The shift away from inpatient rheumatic units also reflected a more general shift in medicine to more outpatient care and less management of chronic conditions in the hospital. Dr. Matteson explains, “There were fewer patients that needed to be hospitalized, and when they did need to be hospitalized, they needed hospitalization for acute problems. That’s the standard today, that we can bring patients in only for acute problems like acute kidney failure, acute pulmonary failure, heart failure, things like that, and then the problems are addressed in an acute fashion.”
He notes that most rheumatic drugs, even ones given by infusion, are now administered in an outpatient setting. “The hospital duration has gone down a lot, and you can see also that hospital censuses have generally gone down,” says Dr. Matteson. Fewer patients are hospitalized than in the past, both rheumatologic patients and patients of other types.
Dr. Matteson explains that at Mayo and other large institutions, the hospital had to start admitting patients who did not have rheumatologic problems to keep up the general census in the rheumatic disease units. “As time went on, there were actually more of those kinds of patients than patients with actual rheumatic disease problems. The whole discipline was more and more evolving to an outpatient discipline, mainly because we just have better treatments for our patients. Our patients are just doing better; they don’t need to be in the hospital for extended periods.”
Dr. Coblyn agrees that it would now be difficult to keep a dedicated rheumatic disease unit full. “I think this happened from cost pressures and from improved efficiency of care. It has changed because of economics, because of the requirements to get people in and out and because of the shifts in disease severity—especially for rheumatoid arthritis.”
A 1993 editorial in Arthritis & Rheumatism questioned whether these units were of benefit, given the shift toward pharmacological treatments and the challenges of constraining healthcare costs. By this time, most studies suggested inpatient care was no more effective than outpatient care for rheumatic disease patients. It was also quite clear that inpatient rheumatic disease units did not save money.3
By then, Brigham and Women’s Hospital no longer had a dedicated rheumatic floor, and other units (such as the one at Denver) had also closed. Dr. Matteson notes that almost all remaining inpatient rheumatology units closed after 1993, partly due to pressures for Medicare reform. Mayo closed its hospital service in 1997, and the University of Michigan closed its service around 15 years ago.
Drawbacks & Benefits to the Consult Model
Dr. Matteson notes that on the whole, the shift reflects a change for the best. People do not have to stay in the hospital as much, and he believes the model generally fosters good patient outcomes. “From a learning standpoint of how to manage disease, I think there are drawbacks that we don’t have a primary service, but in general I think it’s for all the right reasons.”
