Current and Future Trends in the Growth of Hospitalists in California

Background:

The number of hospitalists is growing rapidly, even though managed care, one of the field's major initial stimuli, is abating in California. Little research has examined the current factors responsible for the continued growth of hospitalists.

Methods:

In 2006‐2007 we surveyed hospital leaders at all nonfederal acute‐care hospitals in California (n = 326) about whether and how they employed hospitalists. We asked leaders to indicate: (1) if they had a hospitalist service; (2) if yes, the year they started the service; and (3) if yes, factors influencing the decision to implement the hospitalist service (eg, cost/efficiency, care for patients without a primary doctor or uninsured, primary care physician demand, patient satisfaction, 24‐hour coverage, quality measure performance). We collected other potential predictors of implementation (eg, bed count, teaching status) from the California Office of Statewide Health Planning and Development hospital utilization files (2006); we also flagged those hospitals involved in the voluntary California Hospital Assessment and Reporting Taskforce (CHART) quality reporting project. We used multivariable logistic regression to identify hospital factors associated with the presence of hospitalists in 2006‐2007. Next, to capture recent trends, we divided the factors associated with implementation cited by hospital leaders into 3 periods: (1) before 2002, (2) between 2002 and 2004, and (3) 2005 or later. We then used tests of trend to examine recent changes in factors cited by hospital leaders influencing hospitalist introduction.

Results:

Fifty‐four percent (n = 175) of hospitals in California responded to the survey. Respondents are similar to nonrespondents, except for fewer responses from for‐profit hospitals (15% vs. 29%). Sixty‐three percent of hospital leaders identified at least 1 hospitalist group in their hospital. Fifty‐nine percent expected continued growth, and none expected decreases in their hospitalist service. Among hospitals without a hospitalist program, 44% stated one would be introduced within 5 years. In multivariable models, increasing number of hospital beds (each increase in 50 beds, OR = 1.6, 95% CI 1.1‐2.4) and participation in CHART (OR = 3.0, 95% CI 1.3‐6.7) were independently associated with having a hospitalist service in 2006‐2007. Among recently implemented programs, the need for 24‐hour coverage (P trend = .05) was associated with implementation, whereas quality improvement goals were of borderline significance (P trend = .09).

Conclusions:

There is extensive use of hospitalists in California, especially among larger hospitals and those participating in a voluntary quality reporting initiative. From the perspective of hospital leaders, the needs for 24‐hour coverage and quality improvement are strong rationales for sustaining and growing hospitalist groups, even as cost pressures have ebbed.

Author Disclosure:

E. Vasilevskis, none; R. Knebel, none; A. Auerbach, none; R Wachter, Google Health, member, Scientific Advisory Board; R. Wachter, Intellidot, member, Scientific Advisory Board; Codigy, member, Scientific Advisory Board; Hoana Medical, member, Scientific Advisory Board; American Board of Internal Medicine, member of Board of Directors.