Monday, August 22, 2011

Hospital Medicine is Part of Primary Care

There has been a lot of policy discussions about the emergence of the hospitalist movement. A decade ago, when a patient was hospitalized, the doctor managing their care in the hospital was usually their primary care doctor. Increasingly, primary care doctors do not manage their patients in the hospital. Instead their care is managed by a breed of specialist known as a hospitalist. Many hospitalists limit their clinical practice to the hospital.

It is been debated whether or not having hospital care managed by hospitalists is good for patients. Previous studies have shown that hospitalist management results in a shorter hospital stay. But studies of post hospitalization outcomes are sparse.

A recent study, authored by Yong-Fang Kuo and Geriatrician James Goodwin from the Sealy Center on Aging at the University of Texas in Galveston, suggests the effects of hospitalists are mixed. The study has received extensive media attention, including an excellent review and discussion from Paula Span on the New Old Age Blog.

Kuo examined Medicare billing records to compare the medical costs for those cared for by their primary care doctor to those cared for by a hospitalist during their hospitalization. The study was limited to those hospitalized for medical diagnoses, so can not be directly applied to surgical patients. While analyses of health outcomes using Medicare data are subject to a number of biases, the study is commendable for its use of state of the art analytic methods. The key findings were as follows:

  • Patients cared for by hospitalists spent less time in the hospital than patients cared for by their primary care doctors (5.82 vs 5.17 days). This difference of 0.64 days is quite large--especially when aggregated over millions of hospitalizations

  • This shorter length of stay translated into a $282 lower hospital cost for patients cared for by hospitalists

  • However, the cost of caring for patients in the 30 days after discharge was $332 greater for patients cared for by hospitalists. This included higher rates of nursing home use, readmission, and emergency department visits for patients care for by hospitalists.

If one combined the hospital and post hospital costs, it seems like a near wash, with the overall costs of care similar for patients treated by their primary care doctors and hospitalists. But the situation is more complex. Hospitals are generally paid a fixed dollar amount for each patient they admit. If they keep a patient in the hospital longer than expected, they lose money. If they can discharge a patient more quickly they make money. So, the $282 hospitalist savings goes to the hospitals. In contrast, the $332 in post hospital costs are paid for by Medicare.
So, one way to look at this: The lower cost of hospitalization and the higher cost of care after hospitalization for patients cared for by hospitalists may be a transfer of money from the taxpayer to hospitals.


But there may be a more important lesson than the economic lessons. The study illustrates that what happens in the hospital has important consequences for care that occurs outside of the hospital. This has implications for how we view hospital care. It is a mistake to view hospital care as a unique discreet episode of care. Rather, it is better to view hospital care as a component of primary care.

One of the essential marks of a good hospital physician, irrespective of whether that physician is primarily office based or hospital based, is the ability to view the hospitalization in the larger context of the patient's care and needs. The patient's medical context, functional status, and social context before the hospitalization has crucial impacts on the type of care the patient should receive in the hospital. Further, the patient's post hospitalization needs also strongly influences hospital care.

There is much talk about improving handoffs as patients move across settings, but this talk may be missing an important point. We need much more than good handoffs. We need integration of care. This means care models that don't view hospitalization as isolated care episodes but as an intensive component of the patient's primary care.

Several years ago, there was talk in internal medicine circles about whether residents headed for careers in hospital medicine should have fundamentally different residency training experiences than residents headed for a career in outpatient medicine. This would be a huge mistake. Outpatient internists need intensive training in hospital medicine and hospitalists need intensive training in outpatient medicine. The ideal training program for both hospital and outpatient based internists is a primary care residency, as these training programs offer an ideal mix of hospital and outpatient training.

Regardless of whether hospital care is provided by a hospitalist or primary care provider, we need better ways of providing hospital care that recognize its place in the continuity of care.

by: Ken Covinsky

4 comments:

George Handzo said...

This is a very helpful post. I agree that the more we see patients in the wholeness of their lives, whether that be body-mind-spirit or inpatient-outpatient, the better care we are able to give them. I'm reminded of the difference I often notice in my chaplaincy collegues between those who have done congregational ministry and worked with people "in sickness and in health" at some point in their careers and those who have not.
George Handzo

Susan Lysaght said...

Great post, Ken!

Lindsey Yourman said...

I'm glad to be reminded of this during Gen Med Wards month of intern year. It's easy to get caught up in the efficiency of discharging and forget the true measure of success is what happens afterwards. The Model SFGH pilot clerkship program I did as an MS3 at UCSF tried to educate us in the way that Dr. Covinsky (OK, Ken if he insists :)) describes. They called it the "Blended Clerkship" because within a given week you spent 1/2 your time at the hospital, and the other 1/2 in your primary care clinic. In some ways it was overwhelming because as students we had little continuity of our own care :), but it drove home the concept of continuity of care for our patients, so hopefully we'll be better docs for it. OK, good night GeriPal.

N Swallow MD said...

Your comment about the need for cross training between inpatient and outpatient care arenas is valid, and can be extended to other arenas. Within the past five years, a EM residency program in our area removed their residents from the Gen Med wards. The result? A decrease in the collegiality of the EM and IM residents; a lack of understanding about the levels of care provided by our hospital in the inpatient setting; and a decrease in the comfort level of the ED in general with discharging complex medical patients without acute care needs to home with appropriate oupatient follow up. At about the same time the IM department pulled it's senior residents out of their rotation in the ED (PGY-1 still rotate through), which led to: a decrease in the collegiality of the EM and IM residents; a lack of understanding about the levels of care provided by our ED colleagues; and a perception that the EM residents and attendings wanted to admit every patient who comes through their doors, when in fact they do a solid job of triaging appropriately those patients who need inpatient care, and arranging safe discharge plans from the ED for those patients who can leave. This is a real life example of what happens when you don't "walk a mile in someone else's shoes" - even if you don't intend to practice in a certain setting, it's critical for the good of the patient that you understand the strengths, limitations, and needs of the group one step ahead and one step behind you in the care delivery process, so we can really look at health care as a patient does...in a continuum.