Practice Variation across In-Hospital Practice Settings: Documenting and Explaining Different Resource use by Hospitalists and Teaching Teams

Wednesday, June 15, 2016: 8:50 AM
Robertson Hall (Huntsman Hall)

Author(s): Linda Dynan; Dr. Rebecca Stein; Guy David

Discussant: Jonathan Ketcham

Practice Variation across In-Hospital Practice Settings

Documenting and Explaining Different Resource use by Hospitalists and Teaching Teams

Linda Dynan, Rebecca Stein, Guy David,

Hospitals are charged with delivering high quality patient-centered care, preventing errors, and reducing cost. To accomplish these tasks, hospitals are seeking innovative ways to restructure care processes and reorganize the way care is delivered.  Inpatient dedicated physicians have been an increasing share of the US physician labor force since the turn of the century, and gained further labor market growth when the ACGME regulations limited the working hours of residents.  Subsequently, teaching hospitals increasingly implemented two simultaneous health care delivery methods:  a hospitalist service alongside a teaching service.

The literature suggests that patients managed by hospitalists have lower total costs/charges than do patients in comparison groups because of shorter LOS (see for example Coffman & Rundall, 2005; Kaboli, Barnett, & Rosenthal, 2004; and others) with little to no difference in quality of care (Meltzer et al., 2002). Dynan and colleagues (2009) in a qualitative and quantitative study of hospitalist behavior found that hospitalists are, on average, more efficient diagnosticians and/or enhance throughput, as evidenced by having relatively lower charges, through reductions in testing and LOS, than teaching teams within the same hospital. Much of that benefit is concentrated among more complex patients admitted by intensivists (physicians with training in critical care medicine). The authors further found that among hospitalists there is more variation in achieving shorter LOS and prescriptions but less in use of diagnostic testing.  Examining hospitalists only, some hospitalists appear to tradeoff between testing and longer LOS while others were efficient in reducing both LOS and diagnostic testing.

In this paper, we develop a model of production following Becker and Murphy (1992) to test the findings related to the greater efficiency of hospitalists compared to teaching teams.  Because hospitalists spend more time interacting with patients and staff in hospital wards, they have a greater incentive to invest in a set of specific skills (e.g. diagnostic skills, processes oriented skills, acquaintance with the organization, and even social skills, such as foster relationships with the nursing staff) that eventually make inpatient care more effective, safer, and less costly.  As tasks become more challenging (patient cases are more complex and/or the physician has less time to spend with individual patients) many physicians tend to delegate diagnostic elements of the task to labs whereas hospitalists, who invest more in human capital specific to performing such tasks, rely less on external testing. Specifically our model suggests:

  1. As complexity of patient mix increases, teaching teams turn to an increase in testing more than hospitalists do.

  2. As the number of patients to be seen per day increases, teaching teams turn to an increase in testing more than hospitalists do.

  3. As the academic year progresses and the residents’ stock of human capital approaches that of hospitalists the diagnostic testing gap between the two delivery systems shrinks.