UAB Synopsis, Vol. 25, No. 2, January 23, 2006

Hospitalists expand to 40% of nation’s medical centers
Promoted by factors ranging from insurer mandates to physician satisfaction gains, UAB physicians are participating in a rapidly growing model of health care delivery. A dedicated inpatient physician or “hospitalist” manages inpatient care of general adult medicine patients referred by primary care physicians.

Representing the nation’s 12,000 hospitalists, the National Association of Inpatient Physicians estimates that nationwide 50% of hospitalists are general internists and 40% are medical subspecialists —half of whom are pulmonary/critical care physicians. The Society of Hospital Medicine, a Philadelphia-based trade group, projects that 25,000 hospitalists will work at medical centers nationwide by 2010.

Though most early hospitalist groups were formed in community hospitals, academic centers have begun converting to hospitalist systems during the past 3 years. Well-developed programs are now established in dozens of academic hospitals, including the University of California at San Francisco Medical Center, and Boston’s Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center.

Efficiency

At UAB, the Hospitalist Service is undergoing significant expansion. “UAB Hospitalists, founded in 1998 and housed under UAB Primecare, have moved into a closer relationship with the hospital and now enjoy academic integration with the Division of General Internal Medicine,” Medical Director James Lyman, MD, says. The hospitalist group, which was previously staffed by two to three physicians, has grown to five full-time and two part-time physicians. The service also includes two nurse practitioners, a social worker, a care manager, and an office assistant. It is open 24/7.

Traditionally a non-house staff service, the hospitalist group was identified as a solution for increased inpatient census and fixed resident manpower. “UAB’s new North Pavilion and Emergency Department, along with the resident 80-hour work week limit, are primary driving forces behind our growth,” Dr. Lyman continues.

The teaching medical service’s high census — a 40% increase in admissions since North Pavilion completion — potentially affected its teaching mission, Dr. Lyman says, so the Hospitalist Service significantly decompressed the census by admitting a third of all teaching medicine patients to the Hospitalist Service.

Comanagement Lines

“Having a medicine attending analyzing test results, determining when patients can be discharged, as well as being in house at night, benefits the institution and house staff,” Dr. Lyman says. “The rapid response team currently under development is another area where expanded hospitalist services will add value and quality to patient care,” he says.

In conjunction with the Division of General Internal Medicine, the Hospitalist Service has assumed attending physician responsibilities for the general medicine consult service. The staff envisions developing a “comanagement” line of pre- and postsurgical and other care, where hospitalists would provide medical consultations for surgical inpatients, for example. “For 7 years, comanagement of surgical patients has been a successful model for our orthopaedic colleagues. We would like to extend this to other non-medicine services,” Dr. Lyman says.

Insurance and hospital executives nationwide have embraced hospitalists because they can deliver inpatient care cost effectively. In Philadelphia, for example, the University of Pennsylvania Hospital has expanded from five hospitalists handling 2,000 admissions in 1999 to 11 hospitalists handling 5,000 admissions today, helping decrease average length of stay (LOS) by more than a day and reduce radiology and laboratory services by about 40%.

UAB Hospitalists James Lyman, MD Brian Britt, MD Valerie Brown, MD Chris Bettacchi, MD Mary Prendergast, MD William Camp, Jr, MD Elizabeth Pollard, MD Nurse practitioners are Amanda Crawford, CRNP, and Catherine Brown, CRNP.

As the Philadelphia Business Journal recently reported, a hospitalist program begun in July at Lourdes Medical Center in Willingboro, PA, has lowered LOS by 0.5 days and reduced reimbursement denials. Other key studies provide outcomes data showing consistent results: implementation of a hospitalist program generally leads to a 10% to 25% decrease in costs and LOS with no measurable change in mortality or readmission rates and a possible increase in patient satisfaction.

After several years of decline, hospital-bed occupancy days are now on the rise nationwide. “We believe hospitalist services are invaluable to achieving continuity of care under this situation,” Dr. Lyman says.

“Many individuals made our expanded program a reality. Dr. Michael Waldrum, Dr. Scott Buchalter, and Keith Marks were instrumental from the hospital perspective; from UAB Primecare, Dr. Nancy Dunlap, Mark Schmidt, Hurlecia Maye were invaluable, as were Drs. William Koopman, Robert Centor, and William Curry from the Department of Medicine. Legal support from Kathleen Kauffman and Patricia Pritchett was significant,” adds Dr. Lyman, who extends special gratitude to UAB Health System CEO David Hoidal. “Without his support, the Hospitalist Service expansion would not have taken place.”