Mark Shen, MD, FHM

As bronchiolitis season approaches, my thoughts turn to the yearly struggle that is practicing medicine with others, to include residents, nurses, primary-care providers (PCPs), respiratory therapists, families, colleagues, and subspecialists. What seems to go reasonably well during other parts of the year or with other diagnoses seems to always fall apart at one point or another during “the season.” Inevitably, some manner of awkward conflict will arise with regard to what to do next. I already am filled with anticipation, much in the way that my mouth puckers at the thought of a tart lemon.

It shouldn’t be too much of a stretch for most practicing pediatric hospitalists to understand these feelings. While the care of children hospitalized for bronchiolitis can be remarkably straightforward—watch, wait, and repeat—we recognize that our entire winter existence is filled with machinations of what others seem to want to do to our vulnerable, wheezy infants. Some days I feel as if I am a lone villager defending my baby from possible iatrogenic injury of these marauding tribes.

Although the attackers might be imaginary, the harms are certainly real: irradiation, over-broncho-salinebulization, the antibiotic-probiotic cycle, rhinitis suctionitosa, exsanguination, and, of course, shaken infant “physiotherapy.” If I could grow a beard, I would take my hooded sweatshirt to Montana, because mid-season, that would be my coping mechanism of choice.

In clearer moments, I don’t really see any villains. I simply see human nature. Families come to us looking for a cure. Residents order labs and X-rays because they aren’t sure and they think fancy tests will help (who hasn’t ordered an ESR and CRP in analogous situations?). Nurses and respiratory therapists see improvement after patients visit the ICU pharmacy and wonder why we can’t try those magical drugs pre-decompensation.

As a general rule, the more uncertain and frightening the situation, the more we humans gravitate toward something (perceived to be) more powerful than ourselves for help.

We use the term mythology to describe how the ancient Greeks dealt with this. In medicine, interventions become our myths when we are faced with clinical uncertainty. Or, as I like to say, the less you know, the more you do. When we are dealing primarily with self-limited diseases, our interventional rituals result in overutilization and iatrogenesis.

Pediatric medicine is filled with classic examples of self-limited diseases. Bronchiolitis is the classic inpatient example. Gastroenteritis is another one. Viral pneumonia is a bit of chameleon, but it’s more common than most realize. And lest we forget our outpatient colleagues, we should keep in mind that every day the clinic is filled with visits for colds, viral pharyngitis, or harmless dermatoses.

The Myths of Healing

“Treatments” commonly are used in an attempt to ameliorate the acute course of all these diseases, but not without a healthy degree of safety and/or economic arguments against intervention. I was always taught that the best pediatricians treat only self-limited diseases because everything that they do works. I can pretty much guarantee that whether I give someone with a cold methotrexate or eye of newt, they eventually get better. With all of these diseases, less is more.

As a resident, I remember writing prescriptions for decongestants when my clinic attending told me to, or when I didn’t know how to handle the family. It took the FDA to make the world a safer place for children with colds. A child in Bangladesh with diarrhea and moderate dehydration given oral rehydration and early re-feeding is likely safer than the child receiving intravenous fluids and “clear liquids” in America. Did you know there are actually case reports of iatrogenic kwashiorkor after treatment for gastroenteritis in this country?

Moving beyond safety, the economic imperative for cost-effective care should not be a foreign concept by now. I shudder to think about how the child in Bangladesh might have gotten better for a few pennies, while the child in the U.S. was billed for an ED visit and overnight stay for “poor follow-up.” Waste also comes in forms other than direct costs: Think of how much drug companies spend on marketing drugs for cough and cold medicines instead of investing funds into more research for effective antimicrobials.

As physicians, we know we are doing too much. In a recent report in the Archives of Internal Medicine (2011;171:1582-1585), nearly half of the doctors surveyed felt that their patients received too much care, as opposed to only 6% that felt that they were receiving too little. Reasons for overtreatment included malpractice concerns, clinical performance measures, and inadequate time to spend with patients. The bottom line is that it is often easier to do more than to justify a safer, more cost-effective, and evidence-based course of less intense care. We know what we do.

Our Hospitals, Our Plight

Returning, then, to the wards in winter, how is a lone and oft-overworked hospitalist to solve these problems? Evidence helps, a little. Guidelines built into the flow of care help, a little. Agreement amongst your colleagues helps, a little. But ultimately, I see this as a communication issue.

And by communication, I do not mean beating people over the head with the AAP guidelines (believe me, I’ve tried it and the guidelines just aren’t thick enough).

If we are to enlist the support of families, nurses, learners, respiratory therapists, and other physicians in doing what’s best for the patient, then we must make this work much in the same way that we get others around us change behavior. Think about the PCP who must impact obesity in the family or vaccine distrust. We have to build relationships based on trust. We must elicit others’ goals and describe ours as a shared agenda. Similarly, we need input from everyone around us as to how to move forward. There are far too many humans involved for this to work without constant attention to creating a well-functioning team.

This will not be an easy task, which is perhaps why moving to Montana or a deserted island seems so much easier. But anytime medicine involves more than just one person, there will be a need to communicate effectively. This becomes critically important as the amount of gray regarding risks and benefits increases.

More is less. Less is more. Our patients deserve that we dedicate ourselves to providing them the best possible care.

Dr. Shen is The Hospitalist’s pediatric editor and medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas.

As bronchiolitis season approaches, my thoughts turn to the yearly struggle that is practicing medicine with others, to include residents, nurses, primary-care providers (PCPs), respiratory therapists, families, colleagues, and subspecialists. What seems to go reasonably well during other parts of the year or with other diagnoses seems to always fall apart at one point or another during “the season.” Inevitably, some manner of awkward conflict will arise with regard to what to do next. I already am filled with anticipation, much in the way that my mouth puckers at the thought of a tart lemon.

It shouldn’t be too much of a stretch for most practicing pediatric hospitalists to understand these feelings. While the care of children hospitalized for bronchiolitis can be remarkably straightforward—watch, wait, and repeat—we recognize that our entire winter existence is filled with machinations of what others seem to want to do to our vulnerable, wheezy infants. Some days I feel as if I am a lone villager defending my baby from possible iatrogenic injury of these marauding tribes.

Although the attackers might be imaginary, the harms are certainly real: irradiation, over-broncho-salinebulization, the antibiotic-probiotic cycle, rhinitis suctionitosa, exsanguination, and, of course, shaken infant “physiotherapy.” If I could grow a beard, I would take my hooded sweatshirt to Montana, because mid-season, that would be my coping mechanism of choice.

In clearer moments, I don’t really see any villains. I simply see human nature. Families come to us looking for a cure. Residents order labs and X-rays because they aren’t sure and they think fancy tests will help (who hasn’t ordered an ESR and CRP in analogous situations?). Nurses and respiratory therapists see improvement after patients visit the ICU pharmacy and wonder why we can’t try those magical drugs pre-decompensation.

As a general rule, the more uncertain and frightening the situation, the more we humans gravitate toward something (perceived to be) more powerful than ourselves for help.

We use the term mythology to describe how the ancient Greeks dealt with this. In medicine, interventions become our myths when we are faced with clinical uncertainty. Or, as I like to say, the less you know, the more you do. When we are dealing primarily with self-limited diseases, our interventional rituals result in overutilization and iatrogenesis.

Pediatric medicine is filled with classic examples of self-limited diseases. Bronchiolitis is the classic inpatient example. Gastroenteritis is another one. Viral pneumonia is a bit of chameleon, but it’s more common than most realize. And lest we forget our outpatient colleagues, we should keep in mind that every day the clinic is filled with visits for colds, viral pharyngitis, or harmless dermatoses.

The Myths of Healing

“Treatments” commonly are used in an attempt to ameliorate the acute course of all these diseases, but not without a healthy degree of safety and/or economic arguments against intervention. I was always taught that the best pediatricians treat only self-limited diseases because everything that they do works. I can pretty much guarantee that whether I give someone with a cold methotrexate or eye of newt, they eventually get better. With all of these diseases, less is more.

As a resident, I remember writing prescriptions for decongestants when my clinic attending told me to, or when I didn’t know how to handle the family. It took the FDA to make the world a safer place for children with colds. A child in Bangladesh with diarrhea and moderate dehydration given oral rehydration and early re-feeding is likely safer than the child receiving intravenous fluids and “clear liquids” in America. Did you know there are actually case reports of iatrogenic kwashiorkor after treatment for gastroenteritis in this country?

Moving beyond safety, the economic imperative for cost-effective care should not be a foreign concept by now. I shudder to think about how the child in Bangladesh might have gotten better for a few pennies, while the child in the U.S. was billed for an ED visit and overnight stay for “poor follow-up.” Waste also comes in forms other than direct costs: Think of how much drug companies spend on marketing drugs for cough and cold medicines instead of investing funds into more research for effective antimicrobials.

As physicians, we know we are doing too much. In a recent report in the Archives of Internal Medicine (2011;171:1582-1585), nearly half of the doctors surveyed felt that their patients received too much care, as opposed to only 6% that felt that they were receiving too little. Reasons for overtreatment included malpractice concerns, clinical performance measures, and inadequate time to spend with patients. The bottom line is that it is often easier to do more than to justify a safer, more cost-effective, and evidence-based course of less intense care. We know what we do.

Our Hospitals, Our Plight

Returning, then, to the wards in winter, how is a lone and oft-overworked hospitalist to solve these problems? Evidence helps, a little. Guidelines built into the flow of care help, a little. Agreement amongst your colleagues helps, a little. But ultimately, I see this as a communication issue.

And by communication, I do not mean beating people over the head with the AAP guidelines (believe me, I’ve tried it and the guidelines just aren’t thick enough).

If we are to enlist the support of families, nurses, learners, respiratory therapists, and other physicians in doing what’s best for the patient, then we must make this work much in the same way that we get others around us change behavior. Think about the PCP who must impact obesity in the family or vaccine distrust. We have to build relationships based on trust. We must elicit others’ goals and describe ours as a shared agenda. Similarly, we need input from everyone around us as to how to move forward. There are far too many humans involved for this to work without constant attention to creating a well-functioning team.

This will not be an easy task, which is perhaps why moving to Montana or a deserted island seems so much easier. But anytime medicine involves more than just one person, there will be a need to communicate effectively. This becomes critically important as the amount of gray regarding risks and benefits increases.

More is less. Less is more. Our patients deserve that we dedicate ourselves to providing them the best possible care.

Dr. Shen is The Hospitalist’s pediatric editor and medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas.

As bronchiolitis season approaches, my thoughts turn to the yearly struggle that is practicing medicine with others, to include residents, nurses, primary-care providers (PCPs), respiratory therapists, families, colleagues, and subspecialists. What seems to go reasonably well during other parts of the year or with other diagnoses seems to always fall apart at one point or another during “the season.” Inevitably, some manner of awkward conflict will arise with regard to what to do next. I already am filled with anticipation, much in the way that my mouth puckers at the thought of a tart lemon.

It shouldn’t be too much of a stretch for most practicing pediatric hospitalists to understand these feelings. While the care of children hospitalized for bronchiolitis can be remarkably straightforward—watch, wait, and repeat—we recognize that our entire winter existence is filled with machinations of what others seem to want to do to our vulnerable, wheezy infants. Some days I feel as if I am a lone villager defending my baby from possible iatrogenic injury of these marauding tribes.

Although the attackers might be imaginary, the harms are certainly real: irradiation, over-broncho-salinebulization, the antibiotic-probiotic cycle, rhinitis suctionitosa, exsanguination, and, of course, shaken infant “physiotherapy.” If I could grow a beard, I would take my hooded sweatshirt to Montana, because mid-season, that would be my coping mechanism of choice.

In clearer moments, I don’t really see any villains. I simply see human nature. Families come to us looking for a cure. Residents order labs and X-rays because they aren’t sure and they think fancy tests will help (who hasn’t ordered an ESR and CRP in analogous situations?). Nurses and respiratory therapists see improvement after patients visit the ICU pharmacy and wonder why we can’t try those magical drugs pre-decompensation.

As a general rule, the more uncertain and frightening the situation, the more we humans gravitate toward something (perceived to be) more powerful than ourselves for help.

We use the term mythology to describe how the ancient Greeks dealt with this. In medicine, interventions become our myths when we are faced with clinical uncertainty. Or, as I like to say, the less you know, the more you do. When we are dealing primarily with self-limited diseases, our interventional rituals result in overutilization and iatrogenesis.

Pediatric medicine is filled with classic examples of self-limited diseases. Bronchiolitis is the classic inpatient example. Gastroenteritis is another one. Viral pneumonia is a bit of chameleon, but it’s more common than most realize. And lest we forget our outpatient colleagues, we should keep in mind that every day the clinic is filled with visits for colds, viral pharyngitis, or harmless dermatoses.

The Myths of Healing

“Treatments” commonly are used in an attempt to ameliorate the acute course of all these diseases, but not without a healthy degree of safety and/or economic arguments against intervention. I was always taught that the best pediatricians treat only self-limited diseases because everything that they do works. I can pretty much guarantee that whether I give someone with a cold methotrexate or eye of newt, they eventually get better. With all of these diseases, less is more.

As a resident, I remember writing prescriptions for decongestants when my clinic attending told me to, or when I didn’t know how to handle the family. It took the FDA to make the world a safer place for children with colds. A child in Bangladesh with diarrhea and moderate dehydration given oral rehydration and early re-feeding is likely safer than the child receiving intravenous fluids and “clear liquids” in America. Did you know there are actually case reports of iatrogenic kwashiorkor after treatment for gastroenteritis in this country?

Moving beyond safety, the economic imperative for cost-effective care should not be a foreign concept by now. I shudder to think about how the child in Bangladesh might have gotten better for a few pennies, while the child in the U.S. was billed for an ED visit and overnight stay for “poor follow-up.” Waste also comes in forms other than direct costs: Think of how much drug companies spend on marketing drugs for cough and cold medicines instead of investing funds into more research for effective antimicrobials.

As physicians, we know we are doing too much. In a recent report in the Archives of Internal Medicine (2011;171:1582-1585), nearly half of the doctors surveyed felt that their patients received too much care, as opposed to only 6% that felt that they were receiving too little. Reasons for overtreatment included malpractice concerns, clinical performance measures, and inadequate time to spend with patients. The bottom line is that it is often easier to do more than to justify a safer, more cost-effective, and evidence-based course of less intense care. We know what we do.

Our Hospitals, Our Plight

Returning, then, to the wards in winter, how is a lone and oft-overworked hospitalist to solve these problems? Evidence helps, a little. Guidelines built into the flow of care help, a little. Agreement amongst your colleagues helps, a little. But ultimately, I see this as a communication issue.

And by communication, I do not mean beating people over the head with the AAP guidelines (believe me, I’ve tried it and the guidelines just aren’t thick enough).

If we are to enlist the support of families, nurses, learners, respiratory therapists, and other physicians in doing what’s best for the patient, then we must make this work much in the same way that we get others around us change behavior. Think about the PCP who must impact obesity in the family or vaccine distrust. We have to build relationships based on trust. We must elicit others’ goals and describe ours as a shared agenda. Similarly, we need input from everyone around us as to how to move forward. There are far too many humans involved for this to work without constant attention to creating a well-functioning team.

This will not be an easy task, which is perhaps why moving to Montana or a deserted island seems so much easier. But anytime medicine involves more than just one person, there will be a need to communicate effectively. This becomes critically important as the amount of gray regarding risks and benefits increases.

More is less. Less is more. Our patients deserve that we dedicate ourselves to providing them the best possible care.

Dr. Shen is The Hospitalist’s pediatric editor and medical director of hospital medicine at Dell Children’s Medical Center in Austin, Texas.

Clinical question: What is the effect of fluid resuscitation on mortality in children with shock in resource-limited settings?

Background: Rapid fluid resuscitation is typically recommended for children who present with shock. In resource-limited settings, particularly in Africa, this practice is not commonplace. The exact role of early fluid resuscitation, in addition to the optimal type of fluid (saline or albumin), is unknown.

Study design: Multicenter, randomized, controlled trial.

Setting: Six clinical centers in Africa.

Synopsis: This study was stopped after data for 3,141 of a projected 3,600 enrolled children demonstrated increased mortality in the bolus groups vs. control. Children aged 60 days to 12 years who presented with a severe febrile illness and impaired perfusion without severe hypotension were randomized openly to three groups: saline bolus, albumin bolus, or no bolus (control). Baseline characteristics of the groups were similar. After 48 hours, mortality in the albumin, saline, and control groups was 10.6%, 10.5%, and 7.3% respectively. The relative risk for any bolus vs. control was 1.45 (95% CI, 1.13-1.86; P=.003).

The results of this study are strengthened by the large number of children enrolled and the solid study design. However, it is difficult to immediately generalize the findings due to the unique nature of the study population and environment, which included a high proportion of patients with malaria and notable constraints on resources. Nonetheless, questions are raised regarding the routine practice of rapid and early fluid resuscitation in patients with shock and without clear hypovolemia.

Bottom line: Fluid resuscitation is not beneficial in resource-limited settings for children in shock who are not hypotensive.

Citation: Matiland K, Kiguli S, Opoka RO, et. al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011;364:2483-2495.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the effect of fluid resuscitation on mortality in children with shock in resource-limited settings?

Background: Rapid fluid resuscitation is typically recommended for children who present with shock. In resource-limited settings, particularly in Africa, this practice is not commonplace. The exact role of early fluid resuscitation, in addition to the optimal type of fluid (saline or albumin), is unknown.

Study design: Multicenter, randomized, controlled trial.

Setting: Six clinical centers in Africa.

Synopsis: This study was stopped after data for 3,141 of a projected 3,600 enrolled children demonstrated increased mortality in the bolus groups vs. control. Children aged 60 days to 12 years who presented with a severe febrile illness and impaired perfusion without severe hypotension were randomized openly to three groups: saline bolus, albumin bolus, or no bolus (control). Baseline characteristics of the groups were similar. After 48 hours, mortality in the albumin, saline, and control groups was 10.6%, 10.5%, and 7.3% respectively. The relative risk for any bolus vs. control was 1.45 (95% CI, 1.13-1.86; P=.003).

The results of this study are strengthened by the large number of children enrolled and the solid study design. However, it is difficult to immediately generalize the findings due to the unique nature of the study population and environment, which included a high proportion of patients with malaria and notable constraints on resources. Nonetheless, questions are raised regarding the routine practice of rapid and early fluid resuscitation in patients with shock and without clear hypovolemia.

Bottom line: Fluid resuscitation is not beneficial in resource-limited settings for children in shock who are not hypotensive.

Citation: Matiland K, Kiguli S, Opoka RO, et. al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011;364:2483-2495.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the effect of fluid resuscitation on mortality in children with shock in resource-limited settings?

Background: Rapid fluid resuscitation is typically recommended for children who present with shock. In resource-limited settings, particularly in Africa, this practice is not commonplace. The exact role of early fluid resuscitation, in addition to the optimal type of fluid (saline or albumin), is unknown.

Study design: Multicenter, randomized, controlled trial.

Setting: Six clinical centers in Africa.

Synopsis: This study was stopped after data for 3,141 of a projected 3,600 enrolled children demonstrated increased mortality in the bolus groups vs. control. Children aged 60 days to 12 years who presented with a severe febrile illness and impaired perfusion without severe hypotension were randomized openly to three groups: saline bolus, albumin bolus, or no bolus (control). Baseline characteristics of the groups were similar. After 48 hours, mortality in the albumin, saline, and control groups was 10.6%, 10.5%, and 7.3% respectively. The relative risk for any bolus vs. control was 1.45 (95% CI, 1.13-1.86; P=.003).

The results of this study are strengthened by the large number of children enrolled and the solid study design. However, it is difficult to immediately generalize the findings due to the unique nature of the study population and environment, which included a high proportion of patients with malaria and notable constraints on resources. Nonetheless, questions are raised regarding the routine practice of rapid and early fluid resuscitation in patients with shock and without clear hypovolemia.

Bottom line: Fluid resuscitation is not beneficial in resource-limited settings for children in shock who are not hypotensive.

Citation: Matiland K, Kiguli S, Opoka RO, et. al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011;364:2483-2495.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the efficacy of dexamethasone in mechanically ventilated children younger than two years of age with respiratory syncytial virus (RSV) lower respiratory tract infections?

Background: Although RSV typically causes self-limited respiratory tract disease with stable and low mortality rates, a small proportion of infants will have severe lower respiratory tract disease requiring mechanical ventilation. The authors previously found no evidence of a benefit of corticosteroids in these infants, but post-hoc analysis suggested a benefit in infants with mild oxygenation abnormalities.

Study design: International, multicenter, randomized, double-blind, placebo-controlled trial.

Setting: Twelve ICUs in Europe.

Synopsis: All patients <2 years of age with RSV-positive bronchiolitis requiring mechanical ventilation were eligible if they had not received corticosteroids in the previous two weeks. Patients were categorized as having either mild or severe oxygenation abnormalities based on their arterial partial pressure of oxygen/fractional inspired oxygen concentration and/or mean airway pressure. The primary outcome measure was duration of mechanical ventilation, and the trial was stopped after interim analysis of 89 patients in the mild oxygenation abnormalities arm revealed insufficient power to detect a >20% difference between the groups if the planned number of 128 patients were ultimately enrolled.

Fifty-six patients were enrolled in the severe oxygenation abnormalities arm. For both groups, there were no differences in either the duration of mechanical ventilation or secondary outcomes, such as length of stay or duration of supplemental oxygen, between intervention and control patients.

This well-designed study adds to an established body of literature painting a clear picture of the inefficacy of corticosteroids in infants with bronchiolitis, with or without severe disease. Although enrollment was slow and ultimately the trial was prematurely terminated, the randomization resulted in almost perfectly matched groups, which likely strengthens the findings despite the small sample size.

Bottom line: Corticosteroids should not be administered to critically ill children with bronchiolitis.

Citation: Van Woensel JB, Vyas H, et al. Dexamethasone in children mechanically ventilated for lower respiratory tract infection caused by respiratory syncytial virus: a randomized controlled trial. Crit Care Med. 2011;39(7):1779-1783.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the efficacy of dexamethasone in mechanically ventilated children younger than two years of age with respiratory syncytial virus (RSV) lower respiratory tract infections?

Background: Although RSV typically causes self-limited respiratory tract disease with stable and low mortality rates, a small proportion of infants will have severe lower respiratory tract disease requiring mechanical ventilation. The authors previously found no evidence of a benefit of corticosteroids in these infants, but post-hoc analysis suggested a benefit in infants with mild oxygenation abnormalities.

Study design: International, multicenter, randomized, double-blind, placebo-controlled trial.

Setting: Twelve ICUs in Europe.

Synopsis: All patients <2 years of age with RSV-positive bronchiolitis requiring mechanical ventilation were eligible if they had not received corticosteroids in the previous two weeks. Patients were categorized as having either mild or severe oxygenation abnormalities based on their arterial partial pressure of oxygen/fractional inspired oxygen concentration and/or mean airway pressure. The primary outcome measure was duration of mechanical ventilation, and the trial was stopped after interim analysis of 89 patients in the mild oxygenation abnormalities arm revealed insufficient power to detect a >20% difference between the groups if the planned number of 128 patients were ultimately enrolled.

Fifty-six patients were enrolled in the severe oxygenation abnormalities arm. For both groups, there were no differences in either the duration of mechanical ventilation or secondary outcomes, such as length of stay or duration of supplemental oxygen, between intervention and control patients.

This well-designed study adds to an established body of literature painting a clear picture of the inefficacy of corticosteroids in infants with bronchiolitis, with or without severe disease. Although enrollment was slow and ultimately the trial was prematurely terminated, the randomization resulted in almost perfectly matched groups, which likely strengthens the findings despite the small sample size.

Bottom line: Corticosteroids should not be administered to critically ill children with bronchiolitis.

Citation: Van Woensel JB, Vyas H, et al. Dexamethasone in children mechanically ventilated for lower respiratory tract infection caused by respiratory syncytial virus: a randomized controlled trial. Crit Care Med. 2011;39(7):1779-1783.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the efficacy of dexamethasone in mechanically ventilated children younger than two years of age with respiratory syncytial virus (RSV) lower respiratory tract infections?

Background: Although RSV typically causes self-limited respiratory tract disease with stable and low mortality rates, a small proportion of infants will have severe lower respiratory tract disease requiring mechanical ventilation. The authors previously found no evidence of a benefit of corticosteroids in these infants, but post-hoc analysis suggested a benefit in infants with mild oxygenation abnormalities.

Study design: International, multicenter, randomized, double-blind, placebo-controlled trial.

Setting: Twelve ICUs in Europe.

Synopsis: All patients <2 years of age with RSV-positive bronchiolitis requiring mechanical ventilation were eligible if they had not received corticosteroids in the previous two weeks. Patients were categorized as having either mild or severe oxygenation abnormalities based on their arterial partial pressure of oxygen/fractional inspired oxygen concentration and/or mean airway pressure. The primary outcome measure was duration of mechanical ventilation, and the trial was stopped after interim analysis of 89 patients in the mild oxygenation abnormalities arm revealed insufficient power to detect a >20% difference between the groups if the planned number of 128 patients were ultimately enrolled.

Fifty-six patients were enrolled in the severe oxygenation abnormalities arm. For both groups, there were no differences in either the duration of mechanical ventilation or secondary outcomes, such as length of stay or duration of supplemental oxygen, between intervention and control patients.

This well-designed study adds to an established body of literature painting a clear picture of the inefficacy of corticosteroids in infants with bronchiolitis, with or without severe disease. Although enrollment was slow and ultimately the trial was prematurely terminated, the randomization resulted in almost perfectly matched groups, which likely strengthens the findings despite the small sample size.

Bottom line: Corticosteroids should not be administered to critically ill children with bronchiolitis.

Citation: Van Woensel JB, Vyas H, et al. Dexamethasone in children mechanically ventilated for lower respiratory tract infection caused by respiratory syncytial virus: a randomized controlled trial. Crit Care Med. 2011;39(7):1779-1783.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the incidence of kernicterus over the past few decades?

Background: Recent guidelines for hyperbilirubinemia have recommended a systematic approach to management in order to prevent the occurrence of severe hyperbilirubinemia and, potentially, kernicterus. There has been concern that rates of kernicterus might have increased in the 1990s, when a “kindler, gentler” approach to hyperbilirubinemia was advocated by earlier guidelines.

Study design: Retrospective observational study.

Setting: California registry of developmental services enrollees.

Synopsis: Of 64,346 children born from 1988 to 1997 who received services from the California Department of Developmental Services (DDS) from 1988 to 2002, 25 met a strict definition of kernicterus. The time trend of incidence remained stable during the study years at 0.44 (95% confidence interval [CI]: 0.28-0.65) per 100,000 live births. There were no significant differences in rates before and after 1994.

Data from a national database of death certificates revealed a similar stable trend in deaths attributed to kernicterus.

A primary limitation of this study is the lack of clarity surrounding enrollment in California’s DDS by children with kernicterus. Although all children with developmental disabilities are eligible, the exact enrollment rate likely is unknown. However, this is one of the first studies to put a denominator on kernicterus in this country.

Updated guidelines on the management of hyperbilirubinemia in 2004 advocated a safer, more systematic approach to management, in part because of concerns that there had been a resurgence of kernicterus. This now seems less likely and this article adds to a body of literature that raises questions about whether a large population of patients with hyperbilirubinemia who are at extremely low risk for kernicterus are being overtreated.

Bottom line: Kernicterus rates remained unchanged in the 1990s.

Citation: Brooks JC, Fisher-Owens SA, Wu YW, Strauss DJ, Newman TB. Evidence suggests there was not a “resurgence” of kernicterus in the 1990s. Pediatrics. 2011;127:672-679.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the incidence of kernicterus over the past few decades?

Background: Recent guidelines for hyperbilirubinemia have recommended a systematic approach to management in order to prevent the occurrence of severe hyperbilirubinemia and, potentially, kernicterus. There has been concern that rates of kernicterus might have increased in the 1990s, when a “kindler, gentler” approach to hyperbilirubinemia was advocated by earlier guidelines.

Study design: Retrospective observational study.

Setting: California registry of developmental services enrollees.

Synopsis: Of 64,346 children born from 1988 to 1997 who received services from the California Department of Developmental Services (DDS) from 1988 to 2002, 25 met a strict definition of kernicterus. The time trend of incidence remained stable during the study years at 0.44 (95% confidence interval [CI]: 0.28-0.65) per 100,000 live births. There were no significant differences in rates before and after 1994.

Data from a national database of death certificates revealed a similar stable trend in deaths attributed to kernicterus.

A primary limitation of this study is the lack of clarity surrounding enrollment in California’s DDS by children with kernicterus. Although all children with developmental disabilities are eligible, the exact enrollment rate likely is unknown. However, this is one of the first studies to put a denominator on kernicterus in this country.

Updated guidelines on the management of hyperbilirubinemia in 2004 advocated a safer, more systematic approach to management, in part because of concerns that there had been a resurgence of kernicterus. This now seems less likely and this article adds to a body of literature that raises questions about whether a large population of patients with hyperbilirubinemia who are at extremely low risk for kernicterus are being overtreated.

Bottom line: Kernicterus rates remained unchanged in the 1990s.

Citation: Brooks JC, Fisher-Owens SA, Wu YW, Strauss DJ, Newman TB. Evidence suggests there was not a “resurgence” of kernicterus in the 1990s. Pediatrics. 2011;127:672-679.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the incidence of kernicterus over the past few decades?

Background: Recent guidelines for hyperbilirubinemia have recommended a systematic approach to management in order to prevent the occurrence of severe hyperbilirubinemia and, potentially, kernicterus. There has been concern that rates of kernicterus might have increased in the 1990s, when a “kindler, gentler” approach to hyperbilirubinemia was advocated by earlier guidelines.

Study design: Retrospective observational study.

Setting: California registry of developmental services enrollees.

Synopsis: Of 64,346 children born from 1988 to 1997 who received services from the California Department of Developmental Services (DDS) from 1988 to 2002, 25 met a strict definition of kernicterus. The time trend of incidence remained stable during the study years at 0.44 (95% confidence interval [CI]: 0.28-0.65) per 100,000 live births. There were no significant differences in rates before and after 1994.

Data from a national database of death certificates revealed a similar stable trend in deaths attributed to kernicterus.

A primary limitation of this study is the lack of clarity surrounding enrollment in California’s DDS by children with kernicterus. Although all children with developmental disabilities are eligible, the exact enrollment rate likely is unknown. However, this is one of the first studies to put a denominator on kernicterus in this country.

Updated guidelines on the management of hyperbilirubinemia in 2004 advocated a safer, more systematic approach to management, in part because of concerns that there had been a resurgence of kernicterus. This now seems less likely and this article adds to a body of literature that raises questions about whether a large population of patients with hyperbilirubinemia who are at extremely low risk for kernicterus are being overtreated.

Bottom line: Kernicterus rates remained unchanged in the 1990s.

Citation: Brooks JC, Fisher-Owens SA, Wu YW, Strauss DJ, Newman TB. Evidence suggests there was not a “resurgence” of kernicterus in the 1990s. Pediatrics. 2011;127:672-679.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

It’s been a while since I went to a buffet and stuffed myself silly, but that’s how my mind felt on the flight home from Kansas City, Mo. After four incredibly packed days at Pediatric Hospital Medicine (PHM) 2011, I was one “wafer-thin mint” away from an explosion. What I wanted was some kind of a mental digestif. What I got instead was a light beer. It helped a little bit, but when I awoke during the landing in Austin, Texas, I realized that I remained in need of a better way to distill the thousand points of information from the conference into something more manageable.

Buoyed by Michelle Marks and Joel Tieder’s Top 10 Articles of the Year luncheon, specifically the piece on neurosurgeons and Kangaroo Care, I thought I might try my own version of a decompressive operation.

Without further delay, here are the top 10 things that I learned at Pediatric Hospital Medicine 2011:

10. We continue to grow as a field. Although the exact number of pediatric hospitalists in the U.S. remains somewhat unclear (but is probably between 1,000 and 2,000), what is known is that attendance at our annual meeting grows every year. Our tripartite meeting, sponsored by the American Academy of Pediatrics (AAP), SHM, and the Academic Pediatric Association (APA), hit a record 450 attendees this year. Beyond the physical numbers, it is quite clear that we are growing in many other domains as well.

9. It is time to re-evaluate the impact of CME on physician practice and outcomes. The literature on continuing professional education has been quite sobering to date, with nothing to show for the thousands of dollars spent per individual. But most of those studies were performed in the last century (think eight hours of lecture a day followed by dinners with big pharma) and I’ll bet that there was not the focus on learner-centered education that was evident in Kansas City.

With a dizzying array of workshops and interactive small group sessions spread amongst seven different tracks, it was difficult, if not impossible, to be a passive participant in the process. And since learning retention rates are generally proportionate to how active a role adults play in their own education, I am going to guess that many other attendees’ brains still have that “I’m thinking” hourglass icon over them. We have the conference planning committee to thank for this.

8. The JCPHM (Joint Council of Pediatric Hospital Medicine) will be increasingly important as we develop. Much like the constant stream of unfamiliar new vaccine names that have appeared in recent years, this proposed new committee comes with another long set of initials and an unfamiliar indication.

The JCPHM will function as a coordinating body, ensuring that work done through the AAP, SHM, and AAP are aligned to provide maximal benefit to pediatric hospitalists as a whole. And thus, similar to immunizations, the benefits will be most evident if we remain healthy as we grow in the context of an increasingly complex environment.

7. Our collective research accomplishments merit national recognition. It was not more than just a few years ago that we were in our research infancy. Posters at our meetings largely represented single-site descriptive studies, typically using survey methodology. This year we had four research breakout tracks, in addition to the plenary and three poster sessions.

Pediatric Research in Inpatient Settings (PRIS) leads the way with a Forbes-like listing of million-dollar grants and a partnership with Child Health Corporation of America’s (CHCA) uber-powerful Pediatric Health Information Systems (PHIS) database. Expect some landmark studies in the near future.

In the meantime, it is clear that the rest of the field is not languishing from smaller budgets. From clear outcome and process measurements of family-centered rounds to studying the spectrum of transitions of care to the impact of early warning systems, there was a predominant focus on quality and safety.

In fact, the tone was set at the opening keynote address, as Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), described creative and innovative ways to study and translate work in this area to improved patient care.

6. We are poised to develop effective training systems for our future workforce. From the use of our core competencies in sessions to a full complement of workshops on education (from individual to team and from student to fellow), it is clear that thoughtful deliberation has paved the way for our future. We possess expertise in education that dovetails nicely with our need to grow and sustain an experienced, well-trained workforce.

Intrinsically, we know that we possess a unique body of skills, knowledge, and attitudes. The explicit articulation of this into longitudinal curricula will headline our evolution as a field.

5. Our new peer-reviewed journal has a bright future. Kudos to Shawn Ralston and the rest of the editorial board for publishing the first peer-reviewed edition of Hospital Pediatrics. Original research, evidence-based content, and practical commentary grace the pages with a little bit of something for everyone. The AAP has demonstrated a healthy level of support for this endeavor, as they sent out an introductory email announcing the journal to all of their membership over the weekend. I am confident that support from our pediatric hospitalist community will follow in the form of an exponential increase in quality submissions. Look no further than the PHM 2011 abstract book to get a preview of what our journal will highlight in the near future.

4. We connect with each other through a language of quality and value in our work. Quality spanned the continuum from conversation to collaboration, as like-minded souls shared ideas and passions amidst the sessions. The improved outcomes demonstrated by the Value in Inpatient Pediatrics (VIP) network are a testament to the positive change that can arise from such efforts. VIP, with its focus on inclusive and front-line collaboratives, also announced an upcoming merger with the AAP’s Quality Improvement and Innovation Network (QuIIN), approved by the AAP board in May.

Perhaps more impressive was that more than 12% of the attendees at PHM 2011 attended the annual VIP dinner and similar numbers signed up to participate in future efforts. At this pace, widespread improvement and value are easily within our sights.

3. Complex care is the new family-centered rounds. Atul Gawande’s recent New Yorker article about “Hot Spotters” could very well have been referring to the body of work that is represented by pediatric generalists (to include a fair number of hospitalists) over the past few years. Closing plenary speakers Robert Lyle and Patrick Casey wowed the audience as they described their medical home for medically complex children—and an estimated savings to Arkansas Medicaid of nearly $3 million per year.

As hospitals and hospital systems look to create accountable care organizations (ACOs), this kind of work will be increasingly prioritized, as it has the potential to generate the biggest gains in valued care.

2. STP, yeah, you know me. Chris Maloney and Suzanne Swanson Mendez brought down the house at the PHM Roundtable update as they presented preliminary results of their large and representative STP (strategic planning) Committee, which is mapping out future certification options for pediatric hospitalists. A lively debate ensued as questions surrounding how to best notify and involve pediatric hospitalists in these decisions came to the forefront. Are we a democracy? Are we a republic? Is there a better model for this decision?

Despite the lack of consensus on how to best move toward a decision, the discussion remained open and engaging. In contrast to recent certification decisions from other organizations, the audience clearly relished the opportunity to provide input, and the STP committee continues to look for able and willing participants.

1. A top-10 list is not enough to cover everything from PHM 2011. From clinical and practice conundrums galore to late nights at Spectators to Kevin Powell’s mad acting skills, a 1,500-word-top-10 list simply does not do the meeting justice! I place full blame on the planning committee for this overindulgent buffet and the unfortunate omission of many other meaningful lessons.

Thank you: Erin Stucky Fisher (chair), Brian Pate, Allison Ballantine, Matt Garber, Jeff Simmons, Doug Carlson and Tamara Simon.

If you’re feeling like you missed out, or have already digested and want more, PHM 2012 will be here soon enough to fill your appetite. Cincinnati, look out.

Dr. Shen is pediatric editor of The Hospitalist.

It’s been a while since I went to a buffet and stuffed myself silly, but that’s how my mind felt on the flight home from Kansas City, Mo. After four incredibly packed days at Pediatric Hospital Medicine (PHM) 2011, I was one “wafer-thin mint” away from an explosion. What I wanted was some kind of a mental digestif. What I got instead was a light beer. It helped a little bit, but when I awoke during the landing in Austin, Texas, I realized that I remained in need of a better way to distill the thousand points of information from the conference into something more manageable.

Buoyed by Michelle Marks and Joel Tieder’s Top 10 Articles of the Year luncheon, specifically the piece on neurosurgeons and Kangaroo Care, I thought I might try my own version of a decompressive operation.

Without further delay, here are the top 10 things that I learned at Pediatric Hospital Medicine 2011:

10. We continue to grow as a field. Although the exact number of pediatric hospitalists in the U.S. remains somewhat unclear (but is probably between 1,000 and 2,000), what is known is that attendance at our annual meeting grows every year. Our tripartite meeting, sponsored by the American Academy of Pediatrics (AAP), SHM, and the Academic Pediatric Association (APA), hit a record 450 attendees this year. Beyond the physical numbers, it is quite clear that we are growing in many other domains as well.

9. It is time to re-evaluate the impact of CME on physician practice and outcomes. The literature on continuing professional education has been quite sobering to date, with nothing to show for the thousands of dollars spent per individual. But most of those studies were performed in the last century (think eight hours of lecture a day followed by dinners with big pharma) and I’ll bet that there was not the focus on learner-centered education that was evident in Kansas City.

With a dizzying array of workshops and interactive small group sessions spread amongst seven different tracks, it was difficult, if not impossible, to be a passive participant in the process. And since learning retention rates are generally proportionate to how active a role adults play in their own education, I am going to guess that many other attendees’ brains still have that “I’m thinking” hourglass icon over them. We have the conference planning committee to thank for this.

8. The JCPHM (Joint Council of Pediatric Hospital Medicine) will be increasingly important as we develop. Much like the constant stream of unfamiliar new vaccine names that have appeared in recent years, this proposed new committee comes with another long set of initials and an unfamiliar indication.

The JCPHM will function as a coordinating body, ensuring that work done through the AAP, SHM, and AAP are aligned to provide maximal benefit to pediatric hospitalists as a whole. And thus, similar to immunizations, the benefits will be most evident if we remain healthy as we grow in the context of an increasingly complex environment.

7. Our collective research accomplishments merit national recognition. It was not more than just a few years ago that we were in our research infancy. Posters at our meetings largely represented single-site descriptive studies, typically using survey methodology. This year we had four research breakout tracks, in addition to the plenary and three poster sessions.

Pediatric Research in Inpatient Settings (PRIS) leads the way with a Forbes-like listing of million-dollar grants and a partnership with Child Health Corporation of America’s (CHCA) uber-powerful Pediatric Health Information Systems (PHIS) database. Expect some landmark studies in the near future.

In the meantime, it is clear that the rest of the field is not languishing from smaller budgets. From clear outcome and process measurements of family-centered rounds to studying the spectrum of transitions of care to the impact of early warning systems, there was a predominant focus on quality and safety.

In fact, the tone was set at the opening keynote address, as Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), described creative and innovative ways to study and translate work in this area to improved patient care.

6. We are poised to develop effective training systems for our future workforce. From the use of our core competencies in sessions to a full complement of workshops on education (from individual to team and from student to fellow), it is clear that thoughtful deliberation has paved the way for our future. We possess expertise in education that dovetails nicely with our need to grow and sustain an experienced, well-trained workforce.

Intrinsically, we know that we possess a unique body of skills, knowledge, and attitudes. The explicit articulation of this into longitudinal curricula will headline our evolution as a field.

5. Our new peer-reviewed journal has a bright future. Kudos to Shawn Ralston and the rest of the editorial board for publishing the first peer-reviewed edition of Hospital Pediatrics. Original research, evidence-based content, and practical commentary grace the pages with a little bit of something for everyone. The AAP has demonstrated a healthy level of support for this endeavor, as they sent out an introductory email announcing the journal to all of their membership over the weekend. I am confident that support from our pediatric hospitalist community will follow in the form of an exponential increase in quality submissions. Look no further than the PHM 2011 abstract book to get a preview of what our journal will highlight in the near future.

4. We connect with each other through a language of quality and value in our work. Quality spanned the continuum from conversation to collaboration, as like-minded souls shared ideas and passions amidst the sessions. The improved outcomes demonstrated by the Value in Inpatient Pediatrics (VIP) network are a testament to the positive change that can arise from such efforts. VIP, with its focus on inclusive and front-line collaboratives, also announced an upcoming merger with the AAP’s Quality Improvement and Innovation Network (QuIIN), approved by the AAP board in May.

Perhaps more impressive was that more than 12% of the attendees at PHM 2011 attended the annual VIP dinner and similar numbers signed up to participate in future efforts. At this pace, widespread improvement and value are easily within our sights.

3. Complex care is the new family-centered rounds. Atul Gawande’s recent New Yorker article about “Hot Spotters” could very well have been referring to the body of work that is represented by pediatric generalists (to include a fair number of hospitalists) over the past few years. Closing plenary speakers Robert Lyle and Patrick Casey wowed the audience as they described their medical home for medically complex children—and an estimated savings to Arkansas Medicaid of nearly $3 million per year.

As hospitals and hospital systems look to create accountable care organizations (ACOs), this kind of work will be increasingly prioritized, as it has the potential to generate the biggest gains in valued care.

2. STP, yeah, you know me. Chris Maloney and Suzanne Swanson Mendez brought down the house at the PHM Roundtable update as they presented preliminary results of their large and representative STP (strategic planning) Committee, which is mapping out future certification options for pediatric hospitalists. A lively debate ensued as questions surrounding how to best notify and involve pediatric hospitalists in these decisions came to the forefront. Are we a democracy? Are we a republic? Is there a better model for this decision?

Despite the lack of consensus on how to best move toward a decision, the discussion remained open and engaging. In contrast to recent certification decisions from other organizations, the audience clearly relished the opportunity to provide input, and the STP committee continues to look for able and willing participants.

1. A top-10 list is not enough to cover everything from PHM 2011. From clinical and practice conundrums galore to late nights at Spectators to Kevin Powell’s mad acting skills, a 1,500-word-top-10 list simply does not do the meeting justice! I place full blame on the planning committee for this overindulgent buffet and the unfortunate omission of many other meaningful lessons.

Thank you: Erin Stucky Fisher (chair), Brian Pate, Allison Ballantine, Matt Garber, Jeff Simmons, Doug Carlson and Tamara Simon.

If you’re feeling like you missed out, or have already digested and want more, PHM 2012 will be here soon enough to fill your appetite. Cincinnati, look out.

Dr. Shen is pediatric editor of The Hospitalist.

It’s been a while since I went to a buffet and stuffed myself silly, but that’s how my mind felt on the flight home from Kansas City, Mo. After four incredibly packed days at Pediatric Hospital Medicine (PHM) 2011, I was one “wafer-thin mint” away from an explosion. What I wanted was some kind of a mental digestif. What I got instead was a light beer. It helped a little bit, but when I awoke during the landing in Austin, Texas, I realized that I remained in need of a better way to distill the thousand points of information from the conference into something more manageable.

Buoyed by Michelle Marks and Joel Tieder’s Top 10 Articles of the Year luncheon, specifically the piece on neurosurgeons and Kangaroo Care, I thought I might try my own version of a decompressive operation.

Without further delay, here are the top 10 things that I learned at Pediatric Hospital Medicine 2011:

10. We continue to grow as a field. Although the exact number of pediatric hospitalists in the U.S. remains somewhat unclear (but is probably between 1,000 and 2,000), what is known is that attendance at our annual meeting grows every year. Our tripartite meeting, sponsored by the American Academy of Pediatrics (AAP), SHM, and the Academic Pediatric Association (APA), hit a record 450 attendees this year. Beyond the physical numbers, it is quite clear that we are growing in many other domains as well.

9. It is time to re-evaluate the impact of CME on physician practice and outcomes. The literature on continuing professional education has been quite sobering to date, with nothing to show for the thousands of dollars spent per individual. But most of those studies were performed in the last century (think eight hours of lecture a day followed by dinners with big pharma) and I’ll bet that there was not the focus on learner-centered education that was evident in Kansas City.

With a dizzying array of workshops and interactive small group sessions spread amongst seven different tracks, it was difficult, if not impossible, to be a passive participant in the process. And since learning retention rates are generally proportionate to how active a role adults play in their own education, I am going to guess that many other attendees’ brains still have that “I’m thinking” hourglass icon over them. We have the conference planning committee to thank for this.

8. The JCPHM (Joint Council of Pediatric Hospital Medicine) will be increasingly important as we develop. Much like the constant stream of unfamiliar new vaccine names that have appeared in recent years, this proposed new committee comes with another long set of initials and an unfamiliar indication.

The JCPHM will function as a coordinating body, ensuring that work done through the AAP, SHM, and AAP are aligned to provide maximal benefit to pediatric hospitalists as a whole. And thus, similar to immunizations, the benefits will be most evident if we remain healthy as we grow in the context of an increasingly complex environment.

7. Our collective research accomplishments merit national recognition. It was not more than just a few years ago that we were in our research infancy. Posters at our meetings largely represented single-site descriptive studies, typically using survey methodology. This year we had four research breakout tracks, in addition to the plenary and three poster sessions.

Pediatric Research in Inpatient Settings (PRIS) leads the way with a Forbes-like listing of million-dollar grants and a partnership with Child Health Corporation of America’s (CHCA) uber-powerful Pediatric Health Information Systems (PHIS) database. Expect some landmark studies in the near future.

In the meantime, it is clear that the rest of the field is not languishing from smaller budgets. From clear outcome and process measurements of family-centered rounds to studying the spectrum of transitions of care to the impact of early warning systems, there was a predominant focus on quality and safety.

In fact, the tone was set at the opening keynote address, as Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), described creative and innovative ways to study and translate work in this area to improved patient care.

6. We are poised to develop effective training systems for our future workforce. From the use of our core competencies in sessions to a full complement of workshops on education (from individual to team and from student to fellow), it is clear that thoughtful deliberation has paved the way for our future. We possess expertise in education that dovetails nicely with our need to grow and sustain an experienced, well-trained workforce.

Intrinsically, we know that we possess a unique body of skills, knowledge, and attitudes. The explicit articulation of this into longitudinal curricula will headline our evolution as a field.

5. Our new peer-reviewed journal has a bright future. Kudos to Shawn Ralston and the rest of the editorial board for publishing the first peer-reviewed edition of Hospital Pediatrics. Original research, evidence-based content, and practical commentary grace the pages with a little bit of something for everyone. The AAP has demonstrated a healthy level of support for this endeavor, as they sent out an introductory email announcing the journal to all of their membership over the weekend. I am confident that support from our pediatric hospitalist community will follow in the form of an exponential increase in quality submissions. Look no further than the PHM 2011 abstract book to get a preview of what our journal will highlight in the near future.

4. We connect with each other through a language of quality and value in our work. Quality spanned the continuum from conversation to collaboration, as like-minded souls shared ideas and passions amidst the sessions. The improved outcomes demonstrated by the Value in Inpatient Pediatrics (VIP) network are a testament to the positive change that can arise from such efforts. VIP, with its focus on inclusive and front-line collaboratives, also announced an upcoming merger with the AAP’s Quality Improvement and Innovation Network (QuIIN), approved by the AAP board in May.

Perhaps more impressive was that more than 12% of the attendees at PHM 2011 attended the annual VIP dinner and similar numbers signed up to participate in future efforts. At this pace, widespread improvement and value are easily within our sights.

3. Complex care is the new family-centered rounds. Atul Gawande’s recent New Yorker article about “Hot Spotters” could very well have been referring to the body of work that is represented by pediatric generalists (to include a fair number of hospitalists) over the past few years. Closing plenary speakers Robert Lyle and Patrick Casey wowed the audience as they described their medical home for medically complex children—and an estimated savings to Arkansas Medicaid of nearly $3 million per year.

As hospitals and hospital systems look to create accountable care organizations (ACOs), this kind of work will be increasingly prioritized, as it has the potential to generate the biggest gains in valued care.

2. STP, yeah, you know me. Chris Maloney and Suzanne Swanson Mendez brought down the house at the PHM Roundtable update as they presented preliminary results of their large and representative STP (strategic planning) Committee, which is mapping out future certification options for pediatric hospitalists. A lively debate ensued as questions surrounding how to best notify and involve pediatric hospitalists in these decisions came to the forefront. Are we a democracy? Are we a republic? Is there a better model for this decision?

Despite the lack of consensus on how to best move toward a decision, the discussion remained open and engaging. In contrast to recent certification decisions from other organizations, the audience clearly relished the opportunity to provide input, and the STP committee continues to look for able and willing participants.

1. A top-10 list is not enough to cover everything from PHM 2011. From clinical and practice conundrums galore to late nights at Spectators to Kevin Powell’s mad acting skills, a 1,500-word-top-10 list simply does not do the meeting justice! I place full blame on the planning committee for this overindulgent buffet and the unfortunate omission of many other meaningful lessons.

Thank you: Erin Stucky Fisher (chair), Brian Pate, Allison Ballantine, Matt Garber, Jeff Simmons, Doug Carlson and Tamara Simon.

If you’re feeling like you missed out, or have already digested and want more, PHM 2012 will be here soon enough to fill your appetite. Cincinnati, look out.

Dr. Shen is pediatric editor of The Hospitalist.

Background: The management of young febrile infants with UTIs is marked by uncertainty and variation. Although recent studies have demonstrated the safety and efficacy of oral antibiotics as primary treatment in infants younger than six months of age, younger infants tend to receive a longer duration of intravenous antibiotics. This might reflect a lack of clear delineation of the risk of adverse events and bacteremia in this population.

Study design: Retrospective chart review.

Setting: Twenty primarily tertiary-care EDs.

Synopsis: Infants aged 29 to 60 days with febrile UTIs were identified through laboratory and chart review at the participating centers. Bacteremia and adverse events (death, shock, bacterial meningitis, intensive care, surgical intervention, or other substantial clinical complications) were identified, as well as patients with a high-risk past medical history (PMH) or who were clinically ill on examination, based on a priori definitions of chart wording.

Adverse events occurred in 2.8% of the 1,895 patients; bacteremia occurred in 6.5%. Recursive partitioning analysis was used to identify a very-low-risk population for adverse events—those who were not clinically ill and without high-risk PMH (prediction model sensitivity 98% and negative predictive value 99.9%)—but it was not as successful in accurately identifying infants at very low risk for bacteremia.

Limitations of this study include the lack of a clear description of the adverse events identified (and their presumed relationship to the UTIs), the reliance on ED documentation, and conservative definitions of bacterial meningitis. Nonetheless, this is a study of significant magnitude in a population marked by uncertainty. Results of this study further strengthen data that support the feasibility of outpatient antibiotic therapy in well-appearing infants.

Bottom line: Well-appearing infants aged 29-60 days and without significant past medical history are at very low risk for adverse events.

Citation: Schnadower D, Kupperman N, Macias CG, et al. Febrile infants with urinary tract infections at very low risk for adverse events and bacteremia. Pediatrics. 2010;126:1074-1083.

Background: The management of young febrile infants with UTIs is marked by uncertainty and variation. Although recent studies have demonstrated the safety and efficacy of oral antibiotics as primary treatment in infants younger than six months of age, younger infants tend to receive a longer duration of intravenous antibiotics. This might reflect a lack of clear delineation of the risk of adverse events and bacteremia in this population.

Study design: Retrospective chart review.

Setting: Twenty primarily tertiary-care EDs.

Synopsis: Infants aged 29 to 60 days with febrile UTIs were identified through laboratory and chart review at the participating centers. Bacteremia and adverse events (death, shock, bacterial meningitis, intensive care, surgical intervention, or other substantial clinical complications) were identified, as well as patients with a high-risk past medical history (PMH) or who were clinically ill on examination, based on a priori definitions of chart wording.

Adverse events occurred in 2.8% of the 1,895 patients; bacteremia occurred in 6.5%. Recursive partitioning analysis was used to identify a very-low-risk population for adverse events—those who were not clinically ill and without high-risk PMH (prediction model sensitivity 98% and negative predictive value 99.9%)—but it was not as successful in accurately identifying infants at very low risk for bacteremia.

Limitations of this study include the lack of a clear description of the adverse events identified (and their presumed relationship to the UTIs), the reliance on ED documentation, and conservative definitions of bacterial meningitis. Nonetheless, this is a study of significant magnitude in a population marked by uncertainty. Results of this study further strengthen data that support the feasibility of outpatient antibiotic therapy in well-appearing infants.

Bottom line: Well-appearing infants aged 29-60 days and without significant past medical history are at very low risk for adverse events.

Citation: Schnadower D, Kupperman N, Macias CG, et al. Febrile infants with urinary tract infections at very low risk for adverse events and bacteremia. Pediatrics. 2010;126:1074-1083.

Background: The management of young febrile infants with UTIs is marked by uncertainty and variation. Although recent studies have demonstrated the safety and efficacy of oral antibiotics as primary treatment in infants younger than six months of age, younger infants tend to receive a longer duration of intravenous antibiotics. This might reflect a lack of clear delineation of the risk of adverse events and bacteremia in this population.

Study design: Retrospective chart review.

Setting: Twenty primarily tertiary-care EDs.

Synopsis: Infants aged 29 to 60 days with febrile UTIs were identified through laboratory and chart review at the participating centers. Bacteremia and adverse events (death, shock, bacterial meningitis, intensive care, surgical intervention, or other substantial clinical complications) were identified, as well as patients with a high-risk past medical history (PMH) or who were clinically ill on examination, based on a priori definitions of chart wording.

Adverse events occurred in 2.8% of the 1,895 patients; bacteremia occurred in 6.5%. Recursive partitioning analysis was used to identify a very-low-risk population for adverse events—those who were not clinically ill and without high-risk PMH (prediction model sensitivity 98% and negative predictive value 99.9%)—but it was not as successful in accurately identifying infants at very low risk for bacteremia.

Limitations of this study include the lack of a clear description of the adverse events identified (and their presumed relationship to the UTIs), the reliance on ED documentation, and conservative definitions of bacterial meningitis. Nonetheless, this is a study of significant magnitude in a population marked by uncertainty. Results of this study further strengthen data that support the feasibility of outpatient antibiotic therapy in well-appearing infants.

Bottom line: Well-appearing infants aged 29-60 days and without significant past medical history are at very low risk for adverse events.

Citation: Schnadower D, Kupperman N, Macias CG, et al. Febrile infants with urinary tract infections at very low risk for adverse events and bacteremia. Pediatrics. 2010;126:1074-1083.

Pediatric hospitalists demonstrated their leadership and ownership of clinical hospital medicine on this year’s pediatric track at HM11.

Joel Tieder, MD, MPH, advocated for a balanced and risk-based approach to apparent life-threatening events (ALTEs). Although the differential for this observer-defined symptom remains broad, a link to perhaps the most worrisome outcome, sudden infant death syndrome (SIDS), has not been borne out in the medical literature. Testing seldom offers conclusive answers, Dr. Tieder said in his review.

Thus, a risk-based approach to guide work-up is prudent. Young age and a history of recurrent events are two factors that could signify risk for worrisome underlying pathology, to include infection and nonaccidental trauma. Dr. Tieder has worked with SHM to organize and lead an expert panel that hopes to release a white paper on this topic in the future.

John Pope, MD, Kris Rehm, MD, and Brian Alverson, MD, collectively presented an update on the top articles of the year relevant to pediatric HM.

Highlights included:

• The potential utility of the Pediatric Early Warning Score in identifying clinical deterioration;
• A reduction in symptoms in patients with irritable bowel syndrome given Lactobacillus GG;
• The positive impact of an antimicrobial stewardship program on vancomycin usage;
• The utility of the clinical examination in deciding whether a lumbar puncture is warranted to evaluate for bacterial meningitis in patients presenting with complex febrile seizures; and
• The adequacy of short-term IV antibiotic therapy in young infants with UTIs.

Dr. Alverson provided an update on the development of clinical practice guidelines for community-acquired pneumonia in children, highlighting his participation on a committee cosponsored by the Pediatric Infectious Disease Society and the Infectious Disease Society of America. Laboratory and radiographic data rarely clarify the diagnosis of clinical pneumonia and are not as useful in the outpatient setting but may be justified to look for complications in children who are hospitalized, he reported.

Other take-home points:

• Antimicrobial therapy in uncomplicated pneumonia should primarily target pneumococcus;
• Ampicillin and amoxicillin penetrate lung tissue well, and in high dosages can overcome most pneumococcal resistance; and
• Management of mycoplasma in children remains controversial and requires further investigation.
• The final guidelines are expected to be published sometime toward the end of the year.

Dr. Shen is pediatric editor of The Hospitalist.

Pediatric hospitalists demonstrated their leadership and ownership of clinical hospital medicine on this year’s pediatric track at HM11.

Joel Tieder, MD, MPH, advocated for a balanced and risk-based approach to apparent life-threatening events (ALTEs). Although the differential for this observer-defined symptom remains broad, a link to perhaps the most worrisome outcome, sudden infant death syndrome (SIDS), has not been borne out in the medical literature. Testing seldom offers conclusive answers, Dr. Tieder said in his review.

Thus, a risk-based approach to guide work-up is prudent. Young age and a history of recurrent events are two factors that could signify risk for worrisome underlying pathology, to include infection and nonaccidental trauma. Dr. Tieder has worked with SHM to organize and lead an expert panel that hopes to release a white paper on this topic in the future.

John Pope, MD, Kris Rehm, MD, and Brian Alverson, MD, collectively presented an update on the top articles of the year relevant to pediatric HM.

Highlights included:

• The potential utility of the Pediatric Early Warning Score in identifying clinical deterioration;
• A reduction in symptoms in patients with irritable bowel syndrome given Lactobacillus GG;
• The positive impact of an antimicrobial stewardship program on vancomycin usage;
• The utility of the clinical examination in deciding whether a lumbar puncture is warranted to evaluate for bacterial meningitis in patients presenting with complex febrile seizures; and
• The adequacy of short-term IV antibiotic therapy in young infants with UTIs.

Dr. Alverson provided an update on the development of clinical practice guidelines for community-acquired pneumonia in children, highlighting his participation on a committee cosponsored by the Pediatric Infectious Disease Society and the Infectious Disease Society of America. Laboratory and radiographic data rarely clarify the diagnosis of clinical pneumonia and are not as useful in the outpatient setting but may be justified to look for complications in children who are hospitalized, he reported.

Other take-home points:

• Antimicrobial therapy in uncomplicated pneumonia should primarily target pneumococcus;
• Ampicillin and amoxicillin penetrate lung tissue well, and in high dosages can overcome most pneumococcal resistance; and
• Management of mycoplasma in children remains controversial and requires further investigation.
• The final guidelines are expected to be published sometime toward the end of the year.

Dr. Shen is pediatric editor of The Hospitalist.

Pediatric hospitalists demonstrated their leadership and ownership of clinical hospital medicine on this year’s pediatric track at HM11.

Joel Tieder, MD, MPH, advocated for a balanced and risk-based approach to apparent life-threatening events (ALTEs). Although the differential for this observer-defined symptom remains broad, a link to perhaps the most worrisome outcome, sudden infant death syndrome (SIDS), has not been borne out in the medical literature. Testing seldom offers conclusive answers, Dr. Tieder said in his review.

Thus, a risk-based approach to guide work-up is prudent. Young age and a history of recurrent events are two factors that could signify risk for worrisome underlying pathology, to include infection and nonaccidental trauma. Dr. Tieder has worked with SHM to organize and lead an expert panel that hopes to release a white paper on this topic in the future.

John Pope, MD, Kris Rehm, MD, and Brian Alverson, MD, collectively presented an update on the top articles of the year relevant to pediatric HM.

Highlights included:

• The potential utility of the Pediatric Early Warning Score in identifying clinical deterioration;
• A reduction in symptoms in patients with irritable bowel syndrome given Lactobacillus GG;
• The positive impact of an antimicrobial stewardship program on vancomycin usage;
• The utility of the clinical examination in deciding whether a lumbar puncture is warranted to evaluate for bacterial meningitis in patients presenting with complex febrile seizures; and
• The adequacy of short-term IV antibiotic therapy in young infants with UTIs.

Dr. Alverson provided an update on the development of clinical practice guidelines for community-acquired pneumonia in children, highlighting his participation on a committee cosponsored by the Pediatric Infectious Disease Society and the Infectious Disease Society of America. Laboratory and radiographic data rarely clarify the diagnosis of clinical pneumonia and are not as useful in the outpatient setting but may be justified to look for complications in children who are hospitalized, he reported.

Other take-home points:

• Antimicrobial therapy in uncomplicated pneumonia should primarily target pneumococcus;
• Ampicillin and amoxicillin penetrate lung tissue well, and in high dosages can overcome most pneumococcal resistance; and
• Management of mycoplasma in children remains controversial and requires further investigation.
• The final guidelines are expected to be published sometime toward the end of the year.

Dr. Shen is pediatric editor of The Hospitalist.

Eight glorious months ago, my wife, Bridget, and I went to the hospital for the birth of our daughter, Livia. I remember the night clearly. It was a planned induction. Labor and delivery was quite busy, so we spent a few hours in the waiting area before our room was ready. Prominently displayed, a royal blue banner and crystal piece announced a Codman Award from the Joint Commission. Presented to only a few healthcare champions annually, this award represented a significant achievement in birth safety. I was proud to have Bridget (and Livia) there.

But had it not been for the Institute for Healthcare Improvement (IHI) Annual Forum’s plenary sessions earlier that year, I probably would have ignored the flashy cabinet, mistaking it for propaganda or a feel-good award that everyone receives if they are nice to Joint Commission inspectors. As it were, I recalled the IHI panel discussion where I had first heard the CEO of Seton Family of Hospitals describe dramatic reductions in the network’s rates of birth injury. Most contentious had been the elimination of elective labor inductions and C-sections at our hospitals before 39 weeks’ gestation.

Perhaps understandably, Bridget was not distracted by any of this. Eyes closed, she was trying to make it through one last uncomfortable night while resting sideways on four chairs pushed together. I knew better than to force the conversation. Two weeks earlier, we had a heated discussion about whether there was any reason to induce earlier for convenience (i.e. obstetrician and grandparents-to-be schedules).

A few months later, at a meeting of physician leadership in our network, the question of whether doctors could lead transformative improvements in care in our community was raised. Thinking back to the Codman Award, I asked an obstetrician if the birth-safety initiative had increased the leadership capacity of physicians.

The reply was quick. “Not really,” she said. “The physicians felt like they were just following some rules.”

Rules? Nobody wanted to bask in the glory of a project that greatly improved outcomes and reduced costs? As I sat in silence and tried to absorb the significance of the response, I was hit from the right with another revelation. A hospital executive in the group noted that this was a very unpopular initiative amongst administrators. There were now fewer feeders and growers populating our NICUs, and this significantly and negatively impacted the bottom line of the hospitals. NICU reimbursement, of course, is a cash cow.

Thus, it came as no surprise when my editor forwarded a recent New York Times piece (www.nytimes.com/2011/03/20/us/20ttnicus.html) on this very issue of overuse in NICU care. The article even profiled my hospital network in Austin, Texas. The drama in the story was the millions of dollars lost by hospitals, potential Texas Medicaid crackdowns on NICU care, and the move away from convenience care.

But a much more important point was missed … value.

The Only Goal

Simply stated, value in healthcare is quality outcomes divided by total costs of care. The real storyline here is that a multidisciplinary team within Seton has greatly improved the single most important metric in healthcare—value. The numerator is healthy deliveries. The denominator is total costs of care. Quality outcomes will drive costs lower, and maximizing this equation should be the only goal we work toward. And yet, routine discussions of how we achieve value are all but absent in our daily conversations.

I suppose it’s only natural that we are distracted. The media will always focus on the dramatic aspect of the story. Political strategists spend days in fluorescently lit rooms devising new ways to keep us misdirected (think death panels). Our academic research agenda continues to prioritize technological advances over efficient healthcare delivery. And our fragmented payment systems all but guarantee that care providers will waste their time on the wrong financial analyses. “Perverse” is an oft-used term to describe our reimbursement system; it aptly describes my experience with “performance” data. How is it that I am regularly subjected to financial reports detailing every bit of billing and coding minutiae, but it takes an act of Congress for me to find simple clinical outcomes data, let alone costs of care? Value is the forgotten stepchild of healthcare reform rhetoric.

Thus, the publicizing of overuse in NICUs is a microcosm of the quagmire that we find ourselves in today. Healthcare spending is a tsunami projected to devastate the shores of our national economy in as little as five years. In the shadow of this rapidly receding financial wave, competing interest groups stand barefoot on the beach debating whether the clinical waste surrounding us is really pollution (one person’s waste is another’s income, as the saying goes). It’s as if we’re all frozen by the spectacle, unable to move toward higher-level value solutions.

All sides will agree, however, that we are quickly running out of time. Continued inaction will condemn us to a crash financial evacuation of cholera-like proportions.

Simple Solution: HM

How do we avert such a natural disaster? I see front-line clinicians—yes, hospitalists—leading the way. Hospitals and healthcare networks are actively mobilizing to create accountable-care organizations (ACOs) in preparation for payment reform almost certain to resurrect some form of capitation or bundling. The finance department of these organizations can only do so much. As they feel the tremors of financial instability, they will cling to what they know—increasing revenue through new services and budget line-item reductions (e.g. decreased funding for hospitalists).

These are short-term solutions at best, and your HM group might already be experiencing the after-effects of such activity.

Hospital administrators will tighten the financial belts, but they cannot improve clinical quality by reducing waste. To paraphrase Atul Gawande, doctors must cap their own pens if we are to reduce waste in the system. Value, then, can only be defined at the bedside in the context of a healthy physician-patient relationship. And as hospitalists, we are at the bedside of the most expensive decisions in medicine.

Although the future landscape might seem bleak, opportunities for HM are aglow with promise. We have the best view of how the system might make the biggest gains. We have been raised with a focus on quality. Scores of improvement success stories are told annually at our national meetings. If we can shift our conversations to improving quality while lowering costs, I believe that defining value will prove to be our field of dreams. TH

Dr. Shen is medical director of hospital medicine at Dell Children’s Hospital in Austin, Texas, and The Hospitalist’s pediatric editor.

Eight glorious months ago, my wife, Bridget, and I went to the hospital for the birth of our daughter, Livia. I remember the night clearly. It was a planned induction. Labor and delivery was quite busy, so we spent a few hours in the waiting area before our room was ready. Prominently displayed, a royal blue banner and crystal piece announced a Codman Award from the Joint Commission. Presented to only a few healthcare champions annually, this award represented a significant achievement in birth safety. I was proud to have Bridget (and Livia) there.

But had it not been for the Institute for Healthcare Improvement (IHI) Annual Forum’s plenary sessions earlier that year, I probably would have ignored the flashy cabinet, mistaking it for propaganda or a feel-good award that everyone receives if they are nice to Joint Commission inspectors. As it were, I recalled the IHI panel discussion where I had first heard the CEO of Seton Family of Hospitals describe dramatic reductions in the network’s rates of birth injury. Most contentious had been the elimination of elective labor inductions and C-sections at our hospitals before 39 weeks’ gestation.

Perhaps understandably, Bridget was not distracted by any of this. Eyes closed, she was trying to make it through one last uncomfortable night while resting sideways on four chairs pushed together. I knew better than to force the conversation. Two weeks earlier, we had a heated discussion about whether there was any reason to induce earlier for convenience (i.e. obstetrician and grandparents-to-be schedules).

A few months later, at a meeting of physician leadership in our network, the question of whether doctors could lead transformative improvements in care in our community was raised. Thinking back to the Codman Award, I asked an obstetrician if the birth-safety initiative had increased the leadership capacity of physicians.

The reply was quick. “Not really,” she said. “The physicians felt like they were just following some rules.”

Rules? Nobody wanted to bask in the glory of a project that greatly improved outcomes and reduced costs? As I sat in silence and tried to absorb the significance of the response, I was hit from the right with another revelation. A hospital executive in the group noted that this was a very unpopular initiative amongst administrators. There were now fewer feeders and growers populating our NICUs, and this significantly and negatively impacted the bottom line of the hospitals. NICU reimbursement, of course, is a cash cow.

Thus, it came as no surprise when my editor forwarded a recent New York Times piece (www.nytimes.com/2011/03/20/us/20ttnicus.html) on this very issue of overuse in NICU care. The article even profiled my hospital network in Austin, Texas. The drama in the story was the millions of dollars lost by hospitals, potential Texas Medicaid crackdowns on NICU care, and the move away from convenience care.

But a much more important point was missed … value.

The Only Goal

Simply stated, value in healthcare is quality outcomes divided by total costs of care. The real storyline here is that a multidisciplinary team within Seton has greatly improved the single most important metric in healthcare—value. The numerator is healthy deliveries. The denominator is total costs of care. Quality outcomes will drive costs lower, and maximizing this equation should be the only goal we work toward. And yet, routine discussions of how we achieve value are all but absent in our daily conversations.

I suppose it’s only natural that we are distracted. The media will always focus on the dramatic aspect of the story. Political strategists spend days in fluorescently lit rooms devising new ways to keep us misdirected (think death panels). Our academic research agenda continues to prioritize technological advances over efficient healthcare delivery. And our fragmented payment systems all but guarantee that care providers will waste their time on the wrong financial analyses. “Perverse” is an oft-used term to describe our reimbursement system; it aptly describes my experience with “performance” data. How is it that I am regularly subjected to financial reports detailing every bit of billing and coding minutiae, but it takes an act of Congress for me to find simple clinical outcomes data, let alone costs of care? Value is the forgotten stepchild of healthcare reform rhetoric.

Thus, the publicizing of overuse in NICUs is a microcosm of the quagmire that we find ourselves in today. Healthcare spending is a tsunami projected to devastate the shores of our national economy in as little as five years. In the shadow of this rapidly receding financial wave, competing interest groups stand barefoot on the beach debating whether the clinical waste surrounding us is really pollution (one person’s waste is another’s income, as the saying goes). It’s as if we’re all frozen by the spectacle, unable to move toward higher-level value solutions.

All sides will agree, however, that we are quickly running out of time. Continued inaction will condemn us to a crash financial evacuation of cholera-like proportions.

Simple Solution: HM

How do we avert such a natural disaster? I see front-line clinicians—yes, hospitalists—leading the way. Hospitals and healthcare networks are actively mobilizing to create accountable-care organizations (ACOs) in preparation for payment reform almost certain to resurrect some form of capitation or bundling. The finance department of these organizations can only do so much. As they feel the tremors of financial instability, they will cling to what they know—increasing revenue through new services and budget line-item reductions (e.g. decreased funding for hospitalists).

These are short-term solutions at best, and your HM group might already be experiencing the after-effects of such activity.

Hospital administrators will tighten the financial belts, but they cannot improve clinical quality by reducing waste. To paraphrase Atul Gawande, doctors must cap their own pens if we are to reduce waste in the system. Value, then, can only be defined at the bedside in the context of a healthy physician-patient relationship. And as hospitalists, we are at the bedside of the most expensive decisions in medicine.

Although the future landscape might seem bleak, opportunities for HM are aglow with promise. We have the best view of how the system might make the biggest gains. We have been raised with a focus on quality. Scores of improvement success stories are told annually at our national meetings. If we can shift our conversations to improving quality while lowering costs, I believe that defining value will prove to be our field of dreams. TH

Dr. Shen is medical director of hospital medicine at Dell Children’s Hospital in Austin, Texas, and The Hospitalist’s pediatric editor.

Eight glorious months ago, my wife, Bridget, and I went to the hospital for the birth of our daughter, Livia. I remember the night clearly. It was a planned induction. Labor and delivery was quite busy, so we spent a few hours in the waiting area before our room was ready. Prominently displayed, a royal blue banner and crystal piece announced a Codman Award from the Joint Commission. Presented to only a few healthcare champions annually, this award represented a significant achievement in birth safety. I was proud to have Bridget (and Livia) there.

But had it not been for the Institute for Healthcare Improvement (IHI) Annual Forum’s plenary sessions earlier that year, I probably would have ignored the flashy cabinet, mistaking it for propaganda or a feel-good award that everyone receives if they are nice to Joint Commission inspectors. As it were, I recalled the IHI panel discussion where I had first heard the CEO of Seton Family of Hospitals describe dramatic reductions in the network’s rates of birth injury. Most contentious had been the elimination of elective labor inductions and C-sections at our hospitals before 39 weeks’ gestation.

Perhaps understandably, Bridget was not distracted by any of this. Eyes closed, she was trying to make it through one last uncomfortable night while resting sideways on four chairs pushed together. I knew better than to force the conversation. Two weeks earlier, we had a heated discussion about whether there was any reason to induce earlier for convenience (i.e. obstetrician and grandparents-to-be schedules).

A few months later, at a meeting of physician leadership in our network, the question of whether doctors could lead transformative improvements in care in our community was raised. Thinking back to the Codman Award, I asked an obstetrician if the birth-safety initiative had increased the leadership capacity of physicians.

The reply was quick. “Not really,” she said. “The physicians felt like they were just following some rules.”

Rules? Nobody wanted to bask in the glory of a project that greatly improved outcomes and reduced costs? As I sat in silence and tried to absorb the significance of the response, I was hit from the right with another revelation. A hospital executive in the group noted that this was a very unpopular initiative amongst administrators. There were now fewer feeders and growers populating our NICUs, and this significantly and negatively impacted the bottom line of the hospitals. NICU reimbursement, of course, is a cash cow.

Thus, it came as no surprise when my editor forwarded a recent New York Times piece (www.nytimes.com/2011/03/20/us/20ttnicus.html) on this very issue of overuse in NICU care. The article even profiled my hospital network in Austin, Texas. The drama in the story was the millions of dollars lost by hospitals, potential Texas Medicaid crackdowns on NICU care, and the move away from convenience care.

But a much more important point was missed … value.

The Only Goal

Simply stated, value in healthcare is quality outcomes divided by total costs of care. The real storyline here is that a multidisciplinary team within Seton has greatly improved the single most important metric in healthcare—value. The numerator is healthy deliveries. The denominator is total costs of care. Quality outcomes will drive costs lower, and maximizing this equation should be the only goal we work toward. And yet, routine discussions of how we achieve value are all but absent in our daily conversations.

I suppose it’s only natural that we are distracted. The media will always focus on the dramatic aspect of the story. Political strategists spend days in fluorescently lit rooms devising new ways to keep us misdirected (think death panels). Our academic research agenda continues to prioritize technological advances over efficient healthcare delivery. And our fragmented payment systems all but guarantee that care providers will waste their time on the wrong financial analyses. “Perverse” is an oft-used term to describe our reimbursement system; it aptly describes my experience with “performance” data. How is it that I am regularly subjected to financial reports detailing every bit of billing and coding minutiae, but it takes an act of Congress for me to find simple clinical outcomes data, let alone costs of care? Value is the forgotten stepchild of healthcare reform rhetoric.

Thus, the publicizing of overuse in NICUs is a microcosm of the quagmire that we find ourselves in today. Healthcare spending is a tsunami projected to devastate the shores of our national economy in as little as five years. In the shadow of this rapidly receding financial wave, competing interest groups stand barefoot on the beach debating whether the clinical waste surrounding us is really pollution (one person’s waste is another’s income, as the saying goes). It’s as if we’re all frozen by the spectacle, unable to move toward higher-level value solutions.

All sides will agree, however, that we are quickly running out of time. Continued inaction will condemn us to a crash financial evacuation of cholera-like proportions.

Simple Solution: HM

How do we avert such a natural disaster? I see front-line clinicians—yes, hospitalists—leading the way. Hospitals and healthcare networks are actively mobilizing to create accountable-care organizations (ACOs) in preparation for payment reform almost certain to resurrect some form of capitation or bundling. The finance department of these organizations can only do so much. As they feel the tremors of financial instability, they will cling to what they know—increasing revenue through new services and budget line-item reductions (e.g. decreased funding for hospitalists).

These are short-term solutions at best, and your HM group might already be experiencing the after-effects of such activity.

Hospital administrators will tighten the financial belts, but they cannot improve clinical quality by reducing waste. To paraphrase Atul Gawande, doctors must cap their own pens if we are to reduce waste in the system. Value, then, can only be defined at the bedside in the context of a healthy physician-patient relationship. And as hospitalists, we are at the bedside of the most expensive decisions in medicine.

Although the future landscape might seem bleak, opportunities for HM are aglow with promise. We have the best view of how the system might make the biggest gains. We have been raised with a focus on quality. Scores of improvement success stories are told annually at our national meetings. If we can shift our conversations to improving quality while lowering costs, I believe that defining value will prove to be our field of dreams. TH

Dr. Shen is medical director of hospital medicine at Dell Children’s Hospital in Austin, Texas, and The Hospitalist’s pediatric editor.