In Minneapolis in 1993, Freese1 described the first experience in the use of physician specialists in inpatient medicine.
In 1996, Wacther and Goldman2 underlined the importance of hospitalists in efficient care for a proper use of resources for inpatients: as hospital stays become shorter and inpatient care becomes more intensive, a greater premium will be placed on the skills, experience, and availability of physicians caring for inpatients with the ability to respond quickly to changes in patient’s conditions. In an academic setting, hospitalists provide a premium on clinical quality improvement, in the development of practice guidelines, and outcome research.
Wachter 3 in 2002 reviewed the Literature on the evolution of the hospitalist model in the US underlying the significant decrease in hospital LOS and costs savings, accounting at that time (calculated on the US 4500 hospitalist base) for a stunning $2.2 billion per year. In fact, with more than 30,000 hospitalist staff approximately 70% of US hospitals that number should be multiplied by 6 ($13 billion). Moreover, Wachter described the core and potential additional activities for hospitalists.
The first published paper that focused on surgical co-management with hospitalist in elective hip and knee arthroplasty dates back to 2004. Huddleston and colleagues4 demonstrated that more patients in the hospitalist group were discharged from the hospital with no complications (61.6% vs. 49.8%), fewer minor complications were observed among hospitalist patients (30.2% vs. 44.3%), and mean length of stay for patients in the hospitalist model of care was shorter (5.1 days vs. 5.6 days). Although total costs did not differ between groups, orthopaedic surgeons and nurses preferred the hospitalist model.
The first review of outcomes and quality measures comparing hospitalists with non-hospitalists cared patients is thanks to Peterson5 in 2009 including orthopaedic surgery, pneumonia and heart failure. The author showed that the inpatient care by hospitalists leads to decreased hospital cost and LOS. Hospitalist care was also reported to improve several measures of care: orthopaedic surgery patients had a shorter time related to surgery, consultation, and hospital LOS. Hospitalists have more practice and experience tending to inpatient medical problems than the so-called disease-specific physician experience.
In 2011 Hinami et al6 studied inpatient services of neurosurgery, urology, and orthopaedic, transplant, and vascular surgeries. Medical co-management was associated with fewer inhospital deaths (odds ratio 0.23), shorter stays (–2.6 days, P < .01) without significant differences in total cost. Their analysis suggests that the widespread adoption of postoperative co-management may find benefits in the role of hospitalists as facilitators of rescue. Hospitalists may play an important supportive role in facilitating care for an increasingly elderly and comorbid surgical population, because of their exclusive focus on surgical patients, their orientation towards improving postsurgical care quality, and the higher intensity of involvement in their patients’ care.
Rohatgi and co-workers 8 firstly demonstrated in 2016 a significant savings estimate of $2,600-4,300 per patient in a cohort of orthopaedic and neurosurgical patients. Surgical co-management with hospitalists was associated with a significant differential decrease in the proportion of patients with at least one medical complication after surgery (P = 0.008), the reduction of LOS (P < 0.001) and of 30-days readmission rate for medical reasons (P < 0.001), and the reduction of medical consultations (P < 0.001). The overall patient satisfaction was elevated (88.3%).
On the contrary, Duplantier et al.7 (2016) retrospectively compared postoperative medical co-management of total hip and knee arthroplasty patients using a hospitalist (H, 1,656 patients) and non-hospitalist model (NH, 1,319 patients), and showed decreased LOS (P < 0.001) in H group, but a total rise in direct costs due to a greater number of tests ordered (P < 0.001) resulting in more new diagnosis (P < 0.001) and with higher costs of hospitalization (P = 0.002); no differences were seen in readmission rates.
In 2018, Fitzgerald et al.9 studied 1,100 patients before and after Hospitalist-Orthopaedic Co-management submitted to TKR or THA showing statistically significant improvements in multiple performance and quality metrics: reduction of mean LOS (from 3.36 to 3.17 days), increase in percentage of patients discharged at home (from 53.9–59% with reduction of unnecessary resource utilization over the episode of care), decrease in medical complications rate (P < 0.05), and 30-days readmission rate (P < 0.05), improved rescue and understanding about the needs of surgical patients, increased collaboration between surgeon and hospitalist and anaesthesiologist, avoiding unnecessary testing resulting in better costs control.
Very recently, in 2019 Salim et al.10 conducted a systematic review and meta-analysis in the impact of hospitalists on the efficiency of inpatient care and patient satisfaction, based on 61 studies. Their analysis showed that hospitalist care is associated with decreased LOS and increased patient satisfaction compared to non-hospitalist model. Hospitalists provide more efficient, less costly inpatient care with equal or higher quality, reducing LOS, readmissions and in-hospital mortality. They stated that there is compelling evidence that hospitalists promote clinical care development and integration: particularly, they supported the development of patient safety guidelines and became more efficient in teaching. As inpatient leaders, hospitalists collaborate well with emergency physicians in discharging those patients, which could well be managed as outpatient. Hospitalists are also used to managing complex patients themselves both in acute postoperative complications and in chronic comorbidities, minimizing use of subspecialists; moreover, hospitalists are well aligned with all the figures involved in health care system focused on decreasing length of stay, improving resource utilization and decreasing readmissions, leading to cost savings.
Consequently, we describe our 17 years of experience in more than 25,000 elective prosthetic joint replacements. In Lombardy (Milan Region of Italy), orthopaedic patients account for about 12% of total medical claims for damages with a mean of reimbursement of 60,000 euro (SD 99,000 euro). More in detail, 54% are related to surgical errors, 10% to diagnostic mistakes and 9% to infections and therapy errors each. In our hospital the total infection rate is about 2% and the PJI accounts for 0.8% of total arthroplasties in the index period. Additionally, in 2009 we had 0.69% of PJI, but we observed a rise of 1.2% in 2010 and our antibiotic prophylaxis approach (duration, timing, dosage) was changed. From 2011 we obtained a statistically significant reduction (P = 0.01) to 0.39%, and maintained 0.39% in 2012 and 0.51% in 2013, stabilizing to less than 1% with a mean of 0.8% in the last 10 years. This excellent
result is probably also due to the presence in our hospital of two hospitalists focused and expert in PJI prevention and treatment. The overall medical cl
aims for damages is approximately 0.6%, far below our standard average of 12%, accounting for about 125 million euro saved in the last 10 years. The gradual implementation of the rapid recovery program together with anaesthesiologists, orthopaedics and physiotherapists allows us to obtain a progressive reduction of LOS from 10 to 5 days in the index period with a mean cost per day of hospitalization of 400 euro per patient, accounting for a total of about 17.5 million euro saved between 2013 and 2019 (Table 1). The 30-day readmission rate for any medical/surgical reasons in THA is 1.7% (much less than the 3.2% of high volume hospitals in Italy and 3.7% of the Italian national mean). We obtain the same very good
results for TKA: 0.8% vs 1.3% of high volume hospitals in Italy and 1.4% of Italian national mean (Table 2). External medical consultations are episodic, mainly due to cardiology and infectious disease specialists (none in the last 2 years as an ID specialist joined our team). The overall patient satisfaction is very high and rates at 95%. These very good
results are related to a strict relevance to evidence-based and internal protocols in patient management starting from the pre-hospitalization through the hospitalization period (ward, surgical theatre, rehabilitation) until the discharge at home. In this patient care management continuum, the hospitalist figure plays a leading role due to the 360 degrees medical outlook of an internist. In our reality we are able to confirm that orthopaedic surgeons, anaesthesiologists and nurses appreciate the hospitalist model for different reasons: firstly, both orthopaedics and anaesthesiologists can be more focused on the operating theatre relying on the presence of an experienced internist to take care of their ward patients; secondly nurses can count on the permanent presence of a referral doctor. This study has some limitations: first, it is a retrospective study; second, our data has become more accurate in the last 5 to 10 years due to the implementation of computerized data storage. Our study also has some strengths: to our knowledge, it is the paper with the biggest number of patients followed by hospitalists over a long period of time (17 years) demonstrating the great importance of such a new specialization for internists. Moreover, this is the first paper considering the cost savings related to a significant decrease in medical claims thanks to the hospitalist figure.