the case of cerebrovascular accident. Stroke
victims cared for by hospitalists stayed an average
8.6 days in hospital, while those seen by non-hospitalists
spent an average 12.5 days. Lead author Dr William Southern
believes this is partly because stroke is a condition
that requires constant bedside assessment that a hospitalist
is better placed to give, but it's also because discharging
a stroke patient typically involves making all sorts
of arrangements that hospitalists learn to handle expertly.
"The more a patient needs close
monitoring, the more they are likely to benefit from
a hospitalist who is on the premises full-time. And
the more complex the discharge, the more the hospitalist
effect shows," he told NRM.
The conditions in which hospitalists
achieved significantly quicker discharges were: cerebrovascular
accident, sepsis, urinary tract infection, congestive
heart failure, asthma/COPD and chest pain. The areas
in which hospitalist-ordered lengths of stay differed
least from non-hospitalists were coronary disease, heart
attack, fluid/electrolyte disorder and gastrointestinal
bleeding.
Shorter length of stay is obviously
a good thing if it doesn't come at a price in outcomes.
And here's the rub — the authors note that "there
were no significant differences between the groups in
readmission, in-hospital mortality or 30-day mortality."
What that means, of course, is
that the 95% confidence intervals for risk of these
events in the hospitalist groups straddled the baseline
of one set by non-hospitalists' rates. But in fact,
there were about 5% more deaths among the hospitalists'
patients, both before and after discharge. It could
easily be a statistical blip — and Dr Southern
suspects they were sicker to start with — but only
a vast study could nail that issue down. "Five percent
extra mortality would certainly be enough to cancel
out an awful lot of benefit," concedes Dr Southern.
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