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REVIEW ARTICLE |
a Department of Medicine, Children's Hospital Boston
b Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
c Robert Wood Johnson Foundation Clinical Scholar Program, University of Pennsylvania, Philadelphia, Pennsylvania
d Department of Pediatrics, University of Utah Health Sciences Center, Salt Lake City, Utah
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OBJECTIVE. Our aim was to determine the effects of pediatric hospitalist systems on length of stay, costs, quality of care, and provider satisfaction and experience.
METHODS. We searched PubMed, Medline, Cochrane Library databases, and the Pediatric Academic Societies National Meeting research abstracts for all primary-data studies published or presented on pediatric hospitalist systems. Studies presenting primary data on efficiency, financial performance, clinical outcomes, or family, referring provider, and housestaff experience in hospitalist systems were included; review articles and case studies were excluded. To minimize publication bias, we contacted all primary authors to obtain information about unpublished studies.
RESULTS. Of 47 publications reviewed, 20 were primary-data studies that met criteria for inclusion. Six of 7 studies that compared traditional and hospitalist systems of care demonstrated improvements in costs and/or length of stay in pediatric hospitalist systems. The average decrease in cost was 10%; average decrease in length of stay was 10%. Three of 3 economic analyses, however, demonstrate that efficiency gains do not generally translate into revenues for the hospitalist programs themselves; most hospitalist programs are currently losing money. Surveys of families, referring providers, and pediatric residents demonstrate neutral or improved experiences in hospitalist systems, although these data are less comprehensive. Data on quality of care are insufficient to draw conclusions.
CONCLUSIONS. Emerging research suggests that pediatric hospitalist systems decrease hospital costs and length of stay without adversely affecting provider, parent, or housestaff experiences. The quality of care in pediatric hospitalist systems is unclear, because rigorous metrics to evaluate quality are lacking. Studies of the processes and outcomes of hospital care are needed.
Key Words: hospitalist • pediatrics • systematic review • health services research • research network • levels of evidence
Abbreviations: SHM—Society of Hospital Medicine • LOS—length of stay • PRIS—Pediatric Research in Inpatient Settings • PCP—primary care provider
Over the past 8 years, pediatric hospitalist systems have become prominent across the United States and Canada. In 1999, 50% of pediatric department chairs in academic centers reported that hospitalists worked in their institutions, only 3 years after the term "hospitalist" was coined,1 and another 27% expected to hire them in the next several years.2 From 1997 to 2004, the membership of the Society of Hospital Medicine (SHM) grew from <100 to >4000,3 and the SHM estimates that nearly twice that many hospitalists may be in practice.4, 5 Over the next 10 years, workforce needs may require between 10000 and 30000 hospitalists in the United States if health care systems continue adopting the hospitalist model.6
Eight percent of SHM members, or 
300, are pediatric hospitalists; the absolute number of pediatric hospitalists has increased rapidly as SHM has grown. On the basis of these data and extrapolations similar to those made by the SHM, it would be reasonable to suspect that between 500 and 1000 pediatric hospitalists are now in practice in the United States, although no formal counts have been made. By 2014, there could be as many as 2000 to 3000, which is comparable in size to the neonatal-perinatal workforce.7
In 1998 researchers began examining the effects of hospitalist systems on the quality and efficiency of inpatient pediatric care. Although many questions regarding the overall value of pediatric hospitalists remain unanswered,8 multiple studies have been conducted in the past 7 years that have measured diverse aspects of pediatric hospitalists' value. To better understand the effect of pediatric hospitalist systems, we therefore conducted a systematic review of the literature that focused on the following key outcomes: length of stay (LOS), inpatient costs, overall quality of care, patient experience of care, provider satisfaction, and housestaff educational experience. In addition, we evaluated studies of the distribution of costs and benefits within pediatric hospitalist systems, because assessment of inpatient costs alone may misrepresent the many potential financial effects of pediatric hospitalist systems.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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All publications that reported primary data on outcomes of interest (measures of care efficiency; clinical outcomes; finances; and patient, family, provider, and housestaff experiences) in pediatric hospitalist systems were included in the review. Publications that did not include significant primary data such as commentaries or case reports were excluded. Studies that were focused solely on adult hospitalist systems were excluded, but pediatric data from studies that included both pediatric and adult hospitalist systems were included. Information on study design and patient populations was extracted. Systematic meta-analyses were not performed because of the absence of randomized, controlled trials that compared hospitalist systems with traditional systems and a diversity of study designs.
The quality of each study was rated by using the Oxford Centre for Evidence-Based Medicine levels of evidence.9 This system defines levels of evidence to be used in rating studies, from 1a (homogeneous systematic reviews of randomized, controlled trials with narrow confidence intervals) through 5 (expert opinion). Well-conducted "outcomes" studies using administrative data receive a rating of 2c; those with wide confidence intervals (small sample sizes) or flawed methodology are appended with a minus sign. To provide readers with additional understanding of the quality of each study, we supplemented the Oxford Centre ratings with information on the size of studies, whether the study cohorts had concurrent or historical controls, and how the patient populations studied were case-mix–adjusted. Because the Oxford Centre levels of evidence are not specifically designed to evaluate survey studies, survey studies were not assigned a formal evidence level.
The strength of evidence underlying conclusions about hospitalists' effects on key outcomes was ranked by using the Oxford Centre's grades of recommendation. Grade A recommendations are provided when a key outcome has been demonstrated consistently using well-conducted randomized, controlled trials (level 1 studies); grade B recommendations are provided if conclusions are derived directly from consistent level 2 or 3 studies; grade C recommendations indicate that recommendations come from extrapolations from cohort or case-control studies or from poor-quality studies; and grade D recommendations are given when studies of any level regarding a key outcome are troublingly inconsistent or inconclusive.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Health Service Use
Six of 7 studies that compared hospitalist systems to traditional systems in which primary pediatricians served as the attending physician of record found that hospitalist systems decreased hospital LOS and/or inpatient hospital costs.10–16 Costs considered in each of these studies were limited to costs to the health care system as a whole for inpatient services provided; this measure tends to closely parallel LOS. The average decrease in cost was 10% (range: 4–16%); the average decrease in LOS was 10% (range: 6–15%); the level of evidence of most of these studies of LOS and inpatient costs was 2c. A detailed description of each study is provided in Table 1. The only pediatric study that reported no efficiency gains in a hospitalist system was a study by Seid et al16 of 722 children (462 in the hospitalist group, 260 in the comparison group) admitted with bronchiolitis and asthma. However, the small size of this study limited power to detect 10% to 15% differences, and both groups strictly adhered to hospital clinical practice guidelines for the management of bronchiolitis and asthma, which may have minimized any differences (level of evidence: 2c–).
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Economics
Several studies to evaluate costs and revenues in pediatric hospitalist systems have been conducted. Melzer et al20 showed that an academic pediatric hospitalist program in the Northwest lost money when caring for an average of 7 patients per day, because compensation for billable services did not equal faculty salaries and other operating expenses of the service. They determined that to cover costs and expenses in a comparable financial market with a similar patient population, a faculty hospital service would need to maintain an average daily census of 9 patients (level of evidence: 2c; economic study with sensitivity analyses).
Tieder et al21 found that expanding the role of hospitalists to include the care of well newborns did not result in financial health for a hospitalist program at a community pediatric hospital. With an average daily census of 7.6 well newborns in addition to 2.9 inpatients, the program continued to lose money, with reimbursements only covering 60% of annual expenses. It is notable that an unpublished analysis indicated that the hospitalist programs could become profitable over time by increasing the average daily census, adding professional services, and expanding the consultative service (level of evidence: 3c; pilot economic study with sensitivity analyses).
In a survey of 40 hospitals conducted through the Pediatric Research in Inpatient Settings (PRIS) network, Chiang et al22 recently found that a minority of pediatric hospitalist programs make money, as the work of Melzer et al20 suggested might be the case. Only 11% of the programs reported making money compared with 39% that lost money; the remainder reported breaking even. Eighty-nine percent of hospitalist programs reported the need for external or additional funding for support, with the hospital or pediatrics department being the most common sources of external funding. Many hospitals were reportedly willing to support hospitalists because they believed that hospitalists' efficiency yielded cost savings to the hospital.
Quality of Care
Limited data have been collected on quality of care in pediatric hospitalist systems. Although 2 adult studies have found decreased mortality in hospitalist systems,23, 24 the only pediatric study to have demonstrated a difference in mortality compared a hospitalist-staffed model of care delivery in an ICU setting to a traditional resident-staffed model. In this study of 1211 patients at the University Hospital in San Antonio, Texas, Tenner et al19 found improved survival in the PICU when hospitalists, rather than residents, provided after-hours care. The unadjusted mortality rate was not significantly different, but the predicted mortality rate was expected to be higher during the hospitalist era, given the higher severity of illness during that time. The adjusted odds ratio of survival was 2.8 for the hospitalist era compared with the resident era (P = .01) (level of evidence: 2c). Mortality in pediatric hospitalist systems compared with traditional systems has been assessed in many of the studies of care efficiency cited above,10–12, 14 but these studies have been universally underpowered to detect differences and have found none (level of evidence: 2c–).
In regards to readmission rates, a study by Bellet and Whitaker10 in Cincinnati, Ohio, found that when hospitalists were used, the 10-day readmission rate increased from 1% to 3% (P = .006), but no other study that measured readmission rate has replicated this finding. These studies have generally been adequately powered to detect a tripling of readmission rates but underpowered to detect smaller but still clinically important differences (level of evidence: 2c–).11, 12, 14 Studies comparing processes of care in hospitalist and traditional systems, such as compliance with evidence-based practices for individual diseases, are lacking.
Parent and Provider Experience of Care and Follow-up
Three of 3 studies of parental experience of care demonstrated unchanged to improved ratings in hospitalist systems. Wells et al13 found that 190 parents surveyed at discharge rated hospitalists as more courteous (P < .05) and friendly (P < .005) than PCPs with no significant difference between the groups on 5 other measures of satisfaction. When the same survey was administered 1 month after discharge, however, advantages for the hospitalists were no longer apparent; in fact, the only significant difference at that time was a higher rating of "explanations" given by PCPs (P < .05). The Boston health maintenance organization study11 found significant improvements in 377 parents' ratings of overall care (P = .02), time spent discussing care with the doctor (P = .01), and coordination of information among providers (P = .02) after implementation of the hospitalist system. Ratings improved nonsignificantly for 8 of the 9 remaining items regarding inpatient care experience. Concurrent comparison groups that did not introduce hospitalist systems showed no comparable improvement in parental ratings over the same time period. In a survey of an undefined number of parents, Ogershok et al14 found that parents' rating of care remained uniformly favorable in both the hospitalist and traditional systems with no significant differences between the 2 services; the absence of data regarding the number of parents surveyed, however, makes the power of this study to detect differences unclear.
In 5 of 5 studies pediatric PCPs have rated quality of care favorably in hospitalist systems. Three of these studies found that approximately half or more of PCPs believed that quality of care was improved in hospitalist systems compared with traditional systems; the other 2 studies did not provide comparative data. PCPs' career satisfaction and income in hospitalist systems have been unchanged or improved.14, 25–28
In a study by Fernandez et al25 of 524 California PCPs (including pediatricians) who worked in hospitalist systems, 53% of pediatricians responded that hospitalists increased the overall quality of patient care. Pediatricians were more likely than internists to view hospitalists as either beneficial or neutral to quality of care (odds ratio: 5.0; 95% confidence interval: 1.6–5.6) and patient satisfaction (odds ratio: 3.2; 95% confidence interval: 1.5–6.9).
A study by Percelay et al27 of 654 pediatricians practicing in office- or clinic-based settings found that of those using hospitalists, 68% reported that hospitalists increase overall quality of patient care, 87% are satisfied with the care provided by hospitalists, and 83% believe their patients are satisfied with the care. Seventy-eight percent agree that hospitalists make office practice more manageable and predictable. Forty-three percent responded that the use of hospitalists improves career satisfaction by allowing specialization in ambulatory pediatrics, whereas 20% said that limited direct inpatient involvement diminishes career satisfaction. Fifty-three percent indicated that attending on inpatients takes too much time away from office practice.
In a survey of 313 community physicians by Srivastava et al,28 45% agreed that caring for hospitalized patients is an inefficient use of time, and 49% reported that use of a hospitalist service improves quality of care for inpatients. Ninety-eight percent of community pediatricians felt less comfortable caring for inpatients than outpatients.
PCPs were found to be satisfied with 2 other hospitalist systems, but these studies did not provide comparative data, which weakens their conclusions. Ponitz et al26 surveyed 100 community pediatricians (precise number not provided: "more than 200 community physicians were surveyed ... approximately 50% of surveys were returned"), who rated the hospitalist service >4.5 on a scale from 1 to 5 (5 most favorable) in terms of quality, access, and collegiality. Ogershok et al14 found that general pediatricians rated the hospitalist system >4 on a scale from 1 to 5 (5 most favorable) in improving efficiency, inpatient care, and allowing outpatient physicians to spend more time with their patients. The sample size in this survey was extremely small, however (only 7 general pediatricians were surveyed), greatly limiting its data even beyond the absence of a comparison group.
Two studies have shown that rates of posthospitalization follow-up did not decrease in hospitalist systems (level of evidence: 2c).11, 13 However, the Percelay et al survey27 found that 45% of pediatricians felt that continuity of care decreased with the use of hospitalists.
Housestaff Educational Experience
In 4 of 4 studies, housestaff rated their educational experience in hospitalist systems as favorable or improved, although most have been small. A study in Boston of house officers that used 2 survey instruments (130 responses to first survey, 371 responses to second survey) found that interns' overall rating of general pediatric ward rotations improved significantly after the introduction of a hospitalist system. Interns' ratings of their skills, knowledge, experience, and quality of life also improved. Senior residents' ratings showed no significant change. Housestaff ratings of teaching and supervisory skills were generally higher for hospitalists than for traditional attending physicians.29
Ponitz et al26 found that 30 surveyed residents (64 pediatric residents were surveyed; 50% of surveys were returned) rated the hospitalist system >4 on a scale from 1 to 5 in terms of quality, access, and collegiality. Ogershok et al14 found that 29 surveyed residents rated hospitalists >4 on a scale from 1 to 5 for improving medical student and housestaff education, easier access to attending physicians, improving efficiency of ward rounds, and creating better inpatient care.
At Valley Children's Hospital in California, a survey of an unspecified number of residents found that their average evaluation scores for the inpatient rotation increased after the introduction of a new model in which hospitalists were responsible for supervising and teaching residents at the bedside whenever complex new patients were admitted after hours, as well as screening admissions to the teaching service based on educational value and case mix.30
In addition, a survey of 313 physicians with medical staff privileges at a tertiary care pediatric teaching hospital found that 58% of community physicians and 78% of faculty physicians agreed that hospitalists may be more effective teachers for housestaff and medical students.28
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Patient, provider, and housestaff experience in hospitalist systems has generally been favorable. Studies suggest that a subset of PCPs, however, are concerned with the effects of hospitalist systems on career satisfaction and economics in private practice.
Few data on outcomes of care in hospitalist systems have been collected. One study has demonstrated decreased mortality when hospitalists compared with residents cared for ICU patients,19 but these findings have not been replicated and represent an atypical practice setting for hospitalists, whose work generally takes place on the inpatient wards. Ten-day readmission rates increased from 1% to 3% in a hospitalist system in Cincinnati10 but were unchanged in 3 larger studies.11, 12, 14 It is unclear, therefore, if the increase in readmission rates in the Cincinnati study was idiosyncratic. Substantial questions regarding subtler markers of health care quality remain, and consequently no firm conclusions about quality of care in pediatric hospitalist systems can be drawn.
Our findings are generally similar to those from a systematic review by Wachter and Goldman31 that focused on hospitalists' care of adult inpatients. Wachter and Goldman found efficiency of care to be improved in 17 of 19 studies conducted, for an average reduction in cost of 13.4% and an average reduction in LOS of 16.6% across all systems studied. Three of the studies considered in this systematic review investigated pediatric hospitalist systems; the remainder concerned adult systems. This study also found that education might be improved in hospitalist systems, patient satisfaction was preserved, and PCPs were generally satisfied. As in our study, no firm conclusions regarding clinical outcomes could be made, although some adult studies have shown improved mortality and readmission rates.23, 24
To place the demonstrated pediatric efficiency gains in context, we found that on average, 0.3 days and several hundred dollars are saved per patient by the introduction of pediatric hospitalist systems. Multiplication of such a decrease by 1000 general pediatric inpatients per year (a typical annual census for an inpatient pediatrics service) yields an annual cost savings to the health care system of several hundred thousand dollars. Who accrues these savings, however, and how they balance with the costs of hospitalist systems is complex and varies by market, as observed in the studies of hospitalist system economics. Although hospitalist systems have been found to increase the efficiency of hospital care, it is not necessarily the case that these efficiency gains benefit all parties equally.8 Limited data suggest that hospitalist programs themselves usually do not benefit financially from the efficiencies they may produce.
A limitation of our study was our inability to conduct formal meta-analyses, given the absence of randomized studies and variability in methodology between studies. Despite this limitation, however, the demonstrated decreases in LOS and costs across diverse settings strongly suggest that pediatric hospitalist systems improve care efficiency. In light of the consistency of this finding, and even more importantly, the reality that hospitalist systems have now been widely adopted nationwide (in many cases regardless of the scientific evidence),2 we believe that additional studies of LOS and costs in hospitalist versus traditional systems would be of limited utility. Future studies should focus instead on the most pressing knowledge gap regarding pediatric hospital medicine: quality of care.
Within the field of hospital medicine as a whole, a major limitation of work to date has been the absence of data on quality. Few interventions are likely to have a measurable impact on mortality in a pediatric ward setting, and more sensitive indicators of care quality are lacking. Pediatrics suffers from a lack of rigorous trials evaluating treatments typically used in the management of even the most common inpatient conditions.32 Consequently, measuring the quality of inpatient pediatric care is a difficult exercise, because what constitutes high-quality care for many conditions remains unclear.
To improve the quality of inpatient care, pediatric hospitalists must begin to systematically collect data on inpatient care processes and outcomes. Despite their high prevalence, little is known about the optimal workup and treatment of even the most common pediatric inpatient conditions such as bronchiolitis, gastroenteritis, gastroesophageal reflux, and complex pneumonia. Many of these conditions have not been well studied historically because of the infrequency with which they lead to death or other severe, easily measured adverse outcomes. In addition, many therapies (for example bronchodilators in the treatment of bronchiolitis) convey relatively subtle benefits, if they convey any benefit at all, that are difficult to definitively detect or exclude in single-center studies.
A critical next step in the hospitalist research agenda should be to address the absence of large multicenter studies and well-conducted trials evaluating therapies commonly used in inpatient pediatrics. To facilitate the completion of such studies, the American Academy of Pediatrics, the Ambulatory Pediatrics Association, and the SHM have worked together to create the PRIS network. More than 80 hospitals and 200 hospitalists have participated in early studies conducted through the PRIS network. The mission of PRIS is to improve the care of hospitalized children and the quality of inpatient practice by developing an evidence base for inpatient pediatric care. Initial work has investigated variability in the diagnosis and treatment of common pediatric illnesses. Ongoing research efforts are beginning to investigate the effectiveness of specific therapies to help guide inpatient clinical decision-making. As practitioners in an emerging field, pediatric hospitalists have a unique opportunity to take leadership roles in the improvement of pediatric hospital medicine, by participating in studies of inpatient care quality, and translating the results of this research into practice.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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ACKNOWLEDGMENTS |
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We thank Dr Bob Phillips from the Oxford Centre for Evidence-Based Medicine for assistance in applying the center's levels of evidence to the studies reviewed in this article.
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FOOTNOTES |
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Address correspondence to Christopher P. Landrigan, MD, MPH, Children's Hospital Boston, Department of Medicine, Hunnewell 3, 300 Longwood Ave, Boston, MA 02115. E-mail: christopher.landrigan{at}childrens.harvard.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This article has been cited by other articles:
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  A. Bekmezian, P. J. Chung, and S. Yazdani Staff-Only Pediatric Hospitalist Care of Patients With Medically Complex Subspecialty Conditions in a Major Teaching Hospital Arch Pediatr Adolesc Med, October 1, 2008; 162(10): 975 - 980. [Abstract] [Full Text] [PDF]
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 C. E. Beck, P. C. Parkin, and J. N. Friedman Pediatric Hospitalist Medicine: An Overview and a Perspective From Toronto, Canada Clinical Pediatrics, July 1, 2008; 47(6): 546 - 548. [PDF]
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 M. V. Williams Hospitalists and the Hospital Medicine System of Care Are Good for Patient Care Arch Intern Med, June 23, 2008; 168(12): 1254 - 1256. [Full Text] [PDF]
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J. S. Tieder, D. S. Migita, C. A. Cowan, and S. M. Melzer Newborn Care by Pediatric Hospitalists in a Community Hospital: Effect on Physician Productivity and Financial Performance Arch Pediatr Adolesc Med, January 1, 2008; 162(1): 74 - 78. [Abstract] [Full Text] [PDF]
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S. E. Krug and M. Gausche-Hill When There Is "No Room at the Inn": Potential Solution for Overcrowding in a Tertiary Pediatric Center Arch Pediatr Adolesc Med, September 1, 2007; 161(9): 911 - 913. [Full Text] [PDF]
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 R. Srivastava, C. P. Landrigan, D. Ross-Degnan, S. B. Soumerai, C. J. Homer, D. A. Goldmann, and S. Muret-Wagstaff Impact of a Hospitalist System on Length of Stay and Cost for Children With Common Conditions Pediatrics, August 1, 2007; 120(2): 267 - 274. [Abstract] [Full Text] [PDF]
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 B. Pate A Systematic Review of Pediatric Hospitalists AAP Grand Rounds, August 1, 2006; 16(2): 21 - 22. [Full Text] [PDF]
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 Hospitalists and Pediatric Care Journal Watch Pediatrics and Adolescent Medicine, May 26, 2006; 2006(526): 9 - 9. [Full Text]
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 Hospitalists and Pediatric Care Journal Watch (General), May 12, 2006; 2006(512): 7 - 7. [Full Text]
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