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).
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
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.
Wachter RM, Katz P, Showstack J, Bindman AB, Goldman L. Reorganizing an Academic Medical Service: Impact on Cost, Quality, Patient Satisfaction, and Education. JAMA. 1998;279(19):1560–1565. doi:10.1001/jama.279.19.1560
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