The probability or chance that a person will have a medical event. Absolute risk is expressed as a percentage. It is the ratio of the number of people who have a medical event divided by all of the people who could have the event because of their medical condition.
A bad or harmful reaction to a drug that is used to treat or prevent a disease.
Anything that a person might feel is a negative or harmful result of a treatment or test.
Any negative or unwanted effect from any drug, device, or medical test.
Any negative or unwanted effect from a drug, device, or medical test.
The process of preparing the results or conclusions of a study. An analysis usually is performed by doing mathematical calculations known as statistics.
A relationship. In research studies, association means that two characteristics (sometimes also called variables or factors) are related so that if one changes, the other changes in a predictable way. An association does not necessarily mean that one variable causes the other.
Any factor, recognized or not, that distorts the findings of a study. In research studies, bias can influence the observations, results, and conclusions of the study and make them less accurate or believable.
An advisory from the U.S. Food and Drug Administration (FDA) that tells health care professionals and consumers that a drug might be very dangerous for some people. The FDA is the U.S. Government agency that regulates and monitors drugs and medical devices to make sure they are safe and effective.
Every prescription drug comes with a package insert. The insert contains information about the drug, including the name, manufacturer, drug class, purpose, benefits, and risks. The Black Box Warning gets its name from the black border around the warning that indicates that the drug sometimes causes serious adverse events.
A way of making sure that the people involved in a research study — participants, clinicians, or researchers — do not know which participants are assigned to each study group. Blinding usually is used in research studies that compare two or more types of treatment for an illness. Blinding is used to make sure that knowing the type of treatment does not affect a participant’s response to the treatment, a health care provider’s behavior, or assessment of the treatment effects.
The branch of medical science devoted to finding information that improves people’s health. It includes research studies that examine the safety and effectiveness of medications, medical devices, diagnostic tests, and treatment regimens intended for human use. Usually, more than one person with the same disease is studied.
A carefully conducted research study that compares the effects of drugs, treatments, or diagnostic tests.
A group of people with some characteristic in common. The characteristic can be:
A clinical research study in which people who presently have a certain condition or receive a particular treatment are followed over time and compared with another group of people who are not affected by the condition.
In a cohort study (also known as a prospective observational study), the researchers take measurements of the people who belong to a cohort at several points in time. The measurements can be symptoms, blood tests, X-rays, or whether the disease has caused the person to die.
A type of health care research that compares the results of one approach for managing a disease to the results of other approaches. Comparative effectiveness usually compares two or more types of treatment, such as different drugs, for the same disease. Comparative effectiveness also can compare types of surgery or other kinds of medical procedures and tests. The results often are summarized in a systematic review.
The kinds of results that are studied to compare drugs or procedures include relief of symptoms, length of life, or whether people need to go to the hopital. These results are called outcomes. Many other kinds of outcomes can also be compared.
The range in which a particular result (such as a laboratory test) is likely to occur for everyone who has a disease. “Likely” usually means 95 percent of the time.
Clinical research studies are conducted on only a certain number of people with a disease rather than all the people who have the disease. The study’s results are true for the people who were in the study but not necessarily for everyone who has the disease.
The confidence interval is a statistical estimate of how much the study findings would vary if other different people participated in the study. A confidence interval is defined by two numbers, one lower than the result found in the study and the other higher than the study’s result. The size of the confidence interval is the difference between these two numbers.
In a research study, the group of people who do not receive the treatment being tested. The control group might receive a placebo, a different treatment for the disease, or no treatment at all.
A type of clinical trial comparing the effectiveness of one medication or treatment with the effectiveness of another medication or treatment. In many controlled trials, the other treatment is a placebo (inactive substance) and is considered the “control.”
A type of analysis that compares the financial costs with the benefits of two or more health care treatments or programs. Health care interventions that have the same or better benefit at a lower cost are better values than treatments or programs that are more expensive.
A type of analysis that is similar to a cost-benefit analysis but is used when the benefits cannot be measured in financial terms or dollars. It would be hard to put a price-tag on living an extra year of life.
In clinical research, the information recorded about a participant in a study. There are many different kinds of data.
A procedure to provide information about a person’s condition that helps health care providers to make a diagnosis. Diagnostic tests provide information about whether a person does or does not have a particular disease.
A medicine (chemical compound) used to prevent, diagnose, or treat conditions. Some drugs need a prescription from a physician or nurse practitioner and other drugs do not need a prescription.
A manufactured product that contains a drug. There are many forms of drug products, including tablets (pills), capsules, creams, or liquids. A drug product often includes other chemicals that are not harmful to most people. They are included in the product for such reasons as making a liquid taste better or binding a tablet together so that it does not crumble in the bottle.
The amount of change in a condition or symptom because of a treatment (compared to not receiving the treatment). It is commonly expressed as a risk ratio (relative risk), odds ratio, or difference in risk.
The amount of a drug most people need to take to control a disease or the symptoms of a disease. A dose lower than the effective dose would not bring about the outcome (such as relieving symptoms).
Whether a drug or other treatment works in real life. Effectiveness studies of drugs look at whether they work when they are used the way that most people take them. Effectiveness means that most people who have the disease would improve if they used the treatment.
Whether a drug or other treatment works under the best possible conditions. In a research study about efficacy, the study participants are carefully selected, and the researchers can make sure the drug is taken properly and stored properly. The study participants may differ from other people in the general public who have the disease. A treatment that has efficacy under the best conditions may not work as well in a different group of people with the same disease.
The field of science that studies the factors causing diseases, illnesses, or injuries in populations or community groups.
Epidemiology includes:
A summary of the most important information from a group of research studies. An evidence table can include information on the number of participants in the research trials and the type and frequency of adverse events that participants had while taking the drugs being studied.
Applying the best available research results (evidence) when making decisions about health care. Health care professionals who perform evidence-based practice use research evidence along with clinical expertise and patient preferences. Systematic reviews (summaries of health care research results) provide information that aids in the process of evidence-based practice.
The criteria, or standards, set out before a study or review. Exclusion criteria are used to determine whether a person should participate in a research study or whether an individual study should be excluded in a systematic review. Exclusion criteria may include age, previous treatments, and other medical conditions. Criteria help identify suitable participants.
The extent to which clinical research studies apply to broader populations. A research study has external validity if its results can be generalized to the larger population.
The diagnostic test that is considered the most accurate test for a particular condition. If the gold standard test is positive, it is highly likely that the person has the disease. If the gold standard test is negative, it is highly likely that the person does not have the disease.
A study of two drugs or treatments that compares the effects of one treatment with the other. In a head-to-head trial, two groups of people with the same disease are compared. One group receives one treatment, and the second group receives the other.
Any type of treatment, preventive care, or test that a person could take or undergo to improve health or to help with a particular problem. Health care interventions include drugs (either prescription drugs or drugs that can be bought without a prescription), foods, supplements (such as vitamins), vaccinations, screening tests (to rule out a certain disease), exercises (to improve fitness), hospital treatment, and certain kinds of care (such as physical therapy).
Differences among research studies. Heterogeneity can apply to either the way the studies were conducted, the methodologies used in the studies, or differences in the way people respond to the treatment. Research reports may describe different types of heterogeneity:
A person who participates in a research study or clinical trial. The person agrees to take part in the study and has been told about the possible dangers and benefits of participation. The participation can include different activities, depending on the goals of the study.
A scientific idea that can be tested in a research study. The hypothesis is the scientific idea that led to the research study.
The criteria, or standards, set out before a study or review. Inclusion criteria are used to determine whether a person can participate in a research study or whether an individual study can be included in a systematic review. Inclusion criteria may include gender, age, type of disease being treated, previous treatments, and other medical conditions. Inclusion criteria help identify suitable participants.
An agreement to receive a treatment or medical procedure. Before a person receives a proposed treatment or medical procedure, he or she must give informed consent. This means that the person must not only agree to the treatment, but also understand what he or she is agreeing to.
Informed consent applies to routine health care, as well as to participation in a clinical research study. Informed consent should always be received before a person undergoes a surgical procedure or before the use of dangerous treatments, such as chemotherapy for the treatment of cancer.
An informed consent form provides a record of the discussion that was held between the person and the doctor or researcher. The person signs the informed consent form before a treatment or procedure is started and before any data are collected for people enrolled in a clinical research study.
Informed consent involves a discussion between a person who would receive the treatment and a professional person who explains the treatment, provides information about possible benefits and risks, and answers questions. Informed consent involves the process of discussion about a treatment. Signing the informed consent form provides a record of the discussion but does not take the place of the discussion.
The extent to which the results of a clinical research study are not biased. Several characteristics of a study affect its internal validity. Are the two groups of people being compared similar in all the important characteristics that may affect the measurements of data? Are the data collected being measured using accurate methods?
The average amount of time a person will live after a certain starting point, like birth or the diagnosis of a disease. The calculation is based on statistical information comparing people with similar characteristics, such as age, gender, race/ethnicity, and health.
A measure of the accuracy of a diagnostic test. It is used to determine how likely it is that a person has a specific disease based on test results. When the test result is positive, the likelihood ratio is known as a positive likelihood ratio (LR+). When the test result is negative, the likelihood ratio is known as a negative likelihood ratio (LR-). The likelihood ratio is a way of comparing the probability that the test result would occur in people with the disease as opposed to occurring in people without the disease.
A positive likelihood ratio greater than 10 (>10) or a negative likelihood ratio less than 0.1 (<0.1) would be considered clinically useful in helping guide health care decision making.
A way of making sure that the people involved in a research study — participants, clinicians, or researchers — do not know which participants are assigned to each study group. Masking usually is used in research studies that compare two or more types of treatment for an illness. Masking is used to make sure that knowing the type of treatment does not affect a participant’s response to the treatment, a health care provider’s behavior, or assessment of the treatment effects.
A way of combining data from many different research studies. A meta-analysis is a statistical process that combines the findings from individual studies.
The number of people who die. Mortality is usually measured for people who have something in common, such as having a particular disease or being of a certain age.
Mortality for a group of people is often reported as the number of people who died and the causes of the deaths. Even people who have the same medical problem do not always have the same cause of death. A person may die from a disease or from another cause, such as an automobile crash.
Indicates the likelihood that people with a negative test result would not have a condition. The higher the value of the negative predictive value (for example, 99 percent would usually be considered a high value), the more useful the test is for predicting that people do not have the condition.
The number of people who would need to be treated over a specific period of time before one bad outcome of the treatment will occur. The number needed to harm (NNH) for a treatment can be known only if clinical trials of the treatment have been performed.
The number of people who need to be treated over a specific period of time to promote one additional good outcome (or prevent one additional bad outcome). The number needed to treat (NNT) for a treatment can be known only if clinical trials of the treatment have been performed.
The chance of an event occurring in one group compared to the chance of it occurring in another group. The odds ratio (OR) is a measure of effect size and is commonly used to compare results in clinical trials.
The practice of prescribing a drug for a condition not listed on the U.S. Food and Drug Administration (FDA) label. The label lists the medical conditions for which the FDA has approved the drug. Off-label uses may be supported by clinical evidence not available or not submitted to the FDA. Accepted medical practice often includes off-label use.
A clinical research study in which the participant, health care professional, and others know the drug and dose being given. The research study is not “blinded.”
A term used to describe drugs you can buy without a prescription.
The end result of health care practices. There are many kinds of outcomes. How long people live following a health care treatment is one kind of outcome, known as survival. Other outcomes measure the effects a treatment has on people’s lives, such as changes in their ability to function or changes in their quality of life. Outcomes also include undesirable events such as side effects of drugs. Another type of outcome is whether people needed to change to another kind of treatment.
A term used to describe drugs you can buy without a prescription.
An individual seeking or receiving medical care.
An inactive substance commonly called a “sugar pill.” In a clinical trial, a placebo is designed to look like the drug being tested and is used as a control. It does not contain anything that could harm a person.
It is not necessarily true that a placebo has no effect on the person taking it. See placebo effect.
A study in which the effect of a drug is compared with the effect of a placebo (an inactive substance designed to resemble the drug). In placebo controlled clinical trials, participants receive either the drug being studied or a placebo. The results of the drug and placebo groups are then compared to see if the drug is more effective in treating the condition than the placebo is.
A physical or emotional change that occurs after a participant in a research study takes a placebo. The change, which may include the lessening of symptoms, is not the result of chemical effects of the placebo because the placebo does not contain any active ingredients. The change is often based on the participant’s or researcher’s expectation that a change will occur.
When the data on odds ratios from multiple studies are combined, the result is a pooled odds ratio (POR). An odds ratio (OR) is the comparison of the chance of an event occurring in one group to the chance of it occurring in another group. The odds ratio is a measure of effect size and is commonly used to compare results in clinical trials.
Indicates the likelihood that a person with a positive test result would actually have the condition for which the test is used. The higher the value of the positive predictive value (for example, 90 percent would be considered a high value), the more useful the test is for predicting that the person has the condition.
The probability that a person has a particular disease before any test results are obtained. The pretest probability for large groups of people (such as the population of a city) is the same as the prevalence of the disease in that group.
Pretest probability is also known as prior probability.
How often or how frequently a disease or condition occurs in a group of people. Prevalence is calculated by dividing the number of people who have the disease or condition by the total number of people in the group.
The probability that a person has a particular disease before any test results are obtained. The prior probability for large groups of people (such as the population of a city) is the same as the prevalence of the disease in that group.
Prior probability is also known as pretest probability.
The likelihood (or chance) that an event will occur. In a clinical research study, it is the number of times a condition or event occurs in a study group divided by the number of people being studied.
The way a health situation is likely to turn out. Prognosis refers to the usual progression and outcome of a condition.
A clinical research study in which people who presently have a certain condition or receive a particular treatment are followed over time and compared with another group of people who are not affected by the condition.
In a prospective observational study (also called a cohort study), the researchers take measurements of the people who belong to a cohort at several points in time. The measurements can be symptoms, blood tests, X-rays, or whether the disease has caused the person to die.
The tendency of researchers to publish experimental findings that have a positive result, while not publishing the findings when the results are negative or inconclusive. The effect of publication bias is that published studies may be misleading. When information that differs from that of the published study is not known, people are able to draw conclusions using only information from the published studies.
A method of assigning participants in clinical trials into two or more groups randomly (by chance). One group receives the treatment or drug being researched, and one group receives either no treatment, a placebo (inactive substance), or another drug. Participants are assigned to a group by various methods.
A controlled clinical trial that randomly (by chance) assigns participants to two or more groups. There are various methods to randomize study participants to their groups.
A comparison of the risk of a particular event for different groups of people. Relative risk (RR) is usually used to estimate exposure to something that could affect health. In a clinical research study, the experimental group is exposed to a particular drug or treatment. The control group is not. The number of events in each group is compared to determine relative risk.
A way of expressing the chance that something will happen. It is a measure of the association between exposure to something and what happens (the outcome). Risk is the same as probability, but it usually is used to describe the probability of an adverse event. It is the rate of events (such as breast cancer) in the total population of people who could have the event (such as women of a certain age).
A characteristic of a person that affects that person’s chance of having a disease. A risk factor may be an inherent trait, such as gender or genetic make-up, or a factor under the person’s control, such as using tobacco. A risk factor does not usually cause the disease. It changes a person’s chance (or risk) of getting the disease.
A method for comparing a treatment’s benefits and risks, such as curing a disease (benefit) versus having a serious side effect from the treatment (risk). The risk/benefit ratio of a treatment is different depending on the disease or condition being treated.
The number of people included in a study. In research reports, sample size is usually expressed as “n.” In general, studies with larger sample sizes have a broader range of participants. This increases the chance that the study’s findings apply to the general population. Larger sample sizes also increase the chance that rare events (such as adverse effects of drugs) will be detected.
Using tests or other methods of diagnosis to find out whether or not a person has a specific disease or condition before it causes any symptoms. For many diseases (for example, cancers), starting treatment earlier leads to better results. The purpose of screening is to find the disease so that treatment can be started as early as possible.
A type of bias caused by an error in the way people are assigned to groups in a clinical research study. This can occur when the study and control groups are chosen so that they differ from each other in ways that may affect the outcome of the study.
The ability of a test to identify correctly people with a condition. A test with high sensitivity will nearly always be positive for people who have the condition (the test has a low rate of false-negative results). Sensitivity is also known as the true-positive rate.
Any effects of a drug or treatment that are not wanted. Side effects may be temporary and go away when the drug is stopped. Sometimes they continue for a longer time, even when the drug is no longer being taken.
The ability of a test to identify correctly people without a condition. A test with high specificity will rarely be wrong about who does NOT have the condition (the test has a low rate of false-positive results). Specificity is also known as the true-negative rate.
The treatment or procedure that is most commonly used to treat a disease or condition. In clinical trials, new or experimental treatments sometimes are compared to standard treatments to measure whether the new treatment is better.
The process of preparing the results or conclusion of a study. A statistical analysis usually is performed by doing mathematical calculations known as statistics.
A mathematical technique to measure whether the results of a study are likely to be true. Statistical significance is calculated as the probability that an effect observed in a research study is occurring because of chance. Statistical significance is usually expressed as a P-value. The smaller the P-value, the less likely it is that the results are due to chance (and more likely that the results are true). Researchers generally believe the results are probably true if the statistical significance is a P-value less than 0.05 (p<.05).
A research process in which information is recorded for a group of people. The information is known as data. The data are used to answer questions about a health care problem.
The group of people participating in a clinical research study. The study population often includes people with a particular problem or disease. It may also include people who have no known diseases.
The length of time people live. Survival can show whether treatments for a disease can prevent or delay death. Survival is usually expressed in terms of how long the people in a group remain alive. It sometimes is summarized by calculating an average. Survival also can be summarized by the number of people who are still alive after a certain length of time, such as 5 years later.
A summary of the clinical literature. A systematic review is a critical assessment and evaluation of all research studies that address a particular clinical issue. The researchers use an organized method of locating, assembling, and evaluating a body of literature on a particular topic using a set of specific criteria. A systematic review typically includes a description of the findings of the collection of research studies. The systematic review may also include a quantitative pooling of data, called a meta-analysis.
A comparative effectiveness review is a type of systematic review in which all the available evidence about particular treatments for a disease is reviewed and compared.
The amount of change in a condition or symptom because of a treatment (compared to not receiving the treatment). It is commonly expressed as a risk ratio (relative risk), odds ratio, or difference in risk.
The ability of a test to identify correctly people without the condition. A test with a high true-negative rate will rarely be wrong about who does NOT have the condition (the test has a low rate of false-positive results). The true-negative rate is also known as specificity .
The ability of a test to identify correctly people with a condition. A test with a high true-positive rate will will nearly always be positive for people who have the condition (the test has a low rate of false-negative results). The true-positive rate is also known as sensitivity.
Whether a test or technique actually measures what it is intended to measure. Validity can refer to an individual measurement or to the design and approach taken in a clinical research study. When referring to a single measurement, validity means the accuracy of the measurement.
Any characteristic that can be measured in different individuals. A variable is also any factor that can affect the outcome of an experiment or study.
Research studies have both independent and dependent variables. A dependent variable is the change or outcome that results from an independent variable. Independent variables, such as receiving an experimental treatment, can be changed by the researchers.
In ancient cultures, religion and medicine were linked. The earliest known institutions aiming to provide cure were Egyptian temples. Greek temples dedicated to the healer-god Asclepius might admit the sick, who would wait for guidance from the god in a dream. The Romans adopted his worship. Under his Roman name Æsculapius, he was provided with a temple (291 BC) on an island in the Tiber in Rome, where similar rites were performed.
Ancient Asia
The Sinhalese (Sri Lankans) are perhaps responsible for introducing the concept of dedicated hospitals to the world. According to the Mahavamsa, the ancient chronicle of Sinhalese royalty written in the 6th century A.D., King Pandukabhaya (4th century BC) had lying-in-homes and hospitals (Sivikasotthi-Sala) built in various parts of the country. This is the earliest documentary evidence we have of institutions specifically dedicated to the care of the sick anywhere in the world. Mihintale Hospital is perhaps the oldest in the world.
Institutions created specifically to care for the ill also appeared early in India. King Ashoka is said to have founded at least 18 hospitals ca. 230 BC, with physicians and nursing staff, the expense being borne by the royal treasury. However, there are historians who strictly dispute the claim that Ashoka built any hospitals at all, and argue that it is based on a mistranslation, with references to ‘rest houses’ being mistaken for hospitals. The error is thought to have occurred because similar edicts and records talk of Ashoka importing medicinal supplies.
State-supported hospitals later appeared in China during the first millennium A.D. The first teaching hospital where students were authorized to methodically practice on patients under the supervision of physicians as part of their education, was the Academy of Gundishapur in the Persian Empire. One expert has argued that “to a very large extent, the credit for the whole hospital system must be given to Persia”.
Roman Empire
The Romans created valetudinaria for the care of sick slaves, gladiators and soldiers around 100 BC, and many were identified by later archeology. While their existence is considered proven, there is some doubt as to whether they were as widespread as was once thought, as many were identified only according to the layout of building remains, and not by means of surviving records or finds of medical tools.
The adoption of Christianity as the state religion of the empire drove an expansion of the provision of care. The First Council of Nicaea in 325 A.D. urged the Church to provide for the poor, sick, widows and strangers. It ordered the construction of a hospital in every cathedral town. Among the earliest were those built by the physician Saint Sampson in Constantinople and by Basil, bishop of Caesarea. The latter was attached to a monastery and provided lodgings for poor and travelers, as well as treating the sick and infirm. There was a separate section for lepers.
Medieval Islam
The earliest recorded hospitals in the medieval Islamic world refer to the hopital of al-Walid ibn ‘Abdul Malik (ruled 705-715 CE) which he built in 86 AH (706-707 CE). It somewhat resembled the Byzantine nosocomia, but was more general as it extended its services to the lepers and the invalid and destitute people. All treatment and care was free of charge and there was more than one physician employed in this hospital.
In the medieval Islamic world, the word “Bimaristan” was used to indicate a hospital in the modern sense, an establishment where the ill were welcomed and cared for by qualified staff. In this way, Muslim physicians were the first to make a distinction between a hospital and other different forms of healing temples, sleep temples, hospices, assylums, lazarets and leper-houses, all of which in ancient times were more concerned with isolating the sick and the mad from society “rather than to offer them any way to a true cure.” Some thus consider the medieval Bimaristan hospitals as “the first hospitals” in the modern sense of the word. The first public hospitals, psychiatric hospitals and medical universities were also introduced by medieval Muslim physicians.
Between the eighth and twelfth centuries CE Muslim hospitals developed a high standard of care. Hospitals built in Baghdad in the ninth and tenth centuries employed up to twenty-five staff physicians and had separate wards for different conditions. Al-Qairawan hospital and mosque, in Tunisia, were built under the Aghlabid rule in 830 CE and was simple but adequately equipped with halls organized into waiting rooms, a mosque, and a special bath. The hospital employed female nurses, including nurses from Sudan, a sign of great breakthrough. In addition to regular physicians who attended the sick, there were Fuqaha al-Badan, a kind of religious physio-therapists, group of religious scholars whose medical services included bloodletting, bone setting, and cauterisation. During Ottoman rule, when hospitals reached a particular distinction, Sultan Bayazid II built a mental hospital and medical madrasa in Edirne, and a number of other early hospitals were also built in Turkey. Unlike in Greek temples to healing gods, the clerics working in these facilities employed scientific methodology far beyond that of their contemporaries in their treatment of patients.
According to Sir John Bagot Glubb:
“By Mamun’s time medical schools were extremely active in Baghdad. The first free public hospital was opened in Baghdad during the Caliphate of Haroon-ar-Rashid. As the system developed, physicians and surgeons were appointed who gave lectures to medical students and issued diplomas to those who were considered qualified to practice. The first hospital in Egypt was opened in 872 AD and thereafter public hospitals sprang up all over the empire from Spain and the Maghrib to Persia.”
Medieval Europe
Medieval hospitals in Europe followed a similar pattern. They were religious communities, with care provided by monks and nuns. (An old French term for hospital is hôtel-Dieu, “hostel of God.") Some were attached to monasteries; others were independent and had their own endowments, usually of property, which provided income for their support. Some hospitals were multi-function while others were founded for specific purposes such as leper hospitals, or as refuges for the poor or for pilgrims: not all cared for the sick. Not until later where most hospitals multi-functional, though the first Spanish hospital, founded by the Catholic Visigoth bishop Masona in 580 at Mérida, was a xenodochium designed as an inn for travellers (mostly pilgrims to the shrine of Eulalia of Mérida) as well as a hospital for citizens and local farmers. The hospital’s endowment consisted of farms to feed its patients and guests.
Colonial America
It is believed that the first Spanish style hospital founded in the Americas [Western Hemisphere] following Columbus arrival to the island now known as Hispaniola was the Hospital San Nicolás de Bari [Calle Hostos] in Santo Domingo, [Distrito Nacional] Dominican Republic.
Fray Nicolas de Ovando, Spanish governor and colonial administrator from 1502-1509, authorized its construction in or after 1504. It is believed that this hospital also served as a church during its lifetime. The first phase of its construction was completed in 1519. Erwin Walter Palm, [former author and professor of Spanish American art, culture, and history] wrote that “the Brotherhood of Our Lady of the Conception continued the construction of the hospital in 1533, adding modern elements, including additional buildings.” Abandoned in the mid-18th century the hospital now lies in ruins near the Cathedral in the colonial zone in Santo Domingo, DR, amid additional historical New World sights.
The Hospital de Jesús Nazareno in Mexico City is the oldest hospital in North America. It was founded in 1524 with the economic support of conquistador Hernán Cortés to care for poor Spanish soldiers and the native inhabitants.
The first hospital in North America north of Mexico is the Hôtel-Dieu de Québec. It was established in New France in 1639 by three Augustinians from l’Hôtel-Dieu de Dieppe in France. The project of the niece of Cardinal de Richelieu was granted a royal charter by King Louis XIII and staffed by colonial physician Robert Giffard de Moncel.
Modern era
In Europe the medieval concept of Christian care evolved during the sixteenth and seventeenth centuries into a secular one, but it was in the eighteenth century that the modern hospital began to appear, serving only medical needs and staffed with physicians and surgeons. The Charité (founded in Berlin in 1710) is an early example.
Guy’s Hospital was founded in London in 1724 from a bequest by wealthy merchant Thomas Guy. Other hospitals sprang up in London and other British cities over the century, many paid for by private subscriptions. In the British American colonies the Pennsylvania General Hospital was chartered in Philadelphia in 1751, after £2,000 from private subscription was matched by funds from the Assembly.
When the Viennese General Hospital (Allgemeines Krankenhaus) opened in 1784 (instantly becoming the world’s largest hospital), physicians acquired a new facility that gradually developed into the most important research center. During the 19th century, the Second Viennese Medical School emerged with the contributions of physicians such as Carl Freiherr von Rokitansky, Josef Škoda, Ferdinand Ritter von Hebra and Ignaz Philipp Semmelweis. Basic medical science expanded and specialization advanced. Furthermore, the first dermatology, eye, as well as ear, nose and throat clinics in the world were founded in Vienna, being considered was the birth of specialized medicine.
By the mid-nineteenth century most of Europe and the United States had established a variety of public and private hospital systems. In Continental Europe the new hospitals were generally built and run from public funds. The National Health Service, the principle provider of healthcare in the United Kingdom, was founded in 1948.
In the United States the traditional hospital is a non-profit hospital, usually sponsored by a religious denomination. One of the earliest of these “almshouses” in what would become the United States was started by William Penn in Philadelphia in 1713. These hospitals are tax-exempt due to their charitable purpose, but provide only a minimum of charitable medical care. They are supplemented by large public hospitals in major cities and research hospitals often affiliated with a medical school. In the late twentieth century, chains of for-profit hospitals arose in the USA.
Criticism
While hospitals, by concentrating equipment, skilled staff and other resources in one place, clearly provide important help to patients with serious or rare health problems, hospitals are also criticised for a number of faults, some of which are endemic to the system, others which develop from what some consider wrong approaches to health care.
One criticism often voiced is the ‘industrialised’ nature of care, with constantly shifting treatment staff, which dehumanises the patient and prevents more effective care as doctors and nurses are rarely intimately familiar with the patient. The high working pressures often put on the staff exacerbates such rushed and impersonal treatment. The architecture and setup of modern hospitals is often voiced as a contributing factor to the feelings of faceless treatment many people complain about.
Another criticism is that hospitals are in themselves a dangerous place for patients, who are often suffering from weakened immune systems - either due to their body having to undergo substantial surgery or because of the illness which placed them in the hospital itself. As an example, it is estimated that as much as 10% of all patients in the United States contract a nosocomical (hospital-caused) infection. Due to the environment in which antibiotics are used in large quantities, the infections are also often multi-resistant to various treatment methods, such as the relatively common MRSA infection.
Funding
In the modern era, hospitals are, broadly, either funded by the government of the country in which they are situated, or survive financially by competing in the private sector (a number of hospitals are also still supported by the historical type of charitable or religious associations).
In the United Kingdom for example, a relatively comprehensive, “free at the point of delivery” healthcare system exists, funded by the state. Hospital care is thus relatively easily available to all legal residents (although as hospitals prioritize their limited resources, there is a tendency for ‘waiting lists’ to be generated for non-emergency treatment, and those who can afford it may take out private healthcare to get treatment faster). On the other hand, many countries, including for example the USA, have in the 20th Century followed a largely private-based, for-profit-approach to providing hospital care, with few state-money supported “charity” hospitals remaining today. Where for-profit hospitals in such countries admit uninsured patients in emergency situations (such as during and after the Hurricane Katrina in the USA), they incur direct financial losses, ensuring that there is a clear disincentive to admit such patients.
While for-profit-based systems have produced some of the best hospitals in the world, a proportion of the populace may have little or no access to healthcare services of adequate quality.
As quality of healthcare has increasingly become an issue around the world, hospitals have increasingly had to pay serious attention to this. Independent external assessment of quality is one of the most powerful ways of assessing the quality of healthcare, and hospital accreditation is one means by which this is achieved. In many parts of the world such accreditation is sourced from other countries, a phenomenon known as international healthcare accreditation, by groups such as the Joint Commission from the USA and the Trent Accreditation Scheme from Great Britain.
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