Dramatic growth in number of hospitalists over last two decades

One of the most striking changes in health care over the last two decades has been a dramatic increase in physicians categorized as "hospitalists" - doctors who practice almost exclusively in hospitals, rather than combining both outpatient and inpatient care.

But while observers of medical trends knew that the number of hospitalists was rising, there was no national or population-based data on hospitalist care.

Now, researchers at the University of Texas Medical Branch at Galveston have produced the first quantitative analysis of the increase in the number of hospitalists. In a paper appearing in the March 12 issue of the New England Journal of Medicine, UTMB associate professor Yong-Fang Kuo uses Medicare data to calculate that the percentage of internal medicine physicians practicing as hospitalists jumped from 5.9 percent in 1995 to 19 percent in 2006.

"These analyses show a substantial increase in the care of hospitalized patients by hospitalists," Kuo said. "Many researchers have raised questions about the growth of hospitalist care having an impact on the continuity of patient care, the role of the primary care physician, patient satisfaction and the patient-physician relationship. This study doesn't answer those questions, but it does give us the first real statistical picture of the phenomenon."

In the paper, Kuo and her co-authors (assistant professor Gulshan Sharma and professors Jean Freeman and James Goodwin) defined a hospitalist as a general internist who derived 90 percent or more of his or her Medicare evaluation-and-management claims from the care of hospitalized patients. Applying this criterion to the physicians who cared for 5 percent of Medicare beneficiaries in 1995, 1997 and 1999, as well as the period from 2001 through 2006, they were able to draw a statistical picture not only of the rise of hospitalist care, but also an increase in the percentage of physicians who primarily saw patients in outpatient settings.

"We're seeing a decrease in the percentage of physicians in general internal medicine with a balanced distribution between inpatient and outpatient services — the traditional office-based general internal medicine physician who also goes to the hospital to treat his or her patients when they need acute care," Kuo said.

Using the Medicare data, the researchers showed increases in hospitalist care over time for patients with different diagnoses and at hospitals of different sizes, and were able to map regional growth in hospitalist care. In 2006, there was marked geographic variation in the rates of care provided by hospitalists, with rates of more than 70 percent in some hospital referral regions. "Although the growth of care by hospitalists has been greater in certain geographic areas, substantial growth occurred in every area." Kuo said.

The UTMB researchers' article is accompanied by an editorial, "The Growth of Hospitalists and the Changing Face of Primary Care." Taking the information presented in the paper as a jumping-off point, the editorial examines the origins of hospitalist care and discusses studies of its benefits and problems.