Generalist vs specialist acute medical admissions - What is the impact of moving towards acute medical subspecialty admissions on efficacy of care provision?

Abstract

The discussion surrounding generalist versus specialist acute medical admissions continues to stimulate debate and patients with certain conditions benefit from specialist care. To determine whether a specialty medical admission program would reduce inpatient length of stay (LOS), mortality and readmission rates. A prospective cohort study of inpatients admitted under a general internal medicine (GIM) service before and after introduction of a specialty-directing programme. We hypothesized that early transfer of patient care to a specialty suited to their presenting complaint would reduce LOS and a specialty-directing early redistribution of care programme was introduced. Seven of the ten clinical teams participating in the GIM roster adopted the programme. On the morning following a specialty-directing team being on call for all new GIM admissions during a 24-hour period, specialty-directing teams were allocated one patient appropriate to their specialty. 5,144 patient-care episodes were analysed over the two-year study period. LOS increased by greater than 15%, one year after introducing the specialty-directing programme (8.5±8.4 vs 7.3±7.5 days, p < 0.001). LOS did not differ between teams that participated and those who did not (8.4±8.1 vs 8.1±7.9 days, p = 0.298). No differences were found in the proportion of patients who were discharged home, died while an inpatient or re-admitted within 30 days of discharge. The proportion of patients aged greater than 80 years increased significantly also - from 24.7% in 2017 to 27.9% in 2019(p == 0.009). Widespread adoption of specialist care may not be beneficial for all medical inpatients and physicians should continue to undergo dual specialist and GIM training.