Bruce Dixon

CHICAGO — The largest-ever study of the influence of hospital-based physicians on outcomes and costs has failed to show significant benefits, David Meltzer, M.D., reported at the annual meeting of the Society of Hospital Medicine.

“There was a slight trend toward lowering hospital mortality. Otherwise, we found no difference in outcomes between hospitalists and nonhospitalists,” said Dr. Meltzer of the University of Chicago.

“I was somewhat surprised. We began the study expecting we'd see a larger difference,” he told this newspaper.

The multicenter study involved 31,013 admissions at six academic centers over a 2-year period. The goal was to compare costs and outcomes of hospitalized general medical patients treated by hospitalists or by nonhospitalist physicians. The researchers used administrative data, patient surveys (including both inpatient interviews and a 1-month follow-up survey), a chart review looking at process of care variables, data from the National Death Index, and surveys of attending physicians, staff, and primary care physicians.

The investigators concluded that hospitalists did not affect the average length of stay, costs, or outcomes of care across all sites. “Length of stay and cost fell with increasing disease-specific experience, but hospitalist experience may have been offset by higher initial resource use,” Dr. Meltzer said during a plenary presentation of the study, which was also presented in a poster session.

Hospitalist care was associated with significant reductions in mean length of stay at two of the six sites, and further analysis of physician factors may improve outcome profiles across all sites, Dr. Meltzer said.

Earlier, single-center studies of the effects of hospitalists have produced mixed results. A 2002 review led by Robert M. Wachter, M.D., at the University of California, San Francisco, concluded, “Empirical research supports the premise that hospitalists improve inpatient efficiency without harmful effects on quality or patient satisfaction” (JAMA 2002;287:487–94).

Dr. Meltzer's own earlier study of over 6,500 patients at the University of Chicago showed that “hospitalist care was associated with lower costs and short-term mortality in the second but not the first year of hospitalists' experience.”

During a later session at the SHM meeting, Dr. Wachter said that the latest study by Dr. Meltzer is not totally relevant to nonacademic hospitals. “It's a different kind of environment. The evidence for improvement resulting from the use of hospitalists remains robust with more than 20 published studies showing average cost and length-of-stay reductions of about 15%.”

Dr. Meltzer cited several caveats that may take some sting out of the findings.

One study limitation is the “spillover effect,” he explained, which may help to raise the quality of the nonhospitalist comparison group and lead to underestimation of the value of hospitalists.

“Interns and residents work with hospitalists and learn new ways of doing things that may be more efficient and lead to better outcomes, and they remember [these new ways] at the end of the month and then go work with and teach other attendings. So we're used to thinking that teaching is from the attending to the resident to the intern, when in fact there's teaching within those levels and even up the levels,” Dr. Meltzer told this newspaper.

Another equalizer is “a sort of selective attrition effect where, because the hospitalists are taking up more ward months, the department or section can be more selective in whom they put on the wards, so you get only the best attendings on the wards and, not surprisingly, they do a little better than the group as a whole would have done if you had not been able to sort of weed out those who might not do such a good job,” he said.

Dr. Meltzer's third caveat is that, as earlier studies show, hospitalists improve over time. “I think our data are consistent with the hypothesis that hospitalists have real effects, but that those effects don't appear so immediately in the data that we see for all these reasons.”

Finally, Dr. Meltzer was impressed by the finding that the average hospitalist in the study cared for 134 patients, compared with a 46-patient case volume for the average nonhospitalist.

“What's even more striking,” he said, “is that when we go to disease-specific experience, the average hospitalist cared for two-and-a-half patients with that same diagnosis, and the average nonhospitalist cared for less than one (0.93). We found that every doubling of disease-specific experience decreases length of stay and cost by about 3%.”

The next step, he added, is for someone to conduct a similar multicenter comparison study in community hospitals. And “further work is needed to assess physician factors, site factors, and spillover effects that could influence comparisons between hospitalists and nonhospitalists.”

In addition to the University of Chicago, study centers included the University of California, San Francisco; the University of New Mexico; the University of Iowa; the University of Wisconsin; and Brigham and Women's Hospital, Boston.

This Month's Talk Back Question

In your experience, how have hospitalists influenced the care that your patients have received?

CHICAGO — The largest-ever study of the influence of hospital-based physicians on outcomes and costs has failed to show significant benefits, David Meltzer, M.D., reported at the annual meeting of the Society of Hospital Medicine.

“There was a slight trend toward lowering hospital mortality. Otherwise, we found no difference in outcomes between hospitalists and nonhospitalists,” said Dr. Meltzer of the University of Chicago.

“I was somewhat surprised. We began the study expecting we'd see a larger difference,” he told this newspaper.

The multicenter study involved 31,013 admissions at six academic centers over a 2-year period. The goal was to compare costs and outcomes of hospitalized general medical patients treated by hospitalists or by nonhospitalist physicians. The researchers used administrative data, patient surveys (including both inpatient interviews and a 1-month follow-up survey), a chart review looking at process of care variables, data from the National Death Index, and surveys of attending physicians, staff, and primary care physicians.

The investigators concluded that hospitalists did not affect the average length of stay, costs, or outcomes of care across all sites. “Length of stay and cost fell with increasing disease-specific experience, but hospitalist experience may have been offset by higher initial resource use,” Dr. Meltzer said during a plenary presentation of the study, which was also presented in a poster session.

Hospitalist care was associated with significant reductions in mean length of stay at two of the six sites, and further analysis of physician factors may improve outcome profiles across all sites, Dr. Meltzer said.

Earlier, single-center studies of the effects of hospitalists have produced mixed results. A 2002 review led by Robert M. Wachter, M.D., at the University of California, San Francisco, concluded, “Empirical research supports the premise that hospitalists improve inpatient efficiency without harmful effects on quality or patient satisfaction” (JAMA 2002;287:487–94).

Dr. Meltzer's own earlier study of over 6,500 patients at the University of Chicago showed that “hospitalist care was associated with lower costs and short-term mortality in the second but not the first year of hospitalists' experience.”

During a later session at the SHM meeting, Dr. Wachter said that the latest study by Dr. Meltzer is not totally relevant to nonacademic hospitals. “It's a different kind of environment. The evidence for improvement resulting from the use of hospitalists remains robust with more than 20 published studies showing average cost and length-of-stay reductions of about 15%.”

Dr. Meltzer cited several caveats that may take some sting out of the findings.

One study limitation is the “spillover effect,” he explained, which may help to raise the quality of the nonhospitalist comparison group and lead to underestimation of the value of hospitalists.

“Interns and residents work with hospitalists and learn new ways of doing things that may be more efficient and lead to better outcomes, and they remember [these new ways] at the end of the month and then go work with and teach other attendings. So we're used to thinking that teaching is from the attending to the resident to the intern, when in fact there's teaching within those levels and even up the levels,” Dr. Meltzer told this newspaper.

Another equalizer is “a sort of selective attrition effect where, because the hospitalists are taking up more ward months, the department or section can be more selective in whom they put on the wards, so you get only the best attendings on the wards and, not surprisingly, they do a little better than the group as a whole would have done if you had not been able to sort of weed out those who might not do such a good job,” he said.

Dr. Meltzer's third caveat is that, as earlier studies show, hospitalists improve over time. “I think our data are consistent with the hypothesis that hospitalists have real effects, but that those effects don't appear so immediately in the data that we see for all these reasons.”

Finally, Dr. Meltzer was impressed by the finding that the average hospitalist in the study cared for 134 patients, compared with a 46-patient case volume for the average nonhospitalist.

“What's even more striking,” he said, “is that when we go to disease-specific experience, the average hospitalist cared for two-and-a-half patients with that same diagnosis, and the average nonhospitalist cared for less than one (0.93). We found that every doubling of disease-specific experience decreases length of stay and cost by about 3%.”

The next step, he added, is for someone to conduct a similar multicenter comparison study in community hospitals. And “further work is needed to assess physician factors, site factors, and spillover effects that could influence comparisons between hospitalists and nonhospitalists.”

In addition to the University of Chicago, study centers included the University of California, San Francisco; the University of New Mexico; the University of Iowa; the University of Wisconsin; and Brigham and Women's Hospital, Boston.

This Month's Talk Back Question

In your experience, how have hospitalists influenced the care that your patients have received?

CHICAGO — The largest-ever study of the influence of hospital-based physicians on outcomes and costs has failed to show significant benefits, David Meltzer, M.D., reported at the annual meeting of the Society of Hospital Medicine.

“There was a slight trend toward lowering hospital mortality. Otherwise, we found no difference in outcomes between hospitalists and nonhospitalists,” said Dr. Meltzer of the University of Chicago.

“I was somewhat surprised. We began the study expecting we'd see a larger difference,” he told this newspaper.

The multicenter study involved 31,013 admissions at six academic centers over a 2-year period. The goal was to compare costs and outcomes of hospitalized general medical patients treated by hospitalists or by nonhospitalist physicians. The researchers used administrative data, patient surveys (including both inpatient interviews and a 1-month follow-up survey), a chart review looking at process of care variables, data from the National Death Index, and surveys of attending physicians, staff, and primary care physicians.

The investigators concluded that hospitalists did not affect the average length of stay, costs, or outcomes of care across all sites. “Length of stay and cost fell with increasing disease-specific experience, but hospitalist experience may have been offset by higher initial resource use,” Dr. Meltzer said during a plenary presentation of the study, which was also presented in a poster session.

Hospitalist care was associated with significant reductions in mean length of stay at two of the six sites, and further analysis of physician factors may improve outcome profiles across all sites, Dr. Meltzer said.

Earlier, single-center studies of the effects of hospitalists have produced mixed results. A 2002 review led by Robert M. Wachter, M.D., at the University of California, San Francisco, concluded, “Empirical research supports the premise that hospitalists improve inpatient efficiency without harmful effects on quality or patient satisfaction” (JAMA 2002;287:487–94).

Dr. Meltzer's own earlier study of over 6,500 patients at the University of Chicago showed that “hospitalist care was associated with lower costs and short-term mortality in the second but not the first year of hospitalists' experience.”

During a later session at the SHM meeting, Dr. Wachter said that the latest study by Dr. Meltzer is not totally relevant to nonacademic hospitals. “It's a different kind of environment. The evidence for improvement resulting from the use of hospitalists remains robust with more than 20 published studies showing average cost and length-of-stay reductions of about 15%.”

Dr. Meltzer cited several caveats that may take some sting out of the findings.

One study limitation is the “spillover effect,” he explained, which may help to raise the quality of the nonhospitalist comparison group and lead to underestimation of the value of hospitalists.

“Interns and residents work with hospitalists and learn new ways of doing things that may be more efficient and lead to better outcomes, and they remember [these new ways] at the end of the month and then go work with and teach other attendings. So we're used to thinking that teaching is from the attending to the resident to the intern, when in fact there's teaching within those levels and even up the levels,” Dr. Meltzer told this newspaper.

Another equalizer is “a sort of selective attrition effect where, because the hospitalists are taking up more ward months, the department or section can be more selective in whom they put on the wards, so you get only the best attendings on the wards and, not surprisingly, they do a little better than the group as a whole would have done if you had not been able to sort of weed out those who might not do such a good job,” he said.

Dr. Meltzer's third caveat is that, as earlier studies show, hospitalists improve over time. “I think our data are consistent with the hypothesis that hospitalists have real effects, but that those effects don't appear so immediately in the data that we see for all these reasons.”

Finally, Dr. Meltzer was impressed by the finding that the average hospitalist in the study cared for 134 patients, compared with a 46-patient case volume for the average nonhospitalist.

“What's even more striking,” he said, “is that when we go to disease-specific experience, the average hospitalist cared for two-and-a-half patients with that same diagnosis, and the average nonhospitalist cared for less than one (0.93). We found that every doubling of disease-specific experience decreases length of stay and cost by about 3%.”

The next step, he added, is for someone to conduct a similar multicenter comparison study in community hospitals. And “further work is needed to assess physician factors, site factors, and spillover effects that could influence comparisons between hospitalists and nonhospitalists.”

In addition to the University of Chicago, study centers included the University of California, San Francisco; the University of New Mexico; the University of Iowa; the University of Wisconsin; and Brigham and Women's Hospital, Boston.

This Month's Talk Back Question

In your experience, how have hospitalists influenced the care that your patients have received?

CHICAGO – The Society of Hospital Medicine has taken a major step toward defining the core content areas and competencies for practicing hospitalists.

Members of SHM got their first glimpse of a draft document at the society's annual meeting. Authors of the curriculum hope that the document, which is considered a crucial part of becoming a bona fide specialty, will be published in early 2006, possibly in the first issue of the Journal of Hospital Medicine, which is scheduled for publication in January.

“The current iteration of the core curriculum that we've developed was really borne from the first education summit that SHM held in September 2002,” Michael J. Pistoria, D.O., chairman of the curriculum task force, said during the meeting in Chicago. “The concept of the core curriculum was really one of trying to find who we are and what we are. We know that what we do we do very well, [but] we don't always know how or why, and we don't know maybe how to teach [to achieve] the best possible hospitalists.”

The core curriculum will be a valuable resource for adult and pediatric hospitalists and for medical education, said Dr. Pistoria, associate program director at Lehigh Valley Hospital in Allentown, Pa.

“For example, a program director who wants to design a hospitalist track within his or her residency program, or a hospitalist fellowship, or even simply a class on congestive heart failure–say a lecture series–would have some of the core elements of that training,” he said. “And we felt we had significant buy-in from medical education.”

The content of the core curriculum will be available to institutions that decide to have a hospitalist track in their medical residency programs, or it could be part of the development of a hospitalist track within a fellowship, said coauthor Syliva McKean, M.D., of Brigham and Women's Hospital, Boston. It's important to note that hospitalists do more than provide inpatient care, she said.

According to the American Hospital Association, some 1,200 U.S. hospitals now have hospitalist programs employing an estimated 10,000 physicians. More than 4,000 of these doctors are SHM members.

In addition to Dr. Pistoria and Dr. McKean, the core curriculum authors included: Alpesh Amin, M.D., University of California, Irvine; Tina Budnitz, Society of Hospital Medicine; and Daniel Dressler, M.D., Emory University, Atlanta.

CHICAGO – The Society of Hospital Medicine has taken a major step toward defining the core content areas and competencies for practicing hospitalists.

Members of SHM got their first glimpse of a draft document at the society's annual meeting. Authors of the curriculum hope that the document, which is considered a crucial part of becoming a bona fide specialty, will be published in early 2006, possibly in the first issue of the Journal of Hospital Medicine, which is scheduled for publication in January.

“The current iteration of the core curriculum that we've developed was really borne from the first education summit that SHM held in September 2002,” Michael J. Pistoria, D.O., chairman of the curriculum task force, said during the meeting in Chicago. “The concept of the core curriculum was really one of trying to find who we are and what we are. We know that what we do we do very well, [but] we don't always know how or why, and we don't know maybe how to teach [to achieve] the best possible hospitalists.”

The core curriculum will be a valuable resource for adult and pediatric hospitalists and for medical education, said Dr. Pistoria, associate program director at Lehigh Valley Hospital in Allentown, Pa.

“For example, a program director who wants to design a hospitalist track within his or her residency program, or a hospitalist fellowship, or even simply a class on congestive heart failure–say a lecture series–would have some of the core elements of that training,” he said. “And we felt we had significant buy-in from medical education.”

The content of the core curriculum will be available to institutions that decide to have a hospitalist track in their medical residency programs, or it could be part of the development of a hospitalist track within a fellowship, said coauthor Syliva McKean, M.D., of Brigham and Women's Hospital, Boston. It's important to note that hospitalists do more than provide inpatient care, she said.

According to the American Hospital Association, some 1,200 U.S. hospitals now have hospitalist programs employing an estimated 10,000 physicians. More than 4,000 of these doctors are SHM members.

In addition to Dr. Pistoria and Dr. McKean, the core curriculum authors included: Alpesh Amin, M.D., University of California, Irvine; Tina Budnitz, Society of Hospital Medicine; and Daniel Dressler, M.D., Emory University, Atlanta.

CHICAGO – The Society of Hospital Medicine has taken a major step toward defining the core content areas and competencies for practicing hospitalists.

Members of SHM got their first glimpse of a draft document at the society's annual meeting. Authors of the curriculum hope that the document, which is considered a crucial part of becoming a bona fide specialty, will be published in early 2006, possibly in the first issue of the Journal of Hospital Medicine, which is scheduled for publication in January.

“The current iteration of the core curriculum that we've developed was really borne from the first education summit that SHM held in September 2002,” Michael J. Pistoria, D.O., chairman of the curriculum task force, said during the meeting in Chicago. “The concept of the core curriculum was really one of trying to find who we are and what we are. We know that what we do we do very well, [but] we don't always know how or why, and we don't know maybe how to teach [to achieve] the best possible hospitalists.”

The core curriculum will be a valuable resource for adult and pediatric hospitalists and for medical education, said Dr. Pistoria, associate program director at Lehigh Valley Hospital in Allentown, Pa.

“For example, a program director who wants to design a hospitalist track within his or her residency program, or a hospitalist fellowship, or even simply a class on congestive heart failure–say a lecture series–would have some of the core elements of that training,” he said. “And we felt we had significant buy-in from medical education.”

The content of the core curriculum will be available to institutions that decide to have a hospitalist track in their medical residency programs, or it could be part of the development of a hospitalist track within a fellowship, said coauthor Syliva McKean, M.D., of Brigham and Women's Hospital, Boston. It's important to note that hospitalists do more than provide inpatient care, she said.

According to the American Hospital Association, some 1,200 U.S. hospitals now have hospitalist programs employing an estimated 10,000 physicians. More than 4,000 of these doctors are SHM members.

In addition to Dr. Pistoria and Dr. McKean, the core curriculum authors included: Alpesh Amin, M.D., University of California, Irvine; Tina Budnitz, Society of Hospital Medicine; and Daniel Dressler, M.D., Emory University, Atlanta.

CHICAGO — The Society of Hospital Medicine has taken a major step toward defining the core content areas and competencies for practicing hospitalists.

Members of SHM got their first glimpse of a draft document at the society's annual meeting. Authors of the curriculum hope that the document, which is considered a crucial part of becoming a bona fide specialty, will be published in early 2006, possibly in the first issue of the Journal of Hospital Medicine, which is scheduled for publication in January.

“The current iteration of the core curriculum that we've developed was really borne from the first education summit that SHM held in September 2002,” Michael J. Pistoria, D.O., chairman of the curriculum task force, said during the meeting in Chicago. “The concept of the core curriculum was really one of trying to find who we are and what we are. We know that what we do we do very well, [but] we don't always know how or why, and we don't know maybe how to teach [to achieve] the best possible hospitalists.”

The core curriculum will be a valuable resource for adult and pediatric hospitalists and for medical education, said Dr. Pistoria, associate program director at Lehigh Valley Hospital in Allentown, Pa.

“For example, a program director who wants to design a hospitalist track within his or her residency program, or a hospitalist fellowship, or even simply a class on congestive heart failure—say a lecture series—would have some of the core elements of that training,” he said. “And we felt we had significant buy-in from medical education.”

The content of the core curriculum will be available to institutions that decide to have a hospitalist track in their medical residency programs, or it could be part of the development of a hospitalist track within a fellowship, said coauthor Syliva McKean, M.D., of Brigham and Women's Hospital, Boston. “For example, some programs have general internal medicine fellowships that take different paths, and they could use this for those people who are interested in doing research in hospital medicine and are eager to go down a hospitalist track.”

It's important to note that hospitalists do more than provide inpatient care, Dr. McKean said. They also “have the opportunity to lead, participate, and coordinate quality improvement projects in the local hospital.”

According to the American Hospital Association, some 1,200 U.S. hospitals now have hospitalist programs employing an estimated 10,000 physicians. More than 4,000 of these doctors are SHM members.

In addition to Dr. Pistoria and Dr. McKean, the core curriculum authors included: Alpesh Amin, M.D., University of California, Irvine; Tina Budnitz, Society of Hospital Medicine; and Daniel Dressler, M.D., Emory University, Atlanta.

CHICAGO — The Society of Hospital Medicine has taken a major step toward defining the core content areas and competencies for practicing hospitalists.

Members of SHM got their first glimpse of a draft document at the society's annual meeting. Authors of the curriculum hope that the document, which is considered a crucial part of becoming a bona fide specialty, will be published in early 2006, possibly in the first issue of the Journal of Hospital Medicine, which is scheduled for publication in January.

“The current iteration of the core curriculum that we've developed was really borne from the first education summit that SHM held in September 2002,” Michael J. Pistoria, D.O., chairman of the curriculum task force, said during the meeting in Chicago. “The concept of the core curriculum was really one of trying to find who we are and what we are. We know that what we do we do very well, [but] we don't always know how or why, and we don't know maybe how to teach [to achieve] the best possible hospitalists.”

The core curriculum will be a valuable resource for adult and pediatric hospitalists and for medical education, said Dr. Pistoria, associate program director at Lehigh Valley Hospital in Allentown, Pa.

“For example, a program director who wants to design a hospitalist track within his or her residency program, or a hospitalist fellowship, or even simply a class on congestive heart failure—say a lecture series—would have some of the core elements of that training,” he said. “And we felt we had significant buy-in from medical education.”

The content of the core curriculum will be available to institutions that decide to have a hospitalist track in their medical residency programs, or it could be part of the development of a hospitalist track within a fellowship, said coauthor Syliva McKean, M.D., of Brigham and Women's Hospital, Boston. “For example, some programs have general internal medicine fellowships that take different paths, and they could use this for those people who are interested in doing research in hospital medicine and are eager to go down a hospitalist track.”

It's important to note that hospitalists do more than provide inpatient care, Dr. McKean said. They also “have the opportunity to lead, participate, and coordinate quality improvement projects in the local hospital.”

According to the American Hospital Association, some 1,200 U.S. hospitals now have hospitalist programs employing an estimated 10,000 physicians. More than 4,000 of these doctors are SHM members.

In addition to Dr. Pistoria and Dr. McKean, the core curriculum authors included: Alpesh Amin, M.D., University of California, Irvine; Tina Budnitz, Society of Hospital Medicine; and Daniel Dressler, M.D., Emory University, Atlanta.

CHICAGO — The Society of Hospital Medicine has taken a major step toward defining the core content areas and competencies for practicing hospitalists.

Members of SHM got their first glimpse of a draft document at the society's annual meeting. Authors of the curriculum hope that the document, which is considered a crucial part of becoming a bona fide specialty, will be published in early 2006, possibly in the first issue of the Journal of Hospital Medicine, which is scheduled for publication in January.

“The current iteration of the core curriculum that we've developed was really borne from the first education summit that SHM held in September 2002,” Michael J. Pistoria, D.O., chairman of the curriculum task force, said during the meeting in Chicago. “The concept of the core curriculum was really one of trying to find who we are and what we are. We know that what we do we do very well, [but] we don't always know how or why, and we don't know maybe how to teach [to achieve] the best possible hospitalists.”

The core curriculum will be a valuable resource for adult and pediatric hospitalists and for medical education, said Dr. Pistoria, associate program director at Lehigh Valley Hospital in Allentown, Pa.

“For example, a program director who wants to design a hospitalist track within his or her residency program, or a hospitalist fellowship, or even simply a class on congestive heart failure—say a lecture series—would have some of the core elements of that training,” he said. “And we felt we had significant buy-in from medical education.”

The content of the core curriculum will be available to institutions that decide to have a hospitalist track in their medical residency programs, or it could be part of the development of a hospitalist track within a fellowship, said coauthor Syliva McKean, M.D., of Brigham and Women's Hospital, Boston. “For example, some programs have general internal medicine fellowships that take different paths, and they could use this for those people who are interested in doing research in hospital medicine and are eager to go down a hospitalist track.”

It's important to note that hospitalists do more than provide inpatient care, Dr. McKean said. They also “have the opportunity to lead, participate, and coordinate quality improvement projects in the local hospital.”

According to the American Hospital Association, some 1,200 U.S. hospitals now have hospitalist programs employing an estimated 10,000 physicians. More than 4,000 of these doctors are SHM members.

In addition to Dr. Pistoria and Dr. McKean, the core curriculum authors included: Alpesh Amin, M.D., University of California, Irvine; Tina Budnitz, Society of Hospital Medicine; and Daniel Dressler, M.D., Emory University, Atlanta.

CHICAGO — The largest-ever study of the influence of hospital-based physicians on outcomes and costs has failed to show significant benefits, David Meltzer, M.D., reported at the annual meeting of the Society of Hospital Medicine.

“There was a slight trend toward lowering hospital mortality. Otherwise, we found no difference in outcomes between hospitalists and nonhospitalists,” said Dr. Meltzer of the University of Chicago.

“I was somewhat surprised. We began the study expecting we'd see a larger difference,” he told this newspaper.

The study, which involved 31,013 admissions at six academic centers over a 2-year period, compared costs and outcomes of hospitalized general medical patients treated by hospitalists or by nonhospitalist physicians. The researchers used administrative data, patient surveys (inpatient interviews and a 1-month follow-up survey), a chart review looking at process of care variables, data from the National Death Index, and surveys of attending physicians, staff, and primary care physicians.

The investigators concluded that hospitalists did not affect the average length of stay, costs, or outcomes of care across all sites. “Length of stay and cost fell with increasing disease-specific experience, but hospitalist experience may have been offset by higher initial resource use,” Dr. Meltzer said during a plenary presentation of the study, which was also presented in a poster session.

Hospitalist care was associated with significant reductions in mean length of stay at two of the six sites, Dr. Meltzer said.

Earlier, single-center studies of the effects of hospitalists have produced some mixed results. A 2000 review led by Robert M. Wachter, M.D., at the University of California, San Francisco, concluded, “Empirical research supports the premise that hospitalists improve inpatient efficiency without harmful effects on quality or patient satisfaction” (JAMA 2002;287:487–94).

Dr. Meltzer's own earlier study of over 6,500 patients at the University of Chicago showed that “hospitalist care was associated with lower costs and short-term mortality in the second but not the first year of hospitalists' experience.”

During a later session at the SHM meeting, Dr. Wachter said that the latest study by Dr. Meltzer is not totally relevant to nonacademic hospitals. “It's a different kind of environment. The evidence for improvement resulting from the use of hospitalists remains robust with more than 20 published studies showing average cost and length-of-stay reductions of about 15%.”

Dr. Meltzer cited several caveats that may take some sting out of the findings. One study limitation is the “spillover effect,” he explained, which may help to raise the quality of the nonhospitalist comparison group and lead to underestimation of the value of hospitalists.

“Interns and residents work with hospitalists and learn new ways of doing things that may be more efficient and lead to better outcomes, and they remember [these new ways] at the end of the month and then go work with and teach other attendings. So we're used to thinking that teaching is from the attending to the resident to the intern, when in fact there's teaching within those levels and even up the levels,” Dr. Meltzer told this newspaper.

Another equalizer is “a sort of selective attrition effect where, because the hospitalists are taking up more ward months, the department or section can be more selective in whom they put on the wards, so you get only the best attendings on the wards and, not surprisingly, they do a little better than the group as a whole would have done if you had not been able to sort of weed out those who might not do such a good job,” he said.

Dr. Meltzer's third caveat is that, as earlier studies show, hospitalists improve over time. “I think our data are consistent with the hypothesis that hospitalists have real effects, but that those effects don't appear so immediately in the data that we see for all these reasons.”

Finally, Dr. Meltzer was impressed by the finding that the average hospitalist in the study cared for 134 patients, compared with a 46-patient case volume for the average nonhospitalist.

“What's even more striking,” he said, “is that when we go to disease-specific experience, the average hospitalist cared for two-and-a-half patients with that same diagnosis, and the average nonhospitalist cared for less than one (0.93). We found that every doubling of disease-specific experience decreases length of stay and cost by about 3%.”

The next step, Dr. Meltzer added, is for someone to conduct a similar study in community hospitals. And “further work is needed to assess physician factors, site factors, and spillover effects that could influence comparisons between hospitalists and nonhospitalists.”

This Month's Talk Back Question

In your experience, how have hospitalists influenced the care that your patients have received?

CHICAGO — The largest-ever study of the influence of hospital-based physicians on outcomes and costs has failed to show significant benefits, David Meltzer, M.D., reported at the annual meeting of the Society of Hospital Medicine.

“There was a slight trend toward lowering hospital mortality. Otherwise, we found no difference in outcomes between hospitalists and nonhospitalists,” said Dr. Meltzer of the University of Chicago.

“I was somewhat surprised. We began the study expecting we'd see a larger difference,” he told this newspaper.

The study, which involved 31,013 admissions at six academic centers over a 2-year period, compared costs and outcomes of hospitalized general medical patients treated by hospitalists or by nonhospitalist physicians. The researchers used administrative data, patient surveys (inpatient interviews and a 1-month follow-up survey), a chart review looking at process of care variables, data from the National Death Index, and surveys of attending physicians, staff, and primary care physicians.

The investigators concluded that hospitalists did not affect the average length of stay, costs, or outcomes of care across all sites. “Length of stay and cost fell with increasing disease-specific experience, but hospitalist experience may have been offset by higher initial resource use,” Dr. Meltzer said during a plenary presentation of the study, which was also presented in a poster session.

Hospitalist care was associated with significant reductions in mean length of stay at two of the six sites, Dr. Meltzer said.

Earlier, single-center studies of the effects of hospitalists have produced some mixed results. A 2000 review led by Robert M. Wachter, M.D., at the University of California, San Francisco, concluded, “Empirical research supports the premise that hospitalists improve inpatient efficiency without harmful effects on quality or patient satisfaction” (JAMA 2002;287:487–94).

Dr. Meltzer's own earlier study of over 6,500 patients at the University of Chicago showed that “hospitalist care was associated with lower costs and short-term mortality in the second but not the first year of hospitalists' experience.”

During a later session at the SHM meeting, Dr. Wachter said that the latest study by Dr. Meltzer is not totally relevant to nonacademic hospitals. “It's a different kind of environment. The evidence for improvement resulting from the use of hospitalists remains robust with more than 20 published studies showing average cost and length-of-stay reductions of about 15%.”

Dr. Meltzer cited several caveats that may take some sting out of the findings. One study limitation is the “spillover effect,” he explained, which may help to raise the quality of the nonhospitalist comparison group and lead to underestimation of the value of hospitalists.

“Interns and residents work with hospitalists and learn new ways of doing things that may be more efficient and lead to better outcomes, and they remember [these new ways] at the end of the month and then go work with and teach other attendings. So we're used to thinking that teaching is from the attending to the resident to the intern, when in fact there's teaching within those levels and even up the levels,” Dr. Meltzer told this newspaper.

Another equalizer is “a sort of selective attrition effect where, because the hospitalists are taking up more ward months, the department or section can be more selective in whom they put on the wards, so you get only the best attendings on the wards and, not surprisingly, they do a little better than the group as a whole would have done if you had not been able to sort of weed out those who might not do such a good job,” he said.

Dr. Meltzer's third caveat is that, as earlier studies show, hospitalists improve over time. “I think our data are consistent with the hypothesis that hospitalists have real effects, but that those effects don't appear so immediately in the data that we see for all these reasons.”

Finally, Dr. Meltzer was impressed by the finding that the average hospitalist in the study cared for 134 patients, compared with a 46-patient case volume for the average nonhospitalist.

“What's even more striking,” he said, “is that when we go to disease-specific experience, the average hospitalist cared for two-and-a-half patients with that same diagnosis, and the average nonhospitalist cared for less than one (0.93). We found that every doubling of disease-specific experience decreases length of stay and cost by about 3%.”

The next step, Dr. Meltzer added, is for someone to conduct a similar study in community hospitals. And “further work is needed to assess physician factors, site factors, and spillover effects that could influence comparisons between hospitalists and nonhospitalists.”

This Month's Talk Back Question

In your experience, how have hospitalists influenced the care that your patients have received?

CHICAGO — The largest-ever study of the influence of hospital-based physicians on outcomes and costs has failed to show significant benefits, David Meltzer, M.D., reported at the annual meeting of the Society of Hospital Medicine.

“There was a slight trend toward lowering hospital mortality. Otherwise, we found no difference in outcomes between hospitalists and nonhospitalists,” said Dr. Meltzer of the University of Chicago.

“I was somewhat surprised. We began the study expecting we'd see a larger difference,” he told this newspaper.

The study, which involved 31,013 admissions at six academic centers over a 2-year period, compared costs and outcomes of hospitalized general medical patients treated by hospitalists or by nonhospitalist physicians. The researchers used administrative data, patient surveys (inpatient interviews and a 1-month follow-up survey), a chart review looking at process of care variables, data from the National Death Index, and surveys of attending physicians, staff, and primary care physicians.

The investigators concluded that hospitalists did not affect the average length of stay, costs, or outcomes of care across all sites. “Length of stay and cost fell with increasing disease-specific experience, but hospitalist experience may have been offset by higher initial resource use,” Dr. Meltzer said during a plenary presentation of the study, which was also presented in a poster session.

Hospitalist care was associated with significant reductions in mean length of stay at two of the six sites, Dr. Meltzer said.

Earlier, single-center studies of the effects of hospitalists have produced some mixed results. A 2000 review led by Robert M. Wachter, M.D., at the University of California, San Francisco, concluded, “Empirical research supports the premise that hospitalists improve inpatient efficiency without harmful effects on quality or patient satisfaction” (JAMA 2002;287:487–94).

Dr. Meltzer's own earlier study of over 6,500 patients at the University of Chicago showed that “hospitalist care was associated with lower costs and short-term mortality in the second but not the first year of hospitalists' experience.”

During a later session at the SHM meeting, Dr. Wachter said that the latest study by Dr. Meltzer is not totally relevant to nonacademic hospitals. “It's a different kind of environment. The evidence for improvement resulting from the use of hospitalists remains robust with more than 20 published studies showing average cost and length-of-stay reductions of about 15%.”

Dr. Meltzer cited several caveats that may take some sting out of the findings. One study limitation is the “spillover effect,” he explained, which may help to raise the quality of the nonhospitalist comparison group and lead to underestimation of the value of hospitalists.

“Interns and residents work with hospitalists and learn new ways of doing things that may be more efficient and lead to better outcomes, and they remember [these new ways] at the end of the month and then go work with and teach other attendings. So we're used to thinking that teaching is from the attending to the resident to the intern, when in fact there's teaching within those levels and even up the levels,” Dr. Meltzer told this newspaper.

Another equalizer is “a sort of selective attrition effect where, because the hospitalists are taking up more ward months, the department or section can be more selective in whom they put on the wards, so you get only the best attendings on the wards and, not surprisingly, they do a little better than the group as a whole would have done if you had not been able to sort of weed out those who might not do such a good job,” he said.

Dr. Meltzer's third caveat is that, as earlier studies show, hospitalists improve over time. “I think our data are consistent with the hypothesis that hospitalists have real effects, but that those effects don't appear so immediately in the data that we see for all these reasons.”

Finally, Dr. Meltzer was impressed by the finding that the average hospitalist in the study cared for 134 patients, compared with a 46-patient case volume for the average nonhospitalist.

“What's even more striking,” he said, “is that when we go to disease-specific experience, the average hospitalist cared for two-and-a-half patients with that same diagnosis, and the average nonhospitalist cared for less than one (0.93). We found that every doubling of disease-specific experience decreases length of stay and cost by about 3%.”

The next step, Dr. Meltzer added, is for someone to conduct a similar study in community hospitals. And “further work is needed to assess physician factors, site factors, and spillover effects that could influence comparisons between hospitalists and nonhospitalists.”

This Month's Talk Back Question

In your experience, how have hospitalists influenced the care that your patients have received?