Re: The hospitalist program

We read with interest the article by Dr McGowan and Ms Nightingale on hospitalists (BCMJ 2003;45[8]:391-394), which examined differences in patient care outcomes between hospitalists and family physicians. We are concerned both because the conclusions appear not to have been generated through rigorous experimental design and because these conclusions have been accepted by the Fraser Health Authority. Indeed, this article has been circulated in a slightly different format entitled “Hospitalists in Fraser Health: An update” dated July 2003. That the conclusions in this study may influence health care planning is worrisome and we feel compelled to comment.

Unfortunately there is very little information provided regarding actual study design. It seems to compare hospitalists with a control group that would appear to be family physicians looking after their own patients. The outcomes considered were average length of stay, recidivism, and alternate level of care (ALC) rate. The analysis would seem to indicate that hospitalist care is superior to family physician care in all of these outcome measurements. However, the obvious problem here is that this was a retrospective case control study without the benefit of matching cohorts for diagnosis, complexity, or even age. Indeed, we see from the scant information provided that the average age of the family physicians’ patients was 72.6 years and that of the hospitalists’ was 64.5 years. One can easily argue, on this basis alone, that the family physicians’ patients were probably less healthy and more frail to begin with. Support for this is provided by the authors; the ALC rate was significantly lower in the hospitalist program (though no numbers are reported). The ALC designation is given when a patient is no longer receiving acute care but is awaiting discharge, often to a facility or subacute care. These patients are often the frail elderly with complex care needs impending discharge. There may be dementia, mobility problems, or caregiver issues. We would argue that the higher ALC rate in the family physician group is due to family physicians caring for older, less healthy patients with complex care needs. Therefore, because the hospitalists were caring for younger, healthier patients, we should not be surprised that their outcome measurements were more favorable than those of the family physicians. We suggest then that this study cannot generate any valid comparisons between hospitalists and family physicians.

The authors also suggest that letting hospitalists look after our inpatients (i.e., relinquish our active privileges) will allow us to see more patients in our office and that this will have “a beneficial effect as we are facing increasing physician resource problems.” This ignores the fact that each hospitalist deprives a community of a family physician. Recently, the College of Family Physicians of Canada commissioned a Decima poll, which found that 81% of those polled felt it important to have their family doctor involved in their hospital care. Many of us are concerned about the loss of skills and knowledge that can occur when we leave the hospital setting. In addition, we lose that valuable interaction with our specialist colleagues; the “corridor consult.” Many of us enjoy hospital work.

In these times of endless hospital cutbacks a strong physician voice is essential. One can argue that a physician who is providing episodic hospital care only, is on the Health Authority payroll, and possibly lives outside the community may not be in the best position to provide strong patient advocacy at a time when it is most needed. We believe family physicians providing a continuum of care that spans both the hospital and community are uniquely positioned to provide that strong, unified voice that appears to be essential these days to maintain the hospital services that communities both need and deserve.

The authors inform us that “the main driver for this is the need for hospitals to provide physician coverage for unattached patients.” However, when administrators see numbers like those presented in this article they may be easily seduced by visions of monetary savings through the introduction of hospitalist programs irrespective of the availability of family physician coverage. It is for this reason that studies like this one should meet a high standard experimental design and go through the usual peer review process.

Finally, Dr McGowan is identified as the medical director of Burnaby Hospital and declares no competing interests. We understand that he is also the director of the Hospitalist Program for the Fraser Health Authority and is one of its most vocal proponents, having toured the Authority promoting the program through presentations at various hospitals.

In closing, we thank Dr McGowan and Ms Nightingale for raising this important issue that needs to be debated fully within the medical community.

—Eric Smith, MD
—Barry Turchen, MD

Dr McGowan responds

Drs Smith and Turchen raise some important and noteworthy concerns in their letter. There was no intention of suggesting that the data presented in the article on hospitalists represented findings of a rigorous scientific study. These data were generated through a quality improvement process common to all areas of industry and health care. When systems are exposed to change, indicators are measured to monitor the impact. The conclusions that were generated from the data are soft when compared to a scientific trial, but are consistent with results in more rigorous studies done in hospitalist programs throughout North America and published in peer review journals.[1-3] These figures validate the efficacy and utility of a hospitalist program in a single setting. The intention of this article was to review some of the findings of a pilot hospitalist program in the British Columbia health care environment.

Hospitalist programs have developed where there are significant orphan hospital patient populations. To use the traditional model of doctor-of-the-day management for these patients relies on a less than satisfactory program of care that is usually more episodic (given call arrangements) than hospitalist care. Two groups of patients reside in our hospitals: those with high acuity and those with high personal support needs (ALC). With the complexity of acute inpatients currently cared for in our hospitals, I would respectfully suggest that the morning physician visit, with availability by telephone, cannot produce the results one can expect with a program that provides bedside physician attention, available based on patient need.

Drs Smith and Turchen quite correctly indicate that I am the medical director for Hospitalist Programs in Fraser Health. This appointment occurred after the article was originally submitted for publication and was an oversight at the time of publication.

Finally, hospitalist programs are growing throughout North America and are providing a valuable medical safety net that was not previously available to many of our patients during their periods of greatest need. It is essential, as these programs evolve, that there be open dialogue with primary care physicians in each community and a working relationship developed so that family physicians continue to feel welcomed in hospitals to manage their own patients through the continuum of care.

—Brian McGowan, MD

Eric Smith, MD, Barry Turchen, MD, Brian McGowan, MD. Re: The hospitalist program. BCMJ, Vol. 46, No. 1, January, February, 2004, Page(s) 7-8 - Letters.

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