Accepted Manuscript. Hospitalists, Medical Education, and US Health Care Costs,

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1 Accepted Manuscript Hospitalists, Medical Education, and US Health Care Costs, James E. Dalen MD, MPH, ScD (hon), Kenneth J Ryan MD, Anna L Waterbrook MD, Joseph S Alpert MD PII: S (18) DOI: /j.amjmed Reference: AJM To appear in: The American Journal of Medicine Received date: 28 April 2018 Accepted date: 2 May 2018 Please cite this article as: James E. Dalen MD, MPH, ScD (hon), Kenneth J Ryan MD, Anna L Waterbrook MD, Joseph S Alpert MD, Hospitalists, Medical Education, and US Health Care Costs,, The American Journal of Medicine (2018), doi: /j.amjmed This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

2 TITLE PAGE Hospitalists, Medical Education, and US Health Care Costs Corresponding Author James E. Dalen, MD, MPH, ScD (hon) U Arizona College of Medicine Tucson, Arizona Phone/Fax jdalenmd@gmail.com Co-authors Kenneth J.Ryan, MD. U Arizona College of Medicine Phone kjryan@ .arizona.edu Anna L Waterbrook MD U Arizona College of Medicine Phone/fax waterbro1@yahoo.com Joseph S.Alpert, MD U Arizona College of Medicine Phone/Fax jalpert@ .arizona.edu None of the authors has a conflict of interest All authors have participated in the preparation of this manuscript. There is no funding. Hospitalists, Medical Education, and US Health Care Costs Dalen JE, Waterbrook AL, Ryan KJ, Alpert JS 1

3 Hospitalists are general internists whose full time practice is to treat hospitalized patients. They are the fastest growing medical specialty in the US, They increased from 4,000 in 2000 to 50,000 in 2016 ( 1 ) They now are the largest subspecialty in internal medicine By 2016 nearly all teaching hospitals and 75% of all US hospitals had hospitalists. (1) Their prime responsibility is to be an attending physician and direct the care of inpatients. They must be experts in cost-consciousness. Their decisions determine the length of stay and costs of hospitalization of their patients. (2-5) Outcomes of Care: hospitalists vs general internists. Multiple studies have shown that patients managed by a hospitalist have shorter length of stays and lower hospital costs than management by other physicians. (1,3,6,7) The reduced length of stay, and reduced hospitalization costs are sufficient to strongly encourage community and teaching hospital directors to adopt and support the hospitalist model. It is well established that US health care is the most expensive in the world (8) One-third of US health care expenditures in 2016 were for hospital care (2). The Health care expenditures per capita vary widely in the US. Statespecific hospital spending for Medicare patients in 2004 varied from $17,135 in Idaho to $37,000 in New Jersey. (2) The difference in these charges are due to decision making by the attending physician. Some physicians order more expensive tests and procedures than others. 2

4 Medicare pays hospitals a fixed amount based on the patient s diagnosis (DRG) rather than the number of hospital days or the total hospital procedures or charges. Non Medicare payers usually pay a fixed amount per day or by a modified DRG. (9) As a result, hospital profits are greatest when the length of stay is shortest and the total hospital charges for diagnostic tests and procedures are least. Outcomes of care- quality measures Comparing quality of care is difficult. The two metrics that are used to assess quality of care are the in-hospital death rate and the rate of readmissions. To be valid comparisons of in- hospital mortality or readmission rates would require carefully matched randomized clinical trials. Such studies are not available. Peterson in 2009 reviewed 18 reports that compared care by hospitalists vs nonhospitalists (10). In 15 reports there were no differences in the 30 day death rate or the re-admission rate. In three reports mortality and readmissions were less frequent for hospitalist patients (10). The cost effective care by hospitalists does not diminish the quality of care as measured by in-hospital mortality or the re-admission rate. The Impact of the Hospitalist System on Teaching Hospitals At present most teaching hospitals employ hospitalists (1). Most are based in the department of medicine (11) A smaller number are in departments of Pediatrics ( 12) 3

5 Academic hospitalists serve as attending physicians responsible for patient care on the medical service and for the education of residents and medical students. Prior to the hospitalist system faculty physicians supervised the care of patients on the medical service as well as being responsible for resident and medical student education. The attending physician was often a subspecialist, and often a senior faculty member. They served as an attending for a month or two a year. They made rounds with the residents and students for one to two hours per day while trying to maintain their other academic and clinical obligations and research activities (13) They spend most of their time on rounds seeing the new patients or patients with interesting or complex problems. They did not determine the workup or treatment of each patient being cared for by residents. The typical hospitalist attending in teaching hospitals at present is quite different than the faculty attending of the past. The hospitalist is more likely to be a young general internist with a greater interest in patient care and teaching than research.(13). They directly supervise the work-up and care of each patient on the medical service for an average of 6 months a year. Evaluation of Teaching Hospitalists vs nonhospitalists In an early comparison of teaching by a hospitalist vs the traditional attending at the U of Chicago,86 medical residents rated the quality and value of attending rounds of hospitalists higher than for the traditional attending system (p =.02). (14) 4

6 The impact of hospitalist vs non hospitalist teachers on internal medicine rotations was evaluated by 138 third year medical students at the University of Oregon.(15) The hospitalists who attend 6 months per year were compared to non-hospitalist faculty attendings. The hospitalists received higher evaluations for all Individual attending characteristics ( P <.001). (15) Hauer et al (16) compared teaching by 17 hospitalists and 52 traditional attendings at a community teaching hospital and a tertiary care teaching hospital. The percent generalists was about the same in the two groups of attendings. The hospitalists were younger and less likely to be senior faculty.. Five hundred and ninety-nine Internal medicine residents and 318 medical students expressed greater satisfaction with hospitalists then with traditional attendings. They reported more effective teaching and more satisfying rotations with hospitalists.(16) Kulaga (4) reported the impact of hospitalists on resident education in a community teaching hospital. Ninety-seven per cent of 36 internal medicine residents reported that the presence of hospitalists improved medical education by improving formal and informal teaching as compared to supervision by community attendings. Kripalani (13) compared hospitalists with subspeciality and general medicine faculty on teaching 423 medical residents and medical students at a large teaching hospital. The twelve hospitalists were younger than 24 general medicine and 27 subspeciality attendings. The hospitalists served as attendings on the medical service for 6 months a year. The general medicine and subspeciality attendings served two months or less per year. Hospitalists and general medicine attendings were rated higher than 5

7 subspecialists. Attendings who were recent residency graduates were ranked higher than older physicians. Hospitalists were judged to have a higher level of involvement in patient care and had a greater presence on the wards than the subspecialists. Each of these 5 reports (4, 13-16) used different questionnaires to compare teaching by hospitalists and non-hospitalists; some more elaborate than others. However, in all five reports the residents and medical students concluded that the quality and value of attending rounds by hospitalists was superior to the teaching by traditional attendings. Conclusions Hospitalists will continue to have an important role in directing the care of hospitalized patients in community and teaching hospitals. Their focus will continue to be to provide cost-effective hospital care resulting in a shorter length of stay and lower hospital costs. If the glowing evaluations of hospitalists teaching medical students and medical residents noted here are confirmed it is likely that the hospitalist model will spread to other clinical departments. Hospitalist supervision of in hospital care, and their teaching of cost-effective health care to medical students and residents may lead to a new generation of US physicians who deliver quality care that is cost effective. Maybe these new physicians will lead the way to the reduction of excessive US health care costs! REFERENCES 6

8 1. Wachter RM, Goldman L. Perspective. Zero to 50,000- the 20 th anniversary of the hospitalist. N Engl J Med 2016; 375: Mitchell DM. The critical role of hospitalists in controlling health care costs. J Hosp Med 2010; 5: Halasyamani LK, Valenstein PN, Friedlander MP, et al. A comparison of two hospitalist models with traditional care in a community teaching hospital., Am J Med 2005; 118: Kulaga ME, Charney P, O Mahony SP, et al. The positive impact of initiation of hospitalist clinician educators. J Gen Intern Med 2004; 19: Meltzer D, Manning WC, Morrison J, et al. Effect of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med 2002; Lindenauer PK, Rothberg MB, Pekow PS et al. Outcomes of care by hospitalists, general internists, and family physicians. N Engl J Med 2007; 357: Auerbach AD, Wachter RM, Katz P, et al. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med 2002; 137: Himmelstein DU, Jun M, Busse R, et al. A comparison of hospital administrative costs in eight nations: US costs exceed all others by far. Health Affairs 2014; 33: Reinhardt UE. How do hospitals get paid? A primer.economix January 23, Peterson MC. A systematic review of outcomes and quality measures in adult patients cared for by hospitalists and nonhospitalists. Mayo clin Proceedings 2009; 84: Harrrison, R, Hunter AJ, Sharpe B, et al. Survey of US academic hospitalist leaders about membership and academic activities in hospital groups. J Hosp Med 2011; 6:

9 12. Landrigan CP, Conway PH, Edwards S, et al. Pediatric hospitalists: a systematic review of the literature. Pediatrics 2006; 117: Kripalani S, Pope AC, Rask K, et al. Hospitalists as teachers. How do they compare to subspecialty and general medicine faculty? J Gen Intern Med 2004; 19: Chung P, Morrison J, Jin L, et al. Resident Satisfaction on an academic hospitalist service: time to teach Am J Med 2002; 112: Hunter AJ, Desai SS, Harrison, RA, et al. Medical student evaluation of the quality of hospitalist and nonhospitalist teaching faculty on inpatient medicine rotations. Academic Medicine 2004; 79: Hauer KE, Wachter RM, McCulloch CE, et al. Effects of hospitalist attending physicians on trainee satisfaction with teaching and with internal medicine rotations. Arch Intern Med 2004; 164: words 8