The international hospital medicine scene

In the 15 years since Wachter and Goldman coined the term ‘‘hospitalists’’, the specialty of Hospital Medicine grew faster than any other in the history of American medicine. The early drivers for growth were largely economic: There were significant reductions in resource use, with a 13% decrease in hospital costs and a 16% decrease in hospital lengths of stay (LOS). Hospitalist clinician-educators increased the satisfaction of residents and medical students in academic settings. Patient satisfaction and hospital mortality did not suffer. Recent growth of Hospital Medicine revolves around 3 drivers: 1) improving quality and safety of hospitalized patients—owing in large part to the Institute of Medicine’s 2 compelling reports, ‘‘To Err Is Human’’ and ‘‘Crossing the Quality Chasm’’; 2) hospitalist and specialist (surgeon) comanagement; and 3) the effects of duty hours restrictions imposed by the Accreditation Council for Graduate Medical Education affecting United States (US) teaching hospitals. In this issue of the Journal of Hospital Medicine, Shu and colleagues report on the performance of a hospitalist program in Taiwan. To the best of our knowledge, this report from Asia is the first published report of a successful hospitalist model with measurable patient outcomes outside of North America. Specifically, over a year, the authors found that patients admitted by hospitalists had a shorter LOS and lower cost per case, with no difference in in-hospital mortality and 30-day readmission. These results were obtained despite the fact that the cohort of patients admitted to the hospitalist team was older, sicker, and had worse functional capacity. Additionally, the patients admitted to the hospitalist team, and who died during hospitalization, were more likely to have a do-not-resuscitate (DNR) order signed, when compared with those patients admitted to the general internal medicine teaching service. Comparing LOS with North America may be problematic. As Shu and colleagues point out, there are cultural and economic issues that affect the behavior of patients and physicians in Taiwan. The healthcare system in Taiwan has similarities to the healthcare systems in the United Kingdom (UK) and the US. In 1995, Taiwan implemented a national health insurance system. The UK has had a National Health Service for many years that provides most services for free. The Taiwanese system requires modest copayments for services. The implementation of the national health insurance system in Taiwan increased healthcare access from 57% of the population to 98%. The increase in insurance across the population with modest copayments has made it possible for a larger percentage of the population to access the healthcare system. According to the authors, this has resulted in increased hospital admissions (35% in the decade since the introduction of national health insurance), resulting in a shortage of Hospital Medicine physicians and hospital beds. Compounding the stressors on this system is that the diagnosis related group (DRG) reimbursement model, similar to the American DRG reimbursement model, will soon take effect in Taiwan. As a result, our colleagues in Taiwan are experiencing issues commonly faced by mature hospitalist programs in the US: increased needs in efficiency to improve patient flow and decrease emergency room overcrowding and LOS; and concerns with safe discharges of high-risk patients while ensuring outpatient follow-up. This is a scenario with which US hospitalists are all too familiar. The next step for Taiwan might be to implement a culturally specific patient education program regarding the discharge process. The first step would be a needs assessment survey of patients in Taiwan, inquiring about concerns regarding readiness for discharge. They might inquire about patient beliefs regarding understanding indications for inpatient hospitalization versus discharge to home, home with home services, or skilled nursing facilities. They might be able to drill down to the root cause of refusal to be discharged home. These data could help our colleagues in Taiwan create their own discharge program to drive down LOS closer to that of the US and other Western countries, in order to reap financial benefits and improve resource utilization. Address for correspondence and reprint requests: Efren Manjarrez, MD, Division of General Medicine, University of Miami School of Medicine, (M841) POP Box 016760, Miami, FL 33101; Telephone: 305-585-5657; Fax: 305-326-8302; E-mail: emanjarrez@med.miami.edu