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Efficiency of the Japanese Hospitalist System for Patients with Urinary Tract Infection: A Propensity-matched Analysis
Abstract
Objective
The hospitalist system in the United States has been considered successful in terms of the quality of care and cost effectiveness. In Japan, however, its efficacy has not yet been extensively examined. This study examined the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population using treatment of urinary tract infection as an example.
Methods
We analyzed 271 patients whose most resource-consuming diagnosis at admission was urinary tract infection between April 2017 and March 2019. Propensity-matched analyses were performed to compare health care economics and the quality of care between the hospitalist system and the conventional system.
Results
In matched pairs, care by the hospitalist system was associated with a significantly shorter length of stay than that by the conventional system. The quality of care (oral antibiotics switch rate, rate of appropriate antibiotics change based on urine or blood culture results, detection rate of urinary tract infection etiology and the number of laboratory tests) was also considered to be favorably impacted by the hospitalist system. Although not statistically significant, hospital costs tended to be lower with the hospitalist system than with the conventional system. The mortality rate and 30-day readmission were also not significantly different between the groups.
Conclusion
The hospitalist system had a favorable impact on the quality of care and length of stay without increasing readmission in patients with urinary tract infection. This study is further evidence of the strong potential for the positive impact of an implemented hospitalist system in Japan.
Introduction
Hospitalist care of inpatients has been shown to be effective through reduced costs and an improved patient safety, quality of care and patient experience compared with the conventional system (1-3). Hospitalists have rapidly grown in number and have been shown to play a critical role in most hospitals across the United States (4) and in many hospitals elsewhere (5-8). The significant contribution of the hospitalist movement has led to widespread reform of healthcare systems (9).
In Japan, the medical system continues to be organized into specialist departments based on organ or disease. There is growing concern, however, about the ability of specialist doctors in the conventional system to comprehensively and effectively manage inpatients with multiple comorbidities (10,11). To overcome this situation, the fields general internal medicine (sogo-naika) and general medicine (sogo-shinryoka) were recently established. These fields are considered to include widely trained physicians who, in contrast to the traditional departmental organization, work across department lines. As a concept, the Japanese Society of Hospital General Medicine defines general medicine physicians as those with a certain subspecialty who are educated on a broad range of diseases, making diagnoses for previously undiagnosed patients in a timely manner, managing patients appropriately, and working smoothly with other specialists (12). Hospitalists work within these new systems, specializing in the hospital-based treatment of inpatients with a variety of conditions.
The hospitalist system has been in place for several decades overseas, but its introduction in Japan has only taken place within the last few years. There are plans to establish a board of hospitalist medicine in the near future in Japan to centralize training, certification and support in order to further facilitate the implementation of hospitalist care. However, while this appears to be a reasonable theoretical concept, whether or not such reforms are effective is unclear.
One reason for this lack of clarity concerning efficacy is that the practical role of these generalists (including hospitalists) has not been defined in Japan like it is elsewhere (11). In the United States, hospitalists are defined as general internists for whom ≥90% of their work involves the care of hospitalized patients (13). In contrast, in Japan, physicians typically work in several environments, including in the inpatient ward and outpatient clinic. This tradition has not changed, even with the creation of the general internal medicine department.
Exactly how the general internal medicine or general medicine system can be improved in Japan is a matter of discussion. The next step may be to make changes to not only the specialization of medical fields but also to the site of care. The wider introduction of the hospitalist system has been suggested as a potential solution to these problems faced by the current medical situation in Japan, but its effectiveness on a domestic level has been insufficiently examined. We previously reported the favorable impact of the hospitalist system on the quality of care and cost effectiveness within the Japanese medical system in patients with aspiration pneumonia (14). The effectiveness of the Japanese hospitalist system in other areas, however, remains unclear.
The current study thus examines the effectiveness of the hospitalist system in Japan using treatment of urinary tract infection (UTI), the second-most common infection in the geriatric population following pneumonia (15,16) and considered to be a core clinical condition by the Society of Hospital Medicine (17), as a model. This study places particular focus upon the quality of care and healthcare economics in comparison with that of traditional care managed by various specialized departments.
Materials and Methods
Study design and settings
This retrospective, single-center, observational study investigated the impact of hospitalist care on UTI management at Takatsuki General Hospital between April 1, 2017, and March 31, 2019. Takatsuki General Hospital is a 477-bed, community-based teaching hospital in Osaka, Japan. The hospitalist system was established by the Department of General Internal Medicine in April 2017. Until then, patients with UTI were seen by various specialist departments in the conventional manner (urology, renal transplant, nephrology, pulmonary, cardiology, gastroenterology, hematology, obstetrics and gynecology, and endocrinology). Since the hospitalist system was established, patients with a diagnosis of UTI have in principle been instead assigned to the hospitalist group. If patients had been previously admitted or seen as outpatients, they were not treated by hospitalists but were instead assigned to each department, similarly to their management pre-April 2017. Patients with UTI who required a specific urological intervention, i.e. insertion of urethral stents or nephrostomy tubes, were always referred to the Department of Urology for further treatment.
The hospitalist group comprised three attending physicians and four senior residents in postgraduate years (PGY) 3 to 5, all belonging to the Department of General Internal Medicine. The senior residents were supervised by two attending physicians with Japanese internal medicine certification. These two attending physicians were in turn supervised by the Chief Physician of the Department who had hospitalist training in the United States and held an American internal medicine certification. Working hours for outpatient care in the hospitalist group in our hospital accounted for less than 10% of the total, following the definition used in the United States (13). Conversely, the details of the physicians who treated the control group varied widely, with this group including attending physicians and senior residents.
In the hospitalist group, UTI was managed based on the Core Competencies in Hospital Medicine published by the Society of Hospital Medicine (17,18). In the control group, practice was based on the conventional methods used in each department. Treatment was given based on the current Japanese health insurance system guidelines in both groups. In our hospital, the antimicrobial stewardship team made suggestions to each physician regarding appropriate antimicrobial use, although whether or not to follow the suggestions was left to the physician's discretion.
Participants
We enrolled patients ≥18 years old whose principal or most resource-consuming diagnosis was UTI based on the Diagnostic Procedure Combination (DPC) system. We reviewed medical charts and excluded patients whose diagnoses of UTI could not be confirmed. We also excluded pregnant patients and those who required specific urologic intervention with either insertion of urethral stents or nephrostomy tubes. If the patients were readmitted within 30 days after their last admission, the data of this admission were not included in our study. The remaining patients after exclusion were examined within the hospitalist or control group.
Data collection and definitions
To assess the risk factors of UTI, the following patient characteristic covariates were collected, based on previous studies: age, gender, benign prostate hypertrophy, neurogenic bladder, diabetes mellitus, cerebrovascular disease, dementia, other neurological disease (Parkinson's disease, multiple sclerosis, spinal cord injuries) (19), immunosuppressant medication, and medication use related to urinary retention (20,21). The severity of infection was classified into non-sepsis, sepsis, or septic shock, defined based on Sepsis-3 criteria (22). Types of UTI were categorized based on the current guidelines into those with pyelonephritis, catheter-associated urinary tract infection (CAUTI), prostatitis, renal or perirenal abscess, cystitis, and those that were otherwise unspecified (23-26). We excluded patients with cystitis, prostatitis, and renal or perirenal abscess because the total duration of antimicrobial therapy for these diseases differs greatly from that with other types of UTI. Charlson's comorbidity index on admission was evaluated. To evaluate the rate of previous UTIs, the patient history was analyzed in order to determine whether or not they had ever had a UTI prior to this study. To this end, we searched for the medical insurance name of UTIs among health insurance claims in our hospital.
The primary outcome was the length of stay (LOS). The LOS was evaluated by both days and rate of each DPC hospitalization period (period I: first quartile of all LOSs of each diagnosis, period II: average LOS of each diagnosis, period III: average LOS of each disease plus two standard deviations). Secondary outcomes were hospital costs, rate of oral antibiotics switch, rate of appropriate antibiotics change based on urine or blood culture results, duration of antibiotics therapy, detection rate of UTI etiology, number of blood tests, mortality rate, rate of readmission within 30 days secondary to UTI flare, and rate of unscheduled outpatient visits due to treatment failure or hospitalization hazard during the previous admission. We also evaluated the rate of patients who experienced treatment failure by analyzing the rate of IV antibiotics change and requirement of drainage for abscess formation.
Hospital costs per patient were calculated as the sum of each medical care expense (fee-for-service system payment), not as the bundled payment by the diagnosis procedure combination/per-diem payment system. We defined appropriate antibiotics changes as de-escalation to either intravenous or oral antibiotics based on urine or blood culture results. De-escalation was defined as changing the intravenous broad-spectrum antibiotic regimen to an oral or intravenous culture-directed agent. Based on the current guidelines, this agent has either a narrower spectrum than the original empiric regimen, better tissue penetration, or both (27). A broad-spectrum antibiotic was defined as third- or fourth-generation cephalosporin, piperacillin/tazobactam or carbapenems. Acceptable antibiotics for de-escalation included fluoroquinolones, first- to third-generation cephalosporins, aminopenicillin with or without beta-lactamase inhibitor, and trimethoprim/sulfamethoxazole (28). The indication of oral switching was determined based on the following previously reported criteria: clinical improvement observed, non-compromised oral route, markers showing a trend towards normal, and no specific indication/deep-seated infection requiring prolonged IV therapy (29-31). To evaluate the rate of oral switching, the number of patients who were switched to oral therapy was divided by the total number of patients in each group. The detection rate of UTI etiology (e.g. benign prostate hypertrophy, neurogenic bladder, urinary catheter use, use of medications related to urinary retention) was evaluated by a chart review. Readmission within 30 days secondary to UTI flare or other causes and unscheduled outpatient visits due to treatment failure or hospitalization hazard during previous admission were evaluated (32,33).
Data extraction and outcome assessments were carried out by two physicians (O.H., T.T.). Disagreements concerning the assessment of unscheduled outpatient visits due to treatment failure or hospitalization hazard during prior admission were planned to be resolved by consensus if necessary.
Ethics
The study protocol was approved by the Takatsuki General Hospital Institutional Review Board and the study was carried out in accordance with the approved guidelines. This was a retrospective study, and informed consent was obtained in the form of opt-out on the hospital website.
Statistical analyses
Demographic data differences between the two groups were determined by Wilcoxon's test for continuous and ordinal variables and a chi-squared test for categorical variables. The multiple logistic regression model was used to calculate the propensity score for each individual, which was the probability of the patient being managed by hospitalists. Independent variables were the age, gender, severity of infection (non-sepsis, sepsis, and septic shock), Charlson's comorbidity index, presence of bacteremia, immunosuppressant use, use of medications related to urinary retention, type of UTI, and history of benign prostate hypertrophy, neurogenic bladder, diabetes mellitus, dementia, cerebrovascular disease, and other neurological disease. One-to-one propensity score matching without replacement was completed using the nearest neighbor match on the propensity score logit for each individual with the caliper width set to 0.05 times the standard deviation of the propensity score logit. Differences between matched patients were evaluated using Wilcoxon's test. Using Clopper & Pearson 95% confidential intervals (CIs) with frequencies and proportions, we summarized rate of switching oral antibiotics, rate of appropriate antibiotics changes (based on urine or blood culture results), duration of antibiotics therapy, detection rate of etiology, number of blood tests, mortality rate, readmission within 30 days after UTI flare or other causes, and unscheduled outpatient visits due to treatment failure or hospitalization hazards during previous admission. Fisher's exact test was used to compare the hospitalist and control groups.
All analyses were performed using the JMP software program, version 13 (SAS Institute, Cary, USA) and EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan). All statistical tests were two-sided, and statistical significance was defined as p＜0.05.
Results
We enrolled 296 patients between April 2017 and March 2019 at our hospital. We excluded 11 patients who were readmitted within 30 days (hospitalist group: 5, control group: 6) and 5 patients whose diagnosis of UTI could not be confirmed based on a chart review. We also excluded eight pregnant patients and one patient who required insertion of a urethral stent. After exclusions, 271 patients were analyzed (hospitalist group: 171, control group: 100) (Figure). Using propensity scores, 73 patients in the hospitalist group were matched to patients in the control group. The multiple logistic regression of propensity had an area under the receiver operating characteristics curve of 0.748 (95% CI, 0.688-0.807).
Characteristics of the patients in the unmatched and propensity-matched groups are shown in Table 1. Among all patients, several factors were unbalanced between the hospitalist and control groups, including the sex, immunosuppressant use, Charlson's comorbidity index, and history of benign prostate hypertrophy, diabetes mellitus, and dementia. After propensity score matching, each factor between the hospitalist group and control group was well-balanced except for the rate of previous UTI (hospitalist group 30.1% vs. control group 47.9%; p=0.041). There were no significant differences in the type of UTI between the two propensity-matched groups (Table 2).
Table 1.
Demographic and Clinical Characteristics of All Patients and Propensity Score-matched Patients*.
| Before propensity score matching | After propensity score matching | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Hospitalist | Control | p value | Hospitalist | Control | p value | ||||||
| N | 171 | 100 | 73 | 73 | |||||||
| Demographics | |||||||||||
| age mean, SD | 80 | (15.5) | 76.7 | (14.3) | 0.08 | 76.9 | (14.9) | 76.9 | (14.9) | 0.987 | |
| sex -male | 55 | (32.2%) | 55 | (55.0%) | <0.001 | 37 | (50.7%) | 35 | (47.9%) | 0.869 | |
| BPH | 21 | (12.3%) | 24 | (24.0%) | 0.017 | 15 | (20.5%) | 12 | (16.4%) | 0.670 | |
| Neurogenic bladder | 29 | (17.0%) | 17 | (17.0%) | 1.00 | 16 | (21.9%) | 15 | (20.5%) | 1.000 | |
| DM | 35 | (20.5%) | 37 | (37.0%) | 0.004 | 21 | (28.8%) | 23 | (31.5%) | 0.857 | |
| Cerebrovascular disease | 42 | (24.6%) | 30 | (30.0%) | 0.393 | 20 | (27.4%) | 18 | (24.7%) | 0.851 | |
| Other Neurological diesase | 21 | (12.3%) | 9 | (9.0%) | 0.548 | 11 | (15.1%) | 8 | (11.0%) | 0.624 | |
| Dementia | 55 | (32.2%) | 19 | (19.0%) | 0.023 | 17 | (23.3%) | 16 | (21.9%) | 1.000 | |
| Immunosuppressant use | 9 | (5.3%) | 18 | (18.0%) | 0.001 | 8 | (11.0%) | 7 | (9.6%) | 1.000 | |
| Medication use related to urinary retention | 46 | (26.9%) | 17 | (17.0%) | 0.074 | 19 | (26.0%) | 17 | (23.3%) | 0.848 | |
| Bacteremia | 53 | (31.0%) | 36 | (36.0%) | 0.423 | 22 | (30.1%) | 27 | (37.0%) | 0.483 | |
| Severity | |||||||||||
| Non-sepsis | 137 | (80.1%) | 85 | (85.0%) | 0.203 | 63 | (86.3%) | 60 | (82.2%) | 0.726 | |
| Sepsis | 32 | (18.7%) | 12 | (12.0%) | 9 | (12.3%) | 11 | (15.1%) | |||
| Septic shock | 2 | (1.2%) | 3 | (3.0%) | 1 | (1.4%) | 2 | (2.7%) | |||
| Charlson's comorbidity index, SD | 4.7 | (1.8) | 5.3 | (2.4) | 0.019 | 4.7 | (2.2) | 4.7 | (2.3) | 0.885 | |
*Data are presented as the number (%) or mean (standard deviation).
BPH: benign prostate hypertrophy, DM: diabetes mellitus, SD: standard deviation
Table 2.
Type of Urinary Tract Infections.
| Type of UTIs | Hospitalist | Control | p value | ||
|---|---|---|---|---|---|
| N | 73 | 73 | |||
| Pyelonephritis | 15 | (20.5%) | 18 | (24.7%) | 0.535 |
| CAUTI | 9 | (12.3%) | 12 | (16.4%) | |
| Otherwise unspecified | 40 | (54.8%) | 43 | (58.9%) | |
CAUTI: catheter-associated urinary tract infection
Study outcomes are shown in Table 3. In matched pairs, the LOS in the hospitalist group was shorter than that in the control group (11.4 days vs. 13.4 days; p=0.012). Although not statistically significant, the proportion of hospital stay in the hospitalist group was most likely to be period I in DPC. Although not statistically significant, management by the hospitalist group tended to include lower total hospital costs than conventional management (JPY 522,539 vs. JPY 603,932; USD 4,128 vs. USD 4,771 based on exchange rates as of April 9, 2022; p=0.073). On comparing the quality of care, we found favorable outcomes in the hospitalist group with respect to the rate of appropriate antibiotics change based on urine or blood culture results [86.3% vs. 69.9%, odds ratio (OR) 2.7, 95% CI 1.1-7.0; p=0.027], the rate of switching oral antibiotics [58/73 (79.5%) vs. 41/73 (56.2%), odds ratios (OR) 3.0, 95% CI 1.4-6.8; p=0.004], and the duration of antibiotics therapy (11.9 days vs. 13.4 days; p=0.013). Although there was some concern about the possibility of resistant pathogens arising in the control group because of the higher rate of previous UTI, there was still a statistically significant difference in the rate of switching oral antibiotics among patients who met the criteria for oral switching [58/64 (90.6%) vs. 41/63 (65.1%); p＜0.001]. There was no marked difference in the rate of patients who needed antibiotics changes because of treatment failure with the initial antibiotics selection [6/73 (8.2%) vs. 2/73 (2.7%); p=0.275]. There was no patient who required drainage for abscess formation in both groups (p=1.00). Hospitalist care was associated with a higher detection rate of UTI etiology (47.9% vs. 27.4%, OR 2.4, 95% CI 1.2-5.2; p=0.016) and fewer blood tests (4.7 vs. 6.1; p=0.003) than conventional care. There was no marked difference in the rate of readmission within 30 days owing to UTI flare. Although not statistically significant, several outcomes were lower in the hospitalist group than in the control group, including the mortality rate, rate of readmission within 30 days secondary to other causes, and rate of unscheduled outpatient visits due to treatment failure or hospitalization hazard during previous admission.
Table 3.
Outcomes of Propensity Score-matched Patients*.
| Hospitalist | Control | p value | OR | (95%CI) | |||
|---|---|---|---|---|---|---|---|
| N | 73 | 73 | |||||
| Outcome | |||||||
| Length of stay | |||||||
| mean, SD | 11.4 | (2.6) | 13.4 | (4.3) | 0.012 | ||
| median[25%tile, 75%tile] | 9.0 | [3.0, 37.0] | 12.0 | [3.0, 53.0] | 0.016 | ||
| DPC hospitalization periods | |||||||
| period I | 42 | (57.5%) | 38 | (52.1%) | 0.693 | ||
| period II | 27 | (37.0%) | 29 | (39.7%) | |||
| period III | 4 | (5.5%) | 6 | (8.2%) | |||
| Hospital cost mean JPY, SD | 522,539 | (226,810) | 603,932 | (310,527) | 0.073 | ||
| Appropriate antibiotics change based on culture results | 63 | (86.3%) | 51 | (69.9%) | 0.027 | 2.7 | [1.1, 7.0] |
| Oral antibiotics switch | 58 | (79.5%) | 41 | (56.2%) | 0.004 | 3.0 | [1.4, 6.8] |
| Duration of antibiotics therapy | |||||||
| mean, SD | 11.9 | (2.6) | 13.4 | (4.3) | 0.013 | ||
| median[25%tile, 75%tile] | 14.0 | [7.0, 18.0] | 14.0 | [3.0, 28.0] | 0.022 | ||
| Detection rate of UTI etiology | 35 | (47.9%) | 20 | (27.4%) | 0.016 | 2.4 | [1.2, 5.2] |
| Number of blood tests | |||||||
| mean, SD | 4.7 | (2.3) | 6.1 | (3.2) | 0.003 | ||
| median[25%tile, 75%tile] | 4.0 | [1.0, 11.0] | 5.0 | [2.0, 17.0] | 0.003 | ||
| 30-day Readmission secondary to UTI flare | 3 | (4.1%) | 2 | (2.7%) | 1.000 | ||
| Readmission and unscheduled outpatient visit due to treatment failure or hospitalization hazard during previous admission | 2 | (2.7%) | 4 | (5.5%) | 0.681 | 0.5 | [0.04, 3.53] |
| In-hospital death | 0 | (0.0%) | 1 | (1.4%) | 0.492 | ||
*Data are presented as the number (%) or mean [25th and 75th percentiles].
CI: confidential interval, DPC: diagnostic procedure combination, OR: odds ratio, SD: standard deviation, UTI: urinary tract infection
Discussion
In this propensity score-matched analysis, care by the hospitalist group was associated with a significant reduction in the LOS and a better quality of care than that with the conventional system. Although not statistically significant, hospital costs tended to be lower with the hospitalist system than with the conventional system. There was no significant difference in the mortality rate, rate of readmission, or rate of unscheduled outpatient visits after hospitalization.
Ideally, the LOS would be relatively short, and there would be no need for readmission. In the present study, the LOS was significantly shorter with the hospitalist system than with the conventional system, without any increase in rehospitalization. This is noteworthy, as a shorter LOS is typically associated with rehospitalization (34). In the United States, for example, the Centers for Medicaid and Medicare Services reduce reimbursements to hospitals that have high rates of readmission (35). Hospitalist services have been shown to reduce readmissions (36-38). In our study, various benefits of the hospitalist group were shown, which may have contributed to the short LOS and comparatively low rate of readmission. First, the higher rate of switching from intravenous to oral antibiotics in the hospitalist group may have contributed to the shorter LOS than in the control group. Prescribing empirical antimicrobial therapy in accordance with guidelines and early intravenous to oral antibiotics switching were associated in a previous study with a shorter LOS in patients with UTI (39). Hospitalists' proficiency in ensuring the administration of appropriate antimicrobial therapy was demonstrated in a previous study, including the selection of empiric antibiotic therapy and switching from intravenous to oral antibiotics (40). In the hospitalist group, switching from intravenous to oral antibiotics was performed based on the current guidelines. Although the rate of appropriate empiric antibiotic therapy was not analyzed in accordance with the guidelines in our study, our finding of a higher rate of early switching from intravenous to oral antibiotics in the hospitalist group than in the control group is consistent with the findings in previous hospitalist studies (39,40). Second, the higher detection rate of etiology in the hospitalist group than in the control group may also have been associated with a reduced LOS without increased readmission. Modification of risk factors of UTI has been shown to have a positive correlation with a reduction in recurrent UTI (41). Third, hospitalists' high degree of specialization in inpatient medicine, improved accessibility, and better coordination of care than with the conventional system were reportedly associated with a shorter LOS in recent studies (42,43). Although care in the hospitalist group in the present study was based on the Core Competencies in Hospital Medicine published by the Society of Hospital Medicine (17,18), these factors were not included in the scope of our study. Future studies should therefore clarify the relationship between hospitalist care and a shortened LOS in Japan.
Although not statistically significant, hospital costs in the hospitalist group tended to be lower than in the conventional group. There are several possible explanations as to why the hospitalist approach might have been associated with reduced hospital costs. First, avoiding unnecessarily expensive medications, such as intravenous antibiotics, in the hospitalist group may have been a contributing factor. The safety and cost-effectiveness of early switching from intravenous to oral antibiotics before and after the introduction of guidelines for switching therapy was previously shown to help reduce administration costs by $30,000 (JPY 3,780,000 based on exchange rates as of April 9, 2022) and contribute to $27,000 (JPY 3,402,000 based on exchange rates as of April 9, 2022) in savings on purchase costs of antibiotics per year (44). Second, avoiding a high amount of laboratory testing in the hospitalist group may have been related to reduced hospital costs. Hospitalist approaches have been shown to reduce the amount of inappropriate laboratory testing and to contribute to a significant reduction in costs compared with conventional care (45). Third, the shortened LOS in the hospitalist group was shown to be related to lower hospital costs. Basic hospital fees in Japan for treatment in an acute care hospital with a 7:1 patient-to-nurse staffing ratio and an average hospital stay of less than 21 days is JPY 13,320 (USD 106, based on exchange rates as of April 9, 2022) per day (46). In our study, the mean LOS was 2.0 days shorter in the hospitalist group than in the control group, resulting in a cost difference of JPY 26,640 (USD 211, based on exchange rates as of April 9, 2022). Finally, previous studies have demonstrated that hospitalists' prevention and management of hospital-acquired complications (47), early rehabilitation (48), and the involvement of multi-disciplinary teams for the high-quality transition of care (49) are all associated with the lower hospital costs than with conventional care (50-52). While these topics were not evaluated in detail in our study, future studies are expected to explore the comprehensive management approach with hospitalist care. Despite the results of previous studies, our results lacked statistical significance. This may be explained by several factors, including the inclusion of an inadequate number of participants to show statistically significant results. Other costs, including those for rehabilitation, may also have affected the results of the hospitalist treatment, even though these costs are beneficial for patient outcomes.
According to Organization for Economic Co-operation and Development data, total health expenditure increased substantially and accounted for 10.9% of the gross domestic product in Japan in 2018 (ranked 6 among 34 countries) (53). It is predicted that by 2025, elderly patients will account for more than half of the total health expenditure in Japan (54). Reforms of the financing system and greater efficiencies without compromising the quality of care will be necessary to sustain the Japanese healthcare system. Reducing waste by curtailing duplicative and unnecessary care is one potential solution. Hospitalists are reportedly involved in many opportunities for eliminating waste (55), so they may play a key role in the Japanese medical system in the near future.
Several limitations associated with the present study warrant mention. First, it was an observational study, not a randomized controlled trial. Selection bias was adjusted for by propensity score matching, but the possibility of missing important variables may not have been entirely excluded. Second, this study concerned practice in just one hospital. The generalizability of our results should therefore be confirmed in additional cohorts at other hospitals ahead of the wider dissemination of the hospitalist model in the future. Third, there was heterogeneity in the control group because of differences in physician's departments, career levels, and the presence/absence of supervision. Patients with UTI have conventionally been managed by various departments in Japan, however, so our study may be said to be reflective of real-world Japanese settings.
Conclusion
Hospitalist care in our Japanese patients with UTI was associated with a decreased LOS without increased readmission compared with the conventional system. Hospital costs tended to be decreased, however, and medical care could be said to be improved. This study is further evidence of the strong potential for a positive impact of a hospitalist system in Japan.
The authors state that they have no Conflict of Interest (COI).
Acknowledgements
The authors would like to thank Mr. Benjamin Phillis and Professor Toshio Shimokawa for the English language review and statistical analysis, respectively.