Published in the June/July 2004 issue of Today’s Hospitalist
While a growing number of studies have shown how effectively hospitalists can reduce length of stay and lower inpatient costs, relatively few have examined the dual role played by hospitalists who work at community teaching hospitals. New research in the April Journal of General Internal Medicine, however, sheds some light on how that type of hospitalist can make a difference in both roles.
In the late 1990s, Norwalk Hospital, an academic community hospital affiliated with Yale University, hired two hospitalists to care for indigent and unassigned patients and to teach residents. A team of researchers examined data on 11 conditions commonly treated by hospitalists.
While the two hospitalists almost exclusively treated indigent patients, their average length of stay was 20 percent lower than nonhospitalists. The hospitalists also reduced average costs per case by more than 18 percent, saving the hospital an average of nearly $500 per admission.
When the researchers surveyed residents about the hospitalists’ performance as educators, the results were impressive. Nearly all “97 percent “of the residents who responded to a survey said that the presence of the hospitalists improved or greatly improved formal and informal teaching. Most also said that medical care for indigent and unassigned patients had improved.
While the results reinforce what many hospitalists already know “that hospitalists can lower length of stay and utilization “they offered some surprises.
While hospitalists reduced overall costs of care, for example, the savings were particularly dramatic with a handful of conditions. And relatively few housestaff said that they ordered fewer consults or ancillary tests on patients when a hospitalist was the attending physician.
To find out more about the hospitalists’ success as both clinicians and educators, Today’s Hospitalist spoke to lead author Mark E. Kulaga, MD. He and Stephen P. O’Mahony, MD, a co-author of the study, were the two hospitalists profiled in the study.
How did you reduce length of stay and costs of care so quickly?
I think one reason we were so successful is that we were able to quickly learn the culture of the hospital and how to get things done. We had an advantage in that we weren’t working at a huge institution. As a result, we were probably able to learn the system a little faster than if we had been working at one of the big academic centers.
The hospital originally hired us to provide care for uncovered patients and to play a big role in resident education. While our ability to save money and reduce length of stay was not entirely unexpected, it was almost like it was a bonus. It was not the main reason we were brought to Norwalk.
How did you so drastically reduce length of stay in areas like miscellaneous gastrointestinal problems?
If you are admitted with chest pain, you don’t leave without some sort of stress test, and oftentimes it’s a nuclear stress test. As soon as we would hear about this kind of patient, we would see these people first, and we would know to order the stress test right away. That probably had the biggest impact on reducing length of stay.
My theory is that because we’re in the building, we can order the stress test sooner. As soon as the procedure is done, we’re able to go down to nuclear medicine, and when the test result is negative, we’re able to discharge the patient right away. Logistically, it’s just very hard for outpatient physicians to do that same sort of thing.
Why you were able to reduce length of stay for complications from diabetes in patients 35 and older?
I’m not certain, but again, it may have been because we were right there. We could better instruct residents when it was safe to shut off the insulin drip. And to some degree, I think we were able to mobilize the system to initiate insulin therapy earlier and provide diabetes education.
You received rave reviews from the residents. As the first hospitalists brought in to teach residents, did you anticipate any problems being accepted?
The residency program was primed for us to come in. The private community had been working with a small number of dedicated faculty to provide resident education, but it just became untenable for a lot of physicians because of pressures from the office. Almost as soon as we arrived, the residents were very enthusiastic about having us here.
Instead of dealing with a hundred odd physicians who were caring for the indigent, they were now dealing with two.
Why do you think residents said they ordered about the same number of tests and consults when a hospitalist was the attending? Didn’t you expect residents to say that they were ordering fewer tests and consults?
That result did surprise me. Maybe they weren’t ordering any fewer tests, but maybe they were being more selective in what tests they ordered, or maybe they weren’t ordering quite so early in the workup process as in the past. At least one article referenced in our study had found the same thing, that residents working with hospitalists don’t tend to order fewer tests.
Residents said they practiced evidence-based medicine more when working with hospitalists. What did you do to encourage the use of evidence?
I think the perception of being more evidence-based came from our overall approach. It wasn’t enough for residents to say we’re doing things a certain way because that’s the way we were told to act. We would ask them to back that up, or we would ask where they learned that.
We questioned residents on their decisions, and that’s probably why they felt they were relying more on the evidence, because they had to back up what they wanted to do.
Were there resident autonomy issues? You started this when hospital medicine as a specialty was still in its infancy.
We didn’t do anything extraordinary to protect residents’ autonomy.
Because we had both just finished our residency, we both realized that we had to tread lightly at first and give the residents some space. We had a strong group of residents, so we could do that. There were certainly times when they would think we were overstepping a little bit, and we would pull back and things would be fine.
Since then, the residents have seen that we basically let them run the show. I think they’ve seen us as big time advocates for them, but especially with the second- and third-year residents, we can develop more of a collegial relationship.
They seek advice from us, not only on our patients, but every so often on a private patient about whom they’re unsure or uncomfortable. We will never make a decision about a patient who is not covered by us, but we’ll sometimes give residents the courage, if you will, to go to nonhospitalist attendings and say, “What do you think about changing the antibiotic?” It’s allowed us to have a strong relationship with the residents.