The hospitalist movement and the benefits for Australian Psychiatry Services

To the Editor

Pai and Vella (2021) address a core debate in psychiatric service configuration about whether inpatient and outpatient treatment should be provided by the same or different psychiatrists. They concluded that ‘continuity of care’ supersedes the current ‘functionally split system’ in Australia, based on better patient care outcomes. We, however, found that of all the sources referenced by authors, there was only one study that directly compared the two systems of care, finding that either option had no substantial impact on patient outcomes over a 1-year period including re-hospitalisation rates, number of inpatient days, adverse events and patients’ social situation (Giacco et al., 2018). Both the Australian public sector and UK National Health Service psychiatric services have largely shifted to the ‘functionally split model’ of having different psychiatrists in inpatient and outpatient care, suggesting that healthcare systems in these countries accrue significant benefits with this form of site-level specialisation.

In this context, it is important to specifically consider the evidence obtained from the US ‘hospitalist movement’ which describes the site-specialisation of US inpatient treatment in general medicine, which has grown exponentially since the 1990s. The studies from the United States demonstrate that utilising hospitalists resulted in reduced costs and hospital length of stay while preserving quality of care and patient satisfaction (Wachter and Goldman, 2016). In summary, evidence from the United States suggests that hospitalists improved the ‘value of care’ by providing high-quality and efficient inpatient care.

The pressures of current rising Australian emergency department mental health presentations with no accompanying increase in psychiatric bed supply make it vital to provide for frequent daily specialist psychiatric expertise and prompt treatment decisions. This is practically difficult when working across both inpatient and outpatient settings. Attempting this integrated model will likely lead to increased inefficiency and increased acute inpatient lengths of stay, inevitably leading to further prolonged waiting times in emergency departments for accessing acute inpatient psychiatric care.

Wachter and Goldman (2016) while agreeing that the hospitalist model is beneficial for greater than 95% of inpatients also suggest that ‘comprehensivist’ clinicians providing continuity of care across inpatients and outpatients may be more appropriate for a minority of patients, who are frequently admitted to acute hospitals.

In summary, we believe that hospitalists are of significant benefit for Australian public sector psychiatric services, providing high value of care, with no clear published evidence that the quality of care is compromised.