Monday, June 07, 2010

Ethics of the hospitalist model

A review in the Journal of Hospital Medicine takes a thoughtful look at some of the ethical issues in the hospitalist model, including the built in discontinuity between hospital and clinic, the loss of patient autonomy and the unique financial conflicts of interest hospitalists face. It would be a landmark article in the field of hospital medicine were it not for a fatal flaw. The whole paper is based on a faulty premise. That premise is stated in the introduction and in several other portions of the paper, including the first sentence of the abstract:

The hospitalist model was founded on the premise that it could improve the quality and reduce the cost of hospital care. Many randomized studies have all but definitively proven this original assertion.

Wrong. This paper, as do all the systematic reviews examining this question, fails to cite one of the largest and most methodologically sound trials ever done. Presented at HM 2005, it showed no difference in utilization efficiency between hospitalist and traditional models. Unfortunately it suffered from a case of publication bias and never saw the light of day. It made a brief splash in the blogs (my comment here, DB's here, Clinical Cases and Images here and California Medicine Man here) and then was forgotten about. Taken into account with all the other evidence, the study weakens the argument, leaving the question open to debate. No one can make a convincing evidential claim that the hospitalist model is more efficient.

So one of the most important ethical issues facing the hospitalist movement is ignored by this review: transparency regarding research data in shaping public perceptions about the model.

No comments: