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.
Wachter3 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 30000 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.
Rohatgi and co-workers7 firstly demonstrated in 2016 a significant savings estimate of $2600-4300 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.6 (2016) retrospectively compared postoperative medical co-management of total hip and knee arthroplasty patients using a hospitalist (H, 1656 patients) and non-hospitalist model (NH, 1319 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.8 studied 1100 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% to 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.
Consequently, we describe our 17 years of experience in more than 25000 elective prosthetic joint replacements. The data become more accurate in the last 10 years due to the implementation of electronic chard and database, consequently the analysis is focused on that period (more than 19000 patients).
In Lombardy (Milan Region of Italy), orthopaedic patients account for about 15% of total medical claims for damages with a mean of reimbursement of 60000 euro (SD 99000 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 0.7% of total arthroplasties in the index period. More precisely, in 2009 we had 0.7% 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 0.4%, and maintained 0.4% in 2012 and 0.5% in 2013, stabilizing to a mean of 0.7% in the last 11 years (Table 3). 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 claims for damages is approximately 0.6%, far below our national standard average of 10% for major orthopaedic procedures, accounting for about 120 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, neurology 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. Hospitalists provide more efficient, less costly inpatient care with higher quality, reducing LOS, readmissions and in-hospital mortality, due to their ability to manage complex patients themselves both in acute postoperative complications and in chronic co-morbidities, minimizing use of other specialists’ consultations.
This study has some limitations: first, it is a retrospective study from a single teaching institution; 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.