Despite the widespread adoption of hospitalist programs in Canada, little evidence about their effectiveness exists. Previous studies have methodological limitations  and are mostly confined to reporting unadjusted before and after measurements [12, 13].
We find that in our institution, both FP-Hospitalists and GIM-Hospitalists appear to perform better on the main outcome measure of hospital mortality compared to traditional FPs. These differences seem to persist if HSMRs are compared using independently derived methodologies developed by CIHI. Previous studies from the U.S. have largely failed to show a mortality benefit for hospitalist programs, but such evidence may not be directly applicable to Canada. Compared to subspecialists, the magnitude of potential mortality benefit with hospitalists in our institution does not appear to be as consistent, ranging from worse outcome with FP-Hospitalists in logistic regression to better outcome with GIM-Hospitalists in HSMRs.
The reduction in 30-day readmission rates realized by our hospitalist programs compared to traditional FPs is also of note, especially as payers focus on system efficiencies in response to economic pressures. Moreover, this finding suggests that some of the inherent discontinuity of care introduced by hospitalists may be offset by other benefits such as 24-hour availability of physicians and better familiarity with health system processes.
Our study shows that the effect of hospitalists on resource utilization (as represented by LOS) is more mixed. Compared to traditional FPs, GIM-Hospitalist patients have a statistically significant lower LOS (p < 0.001). They also appear to perform similarly to other-IM. On the other hand, FP-Hospitalists demonstrate a similar or worse LOS compared to traditional provider groups. Previous studies have suggested that fragmentation of care due to a high number of hospitalists rotating through a patient’s hospitalization episode increases LOS . With 16 full-time equivalent physicians, the FP-Hospitalist program is the largest in our hospital and thus possibly exhibits the most discontinuous care. A prior internal audit revealed that in 2007–2008, an average of 2.46 FP-Hospitalists were involved per medical case (data not shown). In our study we were unable to account for the potential impact of the number of providers on LOS due to limitations of CIHI DAD data set. Nonetheless, our findings suggest that FP-Hospitalists can have at least an equal resource utilization compared to traditional FPs, despite caring for older and sicker patients.
An unexpected finding in our study is the degree of differences observed between FP- and GIM-Hospitalist groups, given broad similarities in patient populations and intertwined care processes. This finding may partly be due to the inherent limitations of using administrative databases and statistical adjustment. Additionally, the work distribution of the two groups is such that FP-Hospitalists tend to have a higher proportion of palliative patients, and also look after more oncology and nephrology patients. However, the possible contribution of training background cannot be discounted. Post-graduate family medicine training in Canada is primarily focused on outpatient care and is considerably shorter in duration than general internal medicine training which is mostly hospital-based. Even in the United States, where family medicine and internal medicine are more similar in terms of length of training and a shared focus on primary care, differences in communication skills, diagnostic certainty and resource utilization have been described [15–18] suggesting potential differences in core competencies and philosophy of care.
Our study has a number of notable features. To our knowledge, our study is the first attempt to systematically evaluate the quality of care delivered by Canadian hospitalists compared to traditional care providers. As well, our study attempts to overcome limitations of other studies by controlling for confounding factors. The hospitalist programs at LH have been in operation for many years, and are amongst some of the more mature programs in Canada. We have previously described a “maturity curve” for Canadian hospital medicine programs . Both programs at LH can be considered “third generation” programs with significant levels of involvement in institutional processes. This “stability” allows for a meaningful assessment of program performance. Similarly, the availability of two hospitalist programs staffed by physicians of different training backgrounds is unusual and provides a unique opportunity for a comparative assessment.
Our study has a number of limitations. First, we retrospectively used an administrative database to compare the performance of different care models that comprise a complex array of processes. While we have made efforts to identify and adjust for confounding factors, our analysis may be limited by the lack of important data points in the Discharge Abstract Database For example, the DAD does not include information on adverse events that could impact hospital mortality and readmission rates. As well, the adjusted r2 of the LOS linear regression is quite low, indicating that there are likely many other variables affecting this length of stay not captured in our dataset. Second, we were not able to obtain costing analysis to compare efficiencies between the various study groups. Third, we have studied programs at a single institution in Ontario, and our results may not be applicable to other settings. For example, in a recent abstract from an academic institution in the same province, no statistically significant benefit to an internist-based hospitalist program was found when compared to Clinical Teaching Units staffed by academic general internists . Finally, the geographic assignment of the two hospitalist groups may have an impact on outcome measures through differences in case mix and implementation of patient safety and quality improvement projects on different units at different times. For example FP-Hospitalists are responsible for patient care on the main oncology-nephrology ward, as well as the rehab units while the GIM-Hospitalist group has a higher proportion of cardiology patients.