Hospitalist System versus Housestaff System, And the Winner Is…

Source: Dwight P, MacArthur C, Friedman JN, et al. Evaluation of a staff-only hospitalist system in a tertiary care, academic children’s hospital. Pediatrics. 2004;114:1545–1549.In 1995, responding to newly limited resident duty hours, the division of pediatrics at The Hospital for Sick Children in Toronto reorganized inpatient pediatric teams to include 2 distinct hospitalist models: a hospitalist/housestaff model (CTU) and hospitalist staff-only model (CPU). Citing a lack of published data assessing the staff-only pediatric hospitalist model, the authors designed a cohort study of 3807 admissions to the general inpatient pediatric unit between July 1, 1996 and June 30, 1997.Length of stay was the primary outcome measure, and secondary outcome measures included frequency of subspecialty consultation, readmission to the hospital, and death. Consultations were measured as none or ≥1, and readmissions were defined as admission within 7 days of discharge for the same or a related diagnosis. Clinically relevant information collected for each patient included age, gender, referral source, stay in a special care unit, most responsible diagnosis, and comorbidity. Comorbidity was defined as a stay complicated by a chronic illness, serious or important conditions, and/or a potentially life-threatening condition. The CTU team had a daily census of 24 to 30 patients and consisted of 1 attending pediatrician, 3–4 pediatric residents, and 2 medical students. CTU pediatricians attended this service 4 to 8 weeks each year. The CPU was staffed with 3 pediatricians who were responsible for all aspects of care Monday through Friday and on weekends during daytime. Medical students were included on this team. During nights and weekends clinical fellows not otherwise associated with the CPU team provided coverage. Each CPU physician maintained a daily census of 8 to 10 patients. These physicians spent approximately 11 months of the year providing inpatient care.During the study there were 3807 admissions, of which 33% were to the CPU and 67% were to the CTU (based on maintaining a census of 24–30 on the CTU, with the remainder assigned to the CPU). Patients admitted to the CPU were older (median age: 95 weeks vs 69 weeks, P<.01) and less likely to have comorbidity (24% vs 30%; P<.01). The patient diagnoses for the 2 teams were not significantly different. The median length of hospital stay for the CPU team was 2.5 days (interquartile range [IQR]: 1.6–4.4 days) versus 2.9 days (IQR: 1.8–4.9) for the CTU team (P<.01). Multivariate linear regression demonstrated that this difference in length of stay remained significant after adjustment for age, gender, and comorbidity (P<.04). Stratified analysis of the 10 most frequent diagnoses demonstrated a shorter median length of stay on the CPU team for these diagnoses when combined as a group (2.1 days vs 2.6 days, P<.01). There was no significant difference between the 2 teams with respect to readmissions, frequency of consultation, or death.Dr. pate has disclosed no financial relationships relevant to this commentary.Demonstrating improved efficiency without an increase in morbidity and mortality is an important first step in evaluation of a new model of providing inpatient care. The decrease in median length of stay shown in this study, although statistically significant, is not clearly clinically and/or financially significant and the study was not designed to test the authors’ assertion that this shortened length of stay might positively affect hospital efficiency by improving throughput. Further investigation needs to be directed at measuring the effect that a hospitalist-only service integrated with a traditional resident-attending service will have on “non-clinical” variables such as resident patient encounters, resident education, and the satisfaction of residents, medical staff, and patients. These effects could be significant and unique.In the United States, pediatric inpatient admissions increased an average of 16% between 1998 and 2002.1 As of July 1, 2003, the Accreditation Council for Graduate Medical Education (ACGME) limited the availability of resident physicians to an 80-hour weekly work limit and 24-hour continuous on-duty time.2 The disparity created between a growing pediatric inpatient census and a more tightly controlled pediatric resident workforce will create a need for novel solutions, and the independent pediatric hospitalist practicing parallel with a resident-attending team is a potential solution.

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