Published in the October 2004 issue of Today’s Hospitalist
Researchers uncover new details about how hospitalists reduce length of stay and cut costs
While many studies have shown that hospitalists can make a dent in length of stay and overall costs of care for inpatients, new research points out exactly how those savings are achieved.
A study in the August 2004 American Journal of Managed Care examined how four groups of physicians cared for just over 1,700 patients at the University of Iowa Hospitals and Clinics. One of those groups included only hospitalists; the other three teams were made up of general internists and subspecialists like endocrinologists, rheumatologists and infectious disease physicians.
The study found that hospitalists reduced length of stay by about one day and lowered overall costs by about $1,000. While those results mirror recent hospitalist research, the Iowa researchers drilled down to uncover some of the details behind those reductions.
For example, they found that while hospitalists slashed costs for nursing and lab services, they made relatively little impact on the costs of diagnostic imaging and pharmacy services. Overall length of stay dropped, but in this study, at least, many of the biggest gains were connected to patients’ proximity to the hospital. And while hospitalists cut overall costs, they spent an average of $122 more per day on patient care than their nonhospitalist colleagues.
Peter J. Kaboli, MD, a staff physician at the Iowa City VA Medical Center in Iowa City and the study’s lead author, says that much of the increased efficiency produced by hospitalists stems from gains in length of stay. Here’s a look at the study’s findings, and some of the surprises about hospitalist performance that it uncovered.
Length of stay
Dr. Kaboli, assistant professor at the University of Iowa College of Medicine, found that one area where hospitalists made significant gains in reducing length of stay stemmed from their care of patients who required nursing services after discharge.
When treated by nonhospitalists, patients who needed home health care or skilled nursing services typically stayed in the hospital an average of 10 days. Hospitalists, however, tended to discharge these same patients 1.7 days earlier.
Dr. Kaboli says this huge difference accounted for much of hospitalists’ reductions in reducing overall length of stay. He also thinks it’s a reflection of how hospitalists learn to master certain aspects of inpatient care that remain a mystery to other physicians who don’t work exclusively in the hospital.
“Hospitalists become more familiar with the processes that need to take place to get patients out of the hospital and into home care or skilled care,” he explains. “If you don’t know all the steps you need to go through to get someone discharged to those services, it’s going to take you a little longer.”
Dr. Kaboli acknowledges that some may question whether hospitalists are reducing length of stay in this population by simply discharging them early, knowing they’ll receive care elsewhere. “Some people might argue that you’re just shifting costs,” Dr. Kaboli acknowledges, “that you’re getting somebody out of the hospital sooner instead of leaving them in the hospital a few days longer so they don’t need home care.”
He notes that researchers found no difference in the rate of discharge to skilled care or home care between the groups to support this, however. Dr. Kaboli says that the only way to rule that out would be to look at each patient on a case-by-case basis. A more practical approach, he says, is to examine rates of readmission and mortality.
Study data show no significant difference in either re-admissions or mortality. (He notes that the relative readmission rate for hospitalists was 10 percent lower and mortality 38 percent lower than other physicians, but that the figures weren’t statistically significant.)
“That’s a concern that a lot of people have, that you get patients out of the hospital a day earlier, but you just have more patients come back,” he says. “But we didn’t see that.”
Distance and experience
The Iowa researchers found that hospitalists’ ability to reduce length of stay was linked to another factor: how close patients live to the hospital. Researchers found that hospitalists tended to discharge patients from the hospital an average of 1.6 days sooner compared to nonhospitalists when the individuals lived within 25 miles of the hospital.
Dr. Kaboli says the results support anecdotal evidence noticed by hospitalists, and he says the explanation is fairly simple: If you discharge patients who live relatively close to the hospital and they need to return for follow-up care, they can come back relatively easily. Patients who live in remote, rural areas, by comparison, tend to have a hard time getting back to the hospital for follow-up care and may come back late “or not at all.
This trend is particularly important to facilities like the University of Iowa Hospitals, because two-thirds of its patients live more than 25 miles away. Hospitalists know that it is often not easy for these patients to return to the hospital for follow-up care, so they may decide to keep them in the hospital a little longer to make sure they’re ready to return to home.
While the Iowa researchers examined the role that physician experience plays in their ability to function as hospitalists, those results were less clear. The study found few differences in performance based on how long the physicians had been practicing or how many days they had practiced in the inpatient setting, but Dr. Kaboli says the study’s categories may have been too broad to detect differences.
“There are things about experience that we’re just starting to figure out,” Dr. Kaboli says. And while the conventional wisdom says that hospitalists are more efficient because they see the same types of patients “people with pneumonia, for example “over and over, he thinks his study shows that same principle applies to nonclinical areas of care.
“It could be the same thing with experience working with social workers and discharge planners, getting patients to skilled care or home care,” he says. “You get experience in those areas, which may be part of the efficiency.”
When compared to their nonhospitalist colleagues, hospitalists reduced the costs of lab tests by $126 and nursing costs by about $600, and they made little difference in areas like diagnostic imaging and pharmacy. What’s interesting is that hospitalists spent $122 “about 8 percent “more per day than their nonhospitalist colleagues.
Dr. Kaboli says that hospitalists lowered nursing costs because they sent patients home a day or two early. As a result, they used fewer nursing services.
While researchers didn’t examine the impact of that savings on hospital revenue, he says it makes sense that the medical center should be able to increase its revenue because of this savings. Because the hospital receives capitated payments for many of its patients, hospitalists’ reduction in length of stay theoretically allows the medical center to increase its patient revenues.
“Hospitalists tend to have increased throughput on patients,” he explains. “Because most medical centers run at or very near capacity, that allows that bed to open sooner for the next patient.”
When it comes to lab tests, however, hospitalists clearly ordered fewer tests. Dr. Kaboli says one possible explanation is hospitalists simply use lab procedures more judiciously and order fewer tests. The finding also could be linked to hospitalists’ reduced length of stay.
“It could be that because patients are in the hospital one less day,” Dr. Kaboli explains, “hospitalists don’t get the extra lab draw they would have ordered that extra day in the hospital.”
Dr. Kaboli says it is unclear why hospitalists didn’t make a dent in imaging test use. He hypothesizes that radiologic evaluations may be less sensitive to practice variation.
Finally, the study’s costs data raise an interesting question: If hospitalists are saving nearly $1,000 per patient, not spending additional money on lab services, and spending about the same amount of money on pharmacy and diagnostic imaging services, how are they spending an additional $122 per day?
Dr. Kaboli says that once again, the answer likely hinges on length of stay. Because hospitalists are giving roughly the same services to patients but in a condensed time frame, he says, their average cost per day goes up. At the same time, patients who remain in the hospital a fifth or sixth day likely receive few major services on those days, which helps lower the average daily costs of nonhospitalists.
“You’re shortening the time patients are in the hospital, but you’re still giving the same amount of diagnostic work up and treatment,” Dr. Kaboli said. “By shortening the period of time, your costs per day actually go up.”