PEDIATRICS Vol. 117 No. 5 May 2006, pp. 1736-1744 (doi:10.1542/peds.2005-0609)
REVIEW ARTICLE |
Pediatric Hospitalists: A Systematic Review of the Literature
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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BACKGROUND. Systematic reviews have demonstrated consistently decreased length of stay and costs in internal medicine hospitalist systems. Systematic reviews of pediatric hospitalist systems have not been conducted.
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 To minimize publication bias, we contacted all primary authors to obtain information about unpublished studies.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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Three reviewers (C.P.L., P.H.C., and S.E.) independently searched PubMed, Medline, Pediatric Academic Societies annual meeting research abstracts, and the Cochrane Library databases from July 1996 through January 2005 to identify all studies of pediatric hospitalists using the key words "hospitalist," "hospitalists," "hospital medicine," "pediatric," and "pediatrics." In addition, the first authors of all primary-data studies were contacted and asked to provide unpublished data or additional unpublished studies or abstracts to minimize the problem of publication bias. From the 3 reviews of the literature and abstracts, and from the information provided by authors, we compiled an inclusive list of candidate studies for the systematic review. If abstracts later led to peer-reviewed manuscripts, only the manuscripts were considered in our analysis.
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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Our search resulted in 47 publications in article or abstract form, 20 of which were primary-data studies and met the criteria for inclusion in our systematic review. Contact with all primary authors identified no additional studies that had not been published at least in abstract form. The 27 excluded publications consisted of case studies of individual programs, nonsystematic reviews of pediatric hospitalists, and commentaries on pediatric hospitalist systems. Ten of the included studies examined inpatient costs, LOS, efficiency of care, and/or clinical outcomes; 3 examined the economic consequences of introducing hospitalist systems; 5 examined primary care provider (PCP) experiences in hospitalist systems; 4 examined housestaff experiences; 3 examined parent experiences; and 1 evaluated pediatric department chairs' experiences and understanding of hospitalist systems. Several studies examined >1 aspect of a hospitalist system and therefore are included more than once in this summary list.
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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In addition to the studies that compared hospitalist and traditional PCP models of care delivery, hospitalists' care has been compared with that of subspecialists and care that involved physicians-in-training (Table 2). Maggioni et al17 in Miami, Florida, retrospectively compared severity-adjusted care by hospitalists and subspecialists of 10231 admissions (3958 in the hospitalist group, 6273 in the subspecialist group) with the 20 most common inpatient diseases and found that hospitalist care was associated with a 20% lower LOS (3.81 vs 4.77 days) and 31% lower costs ($10529 vs $15380) (level of evidence: 2c). In a study of 3807 patients at the Hospital for Sick Children in Toronto, Ontario, Canada, Dwight et al18 compared a hospitalist service that included residents working with hospitalists (2533 patients) to a hospitalist service with no residents (1274 patients) and found that median LOS was 14% (from 2.9 to 2.5 days; P = .04 on multivariate analysis) lower for the hospitalist service without residents (level of evidence: 2c). Tenner et al19 found that adjusted LOS for 1211 patients (596 in the resident era, 615 in the hospitalist era) in the ICU decreased by 21.1 hours (P = .013, multivariate linear regression) when hospitalists rather than residents provided after-hours care (level of evidence: 2c).
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Limited data suggest that beyond the issue of total hospital costs and LOS, resource use in hospitalist systems may be lower than in traditional models of care. Ogershok et al14 at West Virginia University found in a study of 2177 patients (1078 admitted to the traditional ward service, 1099 admitted to the restructured ward service) that there were fewer chemistry (5 vs 7 [28.5%]; P = .004), hematology (2 vs 3 [33%]; P = .001), and radiology (0.8 vs 1 [20%]; P = .001) tests ordered per patient in a hospitalist system than in a traditional ward service (P < .005) as well as a significant decrease in respiratory therapy costs ($106 vs $179 [40.7%]; P = .001) (level of evidence: 2c). Wells et al13 found a reduction in pharmacy ($405 vs $673 [39.8%]; P < .05) and radiologic ($80 vs $114 [29.8%]; P < .05) charges for children who were admitted for asthma in the hospitalist service, although there were no significant differences for 3 other diagnoses (level of evidence: 2c). The Boston health maintenance organization hospitalist study11 (3625 patients in the primary study group) found a tendency toward a reduction in laboratory costs and pharmacy charges under the hospitalist system, but the changes were not statistically significant (level of evidence: 2c). In a study of 1440 patients (627 traditional ward service, 813 hospitalist service), Bellet and Whitaker10 found some decreases in respiratory charges for bronchiolitis ($290 vs $669 [56.6%]; P < .001) and pneumonia ($264 vs $446 [40.8%]; P = .019) hospitalizations in a hospitalist system, even beyond those explained by decreases in LOS (level of evidence: 2c).
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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Six of 7 studies have demonstrated that on average, costs and LOS are 10% lower in pediatric hospitalist systems than in traditional systems of care.10–16 Two of these studies also found that fewer tests and therapies were ordered in hospitalist systems.13, 14 We were unable to identify any study that found costs or LOS to be significantly higher in hospitalist systems compared with any other group. Although no randomized, controlled trials of pediatric hospitalist systems have been conducted, which limits the confidence with which conclusions can be drawn, the consistent decrease in LOS and costs across diverse hospitalist systems suggests that hospitalist systems likely improve the efficiency of hospital care (grade of recommendation: B).
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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The pediatric hospitalist model seems to yield efficiencies, but little is known about the quality of care delivered. Despite this, hospitalist systems have become very well established across North America, and their numbers will likely continue to grow. Focused research on the processes and outcomes of pediatric hospital care are needed to improve the quality of care and the health of hospitalized children.
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ACKNOWLEDGMENTS |
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Dr Landrigan is the recipient of Agency for Healthcare Research and Quality career development award K08 HS13333.
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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Accepted Oct 24, 2005.
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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