Classic Literature

Measuring Quality in the ’60s

Schimmel EM. Hazards of Hospitalization. Ann Int Med. 1964;60:100-110.

“The occurrence of hospital-induced complications on a university medical service was documented in the prospective investigation of over 1,000 patients. The reported episodes were the untoward consequences of acceptable medical care in diagnosis and therapy. During the eight-month study, 240 episodes occurred in 198 patients. In 105 patients, hospitalization was either prolonged by an adverse episode or the manifestations were not yet resolved at the time of discharge. Thus, 20% of the patients admitted to the medical wards experienced one or more untoward episodes and 10% had a prolonged or unresolved episode. The severity of 240 episodes was minor in 110, moderate in 82, major in 48, of which 16 ended fatally. Patients encountering noxious episodes had a mean total hospitalization of 28.7 days, compared with 11.4 days in other patients. The risk of having such episodes was directly related to the length of time spent in the hospital. The number and variety of these reactions emphasizes the magnitude and scope of hazards to which the hospitalized patient is exposed. A judicious selection of diagnostic and therapeutic measures can be made only with the knowledge of these potential hazards as well as the proposed benefits.”

Dr. Schimmel was the chief resident at Yale from 1960 to 1961. It is during that period that he designed the research project. This report stands out as a landmark study in the measurement of quality of care. The study was done at a time when economics of healthcare did not grab headlines, the average cost of one day of hospitalization was under $70, and medicine was practiced with a “doctor knows best” attitude.

One of the most important findings from this study was that the adverse events did not, by themselves, account for the increased length of stay. In fact, the prolonged hospitalization predisposed patients to higher adverse events—a fact that was nothing short of a revelation. Physicians were now forced to consider risk of hospitalization as a factor in deciding whether an admission was warranted for medical care.

Dr. Schimmel’s study pointed out that, with increasing severity of illness, patients received more diagnostic tests and therapeutic interventions, thereby increasing the risk for adverse events. The study also brought into focus the need to discuss and analyze the overall risk–benefit ratio for each procedure or intervention. One of the drawbacks of this study is that it did not take into account adverse events from medical errors. One can only speculate that the actual percentage of adverse events might have been higher than 20%.

A similar study that looked at iatrogenic adverse events done at Boston University Medical Center in 1979 revealed an adverse event rate of 36%. With increasing complexity of medical care, an aging population base (the average age of the patient in Dr. Schimmel’s study was 53), and less-than-ideal information management, this study remains a beacon to all of us who are committed to the principle of “do no harm.”

A system of voluntary reporting of all adverse events, including those from medical errors, should be developed and information shared by all the stakeholders (including patients and their families) in an effort to ameliorate the hazards of hospitalization. To this end the Institute of Healthcare Improvement’s “100K Lives” campaign brings much needed attention on this important issue.—SS

Resources

• Qual Saf Health Care. 2003;12:58-63; discussion 63-64.
• Steel K, Gertman PM, Crescenzi C, et al. Iatrogenic illness on a general medical service in a university hospital. N Eng J Med. 1981;304:638-642.