Resource Utilization for Inpatient Care by Family Physicians:
A Review of the Literature.
CDR John R. Holman, MC, USN
(edited for web page by CDR DL Hufford, MC, USN, 03 JUL 99)
Faculty Development Fellowship
Madigan Army Medical Center
Inpatient hospital care consumes a significant portion of health care expenditures in the United States. While the costs of medical care have slowed in their increase, they are still much higher than in other industrialized countries such as Canada or Great Britain. Family physicians may utilize resources at a lower rate than other providers may with similar outcomes. An extensive literature search was performed using the Medline and Healthstar databases with MeSH terms of family practice and primary care. Keywords included resource use or utilization, inpatient care, comparison of care, cost of care, competency, community hospital, academic medical center, university medical center, and medical outcomes. Pertinent articles are reviewed from the medical and health services literature on resource use by family physicians delivering inpatient care. Most of the articles compared family physicians with other primary care providers and subspecialists. No reports compared resource utilization for inpatient care among family physicians in different practice settings
While payments to physicians account for about 20 percent of health care costs, medical doctors, directly or indirectly influence 70 percent of all health care expenditures. A significant portion of health care costs is a result of inpatient medical care. The use of resources such as laboratory testing, specialist consultations, diagnostic imaging and other diagnostic tests and procedures may add to the cost of inpatient care. More importantly, the utilization of these resources can result in increased lengths of stay, more complications and more surgeries. The ordering of lab tests can be very inefficient. One study indicated that 30 percent of all laboratory tests had no impact on patient care. Another evaluation of potentially avoidable laboratory use found 25 to 34 percent of lab tests were felt to be "inappropriate".
Of all the resources, specialist consultation has the greatest effect on resource consumption. This occurs due to increased use of laboratory testing, diagnostic imaging and other diagnostic testing by the specialists and the increased length of stay required to complete the tests and procedures 4, . In a 1990 study of diagnostic test use by specialist consultants, patients who had consultation had an increase in stay of over 8 days and an increase in charges of over $6000 (1990 dollars). The consultants tended to order invasive, technologically sophisticated and expensive tests that were within their specialty. In fact, consultants recommended 35 percent of all diagnostic tests performed. There was no difference in in-hospital mortality between patients who had consultation and those who did not. Patients who received consultation were definitely sicker, but when stratified by severity of illness, patients in each group who had consultations had a longer length of stay with no difference in in-hospital mortality
Why do attending physicians request consultations? The reasons include the need for specialized procedures, the need for expert advice when dealing with uncertainty in the diagnosis and management of the patient’s illness, and, in the academic medical center, teaching. Pressure from the consultants may influence attending physicians to order tests that may be "inappropriate" or "excessive". The ritual of requesting specialty consultation and the over-utilization of diagnostic testing and procedures may contribute to the rising costs of inpatient medical care. Does the culture where physicians practice affect the utilization of resources such as consultants?
Academic medical centers are the centers of medical teaching. They are often affiliated with a university medical school and have the latest in medical technology. Medical centers are populated by medical and surgical subspecialties and, until recently, are avoided by primary care specialists. Teaching hospitals may use more resources than community hospitals. In 1977, medical teaching units ordered 50 percent more laboratory tests and had double the consultation rate as non-teaching units, even when stratified by case-mix. Family practice residents who practiced at a university center ordered more tests for "academic reasons" than residents who admitted to a community hospital did. In an interesting study in 1994, 36 interns in an internal medicine program completed questionnaires on caring, medical knowledge and clinical judgement. Their lab utilization scores were calculated from hospital data and adjusted by severity of illness. The analysis indicated that increased clinical judgement was related to less laboratory utilization. Increasing amount of medical knowledge was associated with more laboratory utilization. In addition, teaching hospitals are one-third more costly than non-teaching hospitals (adjusted for diagnosis related group case-mix) because of the volume of services teaching hospitals provide rather than the cost per individual unit of service. The presence of large numbers of subspecialists at academic teaching centers with their depth of knowledge of their specialty may foster increased laboratory utilization. Inpatient mortality differences for patients care for by the same type or provider between community and academic hospitals have not been well studied.
Family physicians have been compared to other primary care specialists with regard to their resource utilization. In a study from 1980, family physicians used fewer diagnostic tests than internists and general internists use fewer diagnostic tests than do subspecialists in similar clinical situations. Similar studies in 1983 and 1984 reproduced these results. In the care of chronic obstructive lung disease, similar results were found in a 1987 article. In a report from the Medial Outcomes Study, there were no consistent advantages for any specialty in the care of hypertension and non-insulin-dependent diabetes mellitus. Family physicians are more parsimonious in their utilization of diagnostic testing than are internists and subspecialists in the ambulatory setting with similar outcomes. What about the inpatient setting?
Does the restraint which family physicians show with regard to diagnostic test ordering in the outpatient setting continue in the inpatient setting? In the treatment of diabetic ketoacidosis by internists and family physicians, internists had longer hospitalizations (5.1 vs. 4.6 days) and increased lab usage with no difference in serum glucose or urine glucose spillage at discharge 3. In critical care, family physicians and general internists showed no difference in resource utilization, death rate, readmission rate, median hospital charges or length of stay with adjustment for severity of illness. Internists performed more procedures and their patients had a higher number of complicating conditions than family physicians. The length of stay was no different in higher volume diagnosis related groups. The characteristics of the patients contributed more to explaining variations in the length of stay than did interspecialty differences. In a cohort trial from 1989, patients were randomly assigned to the internal medicine or family practice clinic for their health care. While the average cost of hospitalization was 25 percent higher for internal medicine patients and they had a length of stay 19 percent longer, the major influence these variables was the care received from the specialists who consulted on these patients. One drawback of this study is that the majority of patients from both clinics were not admitted to their own services. Instead, the admitting services were other specialty teams. For the internists, orthopedics was the most common specialty service after internal medicine. For the family physicians, the most common inpatient service after family medicine was obstetrics and gynecology 4. The practice characteristic that influences hospital charges most is not what services the primary care provider gives, but rather what referrals they make.
Family physicians use fewer resources than specialists and other primary care providers. Are their outcomes similar? Most studies have compared the in-hospital mortality and other outcomes of care of patients cared for by family physicians favorably to those cared for by other primary care providers and specialists 3, 9, 22, 2. In a 1995 study comparing care provided by family physicians and obstetricians to women with low-risk pregnancies, patients of family physicians were less likely to have an episiotomy during vaginal delivery (53.7% vs 74.5%, P < .001). They also had a lower frequency of cesarean section deliveries (9.3% vs 16.0%, P < .001), especially for cephalopelvic disproportion. When adjusted for potential confounders, rates for cesarean section and episiotomy for obstetricians were still significantly higher than those of family physicians were. For neonatal outcomes (low 1-minute Apgar score, neonatal intensive care unit admission, birth trauma, or neonatal infection), no significant differences were found between the care delivered by obstetricians and family physicians. Patients who were admitted for congestive heart failure and cared for by either generalists or cardiologists also displayed an all-cause mortality rate that was not significantly different.
Some recent studies have questioned that similar outcomes occur among similar patients cared for by specialists as compared with generalists. A comparison of the care delivered by generalists and cardiologists to congestive heart failure patients admitted to a university teaching hospital showed that although generalists' patients underwent significantly fewer in-hospital diagnostic tests and had shorter lengths of stay, they had a 1.7-fold increased risk of readmission for CHF within 6 months (p < 0.05, 95 percent CI 1.11-2.56). However, the mortality rate for cardiac and all cause death was two to three times greater for the patients cared for by the cardiologists (p < 0.001). Six-month cardiac and all-cause mortality were not significantly different between the groups. The type of physician caring for the patient and a history of diabetes, previous CHF or myocardial infarction were independent predictors of readmission for CHF 26. A 1996 study suggests that patients who were admitted for a myocardial infarction by primary care physicians have a slightly higher risk of dying in the year after admission. After adjustment for characteristics of the patients and hospitals, patients who were admitted to the hospital by a cardiologist were 12 percent less likely to die within one year than those admitted by a primary care physician (P<0.001). The 95 percent confidence interval was only reported graphically and approached, but did not touch, 1.00 for the hazard ratio. Cardiologists also had the highest rate of use of cardiac procedures and medications, including medications (such as thrombolytic agents and beta-blockers) that are associated with improved survival . These studies included both internal medicine and family physicians as generalists. While studies have not shown any difference for in-hospital mortality between family physicians and specialists, there may be differences in mortality over time.
The problem of rising medical costs affects providers of care, payers of care and consumers of care. Rapidly rising costs contribute to price inflation, inadequate health insurance coverage and the increase of managed care in the health care marketplace. Health care’s percent of the US gross domestic product was over 13 percent in 1995 and is predicted to rise to 15 percent by 2000. Inpatient care is a major source of health care expenditures and the main target for managed care, i.e. DRGs, admission pre-authorization and continued stay utilization review.
Resource utilization during an inpatient stay is strongly influenced by specialist consultation. Specialists’ increased use of laboratory testing, diagnostic imaging and diagnostic procedures also contributes to an increased length of inpatient stay. Despite the increased intensity of service, no difference in in-hospital mortality for patients cared for by a primary care physician who did not receive a consultation has been determined. The reasons for obtaining a consultation are complex and may involve the practice setting.
Family physicians have been shown to utilize fewer resources for both outpatient and inpatient care when compared to other primary care physicians and subspecialists in similar practice settings. The inpatients of family physicians also have shorter lengths of stay for patients with the same diagnoses after adjusting for case-mix. Once again, the major influence on hospital charges was the number of referrals made by the attending physician. In-hospital mortality is not different when specialist care is compared with primary physician care. There may be differences in long-term mortality for patients cared for by specialists compared with generalists. The effects of practice setting on resource utilization, mortality and morbidity for inpatient by family physicians has not been completely addressed.
As potential solutions to rising health care costs are considered, the ability of family physicians to provide excellent health care with fewer resources must not be ignored. The goal of family medicine is to provide lifetime health care using the biopsychosocial model. Research is showing that this approach not only delivers excellent health care but also, in many cases, saves resources.
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