Do hospitalists affect clinical outcomes and efficiency for patients with acute upper gastrointestinal hemorrhage (UGIH)?

Abstract

BACKGROUND Care by hospitalists has been associated with improved/similar clinical outcomes and efficiency. However, less is known about their effect on conditions dependent upon specialists for procedures/treatment plans. Our objective was to compare care for upper gastrointestinal hemorrhage (UGIH) patients attended by academic hospitalists and non-hospitalists. METHODS The study included 450 UGIH patients admitted to general medical services of 6 teaching hospitals. Outcomes included in-hospital mortality and complications (i.e., recurrent bleeding, ICU-transfer, decompensation, transfusion, re-endoscopy, 30-day readmission). Efficiency was measured by hospital costs and length of stay (LOS). RESULTS Of 450 patients, 40% (177) were cared for by hospitalists with no differences between groups by endoscopic diagnosis, performance of early esophagogastroduodenoscopy (EGD), Rockall risk score, or Charlson index. Unadjusted clinical outcomes between hospitalists and non-hospitalists were similar except for 2 outcomes: patients cared for by hospitalists were more likely to receive a transfusion (74% vs. 63%; p=.02) or be re-admitted within 30-days (7.3% vs. 3.3%; p=.05). However, differences in adverse outcomes between providers were not seen after multivariable adjustments. Median LOS was similar for hospitalists and non-hospitalists (4 days; p=.69), but patients cared for by hospitalists had higher median costs ($7,359 vs. $6,181; p<.01). In multivariable analyses, LOS was similar (5.2 vs. 4.7 days; p=.15) and costs remained higher for the hospitalist-led teams (p<0.03). CONCLUSIONS Despite having similar overall outcomes and LOS, costs were higher in UGIH patients attended by hospitalists. These results suggest that the academic hospitalist model may be tempered in patients requiring specialists for procedures or management.

Do hospitalist physicians improve the quality of inpatient care delivery? A systematic review of process, efficiency and outcome measures

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Association of Hospitalist Care With Medical Utilization After Discharge: Evidence of Cost Shift From a Cohort Study

“…As the hospitalist model has rapidly disseminated nationally, the outcomes may also have changed. A recent prospective analysis of hospitalist care for patients with upper gastrointestinal hemorrhage at 6 academic hospitals also found higher readmission rates in the patients assigned to hospitalists (34). We also found a higher rate of readmissions after hospitalist care in patients with stroke (35).…”

Comparing Patient Outcomes of Academician-Preceptors, Hospitalist-Preceptors, and Hospitalists on Internal Medicine Services in an Academic Medical Center

“…Because these discharge decisions directly affect the LOS and readmission risk, we measured the service at discharge rather than the service responsible for an earlier component of care, such as the ICU service or admitting provider. 30 The key strength of this study is that we accurately measured trainee involvement and the service type responsible for each patient discharge. Studies using claims data have typically assigned hospital encounters to provider type by the individual provider's billing volume 16,17 or percent time-on-service.…”

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