Hospitalist care associated with higher costs, more medical utilization after discharge

Though hospitalist care is associated with shorter inpatient length of stay and lower hospital costs, these are offset by higher medical utilization and costs after discharge, a new study found.

In an observational cohort study, researchers analyzed hospital admissions from January 2001 to November 2006 in a representative national sample of 5% of Medicare beneficiaries. Researchers looked at claims for hospital stays, outpatient facility use and physician services. They included only admissions for patients with an identified primary care physician (PCP) before admission, in order to better compare patients cared for by hospitalists versus PCPs. Admissions of patients cared for by both, or neither, were excluded. The main analysis included hospitals with at least 20 admissions cared for by hospitalists and 20 by PCPs during the study period, leaving a final cohort of 58,125 admissions at 454 hospitals. Outcomes of interest were length of stay, hospital charges, discharge location and physician visits, rehospitalization, emergency department visits, and Medicare spending in the 30 days after discharge. Results were published in the Aug. 2 Annals of Internal Medicine.

Among patients cared for by hospitalists, length of stay was 0.64 day less (5.17 days vs. 5.82 days; P<0.001) and hospital charges were $282 lower ($15,019 vs. $15,301; P<0.001) than among those cared for by PCPs. Medicare costs 30 days after discharge were $332 higher for patients seen by hospitalists, however ($3,279 vs. $2,947; P<0.001). Patients under hospitalist care also:

• were less likely to be discharged to home (70.6% vs. 76%; odds ratio [OR], 0.82; 95% CI, 0.78 to 0.86),
• were more likely to have emergency department visits within 30 days of discharge (20.7% vs. 17.8%; OR, 1.18; 95% CI, 1.12 to 1.24),
• were more likely to be readmitted within 30 days post-discharge (19% vs. 17.4%; OR, 1.08; 95% CI, 1.02 to 1.14),
• had fewer visits with their PCPs within 30 days post-discharge (0.62 visits vs. 0.79; P<0.001) and
• had more nursing facility visits within 30 days post-discharge (0.58 vs. 0.52; P<0.001).

Study limitations included that only patients on Medicare with an identified PCP and a medical diagnosis were included, thus results might not be generalizable to other kinds of patients. Still, the study's findings indicate that the apparent savings in hospital costs due to hospitalist care is in fact a shifting (and increase) of costs to the post-discharge period, the authors wrote. “If applied to the approximate 25% of Medicare admissions cared for by hospitalists, this represents more than $1.1 billion in additional Medicare costs annually,” they wrote. Hospitalists may be more prone to behaviors that promote cost shifting, they added, but current efforts toward bundling of payments should reduce incentives for these behaviors.

While the findings raise the question of whether hospitalists discharge their patients “more quickly but less appropriately,” such that they bounce back, the results must be interpreted cautiously, as the study examined hospitalizations before the time when 30-day readmissions was a quality benchmark, the authors of an accompanying editorial noted. As for why hospitalist care is associated with greater use of postdischarge services, it may be because hospitalists are under pressure to shorten length of stay, and thus discharge sicker patients, or that they lack knowledge of outpatient services, they wrote. Ultimately, many questions remain unanswered, and more studies that follow patients through their course of care are needed, they concluded.