Two Hundred Years of Hospital Costs and Mortality

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Two Hundred Years of Hospital Costs and Mortality — MGH and Four Eras of Value in MedicineGregg S. Meyer, M.D., Akinluwa A. Demehin, M.P.H., Xiu Liu, M.S., and Duncan Neuhauser, Ph.D.N Engl J Med 2012; 366:2147-2149June 7, 2012Recent discussions about health care delivery have focused on value, defined as health outcomes achieved per dollar spent. One unique window into value over the past two centuries is afforded by mortality and cost data from Massachusetts General Hospital (MGH), which celebrated its 200th anniversary in 2011. These data complement the chronicles of MGH care that the Journal has been publishing since 1924 in the form of “Case Records of the Massachusetts General Hospital.” The story these sources tell has implications beyond MGH, reflecting national trends in acute care.Feeling compelled to document MGH's care in order to justify ongoing philanthropic support, the hospital's trustees sought to evaluate the quality of care from the day the hospital opened in 1821 (after a 10-year delay attributable to the exigencies of the War of 1812 and the difficulty of securing financing). Each month, two trustees were assigned responsibility for the hospital's care and addressed any complaints or suggestions. In addition, MGH reported annually on the condition of patients leaving the hospital, originally classifying them as having left dead, “unfit or eloped” (equivalent to “against medical advice”), not relieved, much relieved, or well (MGH annual reports are available through Google Books). Classifications were simplified in 1916 to include only dead, unchanged, or improved (leading some to erroneously conclude that no patient has left MGH “well” since 1915). The hospital also collected data on the inpatient cost per patient discharged alive (adjusted here to 2010 dollars using the Consumer Price Index method). The graphsMGH's Inpatient Mortality Rate (Brown) and Adjusted Cost per Patient Who Was Discharged Alive (in 2010 Dollars; Blue), 1821–2010. thus represent a run chart on value, as measured in terms of mortality and costs per patient discharged alivehttp://www.nejm.org/doi/full/10.1056/NEJMp1202628