American College of Physicians: Internal Medicine — Doctors for Adults ®


Emerging data on hospitalist care, Medicare core measures

By Linda Gundersen

A large study showed patients spend less time in the hospital when attended by hospitalists than when treated by internists. This is one of several new studies looking at hospitalists’ impact on quality and cost of care, which co-moderators Joseph Li, ACP Member, and Jeff Glasheen, ACP Member, will discuss at the hospital medicine update.

Hospitalists and outcomes of care

Dr. Li, an assistant professor in medicine at Harvard Medical School and Director of Hospital Medicine at Beth Israel Deaconess Medical Center in Boston, and Dr. Glasheen, an associate professor and Director of Hospital medicine at the University of Colorado Health Science Center in Denver, will discuss the New England Journal of Medicine study by Lindenauer (2007;357:2589), which compared outcomes of care by hospitalists, internists, and general practitioners.

The study showed hospitalist care is associated with a small reduction in length of hospital stay when compared to care provided by general internists or family physicians. Hospitalist care is also less expensive than care provided by general internists care but there were no savings compared to care provided by family physicians.

While this is the largest study to look at these data, Dr. Li said he is cautious about its implications.

“Before we get too excited, I think we’ll have to drill down deeper,” Dr. Li said. Because investigators gleaned information from a large database, Dr. Li questions whether physicians were correctly identified.

“Patients are often placed under an attending physician’s name when admitted, but that might not be the physician who ends up treating the patient,” Dr. Li said. He added, “A family physician might be mislabeled as a hospitalist if he or she spends a week in the hospital each year.” However, the study has sparked a number of questions that can be used as a springboard for future studies.

Medicare core measures

Drs. Li and Glasheen will discuss the evolution of the Medicare Core measures and their impact on hospitalists. The measures have increased in number and scope in the last five years, with one in particular causing a furor in the medical community.

One core measure for community-acquired pneumonia (CAP) is the timely administration of antibiotics. Data supported administering antibiotics within 12 hours of ED presentation for patients with CAP. Medicare aggressively lowered the time allowed to administer antibiotics in reaction to new studies suggesting that eight hours, and finally, four hours, could reduce mortality.

“Four hours is really a challenge for any institution,” Dr. Li said. “The clock starts when that patient checks into an ED, not when a patient sees the doctor.” The core measures heaped pressure onto hospitals and ED physicians to follow the mandated guidelines or suffer the consequences. “If measures aren’t met, the hospital gets less reimbursement and bad press,” Dr. Li explained.

The result? Doctors working under enormous pressure and rushing to meet the Medicare-mandated treatment guideline had to devise new systems to meet the four-hour rule.

Drs. Li and Glasheen will discuss a paper in Chest by Kanwar (2007;131:1865-1869) that looked at the inappropriate utilization of antibiotics and its sometimes dire consequences.

Dr. Li commented, “Nobody disputes the fact that these quality mandates have done some very good things—but we need to be careful about unintended consequences.” Some patients were misdiagnosed as having CAP, resulting in inappropriate use of antibiotics. The moderators will discuss how physicians must strike a balance in helping hospitals respond to mandates while ensuring quality of care.


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