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Pediatric Predictions


 

In reflecting on the history of pediatric hospital medicine (HM), I have identified a widening schism between inpatient and outpatient pediatrics as the major threat to HM. Here, I follow Bob Wachter’s lead from SHM’s May annual meeting and detail key steps for pediatric HM in the upcoming 10 years.

Define the field: The SHM Pediatric Committee and the Ambulatory Pediatric Association’s (APA) hospital medicine special interest group are collaborating to publish a list of core clinical procedural and systems domains for pediatric hospital medicine.

This will provide a blueprint of how we have defined our field and supply a framework for pediatric acute care residency tracks, hospitalist electives, hospitalist fellowships, and maintenance of certification (MOC). Related characterizations of the field are available through pediatric hospital medicine textbooks. The Pediatric Research in Inpatient Settings (PRIS) network is studying the epidemiology of pediatric HM practice to provide an evidence basis for these expert decrees.

Individual programs should use these resources to help develop program-specific hospitalist privilege materials based on documented patient acuity, volume, and hospital medicine CME activities. The specific criteria and privileges will differ based on differences in job description between and within tertiary care centers and community hospitals—but all will include the general pediatric ward.

Develop MOC Appropriate for Pediatric Hospitalists: The American Board of Internal Medicine has officially approved the creation of a Focused Recognition of Hospital Medicine through its MOC system. A final decision rests with the American Board of Medical Specialties.

Pediatric hospitalists will do well to wait several years to examine the results of these efforts before deciding whether to pursue a similar designation from the American Board of Pediatrics. In the meantime, we should be on a fast track to create specific pediatric HM materials that will meet the 2010 MOC requirements.

There are at least 1,500 practicing pediatric hospitalists. This is equal to the number of board-certified pediatric ED physicians (1,446) and considerably more than the number of pulmonologists (821). Certainly these numbers merit development of MOC materials specifical to pediatric HM. The American Academy of Pediatrics (AAP) is developing an inpatient Education in Quality Improvement for Pediatric Practice (eQIPP) asthma model. SHM may be able to develop a transitions-of-care personal information manager and/or self-evaluation program (SEP) module appropriate for adult and pediatric hospitalists.

The only things missing are a comprehensive inpatient SEP and a closed-book exam. Pediatric hospitalists are here to stay. The American Board of Pediatrics (ABP) will best fulfill its responsibility to the public by creating an MOC program germane to pediatric HM. The actual designation on the MOC doesn’t need to be changed in 2010, but hospitalists recertifying in 2010 should be participating in relevant activities.

Expand pediatric HM (post-) graduate medical education: The increasing number of hospitalists will undoubtedly influence pediatric graduate medical education.

The ABP’s Residency Review and Redesign in Pediatrics project, which looks at global reform of pediatric residency training, should allow for acute care pediatric residency tracks. These would be amenable to pediatricians planning careers in HM, emergency medicine, and critical care.

Overall, most pediatric hospitalists will continue to begin their careers directly out of residency. Although pediatric hospitalist fellowship programs are likely to increase in number, formal fellowship training will not be required for one to practice as a pediatric hospitalist. These programs will benefit individuals choosing either an academic or administrative career. Frontline hospitalists should be able to gain suitable experience through appropriately mentored and supported clinical practice and focused CME activities—much as a new office-based pediatrician matures during his or her initial years in practice.

Publish, publish, publish: Success within the academic and research environment is crucial to being viewed as equal among subspecialties.

Perceptions of our field improve with each paper published in Pediatrics and the Journal of Hospital Medicine and each plenary presentation at a national meeting. Within our professional community, writing articles for The Hospitalist and the AAP Section on Hospital Medicine newsletter and presenting our work in poster form or hospitalist platform presentation advances knowledge and creates group identity.

Additionally, these activities promote the pediatric HM group and the authors. Some of us have made a career out of LISTSERV postings.

Continue to grow PRIS: We must all contribute to the growth of PRIS over the next decade.

Ultimately, PRIS promises to answer clinical questions faced by hospitalists the same way the Vermont Oxford Network helps neonatology and the Pediatric Emergency Care Applied Research Network helps pediatric emergency medicine. Academic hospitalists can use PRIS to pursue their research interests. Community hospitalists can pick and choose from available projects to identify a study relevant and suitable for them. We all must participate.

My hope is that in 10 to 20 years PRIS will coordinate randomized, controlled clinical trials and universal, integrated, HIPPA-compliant, electronic medical record systems that facilitate real-time analysis of outcomes and practice variation.

Own our diseases: Defining The Core Competencies in Hospital Medicine: A Framework for Curriculum Development, creating a research base, and publishing must lead to the recognition of pediatric hospitalists as the experts for a core set of illnesses.

Potential starting points include bronchiolitis, the ruling out of sepsis in less than 30 days, apparent life-threatening events (ALTE), and the medically complex/technologically dependent child. We’ll know we’ve hit it big when the nationally recognized speakers and authors on these topics identify themselves as hospitalists rather than infectious disease physicians or pulmonologists. For this to occur, hospitalists must participate in research efforts, speak at regional and national meetings, and participate on national consensus panels.

On a purely local program level, individual physicians within a hospital medicine group should cultivate areas of clinical, administrative, and educational expertise. This is particularly valuable in community hospital settings where pediatric infectious disease or pulmonary specialists may not be available—but is equally important to career development in larger academic centers where hospitalists are ideal for quality improvement, safety, and educational roles.

Identify and publicly report national benchmarks: Our adult colleagues suffer and benefit from the public reporting mandated by the Centers for Medicare and Medicaid Services. One hopes the adult tribulations with data collection, attribution, and risk adjustment will make pediatric public reporting easier.

The wide variation in management of ALTE, osteomyelitis, and complicated pneumonias documented by Pediatric Health Information System researchers at the Toronto Pediatric Academic Societies meetings is a clarion call for evidence-based medicine. Parents have a right to make an informed choice about where and how their child is treated based on reliable data. Rational expenditure of limited State Children’s Health Insurance Program (SCHIP) funds requires practicing evidence-based medicine

Pediatric quality measures and standards are being developed through the National Quality Forum as well as the Alliance for Pediatric Quality. This movement will significantly affect pediatric HM. On the positive side, reporting will require that more resources be devoted to pediatric quality improvement (QI) efforts. Pediatric hospitalists are ideally suited to lead inpatient QI efforts. Creation of a hospitalist physician specialty identification code will facilitate comparison of hospitalist with non-hospitalist care in large multicenter data sets. These studies will be key descriptors of the cost and quality outcomes of pediatric HM programs.

Public reporting will highlight variation among hospitals, programs, and, possibly, physicians. Parents and payers will vote with their feet. Overall, this will create less variation in care as best practices are identified and adopted. Shortcomings will be revealed in programs that fail to practice state-of-the-art pediatrics or that are inadequately staffed from either the physician or nursing perspective. This likely will result in a consolidation of pediatric care. Smaller units closer to larger pediatric centers probably will close or become affiliates of the referral center. Geographic proximity will be a secondary concern to outcomes for parents and office-based pediatricians.

The methodological and political considerations of pay for performance are beyond most of us. Nonetheless, we in pediatric HM can begin to prepare for these changes by identifying the benchmarks that highlight our successes and failures as hospitalists, groups, hospitals, and the field as a whole. Potential clinical, quality, economic, and logistic metrics include severity-adjusted lengths of stay (LOS) for asthma and bronchiolitis, readmission rates, time to antibiotics for ruling out sepsis less than 30 days, patient and referring physician satisfaction, and coordination of transitions of care.

Expand children’s health insurance: SCHIP and universal insurance for children enjoys significant support.

The AAP’s efforts in this area deserve praise and demand continued support. As noted previously, large public expenditures on SCHIP likely will be linked to public reporting of outcomes. It is crucial to the economic viability of pediatrics that SCHIP reimbursement is equivalent to Medicare reimbursement on a code-for-code basis. It is indefensible to suggest that we as a nation value the care of children less than the care of the elderly.

Ultimately, SCHIP and state Medicaid programs would do well to move beyond a per diem-based system of reimbursement for pediatric inpatient care to a system based either on diagnosis-related groups (DRGs) or disease episodes. This would benefit HM programs by rewarding hospitals that can shorten LOS while providing the same high-quality outcomes. Current per diem reimbursement paradigms at best fail to maximally encourage efficiency and at worst create perverse incentives to prolong LOS.

Relentlessly pursue career satisfaction: Many programs are asking pediatric hospitalists to work at a clinical pace not sustainable over a 20- to 30-year career. Particularly efficient programs can produce burnout in one to three years of excessive workloads and call obligations.

SHM’s “A White Paper on Hospitalist Career Satisfaction” identifies four pillars: reward/recognition, workload/schedule, autonomy/control, and community/environment. (Each pillar has been featured in the “Career Development” section, starting with the June issue.) In pediatrics we can turn to neonatology, pediatric critical care, and (pediatric) emergency medicine for help in establishing realistic guidelines for clinical hours in house.

The harder question to answer is: What is a reasonable number of patients for a hospitalist to cover at a time? This depends on patient acuity, patient and family expectations, teaching responsibilities, hospitalist responsibilities outside the ward, and physician style. It is unlikely that prospective randomized controlled trials will be conducted to answer this question. The answer is likely to come from individual programs, hospitalists, and—regrettably—patients suffering the consequences of pushing the limits too far. We will learn from our mistakes. Failed models will not be repeated. To the extent that quality rather than economics becomes the overriding driver for HM programs, I favor 15 encounters per hospitalist per day over 20.

Hospitalists also must diversify beyond pure clinical practice for long-term career satisfaction. Focusing on a specific clinical interest, subspecialty, or practice environment can provide some variety.

Teaching and research is another source of career satisfaction. Each hospitalist within a group should be involved in at least one QI project and/or committee—if only to appreciate the importance and complexity of a systems approach to improving overall outcomes. Job descriptions must include protected time for these nonclinical activities. Career growth and satisfaction will be stifled without these additional outlets.

Expand beyond traditional roles: The push for improved quality will lead to expanded roles for pediatric hospitalists—some of which may be unwelcome.

In particular, larger programs will move to 24/7 in-house hospitalist presence. Given the acuity and complexity of the patients we care for, particularly in tertiary care centers, the quality argument for 24/7 in-house coverage will quickly trump the economic argument against it. The choice is obvious in terms of quality and safety and from the perspective of the most important “decider” when it comes to healthcare—the patient.

As educators exploit the opportunities of 24/7 coverage, resident teaching will increase and academic hospitalists will master the art of promoting autonomy 24/7 while providing appropriate supervision. If we learned to teach with family-centered rounds, we can learn to teach at 3 a.m.

In addition to expanded hours, we will follow the lead of adult hospitalists and increase our co-management role beyond the traditional general medical patient on the hospitalist service. This will include surgical and subspecialty patients. From the patient’s and family’s perspective the improved care that can result is valuable. It may not be necessary for every patient or for every surgeon or subspecialist, but on the whole hospitalists provide added value.

Within individual programs and among various physicians, the rules of engagement will need to be defined to promote collegial, respectful relationships with clear lines of communication and defined clinical responsibilities. “Inappropriate behavior” from “difficult” physicians (surgeons, subspecialists, and hospitalists) will need to be addressed. Specific arrangements will need to be defined (co-management versus specialist/surgeon attending with hospitalist consultation or hospitalist attending with specialist/surgeon consultant). But once the rules of engagement are established and appropriate resources allotted, it becomes impossible for hospitalists to argue that it’s not within our job description to contribute to improved quality of care for hospitalized patients. Improving patient care is not scutwork.

In particular, given the limited availability of pediatric sub-specialists and surgeons, to the extent that we as hospitalists can increase the efficiency of our subspecialty and surgical colleagues, we can improve access to pediatric subspecialty care within both the inpatient and outpatient settings These manpower issues will also drive involvement of pediatric hospitalists into other parts of the hospital such as sedation services, the ED, the NICU, and PICU. As these other services become vocal advocates for pediatric hospitalists, the economic viability of pediatric hospital medicine programs will increase.

Make the economic argument for value-added services: Pediatric hospitalists must do better at the economic arguments of value-added services.

Until pediatric inpatient stays are reimbursed on a DRG basis or physician charges are based on a global fee, we most move beyond the simple formulation of decreased costs for inpatient stays. We must highlight the value of our critical roles in coordination of care; quality and safety; 24/7 coverage; improved throughput in the emergency department (ED), ward, and PICU; and increased efficiency for surgeons and subspecialists.

Success for pediatric HM in these arenas will come only at the cost of failed individual programs. As implied above, it is only natural for non-hospitalist administrators and department leaders to push the limits of hospitalist programs to the maximum. Programs that place excessive demands on hospitalists will implode. Good hospitalists will leave for positions that offer them respect, autonomy, and a reasonable workload and lifestyle. Small community programs with low-volume services may not be economically viable. As we develop a history of successful programs and failed programs, hospitalists and administrators will have more realistic expectations of the ingredients of success.

Conclusion

Programs that meet the above challenges will succeed. Pediatric HM is a tremendously rewarding and challenging field. National recognition of pediatric HM as a unique field combined with the respect of local pediatricians, subspecialists, and surgeons will create the pride and ownership among hospitalists necessary for us to raise the bar for standards of inpatient care.

Public reporting will provide the external pull for the same high-quality outcomes. Divisions of HM led by hospitalists in which each hospitalist has an additional clinical, administrative, or academic focus will create the workload, autonomy, and diversity necessary for long-term career satisfaction and support the research and QI activities necessary for the evidence-based practice of high-quality pediatric inpatient care by hospitalists and non-hospitalists alike. Universal access, economic parity with Medicare, and a full understanding of the value-added nature of pediatric hospital medicine practice will provide the margin necessary for this mission. It will be a challenging but rewarding 10 years. TH

Dr. Percelay is SHM’s treasurer and a pediatric hospitalist.

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