Research Activities, October 2010: Outcomes/Effectiveness Research: The role of hospital care in general medical care has declined over time

Outcomes/Effectiveness Research
The role of hospital care in general medical care has declined over time

Not long ago, general medicine physicians, such as general internists and family practitioners, usually cared for their patients when they were hospitalized. Since the mid-1990s, however, dedicated hospital physicians known as hospitalists have increasingly replaced the role of these generalists in providing hospital care. A new study has found that other factors—and not the arrival of hospitalists—are responsible for the declining role of inpatient care in general medical practice. These include reduced length of stay in the hospital and an increase in the number of generalist physicians.

Researchers examined hospital discharge data taken from the National Hospital Discharge Survey during the period from 1980 to 2005. Other data that were analyzed included information on physician office visits and physician manpower. During the study period, admissions and inpatient encounters by generalist physicians declined steadily. The biggest decline occurred from 1980 to 1994 before hospitals began using hospitalists. The total inpatient encounters by generalists decreased 35 percent during the prehospitalist era. During this same period, the number of generalists increased from less than 100,000 to more than 200,000. Inpatient generalist encounters declined by half as a result of this dramatic increase in the generalist workforce. Shorter length of stays, but not decreased hospital admissions, was also responsible for these declining inpatient encounters. During the study period, generalist office visits resulting in hospital admission decreased from 1.34 percent to 0.77 percent.

The researchers conclude that the declining inpatient activity of generalists is not the result of hospitalists "crowding them out," but rather due to declines in length of stay and increase in the generalist workforce. They note that the cost of maintaining skills in inpatient medicine and traveling to the hospital to see a declining number of hospitalized patients may make less hospital activity economically attractive to many generalists. The authors also suggest that a model in which generalist physicians provide both ambulatory and inpatient care for a subset of patients at high risk of hospitalization might provide a viable and beneficial model of general medical care that deserves study. This study was supported in part by the Agency for Healthcare Research and Quality (HS16967).

See "U.S. trends in hospitalization and generalist physician workforce and the emergence of hospitalists," by David O. Meltzer, M.D., Ph.D. and Jeanette W. Chung, Ph.D., in the Journal of General Internal Medicine 25(5), pp. 453-459, 2010.
Research Activities, October 2010: Outcomes/Effectiveness Research: The role of hospital care in general medical care has declined over time