CHICAGO — The old-fashioned, family doctor style of medicine could be lifesaving for elderly hospitalized patients, a big study suggests, showing benefits over a rapidly expanding alternative that has hospital-based doctors overseeing care instead.
Medicare patients with common conditions including pneumonia, heart failure and urinary infections who were treated by their own primary care doctors were slightly more likely to survive after being sent home than those cared for instead by hospitalists — internists who provide care only in hospitals.
While hospitalist care can shorten stays and reduce costs, the new results suggest that, for at least some patients, getting taken care of in the hospital by a doctor who knows them can have important advantages.
Almost 11 percent of patients cared for by a hospitalist died within 30 days of leaving the hospital, compared with just under 9 percent of primary care patients. While that difference was small, it “was certainly a startling finding,” said Dr. Jennifer Stevens, the study’s lead author at Harvard Medical School.
Also, among hospitalist patients, 36 percent were sent to a nursing home or other long-term care center, versus about 30 percent of primary care patients. Studies show that elderly patients who are discharged to nursing homes are less likely than others to ever return to their homes, Stevens said.
Reasons for those advantages are unclear. Stevens noted that primary care doctors who know their patients’ health and family histories may be more attuned to how well they can manage at home after hospitalization and which potentially risky follow-up tests or medicines they can avoid.
Stevens and her colleagues analyzed Medicare claims data on nearly 600,000 hospital admissions in 2013. Their results were published Monday in JAMA Internal Medicine.
The researchers don’t advocate replacing hospitalists, but Stevens said the study “opens the door” to limiting their use with certain hospital patients, particularly the elderly. Patients in the study were aged 80 on average.
The hospitalist specialty has grown since the 1990s amid insurance industry changes, rising demands on primary care doctors’ time and research showing hospitalists can shorten patients’ stays and reduce costs. In 1995, hospitalists provided 9 percent of general medicine services in hospitals, but by 2013 that had grown to nearly 60 percent, a journal editorial noted.
Hospitalists may bring “new eyes” to patients’ problems, but the study results, if valid, suggest there’s a trade-off, the editorial said.
In the study, 60 percent of patients got their hospital care from hospitalists versus only 14 percent from their primary care doctors. The rest got care from other general physicians including partners of patients’ primary physicians. These were physicians who likely didn’t know the patients or the hospital well, Stevens said.
The average length of stay was about 5 days for primary care or general care and about half a day shorter for hospitalists.
Those treated by other general physicians were slightly more likely than the others to die within 30 days of discharge and to be readmitted to the hospital.
— Lindsey Tanner
In the current reproducibility crisis in medical (really virtually all science), individual studies cannot be relied on. Retrospective studies tend to be less reliable than prospective ones; and there is some evidence of greater bias earlier in a researcher’s career.
I was a PCP internist for 17 years and will soon complete my 12th year of hospital only practice. Despite the caveats mentioned, the findings (or at least lack of advantage of hospitalist regarding 30- day mortality) are credible to me. Much of the explosion in hospitalists can be tied to payment and regulatory requirements, and to the over-reliance on specialist care in the US. Payment and regulations virtually tie PCP’s to their offices. They have also led to a marked rise in salaried employment of PCP’s who, at least in my community, are required not to see their hospitalized patients. Meanwhile the Society of Hospital Medicine focuses on meeting regulatory and quality demands considerably more than clinical care and development of judgment. Most hospitalists are employees of or contracted with hospitals. That .5 day they save the hospital per patient can save the hospital thousands per year. Indeed hospitalists are usually subsidized by up to $100,000 per year over insurance payments for their services.
My husband died after “successful” prostate surgery while under the care of a hospitalist. She mishandled the resumption of his Coumadin(taken after heart valve replacement). He bled to death at the age of 58. A jury heard excellent testimony from a renowned hematologist expert witness, but the hospital’s hired Canadian doctor presented his charts and graphs and influenced their no malpractice decision. As my children and granddaughter navigate the path of graduations, weddings, birthdays and anniversaries; we grieve the loss of a wonderful man whose life was shortened by the actions of a young fresh from medical school hospitalist. She consulted with a resident 3 days after the surgery to make her decisions. The procedure should never have been scheduled 4 days before a holiday weekend when most of the specialists were headed out of town.
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