The field of pediatric hospital medicine has grown rapidly over the past 18 years, since the term “hospitalist” was first coined. The number of hospitalists, including pediatric hospitalists, has increased exponentially and is expected to keep growing.^1-4 Numerous pediatric hospital medicine fellowship programs have arisen, producing a new generation of clinician-quality improvement experts and clinician-investigators. Ten years after the first pediatric hospitalist conference, sponsored by the Ambulatory Pediatric Association, which drew more than 120 participants from the United States and Canada, the meeting is now an annual event. Sponsorship comes from the Academy of Pediatrics, the Society of Hospital Medicine, and the Academic Pediatric Association (formerly known as the Ambulatory Pediatric Association, the name change prompted in part by the organization’s recognition of the growth of pediatric hospital medicine). Pediatricians’ organizations have expanded to meet the needs of hospitalists, and hospitalists’ organizations have expanded to meet the needs of their pediatric contingent. The American Academy of Pediatrics Section on Hospital Medicine has one of the largest section memberships in the American Academy of Pediatrics (AAP) and an extremely active listserv; the Academic Pediatric Association Special Interest Group on Pediatric Hospital Medicine is also one of the largest interest groups and has a vital presence at the yearly Pediatric Academic Societies meeting, and the Society of Hospital Medicine (the largest hospitalist organization) continues to foster a home for pediatric hospitalists—several key organizational leadership positions are held by pediatricians. Important research networks and collaboratives have arrived. The Pediatric Research in Inpatient Settings (PRIS; pronounced prize) network is focusing on a series of complementary national funded studies ultimately intended to provide the tools to measure and improve the quality of inpatient care. In addition, the Value in Inpatient Pediatrics (VIP) Network has partnered with the Quality Improvement Innovation Networks (QuINN) to conduct grassroots quality improvement studies engaging clinicians. Finally, pediatric hospitalists are continuing to expand their nonclinical responsibilities to include leadership roles in administration (as division chiefs, medical directors, quality improvement officers, and leaders in patient safety and informatics), research (leading research networks, developing health services research laboratories, and training junior investigators to be competitive in obtaining grants), and education (as clerkship and residency directors).

A tremendous amount of knowledge has been gained from critical early work in the value of pediatric hospitalists in inpatient care delivery. This chapter outlines what we have learned from these early studies, as well as what we still need to learn, and proposes mechanisms to accomplish next steps.

A substantial number of studies have been conducted on the efficiency of care delivered in pediatric hospitalist models. These studies have been largely single-center studies using before-and-after study designs or interrupted time series analyses. Most (but not all) have found 10–20% shorter length of stay (LOS) and reduced resource utilization (measured as charges or costs) in pediatric hospitalist systems.^5-11 The types of pediatric hospitalist services evaluated across studies vary, but collectively the studies include academic and nonacademic pediatric hospitalist systems, managed care organization hospitalist systems, and attending-only hospitalist systems—one service that focused on medically complex cases, and another that focused on common conditions—with comparisons to community, general academic pediatric, and specialist attending physician traditional care systems. These findings, in conjunction with adult hospitalist studies^12-18 showing similar improvements in LOS and total costs and similar preservation of quality outcomes, indicate that the argument for the value of pediatric hospitalist systems is both strong and sound.¹² Future research in this area should attempt to add new knowledge rather than replicate well-established findings. For example, future studies might help answer questions about the advantages and disadvantages of specific types of pediatric hospitalist models, why they work, and which patient populations are most or least likely to benefit from such systems.

A few studies have examined the experiences of medical students and house staff in hospitalist systems. Hospitalists have been rated highly as educators, compared with either traditional academic attending physicians or subspecialists.^19-24 Initial concerns regarding a decrease in students’ exposure to subspecialists and community pediatricians in some medical centers have been mitigated by strategies to give medical students exposure to faculty other than hospitalists during inpatient rotations. However it will be important to continue to ensure that trainees have varied attending types to learn from. The professional development of hospitalist educators is an important area, and more research is needed on the educational impact of the hospitalist model.²¹

Some studies have documented the experiences and attitudes of primary care physicians (those who refer patients to hospitalists) and subspecialists (those who serve as consultants to hospitalists) with regard to hospitalist models in adult medicine. These studies have found that some primary care physicians and subspecialists are concerned about the quality of care, teaching, and patient satisfaction provided by the hospitalist model,^25,26 but others are more positive about the model. One pediatric study found that community physicians and residents rated the hospitalist system as excellent, whereas subspecialty physicians rated it as average.²⁷ Another study of the initiation of a pediatric hospitalist service at a tertiary care children’s hospital found that community physicians were more ambivalent than specialty physicians; community physicians’ specific concerns included impaired communication and maintenance of long-term relationships with their patients.²⁸ As hospitalist models in pediatrics have become more prevalent and are now the dominant inpatient model of care in some hospitals, it appears that the acceptance of, and satisfaction with, hospitalist services have grown, while new challenges such as optimal communication and transitions of care are new areas of research.^29-32

While the body of research evaluating hospitalist systems has become far more robust, measuring quality of care remains a challenge for pediatric hospital medicine, as inpatient quality measures are still largely underdeveloped in pediatrics. The Institute of Medicine defines quality care as that which is effective, efficient, safe, patient centered, timely, and equitable¹³ (see Chapter 4 for further discussion). Evaluating quality involves measuring processes and outcomes of care.

Early studies of adults cared for by hospitalists focused on process measures and found that the quality of the care processes used by hospitalist and nonhospitalist systems is similar, but that hospitalist systems reduce LOS and costs, yielding more efficient care.^14,15

Process measures are particularly challenging in inpatient pediatrics, because few diseases have well-defined quality measures or strong evidence to link particular processes of care with improved outcomes. A notable exception is asthma, for which evidence-based quality metrics have been developed (e.g. the percentage of asthmatic children discharged from the hospital with an inhaled steroid). To measure quality of care using such a process marker, a hospital would need to measure the frequency with which children are sent home with inhaled steroids, ideally controlling for severity of illness and potential confounders. Early work has been conducted to study this particular measure (along with other process and outcome measures) in hospitalized children. One study of 30 children’s hospitals, examining three asthma process quality measures (use of relievers, use of systemic corticosteroids, and use of a written home asthma action plan), found no observed decrease in asthma readmissions within 30 days of being discharged.³³ Another single children’s hospital study, however, found that after an intense period of dissemination and implementation of evidence-based best practices there was a reduction in pediatric readmissions, but it took 9 months to observe this change, and only if the readmission time period was extended to 6 months (and not 30 days).³⁴