The field of Hospital Medicine has enjoyed tremendous growth over the past decade. Although partially driven by manpower needs derived from resident duty-hour restrictions and the declining availability of primary care physicians to oversee inpatient care, the wide-spread adoption of Hospital Medicine practice over the last ten years has also been fueled by the concomitant growth of the health care quality movement. The compelling need for improvement in the quality of care delivery in U.S. hospitals, heralded in two seminal Institute of Medicine reports, one in 2000 (To Err is Human) and the other in 2001 (Crossing the Quality Chasm), created an important platform upon which hospitalists could offer potential value to hospitals, patients, and referring primary care providers as a new field of inpatient specialists offering both the clinical and operational expertise needed to achieve optimal outcomes in hospital-based care.
The definition of “value” in Hospital Medicine has evolved over the last 10 years. The need to demonstrate some concept of “value” to key stakeholders (hospitals, patients, and referring primary care physicians) has been valid since the inception of the field, given that a significant proportion of hospitalist groups rely in some measure upon institutional fiscal support to exist. Hospitals, in particular, have been very much interested in understanding their “return on investment” for their financial commitments to hospitalist groups. Early studies demonstrated that hospitalist-driven care was associated with reduced lengths of stay and enhanced adherence with payor-defined “core measures” of performance. Fiscal value was a primary driver of early adoption of hospitalist medicine practices as lower lengths of stay of medical inpatients implied greater capacity for inpatient volume growth in high-margin specialties, and adherence to payor-defined performance measures meant hospitals could qualify for incentive payments (or avoid disincentive penalties) related to their quality of care delivery. As public reporting of hospital performance evolved, however, there has been increasing focus on clinical outcomes and patient satisfaction survey results as valid measures by which to compare hospitals; such attention has quickly translated into new domains by which the “value” of hospitalist-driven care can be assessed.
Performance Assessment for Hospitalists
Despite a number of studies designed to assess the quality of hospitalist-driven care, there remains a relative paucity of compelling evidence thus far that hospitalist care is necessarily more likely to result in improvements in meaningful outcomes such as mortality, readmission rates, or the quality of patients' hospital experience. In an increasingly financially constrained, and in some regions increasingly competitive, operating environment it may therefore be incumbent upon individual hospitalist groups to be able to demonstrate the value of their work in order to deliver an anticipated “return on investment” to sponsoring institutions through specific measures derived from their groups' own practice and measured at their own institutions.
A useful framework to assess value may be found in the Institute of Medicine's 2001 Crossing the Quality Chasm report, in which ...