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Higher resource use and lower mortality associated with care by PCPs compared with hospitalists
Clinical Question
Does the type of physician who cares for hospitalized patients affect patient outcomes?
Bottom line
Care in the hospital by a primary care physician (PCP) was associated with a higher number of consultations and a longer length of stay, but lower mortality, as compared with care by hospitalists. Nonhospitalist generalists who did not have a longitudinal relationship with the patient provided care for more than 25% of hospitalized Medicare patients, but had the worst outcomes. 2c
Reference
Study design: Cohort (retrospective)
Funding: Government
Setting: Inpatient (any location) with outpatient follow-up
Synopsis
These investigators examined a random 20% sample of Medicare beneficiaries hospitalized in 2013 for the top 20 most common medical diagnoses. Medicare claims data were used to identify the physician who cared for the patient in the hospital as either a PCP, a hospitalist, or another covering generalist physician. Patients who had specialists as physicians of record were excluded from the study. A PCP was identified as a physician who billed for the largest share of the patient's generalist ambulatory visits during the 12 months prior to hospitalization. Of the 560,651 medicine hospitalizations analyzed, patients were cared for by hospitalists, PCPs, and other generalists, 60%, 14%, and 26% of the time, respectively. After adjusting for patient and clinical factors, patients cared for by PCPs and other generalists had a greater number of inpatient specialty consultations (PCP: relative risk [RR] 1.03; other generalists: RR 1.06) and longer lengths of stay (PCP: RR 1.12; other generalists: RR 1.06) as compared with those cared for by hospitalists. However, patients cared for by PCPs were also more likely to be discharged to home versus a postacute care facility (adjusted odds ratio [OR] 1.14) and had lower 30-day mortality rates (adjusted OR 0.94). Patients cared for by generalists who did not have a prior relationship with the patient were less likely to be discharged to home, had greater 30-day mortality, and had higher 7-day and 30-day readmission rates.
Reviewer
Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL
Comments
Good poem
Ici les généralistes commencent à être expulsés de l’hospitalisation . Le rôle d’hospitaliste n’existe pas dans notre province . Ce sont des équipes de tournée hospitalière formées de généralistes qui se succèdent hebdomadairement . Dans la majorité des hôpitaux ils ne connaissent pas les patients .
Par contre , beaucoup de spécialistes , excluant les internautes généraux , qui sont obligés de faire de l’hodpitalisation , sont inconfortables avec des pathologies qui sortent de leur spécialité. Ils demandent bcp de consultations à d’autres spécialistes pour des problèmes de base. Il faudra voir l’inpsct Dur la durée de séjour , la rehospitalidation et... les coûts !
This is very vindicating. A few years ago, the local hospitals pushed to get Family Physician OUT of the hospital and Hospitalists IN. The motivation was to contain costs by getting patients home quicker. Although that seems to be the case in this study, it also appears that outcomes for the patient are WORSE! So much for the patient centered approach!
So, what a shame that PCPs have been driven out of the hospitals in Canada
A practical differentiation between the meanings and implications of "efficiency' (in-hospital MRP care by hospitalists) and effectiveness (in-hospital MRP care by PCP's).
this is very interesting, given that most of us (family docs) no longer admit our own patients and are not encouraged to do so by hospital administration (it is nearly impossible for new docs to get admitting privileges)
I am not surprised. That has been my impression all along.
To many potential confounders in this study to make any conclusions.
Practically speaking, primary care physicians in cities in Ontario have no access to admitting patients. The only places where primary care physicians can admit patients is where there are no specialists, Such as remote communities.
I manage a hospitalist system at a regional hospital where approximately 50% of community FP's have removed themselves from hospital care of their own patients claiming that inpatient work is poorly paid relative to the time and effort expended. Inpatient care fees increased significantly 6 months ago, which helped retain family physicians in caring for inpatients. Unfortunately none of the FP's who left hospital care of their patients returned. Our government just made that worse by increasing office fees - a needed change- but with potential adverse unanticipated effects
The doctor who knows you best is the best doctor for you when hospitalized.
consultations
Complex, but I submit that in my limited experience, you have to be quite ill to be in a Canadian hospital the last years. Therefore many hospital patients will benefit from a specialty consultation. I wonder if hospitalists are under some pressure not to do that.