Hospitals, Hospital Medicine, And Health For All

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In September 2015, world leaders convened at the United Nations Summit to adopt the Sustainable Development Goals. Goal three, to “ensure healthy lives and promote well-being for all at all ages,” is ambitious, and many in the field are asking how nations can contribute to achieving this target. The world has made great health gains, but in order to ensure health for all, the current and highly successful strategies of investing in primary health care (PHC), outreach, and implementing vertical, disease-oriented programs must be integrated with a safety net of high quality hospitals. We believe that the field of hospital medicine—a clinical specialty that combines knowledge in acute care and inpatient medicine with expertise in hospital care delivery—can steward the valuable resource of hospital care toward high performance.

Since the Alma Ata Declaration in 1978—the landmark declaration that affirmed the importance of primary care—the health care system strengthening strategy has emphasized PHC. With its successes in equitably delivering cost-effective health care services, the PHC movement has become a priority for achieving universal health coverage. Meanwhile, hospitals have either primarily served the well-to-do or catastrophically impoverished the poor, and have been seen as cost sinks for ministry of health budgets; hospital expenditures account for a quarter to half of total health expenditures in Organization for Economic Co-operation and Development (OECD) countries, and can be higher in low- and middle-income countries (LMIC). Although both non-health care interventions (for example, road safety policy) and PHC can prevent the lion’s share of the global burden of disease, which is shifting toward predominantly non-communicable and chronic diseases, prevention and early intervention do not obviate the need for hospital care. There is mounting evidence of the important role hospitals will need to play in health care systems.

An integrated continuum of care allows patients to move seamlessly from the community to the clinic to the hospital, and then back home as illness episodes come and go. Yet access to high quality hospital care remains inadequate, particularly in LMICs. Of the 42.7 million adverse events and consequent 23 million disability adjusted life years lost in hospitals worldwide, two-thirds occurred in LMIC. Furthermore, as many as one in 50 hospital admissions in a group of eight LMICs led to death from preventable adverse events, or errors. Simply put, hospitals around the world are underperforming.

Hospital Medicine: A Response To Quality And Value Needs

The recognition that hospital care requires a specialized skill set, and the organization of a discipline to supply that skill set, is relatively new. Unlike other medical specialties that focus on an organ system (e.g. cardiology), group of diseases (e.g. infectious disease), or diagnostic or treatment modalities (e.g. surgery), the field of hospital medicine has emerged to develop expertise in a platform of care delivery: acute hospital care. Two forces of the 1990s catalyzed this change. First, hospitals in high-income countries were (and still are) put under increasing financial pressures to reduce hospital costs. Second, increasing attention to quality and safety of care put a spotlight on the systems and processes of hospital care. One response to these forces was at the point of service delivery: a hospital medicine discipline emerged to equip generalist health care professionals with a specialized knowledge of the nuances of hospital care. The field came to be known as hospital medicine in the United States, and while that name has gained international traction, the discipline draws from a legacy of hospital care worldwide and has a distinctly international value proposition. Today, hospital medicine has three core offerings that support delivery of high-value hospital care.

Core Value Add Hospital Medicine Attributes
1. Clinical generalists, system specialists Holistic, patient-centered care
Coordination of complex care
Cost-conscious care
2. Performance orientation Clinical education
Care transition manager
3. Interdisciplinary culture Quality, safety, and process improvement
System leadership and hospital management

First, the combination of clinical generalism and site-based, system specialization can promote hospital effectiveness. Akin to its primary care counterpart, hospital medicine is a generalist clinical specialty, poised to deliver holistic and patient-centered care to patients presenting with any combination of undifferentiated disease, systemic disease, or multiple pre-existing comorbidities. However, the nature of acute and hospital care is complex — some problems, like nosocomial infections (i.e. hospital acquired infections) or venous thromboembolism (a group of blood clotting disorders), require a nuanced skill set that generalist training alone might not provide. Hospital medicine develops a specialized understanding of the implications of hospitalization to make hospital care more effective, and data are increasingly justifying the field’s value. An emphasis on the systems and processes of hospital service delivery can bring hospital care to its full potential. Tasks that are technically nonclinical, like coordinating care among specialists and outpatient providers, managing care transitions across the care continuum, or conducting quality improvement projects or safety inquiries, can make hospital care more effective, and have thus become a major focus of hospital medicine.

Second, the field of hospital medicine can promote hospital efficiency. Staffing hospitals with generalists trained in hospital medicine can better allocate human resources, improving cost allocation and cost-effectiveness. In such an environment, patients receive specialist care only when a generalist’s training is insufficient to address the patient’s needs (as might be the case when a patient with congestive heart failure needs the care of a cardiologist, for example), freeing specialists to see more patients better matched to their skill sets. Moreover, dedicated inpatient staffing can improve outpatient access to primary care by freeing primary care physicians of hospital duties. Hospital medicine encourages rational utilization of health care resources in areas such as length of hospital stay, readmission rates, or cost awareness and cost-effective interventions. Because of its value in improving hospital efficiency, hospital medicine expertise is becoming increasingly valued on hospital management teams and in system leadership positions.

Third, new understandings in the field of hospital medicine have bolstered the case for using and improving team-based care. The complexity of acute care means doctors and nurses are no longer the only ones participating in a hospitalized patient’s care. Physical and occupational therapists, case managers, social workers, medical interpreters, and volunteer health workers are among the many roles on a modern inpatient care team. Because of increasing pressures on performance and patient flow, these interdisciplinary teams need leadership that keeps the patient at the center, yet draws upon a strong system understanding — hospital medicine naturally supplies such leadership.

The hospital medicine value proposition is rooted in both a whole-of-patient and a whole-of-system perspective. Driven by its value proposition, the number of practitioners of hospital medicine has grown exponentially. Today, most of the supporting evidence of value comes from the United States — this, and that the term hospital medicine is widely considered “American,” limits the conceptual generalizability of the field. However, many countries have experience with staffing models that include hospital-based health care professionals, or with staffing of hospital medicine-trained personnel. This evidence base may provide some guide to how the field can affect hospitals worldwide.

A Global View Of Hospital Medicine

There are myriad international examples of hospital staffing models whereby providers spend most or all of their time caring for hospitalized patients. In many cases, the connection between those models and the growing movement of hospital medicine has not yet been made, and they are distinct in two ways. First, much of international hospital-based care is provided by early-career physicians who face common district-level challenges like lower pay or prestige, specialists, or nurses and auxiliary staff. Specialists are more costly and likely better suited in a consultative role since patients rarely present with problems that fall discretely into one scope of practice, while challenges of respect and remuneration traditionally experienced by early-career or non-physician health workers may limit their access to hospital-specific training and development. Second, hospital medicine treats the hospital as part of a patient’s pathology. This clinical and systemic expertise widens the range of intervention possibilities, from traditional case management to quality improvement initiatives to medical informatics solutions, among other possibilities.

The scope of hospital medicine practice is expanding worldwide. We searched the literature, sought country information from the International Section of the Society of Hospital Medicine, and explored our own network to identify hospital medicine practices in 37 countries (Figure 1). Of these, we identified only 12 middle-income countries and no low-income countries practicing hospital medicine. Although the practice is not widespread outside North America, these numbers likely underrepresent its global impact. Furthermore, we are aware of four national or international professional organizations related to the practice of hospital medicine outside of the US-based Society of Hospital Medicine, and more are planned. Hospital medicine groups around the world have replicated results seen in the United States, showing that hospital medicine can improve select hospital outcomes, quality, utilization, cost, research, or education indicators.

Hospital medicine can catalyze needed integration of high quality hospital care into health care systems globally. As countries transition from low to middle income status over the next generation, there is potential for a surge in domestic health care investment, including in hospital care. As access to hospital care is achieved, health care systems must be ready to ensure those hospitals are providing high value care. Though a global expansion of hospital medicine is far from a panacea, it should account for a small—but important—share of the human resources for health strategy worldwide.

The Intersection Of Hospital Medicine And Global Health: The Way Forward

To date, the expansion of hospital medicine has mostly been from the bottom-up, emerging at the local level in response to local needs. However, there is much that can and should be done from ministry and leadership levels to facilitate appropriate hospital medicine uptake worldwide.

First, while health care system stewardship needs to be country-led, global institutions can advocate for creation (and universal coverage) of a complete continuum of care, and supply both capital and technical assistance to meet this end. Leading global institutions should engage with national ministries of health, professional societies, and donor organizations to advocate for integration of hospitals with PHC, and for careful stewardship. Refocusing a share of existing hospital investments on hospital medicine training could help hospitals operate at greater value and would not divert needed funds from PHC. Ultimately, however, many LMIC health care systems will need to simultaneously strengthen all platforms of care delivery. An either/or world of hospitals or PHC is both dogmatic and unrealistic, and has potential to constrain health care system effectiveness.

Second, there is a knowledge gap on how to make hospital care more cost-effective, and research will be needed to understand how the principles of hospital medicine add value to existing hospitals, financing structures, and health care system cultures across a variety of international settings — and then to make the case that this is a global public good that donors should fund. This need is particularly glaring in low-income countries, where resources are limited, hospital performance is poor, and the burden of disease is shifting such that hospital care will be increasingly pressing.

Finally, the expansion of hospital medicine has demonstrated a valuable opportunity to transform health care education. The experience of hospital medicine has shown that over a generation there can be a remarkable shift in the culture of care delivery. The near simultaneous emergence of the field of hospital medicine with the quality and safety movements was both coincidental and synergistic — the latter because hospital medicine rapidly became the leader in performance improvement efforts. If there is any ultimate lesson to carry forward, it is that the experience of hospital medicine should not be unique. All health care providers practicing in all settings would benefit from specialized training on their respective practice models. We now know that knowledge of disease is only one part of achieving high health care performance. How we deliver the care, and how we improve upon it, is the other.

Health care systems display emergent properties: if hospitals remain neglected, inefficient, or mismanaged, all aspects of the system suffer. The field of hospital medicine can be a powerful force in strengthening the value of hospital care, thereby balancing the health care system and potentiating its net effect. Unsurprisingly, the field is spreading worldwide. To maximize its effect, the global community should manage and cultivate it across health care contexts. If the Sustainable Development Goals are asking for health for all, hospitals—and their core discipline, hospital medicine—have an important role to play in integrated health care systems.

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