search text   Advanced Search

This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Srivastava, R. Articles by Muret-Wagstaff, S. Search for Related Content PubMed PubMed Citation Articles by Srivastava, R. Articles by Muret-Wagstaff, S. Related Collections Office Practice

Impact of a Hospitalist System on Length of Stay and Cost for Children With Common Conditions

^a Department of Pediatrics, Primary Children's Medical Center, University of Utah Health Sciences Center, Salt Lake City, Utah
^b Department of Medicine, Children's Hospital Boston, Boston, Massachusetts
^c Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
^d Department of Ambulatory Care and Prevention, Harvard Medical School, Boston, Massachusetts

	ABSTRACT

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
OBJECTIVE. This study examined mechanisms of efficiency in a managed care hospitalist system on length of stay and total costs for common pediatric conditions.

PATIENTS AND METHODS. We conducted a retrospective cohort study (October 1993 to July 1998) of patients in a not-for-profit staff model (HMO 1) and a non–staff-model (HMO 2) managed care organization at a freestanding children's hospital. HMO 1 introduced a hospitalist system for patients in October 1996. Patients were included if they had 1 of 3 common diagnoses: asthma, dehydration, or viral illness. Linear regression models examining length-of-stay–specific costs for prehospitalist and posthospitalist systems were built. Distribution of length of stay for each diagnosis before and after the system change in both study groups was calculated. Interrupted time series analysis tested whether changes in the trends of length of stay and total costs occurred after implementation of the hospitalist system by HMO1 (HMO 2 as comparison group) for all 3 diagnoses combined.

RESULTS. A total of 1970 patients with 1 of the 3 study conditions were cared for in HMO 1, and 1001 in HMO 2. After the hospitalist system was introduced in HMO 1, length of stay was reduced by 0.23 days (13%) for asthma and 0.19 days (11%) for dehydration; there was no difference for patients with viral illness. The largest relative reduction in length of stay occurred in patients with a shorter length of stay whose hospitalizations were reduced from 2 days to 1 day. This shift resulted in an average cost-per-case reduction of $105.51 (9.3%) for patients with asthma and $86.22 (7.8%) for patients with dehydration. During the same period, length of stay and total cost rose in HMO 2.

CONCLUSIONS. Introduction of a hospitalist system in one health maintenance organization resulted in earlier discharges and reduced costs for children with asthma and dehydration compared with another one, with the largest reductions occurring in reducing some 2-day hospitalizations to 1 day. These findings suggest that hospitalists can increase efficiency and reduce costs for children with common pediatric conditions.

Key Words: hospitalists, pediatrics • health services research • cost savings • length of stay

Abbreviations: LOS—length of stay • HMO—health maintenance organization • AP-DRG—all patient diagnosis-related groups

Hospitalist systems have been shown to reduce length of stay (LOS) and cost with no decrease in quality (usually measured by mortality and readmission rate) for children and adults in both community and academic environments.^1,2 We demonstrated previously that a managed care pediatric hospitalist system reduced LOS and total costs when all diagnoses were included.³

However, little research has been conducted to understand which types of patients are better cared for in a hospitalist system and why. The majority of hospitalist studies to date have been conducted in tertiary care centers or teaching hospitals that include patients with complex conditions. This raises concern about generalizability to common conditions that predominate in nonteaching community hospitals, where about half of children's admissions occur.⁴ Most studies have focused on all diagnoses combined, with few examining specific diagnoses or groups of patients. Three studies (only 1 pediatric) that included analysis of the 10 or 11 most frequent diagnoses reported hospitalist reductions in LOS and cost for some or for overall diagnoses.^5–7 With respect to specific diseases, 1 pediatric study found that hospitalists' patients with bronchiolitis experienced reductions in LOS, but this may have been attributable to the introduction of a clinical practice guideline coinciding with the hospitalist system.⁸ Another pediatric study found a reduction in LOS and costs for patients with asthma but not for other common conditions.⁹ In contrast, a pediatric study focused on patients with asthma and bronchiolitis found no differences in LOS or costs after a hospitalist system was introduced. The study reported that both the hospitalist and control group adhered to clinical practice guidelines, which may have minimized any differences.¹⁰ An adult study focusing on patients with community-acquired pneumonia found a lower LOS in the hospitalist group.¹¹ Regarding specific demographic groups, 1 adult study found that a hospitalist system was more efficient for patients over the age of 65, compared with those under the age of 65, because of less frequent subspecialty consultation.¹² Another adult hospitalist study demonstrated greater cost savings for routine admissions than for those patients admitted with severe illness.¹³ The potential for pediatric hospitalist systems to reduce LOS and costs for common pediatric conditions has not been sufficiently studied.

The mechanisms by which hospitalist systems reduce hospital costs or charges by an average of 14% are uncertain.^2,14 LOS reductions may be driven by hospitalist, patient diagnostic group, hospitalist microsystem, or institutional factors. Relationships between reductions in LOS and cost savings are complex and depend in large measure on the economic environment and reimbursement arrangements under which individual hospitals operate. The impact on cost savings may vary depending on whether the LOS reduction occurs primarily among patients with the shortest stays (eg, 1 or 2 days) or those with longer stays (eg, 4 or 5 days) because of differential reimbursement formulas. Ways that hospitalists reduce LOS for common, short-stay conditions may be different from uncommon or longer-stay conditions, given the medical complexity of children in the latter group.

The specific aim of this study was to examine the impact of a managed care hospitalist system on LOS and total costs for each of 3 common pediatric conditions compared with a traditional nonhospitalist system. In addition, we sought to identify the specific foci of cost savings and LOS reductions.

	METHODS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Study Population
After institutional review board approval by both the study hospital and a staff-model, not-for-profit managed care system (HMO 1), we conducted a retrospective cohort study (October 1993–July 1998) of all pediatric patients (0–17 years of age) admitted to the study hospital who received primary care from any of the 11 HMO 1 health centers (medical offices operated by the health maintenance organization [HMO] to provide outpatient services to its enrollees) that admitted patients exclusively to the study hospital. Three health centers that primarily admitted to other hospitals were excluded to avoid possible selection bias. The inclusion criterion for this study was admission with any 1 of the following 3 conditions as specified by all patient diagnosis-related groups (AP-DRGs, NY8 version): asthma, dehydration, or viral illness (Table 1). The AP-DRG classification system includes severity of illness and has been used for case-mix trending, utilization management, and improved patient identification for payment related issues in pediatrics.^15–21

HMO 1 admits 700 to 1000 general pediatrics patients per year, and typically has a census of 10 to 20 patients (50% of these were 1 of the 3 common conditions in this study). Since October 1996, the patient census has been divided among 2 or 3 hospitalists, who spend 0.5 to 1.0 full-time equivalencies caring for inpatients. Housestaff and medical students are involved in the care of these patients and are supervised by the hospitalists. The nature of the relationship between staff physicians from HMO 1 and trainees did not change with the advent of the hospitalist system and was fundamentally similar to the relationship between trainees and providers from other HMOs and private practices. The use of clinical practice guidelines has been high for many years at the study hospital and is applied to all patients, regardless of attending type. On weekends, a pediatrician from the hospitalist group or from 1 of the local health centers cares for the patients. All of the hospitalists hired by HMO 1 were experienced general pediatricians from the community. Individuals in the group working 1.0 full-time equivalencies as hospitalists spend the remainder of their time on administrative committees. The hospitalist group employs nurse liaisons who aid in the care and discharge planning of all patients. There was little turnover in the hospitalist staff between 1993 and 1998; 2 of 3 hospitalists worked throughout the entire study period.

Data Collection
For all study and comparison group patients, we extracted demographic, case-mix, financial, and clinical data from the hospital database. To validate insurance status, HMO 1 patients who were cared for in any of the 11 HMO 1 centers were identified through the hospital's computerized database and cross-referenced with patient lists maintained by their insurer. Resource utilization outcomes included LOS and total inflation-adjusted direct costs. Costs were determined by using the hospital's utilization-based cost-allocation system, which controls for relative shifts in charges over time and for differences in negotiated payment scales by different payers. Total direct costs were adjusted for inflation using the Medical Care Index of the Consumer Price Index.²² Costs are reported in 1993 dollars.

Analyses
We analyzed data for each of the 3 diagnoses using time (prepost hospitalist system) and the interaction between time and study group (our primary variable of interest) as predictors in diagnosis-specific, patient-level linear regression models to test the significance of differences between study and comparison groups in the prepost changes in LOS and costs.²³ These models also included terms to adjust for disease severity and patient demographics. Age was classified in 5 groups; 0 to 2, 3 to 5, 6 to 10, 11 to14, and 15 to 18 years of age.²⁴ Race was coded as white, black, or other. Severity weights attached to the diagnosis of each AP-DRG were used in the analyses. We logged the values of total cost and LOS in all multivariate regression analyses to normalize their distributions; for clarity of interpretation, results reported in the article are reconverted to normal scale.

Next, by using the adjusted LOS data from these regression models, LOS-specific costs for prehospitalist and posthospitalist system were calculated and compared in the 2 HMOs to identify which durations of hospitalization (with each patient categorized according to number of days of hospitalization) were associated with the greatest savings. For diagnoses for which the prepost changes in LOS in the hospitalist system were significantly different from the comparison group, we calculated the changes in average cost per case in the hospitalist system for admissions during that period. Average cost per case for each LOS category was calculated by using adjusted data from regression models in the prehospitalist period (eg, a patient with asthma who stayed 1 day cost the hospital $592, a patient with asthma who stayed 2 days cost the hospital $978). These LOS-specific costs were then assigned to the number and proportion of patients hospitalized in each period, and average daily costs for the sample as a whole were calculated by summing across LOS categories.

Finally, we used time-series analyses to examine trends in LOS for HMO 1 and HMO 2 for the total sample of patients for the 3 diagnoses combined.³

	RESULTS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
A total of 1970 patients with 1 of the 3 study conditions were cared for in HMO 1 and 1001 patients were cared for in HMO 2 during the study period. These accounted for 54% and 52% of total pediatric admissions for HMO 1 and HMO 2 to the hospitals' general medical services, respectively. Among patients admitted with all diagnoses during the study period, HMO 1 patients were more likely to be nonwhite and had somewhat more serious illness than those in the HMO 2 group (Table 2). The HMO 1 group included proportionately more patients with a diagnosis of asthma (32.1% vs 25%; P < .001) and fewer patients with a diagnosis of dehydration (12.8% vs 16.7%; P < .001).

View larger version (15K): [in this window] [in a new window]   FIGURE 1 Change in mean LOS days for 2 HMOs after hospitalist introduction in HMO 1 (results from the multivariate-regression equations). Change indicates the difference in mean LOS days between 2 periods: 3 years before and 2 years after introduction of a hospitalist system in HMO 1; a decrease indicates improved efficiency. NS indicates not significant.

	DISCUSSION

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
For 2 of the most common causes of hospitalization of children, asthma and dehydration, we found reductions in LOS and average cost per case in a tertiary children's hospital after the introduction of a hospitalist system. The greatest impact occurred among children who, under the care of a hospitalist, were hospitalized for 1 rather than 2 days for these conditions. No change was observed for the category of children admitted for viral illnesses. During the same time period in the same hospital, LOS and costs for asthma and dehydration increased for a nonhospitalist comparison HMO. Time-series analysis demonstrated no significant overall differences in LOS or costs for the 3 conditions combined, but differences for asthma and dehydration may have been masked by inclusion of patients with viral syndrome, for whom there was no difference.

The estimated hospital net savings calculated in 1993 dollars were approximately $41446 and $18748 per year for study group patients with asthma and dehydration, respectively. This is a conservative estimate of savings for several reasons. First, it does not take into account the increases in hospital costs that were noted in HMO 2 during the same time period. Second, we were unable to include possible differences in resource utilization (radiology, laboratory test, and pharmacy). Several studies have suggested a lower use of such resources and fewer consultations requested by hospitalists.^3,9,25 Third, we did not calculate or account for the increased capacity for throughput related to shortened LOS, a potential source of substantial revenue benefit.²⁶

The cost reduction of 9.3% and 7.8% for patients with asthma and dehydration is modest on a per case basis (not accounting for the increase in cost by the comparison group during the same time period), but because a large number of patients are admitted each year with these diagnoses, the total cost savings generated are substantial. The value of these cost savings from a hospitalist system depends on the perspective of the involved parties, the reimbursement methods of the payers to the hospital, and the market forces. These perspectives include the payer, the hospital, the patient, the physicians (hospitalist group), and the health care system as a whole.²⁷ For the purposes of this article, we have restricted our discussion primarily to the perspective of the hospital.

Two reimbursement systems^28,29 were prevalent in our study hospital: per-diem charges and discounted billed charges (1 form of this is the case rate from Medicaid, which remained constant during the study period at 15% of total reimbursement to the hospital from payers). Diagnosis Related Groups (DRG) reimbursement has the most potential for favoring an efficient hospitalist system from the hospital's perspective; however, this did not apply to our study population of HMO 1 patients.³⁰ At the study hospital, there was a shift in the reimbursement systems for HMO 1 patients over the study period from 1993 through 1998. In 1993, the reimbursement system was mostly discounted billed charges. In early 1995, contractual relationships were renegotiated between the hospital and the HMO 1, and HMO 1 moved to a per-diem system. HMO 2 (comparison group) remained on an unchanged contractual DRG system throughout the study period (D. Kirschner, MBA, CPA, verbal communication, 2004).^28,31

In the discounted billed charges system of reimbursement, the impact of an efficient hospitalist system had the potential effect of an overall reduction in total revenue to the hospital (by reducing the total charges to the payer), leading to an advantage to the payer and a disadvantage to the hospital. This reduction in total revenue may have been partially offset by an increase in intensity of care (the number of services delivered per period of time).

In 1995, the impact of a change for the HMO 1 patients to a per-diem payment system to the hospital may have led to an increase in reimbursement for the hospital after the introduction of the managed care hospitalist system. This may have occurred for several reasons. First, the economic situation changed to a high demand (patients waiting for hospital beds) and a low supply (hospital beds) market. Second, the efficient managed care hospitalist system was able to reduce LOS by 0.23 days for asthma and 0.19 days for dehydration (accounting for 30% of their inpatient volume). Third, there was an increase in the opportunity to gain from increased throughput, thereby increasing total revenues for the hospital.³²

The primary reason for the creation of the hospitalist system was to improve the quality of care delivered to children admitted to the inpatient pediatric service by relieving the majority of physicians of their inpatient responsibilities and creating a core group of dedicated inpatient physicians, easily accessed by housestaff. As a secondary goal, the efficiencies achieved were hoped to be sufficient to pay for the program although this was found not be true, given specifics of the reimbursement system (J. Graef, MD, verbal communication, 2002).

In our previous time-series study, we found that introduction of this hospitalist system led to reductions in LOS and costs overall in a large tertiary care center, including children with complex conditions.³ In considering only the subgroup of patients with asthma, dehydration, and viral illness in this study, we also found significant differences in LOS or costs with 2 of the 3 conditions. These combined findings suggest that hospitalist system effects on LOS and costs were distributed among children with both complex and common conditions.

These findings address 1 of several key questions dominating the current hospitalist debate: How ironclad is the case that the hospitalist model improves quality and efficiency?³³ Although this study was not designed to assess quality improvements, it demonstrates that a hospitalist model can significantly increase efficiency for 2 high-frequency diagnoses in children, asthma and dehydration, particularly for the more common short stays. This opens the opportunity to focus efforts to understand, enhance, and replicate the mechanisms of hospitalist efficiency through condition-specific process and outcome studies. Hospitalist systems may also provide substantial noneconomic benefits, which have been summarized recently in the literature.^14,34

Numerous mechanisms have been postulated to explain hospitalist efficiency, but findings are inconsistent. These include differences at the levels of hospitalist and patient characteristics, various hospitalist models and teams, and hospital systems. Although "practice makes perfect" has been suggested, and beneficial volume–outcome relationships for physicians and hospitals frequently hold true in health care, the magnitude of association varies widely, and effects often are modest.³⁵ Multilevel modeling and other rigorous methodologic approaches can strengthen hospitalist research in this regard.³⁶ A new generation of studies is needed to advance from "whether" hospitalist systems work to "for whom" and "how" hospitalist systems work.¹⁴ Only then will be we able to meet the design principles and targets for hospitalist systems recently recommended by pediatric leaders.^37–39

As in all studies, our findings are limited in generalizability to the types of hospitals and systems in which the study was conducted. However, the discovery of efficiencies of care specific to common diagnoses increases the likelihood that hospitalist systems can improve care not only in tertiary centers but also in community hospitals where these diagnoses predominate. This study's limitation in estimating cost savings noted above yields a conservative estimate of efficiency and lends additional strength to the overall finding. The lack of change noted for the children with viral illnesses may not be applicable to other hospitals. In the study hospital, this AP-DRG is comprised of disparate groups of patients with croup, viral meningitis, and fever of unknown origin, and proportions of children with these varying conditions may differ in other institutions. The comparison group HMO 2 was not identical to HMO 1 in all aspects; however, it was the closest analog to HMO 1 that existed at the study hospital. Both managed care organizations were large, not-for-profit HMOs that had a large number of patients admitted to the study hospital each year. Both have been consistently ranked highly in national studies of HMO quality. Both have comprehensive preventive and hospital care plans. A causal relationship between the divergence in costs and LOS for patients with asthma and dehydration after October 1996 and the introduction of hospitalists is an implied one, and not proven. However, no other significant changes occurred in the care of inpatients from either of these 2 HMOs during the intervention period.

	CONCLUSIONS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
The introduction of a hospitalist system in 1 HMO was associated with earlier discharges for children with asthma and dehydration, with the greatest reductions related to changing 2-day into 1-day hospitalizations. This resulted in significant estimated cost savings for these 2 diagnoses at a time when costs for the comparison group were increasing. This new finding of hospitalist efficiencies in care of children with common diagnoses extends our understanding of the scope of hospitalist impact. The results allow us to focus efforts in uncovering mechanisms that can inform decision-making by clinicians and administrators and the design of emerging pediatric hospitalist models.

	ACKNOWLEDGMENTS

 
This work was supported, in part, by grants from the Health Resources and Services Administration (T32 PE10018), Rockville, Maryland, to the Harvard Pediatric Health Services Research Fellowship Program, and from the Harvard Pilgrim Health Care Foundation, Boston, Massachusetts. Dr Srivastava is the recipient of National Institute for Child Health and Human Development career development award K23 HD052553-01A1. Dr Landrigan is the recipient of Agency for Healthcare Research and Quality career development award K08 HS13333.

	FOOTNOTES

 
Accepted Mar 19, 2007.

Address correspondence to Rajendu Srivastava, MD, FRCP(C), MPH, Division of Inpatient Medicine, University of Utah Health Sciences Center, 100 N Medical Dr, Primary Children's Medical Center, Salt Lake City, UT 84113. E-mail: raj.srivastava{at}hsc.utah.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.

	REFERENCES

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 

1. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287 :487 –494[Abstract/Free Full Text]
2. Coffman J, Rundall TG. The impact of hospitalists on the cost and quality of inpatient care in the United States: a research synthesis. Med Care Res Rev. 2005;62 :379 –406[Abstract]
3. Landrigan CP, Srivastava R, Muret-Wagstaff S, et al. Impact of a health maintenance organization hospitalist system in academic pediatrics. Pediatrics. 2002;110 :720 –728[Abstract/Free Full Text]
4. HCUPnet. Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality. Available at: hcupnet.ahrq.gov. Accessed October 3, 2005
5. Dwight P, MacArthur C, Friedman JN, Parkin PC. Evaluation of a staff-only hospitalist system in a tertiary care, academic children's hospital. Pediatrics. 2004;114 :1545 –1549[Abstract/Free Full Text]
6. Davis KM, Koch KE, Harvey JK, Wilson R, Englert J, Gerard PD. Effects of hospitalists on cost, outcomes, and patient satisfaction in a rural health system. Am J Med. 2000;108 :621 –626[CrossRef][ISI][Medline]
7. Kulaga ME, Charney P, O'Mahony SP, et al. The positive impact of initiation of hospitalist clinician educators. J Gen Intern Med. 2004;19 :293 –301[CrossRef][ISI][Medline]
8. Bellet PS, Whitaker RC. Evaluation of a pediatric hospitalist service: impact on length of stay and hospital charges. Pediatrics. 2000;105 :478 –484[Abstract/Free Full Text]
9. Wells RD, Dahl B, Wilson SD. Pediatric hospitalists: quality care for the underserved? Am J Med Qual. 2001;16 :174 –180[Abstract]
10. Seid M, Quinn K, Kurtin PS. Hospital-based and community pediatricians: comparing outcomes for asthma and bronchiolitis. J Clin Outcomes Manage. 1997;4 :21 –24
11. Stein MD, Hanson S, Tammaro D, Hanna L, Most AS. Economic effects of community versus hospital-based faculty pneumonia care. J Gen Intern Med. 1998;13 :774 –777[CrossRef][ISI][Medline]
12. Hackner D, Tu G, Braunstein GD, Ault M, Weingarten S, Mohsenifar Z. The value of a hospitalist service: efficient care for the aging population. Chest. 2001;119 :580 –589[CrossRef][ISI][Medline]
13. Meltzer D, Morrison J, Guth T, et al. Effects of hospitalist physicians on an academic general medicine service: results of a randomized trail [abstract]. J Gen Intern Med. 1999;14(suppl 2) :112 . Available at: www.blackwell-synergy.com/doi/abs/10.1046/j.1525-1497.1999.1420083.x. Accessed June 13, 2007
14. Landrigan CP, Conway PH, Edwards S, Srivastava R. Pediatric hospitalists: a systematic review of the literature. Pediatrics. 2006;117 :1736 –1744[Abstract/Free Full Text]
15. Giuliano G, Catalano S, Baldacci S, Capuani A, Donato L. Recovery evaluation in a pediatric heart surgery unit using the AP-DRG classification system (All Patient Diagnosis Related Groups) [in Italian]. G Ital Cardiol. 1996;26 :1157 –1174[Medline]
16. Kawabuchi K. Payment systems and considerations of case mix: are diagnosis-related groups applicable in Japan? Pharmacoeconomics. 2000;18 :95 –110[ISI][Medline]
17. Muldoon JH. Structure and performance of different DRG classification systems for neonatal medicine. Pediatrics. 1999;103 :302 –318[Medline]
18. Boyd J, 3rd, Samaddar K, Parra-Roide L, Allen EP, White B. Comparison of outcome measures for a traditional pediatric faculty service and nonfaculty hospitalist services in a community teaching hospital. Pediatrics. 2006;118 :1327 –1331[Abstract/Free Full Text]
19. Muldoon JH, Neff JM, Gay JC. Profiling the health service needs of populations using diagnosis-based classification systems. J Ambul Care Manage. 1997;20 :1 –18[Medline]
20. Neff JM, Valentine J, Park A, et al. Trends in pediatric hospitalizations of children in Washington State by insurance and chronic condition status, 1991–1998. Arch Pediatr Adolesc Med. 2002;156 :703 –709[Abstract/Free Full Text]
21. Siegrist RB Jr, Kane NM. Exploring the relationship between inpatient hospital costs and quality of care. Am J Manag Care. 2003;9 :SP43 –SP49[ISI][Medline]
22. US Bureau of Labor Statistics. Boston-Brockton-Nashua medical care CPI. Available at: http://stats.bls.gov/cpi. Accessed July 11, 2006
23. Kleinbaum DG. Applied Regression Analysis and Other Multivariable Methods. 3rd ed. Pacific Grove, CA: Duxbury Press; 1998
24. McCormick MC, Weinick RM, Elixhauser A, Stagnitti MN, Thompson J, Simpson L. Annual report on access to and utilization of health care for children and youth in the United States: 2000. Ambul Pediatr. 2001;1 :3 –15[CrossRef][ISI][Medline]
25. Schreiber TL, Elkhatib A, Grines CL, O'Neill WW. Cardiologist versus internist management of patients with unstable angina: treatment patterns and outcomes. J Am Coll Cardiol. 1995;26 :577 –582[Abstract]
26. Gregory D, Baigelman W, Wilson IB. Hospital economics of the hospitalist. Health Serv Res. 2003;38 :905 –918; discussion 919–922[CrossRef][ISI][Medline]
27. Landrigan C, Srivastava R, Muret-Wagstaff S, Dyck IJ, Homer CJ, Goldmann DA. Pediatric hospitalists: what do we know, and where do we go from here. Ambul Pediatr. 2001;1 :340 –345[CrossRef][ISI][Medline]
28. Aas IH. Incentives and financing methods. Health Policy. 1995;34 :205 –220[CrossRef][ISI][Medline]
29. Kongstvedt PK. Negotiating and contracting with hospitals and institutions. In: The Managed Health Care Handbook. 4th ed. Gaithersburg, MD: Aspen; 2001:191 –205
30. Wachter RM, Whitcomb WF, Nelson JR. Financial implications of implementing a hospitalist program. Healthc Financ Manage. 1999;53 :48 –51[Medline]
31. Ginsberg G, Penchas S, Israeli A. Alternative methods of hospital remuneration in Israel. Isr J Med Sci. 1991;27 :583 –589[ISI][Medline]
32. Lutz S. Day of the per diem. Mod Healthc. 1995;25 :44 –46, 48[Medline]
33. Wachter RM. Hospitalists in the United States: mission accomplished or work in progress. N Engl J Med. 2004;350 :1935 –1936[Free Full Text]
34. Freed GL, Uren RL. Hospitalists in children's hospitals: what we know now and what we need to know. J Pediatr. 2006;148 :296 –299[CrossRef][ISI][Medline]
35. Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med. 2002;137 :511 –520[Abstract/Free Full Text]
36. Urbach DR, Austin PC. Conventional models overestimate the statistical significance of volume-outcome associations, compared with multilevel models. J Clin Epidemiol. 2005;58 :391 –400[CrossRef][ISI][Medline]
37. Percelay JM. Physicians' roles in coordinating care of hospitalized children. Pediatrics. 2003;111 :707 –709[Abstract/Free Full Text]
38. Percelay JM, Strong GB. Guiding principles for pediatric hospitalist programs. Pediatrics. 2005;115 :1101 –1102[Abstract/Free Full Text]
39. Lye PS, Rauch DA, Ottolini MC, et al. Pediatric hospitalists: report of a leadership conference. Pediatrics. 2006;117 :1122 –1130[Abstract/Free Full Text]

This article has been cited by other articles:

				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]

This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Srivastava, R. Articles by Muret-Wagstaff, S. Search for Related Content PubMed PubMed Citation Articles by Srivastava, R. Articles by Muret-Wagstaff, S. Related Collections Office Practice

	Home | My Pediatrics | Journal Information | Current Issue | Past Issues | Subscriptions & Services | Contact Us Click here for faster international access © 2007 American Academy of Pediatrics. All rights reserved.