Between 1996 and 2006 there was a large increase in the use of hospitalists.1,2
However, few studies are available using nationally representative data to examine outcomes for patients treated by hospitalists. In these analyses we examined the association of hospitalist care with discharge destination, length of stay, the impact of destination on length of stay, and 30-day post discharge outcomes. We chose stroke because it requires complex care in hospital and has high post discharge complications.
We found that hospitalist care was associated with significantly higher odds of discharge to an inpatient rehabilitation facility. Rehabilitation facilities provide more intensive therapy than that available at a skilled nursing facility or home. Thus, discharging to rehabilitation facilities may represent better overall care. It may be that the differences in discharge setting between patients receiving hospitalist versus nonhospitalist care are due to differences in the health status of the patients or the availability of rehabilitation beds.30
Hospitalists are more likely to work in large hospitals in urban areas.1
Such a location may have more availability of inpatient rehabilitation facilities. However, adjustment for patient factors and hospital and metropolitan size did not affect the association of hospitalist care on discharge to rehabilitation facilities.
The reduced length of stay associated with hospitalist care was expected. The magnitude of the reduction, 0.38 days, is consistent with other studies.2,3,5,28
This reduction may be due to improved clinical pathways in facilities that employ hospitalists. We tested also to see if this reduction was mediated by an increase in discharge to other institutions versus discharge home. The reduction in length of stay after adjustment was almost unchanged. On the basis of these data it does not seem that the shortened length of stay associated with hospitalist care is due to the increase in patients being transferred to other facilities. The decrease in length of stay is similar to that reported by Lindenauer et al5
(0.40 d reduction) comparing hospitalists to nonhospitalist generalist. They estimated that this translated to $268 less cost per admission, an approximate 3% decrease. When applied across 795,000 admissions for new and recurring stroke each year,12
this represents a substantial sum.
We found a nonsignificant trend in increased emergency department use and a significant increase in readmission rates. We found no association with mortality. Readmission rates following discharge after stroke are high.14,18
We found that the 30-day readmission rate for patients treated by hospitalists was significantly higher in both unadjusted and adjusted models. Earlier studies have produced conflicting results, with most reporting no change in readmission rate.3,8,31
Somekh et al32
found readmission rates were higher after care by hospitalists compared with cardiologists for patients admitted for chest pain. In addition, Bellet and Whitaker33
found readmission rates to be higher for patients in hospitalist care compared with nonhospitalists in a pediatric setting.
We focused on a particularly challenging patient population. These patients tend to have multiple comorbidities. The top reasons for readmission in our sample (based on diagnosis related group) were stroke, pneumonia, respiratory infections, heart failure, urinary tract infections, septicemia, and gastrointestinal bleeding. It is not possible to assess using Medicare data whether any particular readmission is preventable. One possible explanation for the higher readmission rates reported here could be a disruption in inpatient to outpatient continuity of care. Despite the benefits they offer, hospitalist care disrupts the continuity of care between the patient and their primary care provider.9,10
Deficits in communication across transition from inpatient to outpatient are common and may adversely impact patient care.34–36
This loss of continuity in turn generates a challenge for coordinating post hospital care.37
Maintaining continuity across transitions decreases emergency department use, lowers hospital admission rates, and improves control of comorbid conditions and patient satisfaction.38,39
It is also possible that the earlier studies that showed no differences in readmission rates with hospitalist care were studying “early adopters” of hospitalist care, and that the physicians may have been more motivated to ensure adequate communication across the discharge process. We also limited our study to patients who receive all of their generalist inpatient care from either a hospitalist or nonhospitalist. Earlier studies were not so exclusive. These factors combined may partially explain the difference in readmission rates reported here.
An additional explanation for both decreased length of stay and increased readmissions might be found in Medicare’s prospective payment system. Medicare pays a fixed price for an episode of care for a given diagnosis related group. Physicians are under increasing pressure to keep costs in line with these boundaries. Physicians who work for hospitals may be faced with greater pressure to contain these costs than nonhospitalist generalists. As such, hospitalists may be more inclined to discharge earlier than a nonhospitalist generalist.
One unusual finding was that incontinence during hospitalization was associated with lower 30-day mortality (). We suspect that a diagnosis of incontinence is an indirect marker for less severe disease because very sick patients would have a indwelling urinary catheter and thus be “continent.”
Several limitations bear acknowledgement. First, this research used administrative data that does not capture the level of detail available on chart review. There may be residual confounding introduced through selection bias. One way to limit such bias is to reduce the heterogeneity of underlying characteristics within the study population. We sought to reduce such heterogeneity by selecting only beneficiaries who had a primary care physician before admission, were seen only by a hospitalist or only a nonhospitalist during inpatient stay, and had that contact on at least 70% of the days of admission. In addition, we controlled for covariates to further reduce bias in our estimates. We also carried out a propensity analysis, which showed no difference between groups. One way to indirectly assess the presence of selection bias is to examine more distal outcomes such as long-term mortality. If patients seen by a hospitalist were less healthy in general than those seen by a nonhospitalist, one might expect to see differences in mortality between 30 days and 1 year. We carried out an analysis of 30-day to 1-year mortality and found no significant difference between patients seen by hospitalists and those seen by nonhospitalists (HR, 1.04; 95% CI, 0.92–1.20). However, as in all observational studies, we cannot rule out the possibility of residual confounding from selection bias. An additional limitation is in our use of Medicaid eligibility as a measure of socioeconomic status. We acknowledge that this is an imprecise measure as eligibility requirements vary from state to state. An advantage found in this measure is that it represents socioeconomic status at the individual level as opposed to using a metric at an aggregated level such as census tract median household income.
In conclusion, care by hospitalist for patients admitted with acute ischemic stroke is associated with increased discharge to inpatient rehabilitation facilities, decreased length of stay, and increased readmission rates. The finding of increased readmission rates reported here should be further explored in other patient populations that require complex discharge planning.