Archives of Internal Medicine paper on hospitalists and “quality”

Do hospitalists improve the quality of inpatient care? I like to think so but you wouldn't convince me with this paper. The investigators found that hospitals with hospitalists had better adherence to selected measures for MI, pneumonia and CHF. One weakness of the paper the authors acknowledged is that adherence to these measures could not be directly attributed to hospitalists. Many patients in hospitals with hospitalists may have been cared for by non-hospitalist practitioners.

But the real weakness of the paper, one which the authors did not directly acknowledge, was revealed in the introduction. After a discussion about hospitalists and quality this statement was made (my italics):

The aim of this study was to examine the link between hospitalists and performance as measured by the HQA benchmark quality measures for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia.

So the whole premise of the paper, that performance equates to real quality, is faulty! I have pointed that fact out in several posts including this one where I dissected the reasons why the performance movement has failed.

Before moving to the related editorial I should mention another unsupported claim in the paper, which was that the hospitalist model results in lower length of stay and costs per case. That notion is entrenched in medical literature and popular perception thanks to a huge dose of publication bias.

Robert Centor (DB) and Benjamin Taylor wrote a related editorial in the same issue. After commenting on the unfortunate confusion between performance and quality and mentioning some methodologic problems with the paper they suggested a change in the research agenda for hospital medicine:

As a young field, hospital medicine has strengths and weaknesses. Future investigations should focus on defining the strengths and minimizing the weaknesses. We believe that hospitalists can help decrease hospital errors and improve safety if they are totally integrated with hospital processes and supported as champions for these important efforts. Lumping hospitalists without a consideration of organizational differences could hide the promise of excellent hospitalist groups. The major contribution of hospital medicine should involve system improvement along with excellent bedside care. We must understand the contributors as well as the detractors to excellence for the hospitalist movement to achieve its full potential.