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Impact on Cost, Quality, Patient Satisfaction, and Education

Robert M. Wachter, MD; Patricia Katz, PhD; Jonathan Showstack, PhD, MPH; Andrew B. Bindman, MD; Lee Goldman, MD, MPH

JAMA. 1998;279:1560-1565.

Context.— Academic medical centers are under enormous pressure to improve quality and cut costs while preserving education.

Objective.— To determine whether a reorganized academic medical service, led by faculty members who attended more often and became involved earlier and more intensively in care, would lower costs without compromising quality and education.

Design.— Alternate-day controlled trial.

Setting.— Inpatient academic general medical service.

Patients.— The 1623 patients discharged from the Moffitt-Long medical service between July 1, 1995, and June 30, 1996.

Interventions.— We divided our 4-team inpatient general medical service into 2 managed care service (MCS) teams and 2 traditional service (TS) teams. The MCS faculty served as attending physicians more often and were required to provide early input into clinical decisions. Patients were assigned to teams based on alternate days of admission.

Main Outcome Measures.— Outcome measures included resource use and outcomes for MCS vs TS patients, and for MCS patients vs patients seen the previous year, adjusted for demographic characteristics and case mix. Satisfaction of patients, house staff, and faculty was also assessed, as was educational emphasis.

Results.— A total of 806 patients were admitted to the MCS and 817 to the TS. Demographic characteristics and case mix were similar. Clinical outcomes, including mortality and readmission rates, were also similar, as was patient satisfaction. Resident and faculty satisfaction were high on both services. The average adjusted length of stay of patients on the MCS was 4.3 days vs 4.9 days on the TS and 5 days in 1994-1995 (adjusted P=.01 for MCS vs TS; MCS vs 1994-1995, P<.001). Average adjusted hospital costs were $7007 on the MCS vs $7777 on the TS and $8078 in 1994-1995 (adjusted P=.05 for MCS vs TS; MCS vs 1994-1995, P=.002).

Conclusions.— A reorganized academic medical service, led by faculty members who attended more often and became involved earlier and more intensively, resulted in significant resource savings with no changes in clinical outcomes or patient, faculty, and house staff satisfaction.

From the Department of Medicine (Drs Wachter, Katz, Showstack, Bindman, and Goldman) and the Institute for Health Policy Studies (Drs Katz, Showstack, and Bindman), University of California, San Francisco; and the Primary Care Research Center, San Francisco General Hospital (Dr Bindman).

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