Comparison of hospitalists and nonhospitalists in inpatient length of stay adjusting for patient and physician characteristics
OBJECTIVE: To determine the independent effect of hospitalist status upon inpatient length of stay after controlling for case mix, as well as patient-level and provider-level variables such as age, years since physician medical school graduation, and volume status of provider.
DESIGN: Observational retrospective cohort study employing a hierarchical random intercept logistic regression model.
SETTING: Tertiary-care teaching hospital.
PATIENTS: All admissions during 2001 to the department of medicine not sent initially to the medical intensive care unit or coronary care unit.
MEASUREMENTS: Observed length of stay (LOS) compared to principle diagnosis related group (DRG)-specific mean LOS for hospitalist and nonhospitalist patients adjusting for patient age, gender, years since physician graduation from medical school, and physician volume status.
MAIN RESULTS: The 9 hospitalists discharged 2,027 patients while the nonhospitalists discharged 9,361 patients. On average, hospitalist patients were younger, 63.3 versus 73.3 years (P<.0001). Hospitalists were more recently graduated from medical school, 13.8 versus 22.5 years (P=.02). Each year of patient age was found to increase the likelihood of an above average LOS (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.01 to 1.02; P<.001). In unadjusted analysis, hospitalists were less likely to have an above average LOS (OR, 0.51; 95% CI, 0.28 to 0.93; P=.03). Adjustment for effects of patient age and gender, physician gender, years since medical school graduation, and quintile of physician admission volume did not appreciably change the point estimate that hospitalist patients remained less likely to have above average LOS (OR, 0.60; 95% CI, 0.32 to 1.11; P=.11).
CONCLUSIONS: For a given principle DRG, hospitalist patients were less likely to exceed the average LOS than were nonhospitalist patients. This effect was rather large, in that hospitalist status reduced the likelihood of above average LOS by about 49%. Adjustment for patient age, years since physician graduation, and admission volume did not significantly alter this finding. Further research should focus on identifying specific practices that account for hospitalism’s effects.
Key wordshospitalist length of stay patient-level variables provider-level variables provider volume
Wachter RM, Katz P, Showstack J, Bindman AB, Goldman L. Reorganizing an academic medical service: impact on cost, quality, patient satisfaction and education. JAMA. 1998;279:1560–5.PubMedCrossRefGoogle Scholar
Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1998;129:197–203.PubMedGoogle Scholar
Stein MD, Hanson S, Tammaro D, Hanna L, Most AS. Economic effects of community versus hospital-based faculty pneumonia care. J Gen Intern Med. 1998;13:774–7.PubMedCrossRefGoogle Scholar
Craig DE, Hartka L, Likosky WH, Caplan WM, Litsky P, Smithey J. Implementation of a hospitalist system in a large health maintenance organization: the Kaiser Permanente experience. Ann Intern Med. 1999;130:355–9.PubMedGoogle Scholar
Freese RB. The Park Nicollet experience in establishing a hospitalist system. Ann Intern Med. 1999;130:(pt 2):350–4.PubMedGoogle Scholar
Davis KM, Koch KE, Harvey JK, Wilson R, Englert J, Gerard PD. Effects of hospitalists on cost, outcomes, and patient satisfaction in a rural health system. Am J Med. 2000;108:621–6.PubMedCrossRefGoogle Scholar
Halpert AP, Pearson SD, LeWine HE, Mckean SC. The impact of an inpatient physician program on quality, utilization, and satisfaction. Am J Manag Care. 2000;6:549–55.PubMedGoogle Scholar
Hackner D, Tu G, Braunstein GD, Ault M, Weingarten S, Mohsenifar Z. The value of a hospitalist service: efficient care for the aging population? Chest. 2001;119:580–9.PubMedCrossRefGoogle Scholar
Molinari C, Short R. Effects of an HMO hospitalist program on inpatient utilization. Am J Manag Care. 2001;7:1051–7.PubMedGoogle Scholar
Palmer HC, Armistead NS, Elnicki DM, et al. The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. Am J Med. 2001;111:627–32.PubMedCrossRefGoogle Scholar
Lindenauer PK, Chehabeddine R, Pekow P, Fitzgerald J, Benjamin EM. Quality of care for patients hospitalized with heart failure: assessing the impact of hospitalists. Arch Intern Med. 2002;162:1251–6.PubMedCrossRefGoogle Scholar
Rifkin WD, Conner D, Silver A, Eichorn A. Comparison of processes and outcomes of pneumonia care between hospitalists and community-based primary care physicians. Mayo Clin Proc. 2002;77:1053–8.PubMedCrossRefGoogle Scholar
Meltzer D, Manning WG, Morrison J, et al. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866–74.PubMedGoogle Scholar
Auerbach AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859–65.PubMedGoogle Scholar
Wachter RM, Flanders S. The hospitalist movement and the future of academic general internal medicine. J Gen Intern Med. 1998;13:783–5.PubMedCrossRefGoogle Scholar
Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. New Engl J Med. 1996;335:514–7.PubMedCrossRefGoogle Scholar
Wachter RM. An introduction to the hospitalist model. Ann Intern Med. 1999;130:338–42.PubMedGoogle Scholar
Hoff TH, Whitcomb WF, Williams K, Nelson JR, Cheesman RA. Characteristics and work experiences of hospitalists in the United States. Arch Intern Med. 2001;161:851–8.PubMedCrossRefGoogle Scholar
Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487–94.PubMedCrossRefGoogle Scholar
Burns LR, Wholey DR. The effects of patient, hospital and physician characteristics on length of stay and mortality. Med Care. 1991;29:251–71.PubMedCrossRefGoogle Scholar
Burns RB, Freund KM, Moskowitz MA, Kasten L, Feldman H, McKinlay JB. Physician characteristics: do they influence the evaluation and treatment of breast cancer in older women? Am J Med. 1997;103:263–9.PubMedCrossRefGoogle Scholar
Norcini JJ, Kimball HR, Lipner RS. Certification and specialization: do they matter in the outcome of acute myocardial infarction? Acad Med. 2000;75:1193–8.PubMedCrossRefGoogle Scholar
Lurie N, Slater J, McGovern P, Ekstrum J, Quam L, Margolis K. Preventive care for women. Does the sex of the physician matter? N Engl J Med. 1993;32:478–82.CrossRefGoogle Scholar
Roetzheim RG, Fox SA, Leake B. Physician-reported determinants of screening mammography in older women: the impact of physician and practice characteristics. J Am Geriatr Soc. 1995;43:1398–402.PubMedGoogle Scholar
Edlefsen KL, Mandelson MT, McIntosh MW, Andersen MR, Wagner EH, Urban N. Prostate-specific antigen for prostate cancer screening. Do physician characteristics affect its use? Am J Prev Med. 1999;17:87–90.PubMedCrossRefGoogle Scholar
McKinlay JB, Lin T, Freund K, Moskowitz M. The unexpected influence of physician attributes on clinical decisions: results of an experiment. J Health Soc Behav. 2002;43:92–106.PubMedCrossRefGoogle Scholar
McKinlay JB, Burns RB, Durante R, et al. Patient, physician and presentational influences on clinical decision making for breast cancer: results from a factorial experiment. J Eval Clin Pract. 1997;3:23–57.PubMedGoogle Scholar
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