Mary C. Ottolini, MD, MPH

Introduction

The Society of Hospital Medicine (SHM) defines hospitalists as physicians whose primary professional focus is the comprehensive general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.1 It is estimated that there are up to 2500 pediatric hospitalists in the United States, with continued growth due to the converging needs for a dedicated focus on patient safety, quality improvement, hospital throughput, and inpatient teaching.2‐9 (Pediatric Hospital Medicine (PHM), as defined today, has been practiced in the United States for at least 30 years10 and continues to evolve as an area of specialization, with the refinement of a distinct knowledgebase and skill set focused on the provision of high quality general pediatric care in the inpatient setting. PHM is the latest site‐specific specialty to emerge from the field of general pediatrics it's development analogous to the evolution of critical care or emergency medicine during previous decades.11 Adult hospital medicine has defined itself within the field of general internal medicine12 and has recently received approval to provide a recognized focus of practice exam in 2010 for those re‐certifying with the American Board of Internal Medicine,13 PHM is creating an identity as a subspecialty practice with distinct focus on inpatient care for children within the larger context of general pediatric care.8, 14

The Pediatric Hospital Medicine Core Competencies were created to help define the roles and expectations for pediatric hospitalists, regardless of practice setting. The intent is to provide a unified approach toward identifying the specific body of knowledge and measurable skills needed to assure delivery of the highest quality of care for all hospitalized pediatric patients. Most children requiring hospitalization in the United States are hospitalized in community settings where subspecialty support is more limited and many pediatric services may be unavailable. Children with complex, chronic medical problems, however, are more likely to be hospitalized at a tertiary care or academic institutions. In order to unify pediatric hospitalists who work in different practice environments, the PHM Core Competencies were constructed to represent the knowledge, skills, attitudes, and systems improvements that all pediatric hospitalists can be expected to acquire and maintain.

Furthermore, the content of the PHM Core Competencies reflect the fact that children are a vulnerable population. Their care requires attention to many elements which distinguishes it from that given to the majority of the adult population: dependency, differences in developmental physiology and behavior, occurrence of congenital genetic disorders and age‐based clinical conditions, impact of chronic disease states on whole child development, and weight‐based medication dosing often with limited guidance from pediatric studies, to name a few. Awareness of these needs must be heightened when a child enters the hospital where diagnoses, procedures, and treatments often include use of high‐risk modalities and require coordination of care across multiple providers.

Pediatric hospitalists commonly work to improve the systems of care in which they operate and therefore both clinical and non‐clinical topics are included. The 54 chapters address the fundamental and most common components of inpatient care but are not an extensive review of all aspects of inpatient medicine encountered by those caring for hospitalized children. Finally, the PHM Core Competencies are not intended for use in assessing proficiency immediately post‐residency, but do provide a framework for the education and evaluation of both physicians‐in‐training and practicing hospitalists. Meeting these competencies is anticipated to take from one to three years of active practice in pediatric hospital medicine, and may be reached through a combination of practice experience, course work, self‐directed work, and/or formalized training.

Methods

Areas of Focused Practice

The PHM Core Competencies were conceptualized similarly to the SHM adult core competencies. Initial sections were divided into clinical conditions, procedures, and systems. However as content developed and reviewer comments were addressed, the four final sections were modified to those noted in Table 2. For the Common Clinical Diagnoses and Conditions, the goal was to select conditions most commonly encountered by pediatric hospitalists. Non‐surgical diagnosis‐related group (DRG) conditions were selected from the following sources: The Joint Commission's (TJC) Oryx Performance Measures Report15‐16 (asthma, abdominal pain, acute gastroenteritis, simple pneumonia); Child Health Corporation of America's Pediatric Health Information System Dataset (CHCA PHIS, Shawnee Mission, KS), and relevant publications on common pediatric hospitalizations.17 These data were compared to billing data from randomly‐selected practicing hospitalists representing free‐standing children's and community hospitals, teaching and non‐teaching settings, and urban and rural locations. The 22 clinical conditions chosen by the CCTF were those most relevant to the practice of pediatric hospital medicine.

The Specialized Clinical Servicessection addresses important components of care that are not DRG‐based and reflect the unique needs of hospitalized children, as assessed by the CCTF, editors, and contributors. Core Skillswere chosen based on the HCUP Factbook 2 Procedures,18 billing data from randomly‐selected practicing hospitalists representing the same settings listed above, and critical input from reviewers. Depending on the individual setting, pediatric hospitalists may require skills in areas not found in these 11 chapters, such as chest tube placement or ventilator management. The list is therefore not exhaustive, but rather representative of skills most pediatric hospitalists should maintain.

The Healthcare Systems: Supporting and Advancing Child Healthchapters are likely the most dissimilar to any core content taught in traditional residency programs. While residency graduates are versed in some components listed in these chapters, comprehensive education in most of these competencies is currently lacking. Improvement of healthcare systems is an essential element of pediatric hospital medicine, and unifies all pediatric hospitalists regardless of practice environment or patient population. Therefore, this section includes chapters that not only focus on systems of care, but also on advancing child health through advocacy, research, education, evidence‐based medicine, and ethical practice. These chapters were drawn from a combination of several sources: expectations of external agencies (TJC, Center for Medicaid and Medicare) related to the specific nonclinical work in which pediatric hospitalists are integrally involved; expectations for advocacy as best defined by the AAP and the National Association of Children's Hospitals and Related Institutions (NACHRI); the six core competency domains mandated by the Accrediting Council on Graduate Medical Education (ACGME), the American Board of Pediatrics (ABP), and hospital medical staff offices as part of Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE)16; and assessment of responsibilities and leadership roles fulfilled by pediatric hospitalists in all venues. In keeping with the intent of the competencies to be timeless, the competency elements call out the need to attend to the changing goals of these groups as well as those of the Institute of Healthcare Improvement (IHI), the Alliance for Pediatric Quality (which consists of ABP, AAP, TJC, CHCA, NACHRI), and local hospital systems leaders.

Contributors and Review

The CCTF selected section (associate) editors from SHM based on established expertise in each area, with input from the SHM Pediatric and Education Committees and the SHM Board. As a collaborative effort, authors for various chapters were solicited in consultation with experts from the AAP, APA, and SHM, and included non‐hospitalists with reputations as experts in various fields. Numerous SHM Pediatric Committee and CCTF conference calls were held to review hospital and academic appointments, presentations given, and affiliations relevant to the practice of pediatric hospital medicine. This vetting process resulted in a robust author list representing diverse geographic and practice settings. Contributors were provided with structure (Knowledge, Skills, Attitudes, and Systems subsections) and content (timeless, competency based) guidelines.

The review process was rigorous, and included both internal and external reviewers. The APA review in 2007 included the PHM Special Interest Group as well as the PHM Fellowship Directors (Table 1). After return to SHM and further editing, the internal review commenced which focused on content and scope. The editors addressed the resulting suggestions and worked to standardize formatting and use of Bloom's taxonomy.19 A list of common terms and phrases were created to add consistency between chapters. External reviewers were first mailed a letter requesting interest, which was followed up by emails, letters, and phone calls to encourage feedback. External review included 29 solicited agencies and societies (Table 3), with overall response rate of 66% (41% for Groups I and II). Individual contributors then reviewed comments specific to their chapters, with associate editor overview of their respective sections. The editors reviewed each chapter individually multiple times throughout the 2007‐2009 years, contacting individual contributors and reviewers by email and phone. Editors concluded a final comprehensive review of all chapters in late 2009.

Chapter Content

Each of the 54 chapters within the four sections of these competencies is presented in the educational theory of learning domains: Knowledge, Skills, Attitudes, with a final Systems domain added to reflect the emphasis of hospitalist practice on improving healthcare systems. Each chapter is designed to stand alone, which may assist with development of curriculum at individual practice locations. Certain key phrases are apparent throughout, such as lead, coordinate, or participate in and work with hospital and community leaders to which were designed to note the varied roles in different practice settings. Some chapters specifically comment on the application of competency bullets given the unique and differing roles and expectations of pediatric hospitalists, such as research and education. Chapters state specific proficiencies expected wherever possible, with phrases and wording selected to help guide learning activities to achieve the competency.

Application and Future Directions

Although pediatric hospitalists care for children in many settings, these core competencies address the common expectations for any venue. Pediatric hospital medicine requires skills in acute care clinical medicine that attend to the changing needs of hospitalized children. The core of pediatric hospital medicine is dedicated to the care of children in the geographic hospital environment between emergency medicine and tertiary pediatric and neonatal intensive care units. Pediatric hospitalists provide care in related clinical service programs that are linked to hospital systems. In performing these activities, pediatric hospitalists consistently partner with ambulatory providers and subspecialists to render coordinated care across the continuum for a given child. Pediatric hospital medicine is an interdisciplinary practice, with focus on processes of care and clinical quality outcomes based in evidence. Engagement in local, state, and national initiatives to improve child health outcomes is a cornerstone of pediatric hospitalists' practice. These competencies provide the framework for creation of curricula that can reflect local issues and react to changing evidence.

As providers of systems‐based care, pediatric hospitalists are called upon more and more to render care and provide leadership in clinical arenas that are integral to healthcare organizations, such as home health care, sub‐acute care facilities, and hospice and palliative care programs. The practice of pediatric hospital medicine has evolved to its current state through efforts of many represented in the competencies as contributors, associate editors, editors, and reviewers. Pediatric hospitalists are committed to leading change in healthcare for hospitalized children, and are positioned well to address the interests and needs of community and urban, teaching and non‐teaching facilities, and the children and families they serve. These competencies reflect the areas of focused practice which, similar to pediatric emergency medicine, will no doubt be refined but not fundamentally changed in future years. The intent, we hope, is clear: to provide excellence in clinical care, accountability for practice, and lead improvements in healthcare for hospitalized children.

Introduction

The Society of Hospital Medicine (SHM) defines hospitalists as physicians whose primary professional focus is the comprehensive general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.1 It is estimated that there are up to 2500 pediatric hospitalists in the United States, with continued growth due to the converging needs for a dedicated focus on patient safety, quality improvement, hospital throughput, and inpatient teaching.2‐9 (Pediatric Hospital Medicine (PHM), as defined today, has been practiced in the United States for at least 30 years10 and continues to evolve as an area of specialization, with the refinement of a distinct knowledgebase and skill set focused on the provision of high quality general pediatric care in the inpatient setting. PHM is the latest site‐specific specialty to emerge from the field of general pediatrics it's development analogous to the evolution of critical care or emergency medicine during previous decades.11 Adult hospital medicine has defined itself within the field of general internal medicine12 and has recently received approval to provide a recognized focus of practice exam in 2010 for those re‐certifying with the American Board of Internal Medicine,13 PHM is creating an identity as a subspecialty practice with distinct focus on inpatient care for children within the larger context of general pediatric care.8, 14

The Pediatric Hospital Medicine Core Competencies were created to help define the roles and expectations for pediatric hospitalists, regardless of practice setting. The intent is to provide a unified approach toward identifying the specific body of knowledge and measurable skills needed to assure delivery of the highest quality of care for all hospitalized pediatric patients. Most children requiring hospitalization in the United States are hospitalized in community settings where subspecialty support is more limited and many pediatric services may be unavailable. Children with complex, chronic medical problems, however, are more likely to be hospitalized at a tertiary care or academic institutions. In order to unify pediatric hospitalists who work in different practice environments, the PHM Core Competencies were constructed to represent the knowledge, skills, attitudes, and systems improvements that all pediatric hospitalists can be expected to acquire and maintain.

Furthermore, the content of the PHM Core Competencies reflect the fact that children are a vulnerable population. Their care requires attention to many elements which distinguishes it from that given to the majority of the adult population: dependency, differences in developmental physiology and behavior, occurrence of congenital genetic disorders and age‐based clinical conditions, impact of chronic disease states on whole child development, and weight‐based medication dosing often with limited guidance from pediatric studies, to name a few. Awareness of these needs must be heightened when a child enters the hospital where diagnoses, procedures, and treatments often include use of high‐risk modalities and require coordination of care across multiple providers.

Pediatric hospitalists commonly work to improve the systems of care in which they operate and therefore both clinical and non‐clinical topics are included. The 54 chapters address the fundamental and most common components of inpatient care but are not an extensive review of all aspects of inpatient medicine encountered by those caring for hospitalized children. Finally, the PHM Core Competencies are not intended for use in assessing proficiency immediately post‐residency, but do provide a framework for the education and evaluation of both physicians‐in‐training and practicing hospitalists. Meeting these competencies is anticipated to take from one to three years of active practice in pediatric hospital medicine, and may be reached through a combination of practice experience, course work, self‐directed work, and/or formalized training.

Methods

Areas of Focused Practice

The PHM Core Competencies were conceptualized similarly to the SHM adult core competencies. Initial sections were divided into clinical conditions, procedures, and systems. However as content developed and reviewer comments were addressed, the four final sections were modified to those noted in Table 2. For the Common Clinical Diagnoses and Conditions, the goal was to select conditions most commonly encountered by pediatric hospitalists. Non‐surgical diagnosis‐related group (DRG) conditions were selected from the following sources: The Joint Commission's (TJC) Oryx Performance Measures Report15‐16 (asthma, abdominal pain, acute gastroenteritis, simple pneumonia); Child Health Corporation of America's Pediatric Health Information System Dataset (CHCA PHIS, Shawnee Mission, KS), and relevant publications on common pediatric hospitalizations.17 These data were compared to billing data from randomly‐selected practicing hospitalists representing free‐standing children's and community hospitals, teaching and non‐teaching settings, and urban and rural locations. The 22 clinical conditions chosen by the CCTF were those most relevant to the practice of pediatric hospital medicine.

The Specialized Clinical Servicessection addresses important components of care that are not DRG‐based and reflect the unique needs of hospitalized children, as assessed by the CCTF, editors, and contributors. Core Skillswere chosen based on the HCUP Factbook 2 Procedures,18 billing data from randomly‐selected practicing hospitalists representing the same settings listed above, and critical input from reviewers. Depending on the individual setting, pediatric hospitalists may require skills in areas not found in these 11 chapters, such as chest tube placement or ventilator management. The list is therefore not exhaustive, but rather representative of skills most pediatric hospitalists should maintain.

The Healthcare Systems: Supporting and Advancing Child Healthchapters are likely the most dissimilar to any core content taught in traditional residency programs. While residency graduates are versed in some components listed in these chapters, comprehensive education in most of these competencies is currently lacking. Improvement of healthcare systems is an essential element of pediatric hospital medicine, and unifies all pediatric hospitalists regardless of practice environment or patient population. Therefore, this section includes chapters that not only focus on systems of care, but also on advancing child health through advocacy, research, education, evidence‐based medicine, and ethical practice. These chapters were drawn from a combination of several sources: expectations of external agencies (TJC, Center for Medicaid and Medicare) related to the specific nonclinical work in which pediatric hospitalists are integrally involved; expectations for advocacy as best defined by the AAP and the National Association of Children's Hospitals and Related Institutions (NACHRI); the six core competency domains mandated by the Accrediting Council on Graduate Medical Education (ACGME), the American Board of Pediatrics (ABP), and hospital medical staff offices as part of Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE)16; and assessment of responsibilities and leadership roles fulfilled by pediatric hospitalists in all venues. In keeping with the intent of the competencies to be timeless, the competency elements call out the need to attend to the changing goals of these groups as well as those of the Institute of Healthcare Improvement (IHI), the Alliance for Pediatric Quality (which consists of ABP, AAP, TJC, CHCA, NACHRI), and local hospital systems leaders.

Contributors and Review

The CCTF selected section (associate) editors from SHM based on established expertise in each area, with input from the SHM Pediatric and Education Committees and the SHM Board. As a collaborative effort, authors for various chapters were solicited in consultation with experts from the AAP, APA, and SHM, and included non‐hospitalists with reputations as experts in various fields. Numerous SHM Pediatric Committee and CCTF conference calls were held to review hospital and academic appointments, presentations given, and affiliations relevant to the practice of pediatric hospital medicine. This vetting process resulted in a robust author list representing diverse geographic and practice settings. Contributors were provided with structure (Knowledge, Skills, Attitudes, and Systems subsections) and content (timeless, competency based) guidelines.

The review process was rigorous, and included both internal and external reviewers. The APA review in 2007 included the PHM Special Interest Group as well as the PHM Fellowship Directors (Table 1). After return to SHM and further editing, the internal review commenced which focused on content and scope. The editors addressed the resulting suggestions and worked to standardize formatting and use of Bloom's taxonomy.19 A list of common terms and phrases were created to add consistency between chapters. External reviewers were first mailed a letter requesting interest, which was followed up by emails, letters, and phone calls to encourage feedback. External review included 29 solicited agencies and societies (Table 3), with overall response rate of 66% (41% for Groups I and II). Individual contributors then reviewed comments specific to their chapters, with associate editor overview of their respective sections. The editors reviewed each chapter individually multiple times throughout the 2007‐2009 years, contacting individual contributors and reviewers by email and phone. Editors concluded a final comprehensive review of all chapters in late 2009.

Chapter Content

Each of the 54 chapters within the four sections of these competencies is presented in the educational theory of learning domains: Knowledge, Skills, Attitudes, with a final Systems domain added to reflect the emphasis of hospitalist practice on improving healthcare systems. Each chapter is designed to stand alone, which may assist with development of curriculum at individual practice locations. Certain key phrases are apparent throughout, such as lead, coordinate, or participate in and work with hospital and community leaders to which were designed to note the varied roles in different practice settings. Some chapters specifically comment on the application of competency bullets given the unique and differing roles and expectations of pediatric hospitalists, such as research and education. Chapters state specific proficiencies expected wherever possible, with phrases and wording selected to help guide learning activities to achieve the competency.

Application and Future Directions

Although pediatric hospitalists care for children in many settings, these core competencies address the common expectations for any venue. Pediatric hospital medicine requires skills in acute care clinical medicine that attend to the changing needs of hospitalized children. The core of pediatric hospital medicine is dedicated to the care of children in the geographic hospital environment between emergency medicine and tertiary pediatric and neonatal intensive care units. Pediatric hospitalists provide care in related clinical service programs that are linked to hospital systems. In performing these activities, pediatric hospitalists consistently partner with ambulatory providers and subspecialists to render coordinated care across the continuum for a given child. Pediatric hospital medicine is an interdisciplinary practice, with focus on processes of care and clinical quality outcomes based in evidence. Engagement in local, state, and national initiatives to improve child health outcomes is a cornerstone of pediatric hospitalists' practice. These competencies provide the framework for creation of curricula that can reflect local issues and react to changing evidence.

As providers of systems‐based care, pediatric hospitalists are called upon more and more to render care and provide leadership in clinical arenas that are integral to healthcare organizations, such as home health care, sub‐acute care facilities, and hospice and palliative care programs. The practice of pediatric hospital medicine has evolved to its current state through efforts of many represented in the competencies as contributors, associate editors, editors, and reviewers. Pediatric hospitalists are committed to leading change in healthcare for hospitalized children, and are positioned well to address the interests and needs of community and urban, teaching and non‐teaching facilities, and the children and families they serve. These competencies reflect the areas of focused practice which, similar to pediatric emergency medicine, will no doubt be refined but not fundamentally changed in future years. The intent, we hope, is clear: to provide excellence in clinical care, accountability for practice, and lead improvements in healthcare for hospitalized children.

Introduction

The Society of Hospital Medicine (SHM) defines hospitalists as physicians whose primary professional focus is the comprehensive general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.1 It is estimated that there are up to 2500 pediatric hospitalists in the United States, with continued growth due to the converging needs for a dedicated focus on patient safety, quality improvement, hospital throughput, and inpatient teaching.2‐9 (Pediatric Hospital Medicine (PHM), as defined today, has been practiced in the United States for at least 30 years10 and continues to evolve as an area of specialization, with the refinement of a distinct knowledgebase and skill set focused on the provision of high quality general pediatric care in the inpatient setting. PHM is the latest site‐specific specialty to emerge from the field of general pediatrics it's development analogous to the evolution of critical care or emergency medicine during previous decades.11 Adult hospital medicine has defined itself within the field of general internal medicine12 and has recently received approval to provide a recognized focus of practice exam in 2010 for those re‐certifying with the American Board of Internal Medicine,13 PHM is creating an identity as a subspecialty practice with distinct focus on inpatient care for children within the larger context of general pediatric care.8, 14

The Pediatric Hospital Medicine Core Competencies were created to help define the roles and expectations for pediatric hospitalists, regardless of practice setting. The intent is to provide a unified approach toward identifying the specific body of knowledge and measurable skills needed to assure delivery of the highest quality of care for all hospitalized pediatric patients. Most children requiring hospitalization in the United States are hospitalized in community settings where subspecialty support is more limited and many pediatric services may be unavailable. Children with complex, chronic medical problems, however, are more likely to be hospitalized at a tertiary care or academic institutions. In order to unify pediatric hospitalists who work in different practice environments, the PHM Core Competencies were constructed to represent the knowledge, skills, attitudes, and systems improvements that all pediatric hospitalists can be expected to acquire and maintain.

Furthermore, the content of the PHM Core Competencies reflect the fact that children are a vulnerable population. Their care requires attention to many elements which distinguishes it from that given to the majority of the adult population: dependency, differences in developmental physiology and behavior, occurrence of congenital genetic disorders and age‐based clinical conditions, impact of chronic disease states on whole child development, and weight‐based medication dosing often with limited guidance from pediatric studies, to name a few. Awareness of these needs must be heightened when a child enters the hospital where diagnoses, procedures, and treatments often include use of high‐risk modalities and require coordination of care across multiple providers.

Pediatric hospitalists commonly work to improve the systems of care in which they operate and therefore both clinical and non‐clinical topics are included. The 54 chapters address the fundamental and most common components of inpatient care but are not an extensive review of all aspects of inpatient medicine encountered by those caring for hospitalized children. Finally, the PHM Core Competencies are not intended for use in assessing proficiency immediately post‐residency, but do provide a framework for the education and evaluation of both physicians‐in‐training and practicing hospitalists. Meeting these competencies is anticipated to take from one to three years of active practice in pediatric hospital medicine, and may be reached through a combination of practice experience, course work, self‐directed work, and/or formalized training.

Methods

Areas of Focused Practice

The PHM Core Competencies were conceptualized similarly to the SHM adult core competencies. Initial sections were divided into clinical conditions, procedures, and systems. However as content developed and reviewer comments were addressed, the four final sections were modified to those noted in Table 2. For the Common Clinical Diagnoses and Conditions, the goal was to select conditions most commonly encountered by pediatric hospitalists. Non‐surgical diagnosis‐related group (DRG) conditions were selected from the following sources: The Joint Commission's (TJC) Oryx Performance Measures Report15‐16 (asthma, abdominal pain, acute gastroenteritis, simple pneumonia); Child Health Corporation of America's Pediatric Health Information System Dataset (CHCA PHIS, Shawnee Mission, KS), and relevant publications on common pediatric hospitalizations.17 These data were compared to billing data from randomly‐selected practicing hospitalists representing free‐standing children's and community hospitals, teaching and non‐teaching settings, and urban and rural locations. The 22 clinical conditions chosen by the CCTF were those most relevant to the practice of pediatric hospital medicine.

The Specialized Clinical Servicessection addresses important components of care that are not DRG‐based and reflect the unique needs of hospitalized children, as assessed by the CCTF, editors, and contributors. Core Skillswere chosen based on the HCUP Factbook 2 Procedures,18 billing data from randomly‐selected practicing hospitalists representing the same settings listed above, and critical input from reviewers. Depending on the individual setting, pediatric hospitalists may require skills in areas not found in these 11 chapters, such as chest tube placement or ventilator management. The list is therefore not exhaustive, but rather representative of skills most pediatric hospitalists should maintain.

The Healthcare Systems: Supporting and Advancing Child Healthchapters are likely the most dissimilar to any core content taught in traditional residency programs. While residency graduates are versed in some components listed in these chapters, comprehensive education in most of these competencies is currently lacking. Improvement of healthcare systems is an essential element of pediatric hospital medicine, and unifies all pediatric hospitalists regardless of practice environment or patient population. Therefore, this section includes chapters that not only focus on systems of care, but also on advancing child health through advocacy, research, education, evidence‐based medicine, and ethical practice. These chapters were drawn from a combination of several sources: expectations of external agencies (TJC, Center for Medicaid and Medicare) related to the specific nonclinical work in which pediatric hospitalists are integrally involved; expectations for advocacy as best defined by the AAP and the National Association of Children's Hospitals and Related Institutions (NACHRI); the six core competency domains mandated by the Accrediting Council on Graduate Medical Education (ACGME), the American Board of Pediatrics (ABP), and hospital medical staff offices as part of Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE)16; and assessment of responsibilities and leadership roles fulfilled by pediatric hospitalists in all venues. In keeping with the intent of the competencies to be timeless, the competency elements call out the need to attend to the changing goals of these groups as well as those of the Institute of Healthcare Improvement (IHI), the Alliance for Pediatric Quality (which consists of ABP, AAP, TJC, CHCA, NACHRI), and local hospital systems leaders.

Contributors and Review

The CCTF selected section (associate) editors from SHM based on established expertise in each area, with input from the SHM Pediatric and Education Committees and the SHM Board. As a collaborative effort, authors for various chapters were solicited in consultation with experts from the AAP, APA, and SHM, and included non‐hospitalists with reputations as experts in various fields. Numerous SHM Pediatric Committee and CCTF conference calls were held to review hospital and academic appointments, presentations given, and affiliations relevant to the practice of pediatric hospital medicine. This vetting process resulted in a robust author list representing diverse geographic and practice settings. Contributors were provided with structure (Knowledge, Skills, Attitudes, and Systems subsections) and content (timeless, competency based) guidelines.

The review process was rigorous, and included both internal and external reviewers. The APA review in 2007 included the PHM Special Interest Group as well as the PHM Fellowship Directors (Table 1). After return to SHM and further editing, the internal review commenced which focused on content and scope. The editors addressed the resulting suggestions and worked to standardize formatting and use of Bloom's taxonomy.19 A list of common terms and phrases were created to add consistency between chapters. External reviewers were first mailed a letter requesting interest, which was followed up by emails, letters, and phone calls to encourage feedback. External review included 29 solicited agencies and societies (Table 3), with overall response rate of 66% (41% for Groups I and II). Individual contributors then reviewed comments specific to their chapters, with associate editor overview of their respective sections. The editors reviewed each chapter individually multiple times throughout the 2007‐2009 years, contacting individual contributors and reviewers by email and phone. Editors concluded a final comprehensive review of all chapters in late 2009.

Chapter Content

Each of the 54 chapters within the four sections of these competencies is presented in the educational theory of learning domains: Knowledge, Skills, Attitudes, with a final Systems domain added to reflect the emphasis of hospitalist practice on improving healthcare systems. Each chapter is designed to stand alone, which may assist with development of curriculum at individual practice locations. Certain key phrases are apparent throughout, such as lead, coordinate, or participate in and work with hospital and community leaders to which were designed to note the varied roles in different practice settings. Some chapters specifically comment on the application of competency bullets given the unique and differing roles and expectations of pediatric hospitalists, such as research and education. Chapters state specific proficiencies expected wherever possible, with phrases and wording selected to help guide learning activities to achieve the competency.

Application and Future Directions

Although pediatric hospitalists care for children in many settings, these core competencies address the common expectations for any venue. Pediatric hospital medicine requires skills in acute care clinical medicine that attend to the changing needs of hospitalized children. The core of pediatric hospital medicine is dedicated to the care of children in the geographic hospital environment between emergency medicine and tertiary pediatric and neonatal intensive care units. Pediatric hospitalists provide care in related clinical service programs that are linked to hospital systems. In performing these activities, pediatric hospitalists consistently partner with ambulatory providers and subspecialists to render coordinated care across the continuum for a given child. Pediatric hospital medicine is an interdisciplinary practice, with focus on processes of care and clinical quality outcomes based in evidence. Engagement in local, state, and national initiatives to improve child health outcomes is a cornerstone of pediatric hospitalists' practice. These competencies provide the framework for creation of curricula that can reflect local issues and react to changing evidence.

As providers of systems‐based care, pediatric hospitalists are called upon more and more to render care and provide leadership in clinical arenas that are integral to healthcare organizations, such as home health care, sub‐acute care facilities, and hospice and palliative care programs. The practice of pediatric hospital medicine has evolved to its current state through efforts of many represented in the competencies as contributors, associate editors, editors, and reviewers. Pediatric hospitalists are committed to leading change in healthcare for hospitalized children, and are positioned well to address the interests and needs of community and urban, teaching and non‐teaching facilities, and the children and families they serve. These competencies reflect the areas of focused practice which, similar to pediatric emergency medicine, will no doubt be refined but not fundamentally changed in future years. The intent, we hope, is clear: to provide excellence in clinical care, accountability for practice, and lead improvements in healthcare for hospitalized children.

Introduction

The Society of Hospital Medicine (SHM) defines hospitalists as physicians whose primary professional focus is the comprehensive general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.1 It is estimated that there are up to 2500 pediatric hospitalists in the United States, with continued growth due to the converging needs for a dedicated focus on patient safety, quality improvement, hospital throughput, and inpatient teaching.2‐9 (Pediatric Hospital Medicine (PHM), as defined today, has been practiced in the United States for at least 30 years10 and continues to evolve as an area of specialization, with the refinement of a distinct knowledgebase and skill set focused on the provision of high quality general pediatric care in the inpatient setting. PHM is the latest site‐specific specialty to emerge from the field of general pediatrics it's development analogous to the evolution of critical care or emergency medicine during previous decades.11 Adult hospital medicine has defined itself within the field of general internal medicine12 and has recently received approval to provide a recognized focus of practice exam in 2010 for those re‐certifying with the American Board of Internal Medicine,13 PHM is creating an identity as a subspecialty practice with distinct focus on inpatient care for children within the larger context of general pediatric care.8, 14

The Pediatric Hospital Medicine Core Competencies were created to help define the roles and expectations for pediatric hospitalists, regardless of practice setting. The intent is to provide a unified approach toward identifying the specific body of knowledge and measurable skills needed to assure delivery of the highest quality of care for all hospitalized pediatric patients. Most children requiring hospitalization in the United States are hospitalized in community settings where subspecialty support is more limited and many pediatric services may be unavailable. Children with complex, chronic medical problems, however, are more likely to be hospitalized at a tertiary care or academic institutions. In order to unify pediatric hospitalists who work in different practice environments, the PHM Core Competencies were constructed to represent the knowledge, skills, attitudes, and systems improvements that all pediatric hospitalists can be expected to acquire and maintain.

Furthermore, the content of the PHM Core Competencies reflect the fact that children are a vulnerable population. Their care requires attention to many elements which distinguishes it from that given to the majority of the adult population: dependency, differences in developmental physiology and behavior, occurrence of congenital genetic disorders and age‐based clinical conditions, impact of chronic disease states on whole child development, and weight‐based medication dosing often with limited guidance from pediatric studies, to name a few. Awareness of these needs must be heightened when a child enters the hospital where diagnoses, procedures, and treatments often include use of high‐risk modalities and require coordination of care across multiple providers.

Pediatric hospitalists commonly work to improve the systems of care in which they operate and therefore both clinical and non‐clinical topics are included. The 54 chapters address the fundamental and most common components of inpatient care but are not an extensive review of all aspects of inpatient medicine encountered by those caring for hospitalized children. Finally, the PHM Core Competencies are not intended for use in assessing proficiency immediately post‐residency, but do provide a framework for the education and evaluation of both physicians‐in‐training and practicing hospitalists. Meeting these competencies is anticipated to take from one to three years of active practice in pediatric hospital medicine, and may be reached through a combination of practice experience, course work, self‐directed work, and/or formalized training.

Methods

Areas of Focused Practice

The PHM Core Competencies were conceptualized similarly to the SHM adult core competencies. Initial sections were divided into clinical conditions, procedures, and systems. However as content developed and reviewer comments were addressed, the four final sections were modified to those noted in Table 2. For the Common Clinical Diagnoses and Conditions, the goal was to select conditions most commonly encountered by pediatric hospitalists. Non‐surgical diagnosis‐related group (DRG) conditions were selected from the following sources: The Joint Commission's (TJC) Oryx Performance Measures Report15‐16 (asthma, abdominal pain, acute gastroenteritis, simple pneumonia); Child Health Corporation of America's Pediatric Health Information System Dataset (CHCA PHIS, Shawnee Mission, KS), and relevant publications on common pediatric hospitalizations.17 These data were compared to billing data from randomly‐selected practicing hospitalists representing free‐standing children's and community hospitals, teaching and non‐teaching settings, and urban and rural locations. The 22 clinical conditions chosen by the CCTF were those most relevant to the practice of pediatric hospital medicine.

The Specialized Clinical Servicessection addresses important components of care that are not DRG‐based and reflect the unique needs of hospitalized children, as assessed by the CCTF, editors, and contributors. Core Skillswere chosen based on the HCUP Factbook 2 Procedures,18 billing data from randomly‐selected practicing hospitalists representing the same settings listed above, and critical input from reviewers. Depending on the individual setting, pediatric hospitalists may require skills in areas not found in these 11 chapters, such as chest tube placement or ventilator management. The list is therefore not exhaustive, but rather representative of skills most pediatric hospitalists should maintain.

The Healthcare Systems: Supporting and Advancing Child Healthchapters are likely the most dissimilar to any core content taught in traditional residency programs. While residency graduates are versed in some components listed in these chapters, comprehensive education in most of these competencies is currently lacking. Improvement of healthcare systems is an essential element of pediatric hospital medicine, and unifies all pediatric hospitalists regardless of practice environment or patient population. Therefore, this section includes chapters that not only focus on systems of care, but also on advancing child health through advocacy, research, education, evidence‐based medicine, and ethical practice. These chapters were drawn from a combination of several sources: expectations of external agencies (TJC, Center for Medicaid and Medicare) related to the specific nonclinical work in which pediatric hospitalists are integrally involved; expectations for advocacy as best defined by the AAP and the National Association of Children's Hospitals and Related Institutions (NACHRI); the six core competency domains mandated by the Accrediting Council on Graduate Medical Education (ACGME), the American Board of Pediatrics (ABP), and hospital medical staff offices as part of Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE)16; and assessment of responsibilities and leadership roles fulfilled by pediatric hospitalists in all venues. In keeping with the intent of the competencies to be timeless, the competency elements call out the need to attend to the changing goals of these groups as well as those of the Institute of Healthcare Improvement (IHI), the Alliance for Pediatric Quality (which consists of ABP, AAP, TJC, CHCA, NACHRI), and local hospital systems leaders.

Contributors and Review

The CCTF selected section (associate) editors from SHM based on established expertise in each area, with input from the SHM Pediatric and Education Committees and the SHM Board. As a collaborative effort, authors for various chapters were solicited in consultation with experts from the AAP, APA, and SHM, and included non‐hospitalists with reputations as experts in various fields. Numerous SHM Pediatric Committee and CCTF conference calls were held to review hospital and academic appointments, presentations given, and affiliations relevant to the practice of pediatric hospital medicine. This vetting process resulted in a robust author list representing diverse geographic and practice settings. Contributors were provided with structure (Knowledge, Skills, Attitudes, and Systems subsections) and content (timeless, competency based) guidelines.

The review process was rigorous, and included both internal and external reviewers. The APA review in 2007 included the PHM Special Interest Group as well as the PHM Fellowship Directors (Table 1). After return to SHM and further editing, the internal review commenced which focused on content and scope. The editors addressed the resulting suggestions and worked to standardize formatting and use of Bloom's taxonomy.19 A list of common terms and phrases were created to add consistency between chapters. External reviewers were first mailed a letter requesting interest, which was followed up by emails, letters, and phone calls to encourage feedback. External review included 29 solicited agencies and societies (Table 3), with overall response rate of 66% (41% for Groups I and II). Individual contributors then reviewed comments specific to their chapters, with associate editor overview of their respective sections. The editors reviewed each chapter individually multiple times throughout the 2007‐2009 years, contacting individual contributors and reviewers by email and phone. Editors concluded a final comprehensive review of all chapters in late 2009.

Chapter Content

Each of the 54 chapters within the four sections of these competencies is presented in the educational theory of learning domains: Knowledge, Skills, Attitudes, with a final Systems domain added to reflect the emphasis of hospitalist practice on improving healthcare systems. Each chapter is designed to stand alone, which may assist with development of curriculum at individual practice locations. Certain key phrases are apparent throughout, such as lead, coordinate, or participate in and work with hospital and community leaders to which were designed to note the varied roles in different practice settings. Some chapters specifically comment on the application of competency bullets given the unique and differing roles and expectations of pediatric hospitalists, such as research and education. Chapters state specific proficiencies expected wherever possible, with phrases and wording selected to help guide learning activities to achieve the competency.

Application and Future Directions

Although pediatric hospitalists care for children in many settings, these core competencies address the common expectations for any venue. Pediatric hospital medicine requires skills in acute care clinical medicine that attend to the changing needs of hospitalized children. The core of pediatric hospital medicine is dedicated to the care of children in the geographic hospital environment between emergency medicine and tertiary pediatric and neonatal intensive care units. Pediatric hospitalists provide care in related clinical service programs that are linked to hospital systems. In performing these activities, pediatric hospitalists consistently partner with ambulatory providers and subspecialists to render coordinated care across the continuum for a given child. Pediatric hospital medicine is an interdisciplinary practice, with focus on processes of care and clinical quality outcomes based in evidence. Engagement in local, state, and national initiatives to improve child health outcomes is a cornerstone of pediatric hospitalists' practice. These competencies provide the framework for creation of curricula that can reflect local issues and react to changing evidence.

As providers of systems‐based care, pediatric hospitalists are called upon more and more to render care and provide leadership in clinical arenas that are integral to healthcare organizations, such as home health care, sub‐acute care facilities, and hospice and palliative care programs. The practice of pediatric hospital medicine has evolved to its current state through efforts of many represented in the competencies as contributors, associate editors, editors, and reviewers. Pediatric hospitalists are committed to leading change in healthcare for hospitalized children, and are positioned well to address the interests and needs of community and urban, teaching and non‐teaching facilities, and the children and families they serve. These competencies reflect the areas of focused practice which, similar to pediatric emergency medicine, will no doubt be refined but not fundamentally changed in future years. The intent, we hope, is clear: to provide excellence in clinical care, accountability for practice, and lead improvements in healthcare for hospitalized children.

Introduction

The Society of Hospital Medicine (SHM) defines hospitalists as physicians whose primary professional focus is the comprehensive general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.1 It is estimated that there are up to 2500 pediatric hospitalists in the United States, with continued growth due to the converging needs for a dedicated focus on patient safety, quality improvement, hospital throughput, and inpatient teaching.2‐9 (Pediatric Hospital Medicine (PHM), as defined today, has been practiced in the United States for at least 30 years10 and continues to evolve as an area of specialization, with the refinement of a distinct knowledgebase and skill set focused on the provision of high quality general pediatric care in the inpatient setting. PHM is the latest site‐specific specialty to emerge from the field of general pediatrics it's development analogous to the evolution of critical care or emergency medicine during previous decades.11 Adult hospital medicine has defined itself within the field of general internal medicine12 and has recently received approval to provide a recognized focus of practice exam in 2010 for those re‐certifying with the American Board of Internal Medicine,13 PHM is creating an identity as a subspecialty practice with distinct focus on inpatient care for children within the larger context of general pediatric care.8, 14

The Pediatric Hospital Medicine Core Competencies were created to help define the roles and expectations for pediatric hospitalists, regardless of practice setting. The intent is to provide a unified approach toward identifying the specific body of knowledge and measurable skills needed to assure delivery of the highest quality of care for all hospitalized pediatric patients. Most children requiring hospitalization in the United States are hospitalized in community settings where subspecialty support is more limited and many pediatric services may be unavailable. Children with complex, chronic medical problems, however, are more likely to be hospitalized at a tertiary care or academic institutions. In order to unify pediatric hospitalists who work in different practice environments, the PHM Core Competencies were constructed to represent the knowledge, skills, attitudes, and systems improvements that all pediatric hospitalists can be expected to acquire and maintain.

Furthermore, the content of the PHM Core Competencies reflect the fact that children are a vulnerable population. Their care requires attention to many elements which distinguishes it from that given to the majority of the adult population: dependency, differences in developmental physiology and behavior, occurrence of congenital genetic disorders and age‐based clinical conditions, impact of chronic disease states on whole child development, and weight‐based medication dosing often with limited guidance from pediatric studies, to name a few. Awareness of these needs must be heightened when a child enters the hospital where diagnoses, procedures, and treatments often include use of high‐risk modalities and require coordination of care across multiple providers.

Pediatric hospitalists commonly work to improve the systems of care in which they operate and therefore both clinical and non‐clinical topics are included. The 54 chapters address the fundamental and most common components of inpatient care but are not an extensive review of all aspects of inpatient medicine encountered by those caring for hospitalized children. Finally, the PHM Core Competencies are not intended for use in assessing proficiency immediately post‐residency, but do provide a framework for the education and evaluation of both physicians‐in‐training and practicing hospitalists. Meeting these competencies is anticipated to take from one to three years of active practice in pediatric hospital medicine, and may be reached through a combination of practice experience, course work, self‐directed work, and/or formalized training.

Methods

Areas of Focused Practice

The PHM Core Competencies were conceptualized similarly to the SHM adult core competencies. Initial sections were divided into clinical conditions, procedures, and systems. However as content developed and reviewer comments were addressed, the four final sections were modified to those noted in Table 2. For the Common Clinical Diagnoses and Conditions, the goal was to select conditions most commonly encountered by pediatric hospitalists. Non‐surgical diagnosis‐related group (DRG) conditions were selected from the following sources: The Joint Commission's (TJC) Oryx Performance Measures Report15‐16 (asthma, abdominal pain, acute gastroenteritis, simple pneumonia); Child Health Corporation of America's Pediatric Health Information System Dataset (CHCA PHIS, Shawnee Mission, KS), and relevant publications on common pediatric hospitalizations.17 These data were compared to billing data from randomly‐selected practicing hospitalists representing free‐standing children's and community hospitals, teaching and non‐teaching settings, and urban and rural locations. The 22 clinical conditions chosen by the CCTF were those most relevant to the practice of pediatric hospital medicine.

The Specialized Clinical Servicessection addresses important components of care that are not DRG‐based and reflect the unique needs of hospitalized children, as assessed by the CCTF, editors, and contributors. Core Skillswere chosen based on the HCUP Factbook 2 Procedures,18 billing data from randomly‐selected practicing hospitalists representing the same settings listed above, and critical input from reviewers. Depending on the individual setting, pediatric hospitalists may require skills in areas not found in these 11 chapters, such as chest tube placement or ventilator management. The list is therefore not exhaustive, but rather representative of skills most pediatric hospitalists should maintain.

The Healthcare Systems: Supporting and Advancing Child Healthchapters are likely the most dissimilar to any core content taught in traditional residency programs. While residency graduates are versed in some components listed in these chapters, comprehensive education in most of these competencies is currently lacking. Improvement of healthcare systems is an essential element of pediatric hospital medicine, and unifies all pediatric hospitalists regardless of practice environment or patient population. Therefore, this section includes chapters that not only focus on systems of care, but also on advancing child health through advocacy, research, education, evidence‐based medicine, and ethical practice. These chapters were drawn from a combination of several sources: expectations of external agencies (TJC, Center for Medicaid and Medicare) related to the specific nonclinical work in which pediatric hospitalists are integrally involved; expectations for advocacy as best defined by the AAP and the National Association of Children's Hospitals and Related Institutions (NACHRI); the six core competency domains mandated by the Accrediting Council on Graduate Medical Education (ACGME), the American Board of Pediatrics (ABP), and hospital medical staff offices as part of Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE)16; and assessment of responsibilities and leadership roles fulfilled by pediatric hospitalists in all venues. In keeping with the intent of the competencies to be timeless, the competency elements call out the need to attend to the changing goals of these groups as well as those of the Institute of Healthcare Improvement (IHI), the Alliance for Pediatric Quality (which consists of ABP, AAP, TJC, CHCA, NACHRI), and local hospital systems leaders.

Contributors and Review

The CCTF selected section (associate) editors from SHM based on established expertise in each area, with input from the SHM Pediatric and Education Committees and the SHM Board. As a collaborative effort, authors for various chapters were solicited in consultation with experts from the AAP, APA, and SHM, and included non‐hospitalists with reputations as experts in various fields. Numerous SHM Pediatric Committee and CCTF conference calls were held to review hospital and academic appointments, presentations given, and affiliations relevant to the practice of pediatric hospital medicine. This vetting process resulted in a robust author list representing diverse geographic and practice settings. Contributors were provided with structure (Knowledge, Skills, Attitudes, and Systems subsections) and content (timeless, competency based) guidelines.

The review process was rigorous, and included both internal and external reviewers. The APA review in 2007 included the PHM Special Interest Group as well as the PHM Fellowship Directors (Table 1). After return to SHM and further editing, the internal review commenced which focused on content and scope. The editors addressed the resulting suggestions and worked to standardize formatting and use of Bloom's taxonomy.19 A list of common terms and phrases were created to add consistency between chapters. External reviewers were first mailed a letter requesting interest, which was followed up by emails, letters, and phone calls to encourage feedback. External review included 29 solicited agencies and societies (Table 3), with overall response rate of 66% (41% for Groups I and II). Individual contributors then reviewed comments specific to their chapters, with associate editor overview of their respective sections. The editors reviewed each chapter individually multiple times throughout the 2007‐2009 years, contacting individual contributors and reviewers by email and phone. Editors concluded a final comprehensive review of all chapters in late 2009.

Chapter Content

Each of the 54 chapters within the four sections of these competencies is presented in the educational theory of learning domains: Knowledge, Skills, Attitudes, with a final Systems domain added to reflect the emphasis of hospitalist practice on improving healthcare systems. Each chapter is designed to stand alone, which may assist with development of curriculum at individual practice locations. Certain key phrases are apparent throughout, such as lead, coordinate, or participate in and work with hospital and community leaders to which were designed to note the varied roles in different practice settings. Some chapters specifically comment on the application of competency bullets given the unique and differing roles and expectations of pediatric hospitalists, such as research and education. Chapters state specific proficiencies expected wherever possible, with phrases and wording selected to help guide learning activities to achieve the competency.

Application and Future Directions

Although pediatric hospitalists care for children in many settings, these core competencies address the common expectations for any venue. Pediatric hospital medicine requires skills in acute care clinical medicine that attend to the changing needs of hospitalized children. The core of pediatric hospital medicine is dedicated to the care of children in the geographic hospital environment between emergency medicine and tertiary pediatric and neonatal intensive care units. Pediatric hospitalists provide care in related clinical service programs that are linked to hospital systems. In performing these activities, pediatric hospitalists consistently partner with ambulatory providers and subspecialists to render coordinated care across the continuum for a given child. Pediatric hospital medicine is an interdisciplinary practice, with focus on processes of care and clinical quality outcomes based in evidence. Engagement in local, state, and national initiatives to improve child health outcomes is a cornerstone of pediatric hospitalists' practice. These competencies provide the framework for creation of curricula that can reflect local issues and react to changing evidence.

As providers of systems‐based care, pediatric hospitalists are called upon more and more to render care and provide leadership in clinical arenas that are integral to healthcare organizations, such as home health care, sub‐acute care facilities, and hospice and palliative care programs. The practice of pediatric hospital medicine has evolved to its current state through efforts of many represented in the competencies as contributors, associate editors, editors, and reviewers. Pediatric hospitalists are committed to leading change in healthcare for hospitalized children, and are positioned well to address the interests and needs of community and urban, teaching and non‐teaching facilities, and the children and families they serve. These competencies reflect the areas of focused practice which, similar to pediatric emergency medicine, will no doubt be refined but not fundamentally changed in future years. The intent, we hope, is clear: to provide excellence in clinical care, accountability for practice, and lead improvements in healthcare for hospitalized children.

Introduction

The Society of Hospital Medicine (SHM) defines hospitalists as physicians whose primary professional focus is the comprehensive general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.1 It is estimated that there are up to 2500 pediatric hospitalists in the United States, with continued growth due to the converging needs for a dedicated focus on patient safety, quality improvement, hospital throughput, and inpatient teaching.2‐9 (Pediatric Hospital Medicine (PHM), as defined today, has been practiced in the United States for at least 30 years10 and continues to evolve as an area of specialization, with the refinement of a distinct knowledgebase and skill set focused on the provision of high quality general pediatric care in the inpatient setting. PHM is the latest site‐specific specialty to emerge from the field of general pediatrics it's development analogous to the evolution of critical care or emergency medicine during previous decades.11 Adult hospital medicine has defined itself within the field of general internal medicine12 and has recently received approval to provide a recognized focus of practice exam in 2010 for those re‐certifying with the American Board of Internal Medicine,13 PHM is creating an identity as a subspecialty practice with distinct focus on inpatient care for children within the larger context of general pediatric care.8, 14

The Pediatric Hospital Medicine Core Competencies were created to help define the roles and expectations for pediatric hospitalists, regardless of practice setting. The intent is to provide a unified approach toward identifying the specific body of knowledge and measurable skills needed to assure delivery of the highest quality of care for all hospitalized pediatric patients. Most children requiring hospitalization in the United States are hospitalized in community settings where subspecialty support is more limited and many pediatric services may be unavailable. Children with complex, chronic medical problems, however, are more likely to be hospitalized at a tertiary care or academic institutions. In order to unify pediatric hospitalists who work in different practice environments, the PHM Core Competencies were constructed to represent the knowledge, skills, attitudes, and systems improvements that all pediatric hospitalists can be expected to acquire and maintain.

Furthermore, the content of the PHM Core Competencies reflect the fact that children are a vulnerable population. Their care requires attention to many elements which distinguishes it from that given to the majority of the adult population: dependency, differences in developmental physiology and behavior, occurrence of congenital genetic disorders and age‐based clinical conditions, impact of chronic disease states on whole child development, and weight‐based medication dosing often with limited guidance from pediatric studies, to name a few. Awareness of these needs must be heightened when a child enters the hospital where diagnoses, procedures, and treatments often include use of high‐risk modalities and require coordination of care across multiple providers.

Pediatric hospitalists commonly work to improve the systems of care in which they operate and therefore both clinical and non‐clinical topics are included. The 54 chapters address the fundamental and most common components of inpatient care but are not an extensive review of all aspects of inpatient medicine encountered by those caring for hospitalized children. Finally, the PHM Core Competencies are not intended for use in assessing proficiency immediately post‐residency, but do provide a framework for the education and evaluation of both physicians‐in‐training and practicing hospitalists. Meeting these competencies is anticipated to take from one to three years of active practice in pediatric hospital medicine, and may be reached through a combination of practice experience, course work, self‐directed work, and/or formalized training.

Methods

Areas of Focused Practice

The PHM Core Competencies were conceptualized similarly to the SHM adult core competencies. Initial sections were divided into clinical conditions, procedures, and systems. However as content developed and reviewer comments were addressed, the four final sections were modified to those noted in Table 2. For the Common Clinical Diagnoses and Conditions, the goal was to select conditions most commonly encountered by pediatric hospitalists. Non‐surgical diagnosis‐related group (DRG) conditions were selected from the following sources: The Joint Commission's (TJC) Oryx Performance Measures Report15‐16 (asthma, abdominal pain, acute gastroenteritis, simple pneumonia); Child Health Corporation of America's Pediatric Health Information System Dataset (CHCA PHIS, Shawnee Mission, KS), and relevant publications on common pediatric hospitalizations.17 These data were compared to billing data from randomly‐selected practicing hospitalists representing free‐standing children's and community hospitals, teaching and non‐teaching settings, and urban and rural locations. The 22 clinical conditions chosen by the CCTF were those most relevant to the practice of pediatric hospital medicine.

The Specialized Clinical Servicessection addresses important components of care that are not DRG‐based and reflect the unique needs of hospitalized children, as assessed by the CCTF, editors, and contributors. Core Skillswere chosen based on the HCUP Factbook 2 Procedures,18 billing data from randomly‐selected practicing hospitalists representing the same settings listed above, and critical input from reviewers. Depending on the individual setting, pediatric hospitalists may require skills in areas not found in these 11 chapters, such as chest tube placement or ventilator management. The list is therefore not exhaustive, but rather representative of skills most pediatric hospitalists should maintain.

The Healthcare Systems: Supporting and Advancing Child Healthchapters are likely the most dissimilar to any core content taught in traditional residency programs. While residency graduates are versed in some components listed in these chapters, comprehensive education in most of these competencies is currently lacking. Improvement of healthcare systems is an essential element of pediatric hospital medicine, and unifies all pediatric hospitalists regardless of practice environment or patient population. Therefore, this section includes chapters that not only focus on systems of care, but also on advancing child health through advocacy, research, education, evidence‐based medicine, and ethical practice. These chapters were drawn from a combination of several sources: expectations of external agencies (TJC, Center for Medicaid and Medicare) related to the specific nonclinical work in which pediatric hospitalists are integrally involved; expectations for advocacy as best defined by the AAP and the National Association of Children's Hospitals and Related Institutions (NACHRI); the six core competency domains mandated by the Accrediting Council on Graduate Medical Education (ACGME), the American Board of Pediatrics (ABP), and hospital medical staff offices as part of Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE)16; and assessment of responsibilities and leadership roles fulfilled by pediatric hospitalists in all venues. In keeping with the intent of the competencies to be timeless, the competency elements call out the need to attend to the changing goals of these groups as well as those of the Institute of Healthcare Improvement (IHI), the Alliance for Pediatric Quality (which consists of ABP, AAP, TJC, CHCA, NACHRI), and local hospital systems leaders.

Contributors and Review

The CCTF selected section (associate) editors from SHM based on established expertise in each area, with input from the SHM Pediatric and Education Committees and the SHM Board. As a collaborative effort, authors for various chapters were solicited in consultation with experts from the AAP, APA, and SHM, and included non‐hospitalists with reputations as experts in various fields. Numerous SHM Pediatric Committee and CCTF conference calls were held to review hospital and academic appointments, presentations given, and affiliations relevant to the practice of pediatric hospital medicine. This vetting process resulted in a robust author list representing diverse geographic and practice settings. Contributors were provided with structure (Knowledge, Skills, Attitudes, and Systems subsections) and content (timeless, competency based) guidelines.

The review process was rigorous, and included both internal and external reviewers. The APA review in 2007 included the PHM Special Interest Group as well as the PHM Fellowship Directors (Table 1). After return to SHM and further editing, the internal review commenced which focused on content and scope. The editors addressed the resulting suggestions and worked to standardize formatting and use of Bloom's taxonomy.19 A list of common terms and phrases were created to add consistency between chapters. External reviewers were first mailed a letter requesting interest, which was followed up by emails, letters, and phone calls to encourage feedback. External review included 29 solicited agencies and societies (Table 3), with overall response rate of 66% (41% for Groups I and II). Individual contributors then reviewed comments specific to their chapters, with associate editor overview of their respective sections. The editors reviewed each chapter individually multiple times throughout the 2007‐2009 years, contacting individual contributors and reviewers by email and phone. Editors concluded a final comprehensive review of all chapters in late 2009.

Chapter Content

Each of the 54 chapters within the four sections of these competencies is presented in the educational theory of learning domains: Knowledge, Skills, Attitudes, with a final Systems domain added to reflect the emphasis of hospitalist practice on improving healthcare systems. Each chapter is designed to stand alone, which may assist with development of curriculum at individual practice locations. Certain key phrases are apparent throughout, such as lead, coordinate, or participate in and work with hospital and community leaders to which were designed to note the varied roles in different practice settings. Some chapters specifically comment on the application of competency bullets given the unique and differing roles and expectations of pediatric hospitalists, such as research and education. Chapters state specific proficiencies expected wherever possible, with phrases and wording selected to help guide learning activities to achieve the competency.

Application and Future Directions

Although pediatric hospitalists care for children in many settings, these core competencies address the common expectations for any venue. Pediatric hospital medicine requires skills in acute care clinical medicine that attend to the changing needs of hospitalized children. The core of pediatric hospital medicine is dedicated to the care of children in the geographic hospital environment between emergency medicine and tertiary pediatric and neonatal intensive care units. Pediatric hospitalists provide care in related clinical service programs that are linked to hospital systems. In performing these activities, pediatric hospitalists consistently partner with ambulatory providers and subspecialists to render coordinated care across the continuum for a given child. Pediatric hospital medicine is an interdisciplinary practice, with focus on processes of care and clinical quality outcomes based in evidence. Engagement in local, state, and national initiatives to improve child health outcomes is a cornerstone of pediatric hospitalists' practice. These competencies provide the framework for creation of curricula that can reflect local issues and react to changing evidence.

As providers of systems‐based care, pediatric hospitalists are called upon more and more to render care and provide leadership in clinical arenas that are integral to healthcare organizations, such as home health care, sub‐acute care facilities, and hospice and palliative care programs. The practice of pediatric hospital medicine has evolved to its current state through efforts of many represented in the competencies as contributors, associate editors, editors, and reviewers. Pediatric hospitalists are committed to leading change in healthcare for hospitalized children, and are positioned well to address the interests and needs of community and urban, teaching and non‐teaching facilities, and the children and families they serve. These competencies reflect the areas of focused practice which, similar to pediatric emergency medicine, will no doubt be refined but not fundamentally changed in future years. The intent, we hope, is clear: to provide excellence in clinical care, accountability for practice, and lead improvements in healthcare for hospitalized children.

Reduction of undesirable variation in care has been a major focus of systematic efforts to improve the quality of the healthcare system.13 The emergence of hospitalists, physicians specializing in the care of hospitalized patients, was spurred by a desire to streamline care and reduce variability in hospital management of common diseases.4, 5 Over the past decade, hospitalist systems have become a leading vehicle for care delivery.4, 6, 7 It remains unclear, however, whether implementation of hospitalist systems has lessened undesirable variation in the inpatient management of common diseases.

While systematic reviews have found costs and hospital length of stay to be 10‐15% lower in both pediatric and internal medicine hospitalist systems, few studies have adequately assessed the processes or quality of care in hospitalist systems.8, 9 Two internal medicine studies have found decreased mortality in hospitalist systems, but the mechanism by which hospitalists apparently achieved these gains is unclear.10, 11 Even less is known about care processes or quality in pediatric hospitalist systems. Death is a rare occurrence in pediatric ward settings, and the seven studies conducted to date comparing pediatric hospitalist and traditional systems have been universally underpowered to detect differences in mortality.9, 1218 There is a need to better understand care processes as a first step in understanding and improving quality of care in hospitalist systems.19

The Pediatric Research in Inpatient Settings (PRIS) Network was formed to improve the quality of care for hospitalized children through collaborative clinical research. In this study, we sought to study variation in the care of common pediatric conditions among a cohort of pediatric hospitalists. We have previously reported that less variability exists in hospitalists' reported management of inpatient conditions than in the reported management of these same conditions by community‐based pediatricians,20 but we were concerned that substantial undesirable variation (ie, variation in practice due to uncertainty or unsubstantiated local practice traditions, rather than justified variation in care based on different risks of harms or benefits in different patients) may still exist among hospitalists. We therefore conducted a study: 1) to investigate variation in hospitalists' reported use of common inpatient therapies, and 2) to test the hypothesis that greater variation exists in hospitalists' reported use of inpatient therapies of unproven benefit than in those therapies proven to be beneficial.

METHODS

RESULTS

213 of the 320 individuals identified through the 3 lists of pediatric hospitalists (67%) responded to the survey. Of these, 198 (93%) identified themselves as hospitalists and were therefore included. As previously reported,20 53% of respondents were male, 55% worked in academic training environments, and 47% had completed advanced training (fellowship) beyond their core pediatric training (residency training); respondents reported completing residency training 11 9 (mean, standard deviation) years prior to the survey, and spending 176 72 days per year in the care of hospitalized patients.

Variation in reported management: asthma

(Figure 1, Panel A). Relatively little variation existed in reported use of the 4 asthma therapies studied. Only 4.4% (95% CI, 1.4‐7.4%) of respondents did not provide the reference response of using inhaled albuterol often or almost always in the care of inpatients with asthma, and only 6.0% (2.5‐9.5%) of respondents did not report using systemic corticosteroids often or almost always. Variation in reported use of ipratropium was somewhat higher.

Figure 1

Proven vs. Unproven Therapies

(Figure 2). Variation in reported use of therapies of unproven benefit was significantly higher than variation in reported use of the 4 proven therapies (albuterol, corticosteroids, and ipratropium in the first 24 h for asthma; IV re‐hydration for gastroenteritis). The mean variation in reported use of unproven therapies was 44.6 20.5%, compared with 15.5 12.5% variation in reported use of therapies of proven benefit (p = 0.02).

Figure 2

As a sensitivity analysis, the use of thickened feeds as a therapy for GERD was re‐categorized as proven and the above analysis repeated, for the reasons outlined in the methods section. This did not alter the identified relationship between variability and the evidence base fundamentally; hospitalists' reported variation in use of therapies of unproven benefit in this sensitivity analysis was 44.6 21.7%, compared with 21.4 17.0% variation in reported use of proven therapies (p = 0.05).

DISCUSSION

Substantial variation exists in the inpatient management of common pediatric diseases. Although we have previously found less reported variability in pediatric hospitalists' practices than in those of community‐based pediatricians,20 the current study demonstrates a high degree of reported variation even among a cohort of inpatient specialists. Importantly, however, reported variation was found to be significantly less for those inpatient therapies supported by a robust evidence base.

Bronchiolitis, gastroenteritis, asthma, and GERD are extremely common causes of pediatric hospitalization throughout the developed world.2125 Our finding of high reported variability in the routine care of all of these conditions except asthma is concerning, as it suggests that experts do not agree on how to manage children hospitalized with even the most common childhood diseases. While we hypothesized that there would be some variation in the use of therapies whose benefit has not been well established, the high degree of variation observed is of concern because it indicates that an insufficient evidentiary base exists to support much of our day‐to‐day practice. Some variation in practice in response to differing clinical presentations is both expected and desirable, but it is remarkable that variance in practice was significantly less for the most evidence‐based therapies than for those grounded less firmly in science, suggesting that the variation identified here is not justifiable variation based on appropriate responses to atypical clinical presentations, but uncertainty in the absence of clear data. Such undesired variability may decrease system reliability (introducing avoidable opportunity for error),26 and lead to under‐use of needed therapies as well as overuse of unnecessary therapies.1

Our work extends prior research that has identified wide variation in patterns of hospital admission, use of hospital resources, and processes of inpatient care,2732 by documenting reported variation in the use of common inpatient therapies. Rates of hospital admission may vary by as much as 7‐fold across regions.33 Our study demonstrates that wide variation exists not only in admission rates, but in reported inpatient care processes for some of the most common diseases seen in pediatric hospitals. Our study also supports the hypothesis that variation in care may be driven by gaps in knowledge.32 Among hospitalists, we found the strength of the evidence base to be a major determinant of reported variability.

Our study has several limitations. First, the data presented here are derived from provider self‐reports, which may not fully reflect actual practice. In the case of the few proven therapies studied, reporting bias could lead to an over‐reporting of adherence to evidence‐based standards of care. Like our study, however, prior studies have found that hospital‐based providers fairly consistently comply with evidence‐based practice recommendations for acute asthma care,34, 35 supporting our finding that variation in acute asthma care (which represented 3 of our 4 proven therapies) is low in this setting.

Another limitation is that classifications of therapies as proven or unproven change as the evidence base evolves. Of particular relevance to this study, the use of thickened feeds as a therapy for GERD, originally classified as being of unknown effectiveness, was reclassified by Clinical Evidence during the course of the study as likely to be beneficial. The relationship we identified between proven therapies and degree of variability in care did not change when we conducted a sensitivity analysis re‐categorizing this therapy as proven, but precisely quantifying variation is complicated by continuous changes in the state of the evidence.

Pediatric hospitalist systems have been found consistently to improve the efficiency of care,9 yet this study suggests that considerable variation in hospitalists' management of key conditions remains. The Pediatric Research in Inpatient Settings (PRIS) Network was formed in 2002 to improve the care of hospitalized children and the quality of inpatient practice by developing an evidence base for inpatient pediatric care. Ongoing multi‐center research efforts through PRIS and other research networks are beginning to critically evaluate therapies used in the management of common pediatric conditions. Rigorous studies of the processes and outcomes of pediatric hospital care will inform inpatient pediatric practice, and ultimately improve the care of hospitalized children. The current study strongly affirms the urgent need to establish such an evidence base. Without data to inform optimal care, efforts to reduce undesirable variation in care and improve care quality cannot be fully realized.

Reduction of undesirable variation in care has been a major focus of systematic efforts to improve the quality of the healthcare system.13 The emergence of hospitalists, physicians specializing in the care of hospitalized patients, was spurred by a desire to streamline care and reduce variability in hospital management of common diseases.4, 5 Over the past decade, hospitalist systems have become a leading vehicle for care delivery.4, 6, 7 It remains unclear, however, whether implementation of hospitalist systems has lessened undesirable variation in the inpatient management of common diseases.

While systematic reviews have found costs and hospital length of stay to be 10‐15% lower in both pediatric and internal medicine hospitalist systems, few studies have adequately assessed the processes or quality of care in hospitalist systems.8, 9 Two internal medicine studies have found decreased mortality in hospitalist systems, but the mechanism by which hospitalists apparently achieved these gains is unclear.10, 11 Even less is known about care processes or quality in pediatric hospitalist systems. Death is a rare occurrence in pediatric ward settings, and the seven studies conducted to date comparing pediatric hospitalist and traditional systems have been universally underpowered to detect differences in mortality.9, 1218 There is a need to better understand care processes as a first step in understanding and improving quality of care in hospitalist systems.19

The Pediatric Research in Inpatient Settings (PRIS) Network was formed to improve the quality of care for hospitalized children through collaborative clinical research. In this study, we sought to study variation in the care of common pediatric conditions among a cohort of pediatric hospitalists. We have previously reported that less variability exists in hospitalists' reported management of inpatient conditions than in the reported management of these same conditions by community‐based pediatricians,20 but we were concerned that substantial undesirable variation (ie, variation in practice due to uncertainty or unsubstantiated local practice traditions, rather than justified variation in care based on different risks of harms or benefits in different patients) may still exist among hospitalists. We therefore conducted a study: 1) to investigate variation in hospitalists' reported use of common inpatient therapies, and 2) to test the hypothesis that greater variation exists in hospitalists' reported use of inpatient therapies of unproven benefit than in those therapies proven to be beneficial.

METHODS

RESULTS

213 of the 320 individuals identified through the 3 lists of pediatric hospitalists (67%) responded to the survey. Of these, 198 (93%) identified themselves as hospitalists and were therefore included. As previously reported,20 53% of respondents were male, 55% worked in academic training environments, and 47% had completed advanced training (fellowship) beyond their core pediatric training (residency training); respondents reported completing residency training 11 9 (mean, standard deviation) years prior to the survey, and spending 176 72 days per year in the care of hospitalized patients.

Variation in reported management: asthma

(Figure 1, Panel A). Relatively little variation existed in reported use of the 4 asthma therapies studied. Only 4.4% (95% CI, 1.4‐7.4%) of respondents did not provide the reference response of using inhaled albuterol often or almost always in the care of inpatients with asthma, and only 6.0% (2.5‐9.5%) of respondents did not report using systemic corticosteroids often or almost always. Variation in reported use of ipratropium was somewhat higher.

Figure 1

Proven vs. Unproven Therapies

(Figure 2). Variation in reported use of therapies of unproven benefit was significantly higher than variation in reported use of the 4 proven therapies (albuterol, corticosteroids, and ipratropium in the first 24 h for asthma; IV re‐hydration for gastroenteritis). The mean variation in reported use of unproven therapies was 44.6 20.5%, compared with 15.5 12.5% variation in reported use of therapies of proven benefit (p = 0.02).

Figure 2

As a sensitivity analysis, the use of thickened feeds as a therapy for GERD was re‐categorized as proven and the above analysis repeated, for the reasons outlined in the methods section. This did not alter the identified relationship between variability and the evidence base fundamentally; hospitalists' reported variation in use of therapies of unproven benefit in this sensitivity analysis was 44.6 21.7%, compared with 21.4 17.0% variation in reported use of proven therapies (p = 0.05).

DISCUSSION

Substantial variation exists in the inpatient management of common pediatric diseases. Although we have previously found less reported variability in pediatric hospitalists' practices than in those of community‐based pediatricians,20 the current study demonstrates a high degree of reported variation even among a cohort of inpatient specialists. Importantly, however, reported variation was found to be significantly less for those inpatient therapies supported by a robust evidence base.

Bronchiolitis, gastroenteritis, asthma, and GERD are extremely common causes of pediatric hospitalization throughout the developed world.2125 Our finding of high reported variability in the routine care of all of these conditions except asthma is concerning, as it suggests that experts do not agree on how to manage children hospitalized with even the most common childhood diseases. While we hypothesized that there would be some variation in the use of therapies whose benefit has not been well established, the high degree of variation observed is of concern because it indicates that an insufficient evidentiary base exists to support much of our day‐to‐day practice. Some variation in practice in response to differing clinical presentations is both expected and desirable, but it is remarkable that variance in practice was significantly less for the most evidence‐based therapies than for those grounded less firmly in science, suggesting that the variation identified here is not justifiable variation based on appropriate responses to atypical clinical presentations, but uncertainty in the absence of clear data. Such undesired variability may decrease system reliability (introducing avoidable opportunity for error),26 and lead to under‐use of needed therapies as well as overuse of unnecessary therapies.1

Our work extends prior research that has identified wide variation in patterns of hospital admission, use of hospital resources, and processes of inpatient care,2732 by documenting reported variation in the use of common inpatient therapies. Rates of hospital admission may vary by as much as 7‐fold across regions.33 Our study demonstrates that wide variation exists not only in admission rates, but in reported inpatient care processes for some of the most common diseases seen in pediatric hospitals. Our study also supports the hypothesis that variation in care may be driven by gaps in knowledge.32 Among hospitalists, we found the strength of the evidence base to be a major determinant of reported variability.

Our study has several limitations. First, the data presented here are derived from provider self‐reports, which may not fully reflect actual practice. In the case of the few proven therapies studied, reporting bias could lead to an over‐reporting of adherence to evidence‐based standards of care. Like our study, however, prior studies have found that hospital‐based providers fairly consistently comply with evidence‐based practice recommendations for acute asthma care,34, 35 supporting our finding that variation in acute asthma care (which represented 3 of our 4 proven therapies) is low in this setting.

Another limitation is that classifications of therapies as proven or unproven change as the evidence base evolves. Of particular relevance to this study, the use of thickened feeds as a therapy for GERD, originally classified as being of unknown effectiveness, was reclassified by Clinical Evidence during the course of the study as likely to be beneficial. The relationship we identified between proven therapies and degree of variability in care did not change when we conducted a sensitivity analysis re‐categorizing this therapy as proven, but precisely quantifying variation is complicated by continuous changes in the state of the evidence.

Pediatric hospitalist systems have been found consistently to improve the efficiency of care,9 yet this study suggests that considerable variation in hospitalists' management of key conditions remains. The Pediatric Research in Inpatient Settings (PRIS) Network was formed in 2002 to improve the care of hospitalized children and the quality of inpatient practice by developing an evidence base for inpatient pediatric care. Ongoing multi‐center research efforts through PRIS and other research networks are beginning to critically evaluate therapies used in the management of common pediatric conditions. Rigorous studies of the processes and outcomes of pediatric hospital care will inform inpatient pediatric practice, and ultimately improve the care of hospitalized children. The current study strongly affirms the urgent need to establish such an evidence base. Without data to inform optimal care, efforts to reduce undesirable variation in care and improve care quality cannot be fully realized.

Reduction of undesirable variation in care has been a major focus of systematic efforts to improve the quality of the healthcare system.13 The emergence of hospitalists, physicians specializing in the care of hospitalized patients, was spurred by a desire to streamline care and reduce variability in hospital management of common diseases.4, 5 Over the past decade, hospitalist systems have become a leading vehicle for care delivery.4, 6, 7 It remains unclear, however, whether implementation of hospitalist systems has lessened undesirable variation in the inpatient management of common diseases.

While systematic reviews have found costs and hospital length of stay to be 10‐15% lower in both pediatric and internal medicine hospitalist systems, few studies have adequately assessed the processes or quality of care in hospitalist systems.8, 9 Two internal medicine studies have found decreased mortality in hospitalist systems, but the mechanism by which hospitalists apparently achieved these gains is unclear.10, 11 Even less is known about care processes or quality in pediatric hospitalist systems. Death is a rare occurrence in pediatric ward settings, and the seven studies conducted to date comparing pediatric hospitalist and traditional systems have been universally underpowered to detect differences in mortality.9, 1218 There is a need to better understand care processes as a first step in understanding and improving quality of care in hospitalist systems.19

The Pediatric Research in Inpatient Settings (PRIS) Network was formed to improve the quality of care for hospitalized children through collaborative clinical research. In this study, we sought to study variation in the care of common pediatric conditions among a cohort of pediatric hospitalists. We have previously reported that less variability exists in hospitalists' reported management of inpatient conditions than in the reported management of these same conditions by community‐based pediatricians,20 but we were concerned that substantial undesirable variation (ie, variation in practice due to uncertainty or unsubstantiated local practice traditions, rather than justified variation in care based on different risks of harms or benefits in different patients) may still exist among hospitalists. We therefore conducted a study: 1) to investigate variation in hospitalists' reported use of common inpatient therapies, and 2) to test the hypothesis that greater variation exists in hospitalists' reported use of inpatient therapies of unproven benefit than in those therapies proven to be beneficial.

METHODS

RESULTS

213 of the 320 individuals identified through the 3 lists of pediatric hospitalists (67%) responded to the survey. Of these, 198 (93%) identified themselves as hospitalists and were therefore included. As previously reported,20 53% of respondents were male, 55% worked in academic training environments, and 47% had completed advanced training (fellowship) beyond their core pediatric training (residency training); respondents reported completing residency training 11 9 (mean, standard deviation) years prior to the survey, and spending 176 72 days per year in the care of hospitalized patients.

Variation in reported management: asthma

(Figure 1, Panel A). Relatively little variation existed in reported use of the 4 asthma therapies studied. Only 4.4% (95% CI, 1.4‐7.4%) of respondents did not provide the reference response of using inhaled albuterol often or almost always in the care of inpatients with asthma, and only 6.0% (2.5‐9.5%) of respondents did not report using systemic corticosteroids often or almost always. Variation in reported use of ipratropium was somewhat higher.

Figure 1

Proven vs. Unproven Therapies

(Figure 2). Variation in reported use of therapies of unproven benefit was significantly higher than variation in reported use of the 4 proven therapies (albuterol, corticosteroids, and ipratropium in the first 24 h for asthma; IV re‐hydration for gastroenteritis). The mean variation in reported use of unproven therapies was 44.6 20.5%, compared with 15.5 12.5% variation in reported use of therapies of proven benefit (p = 0.02).

Figure 2

As a sensitivity analysis, the use of thickened feeds as a therapy for GERD was re‐categorized as proven and the above analysis repeated, for the reasons outlined in the methods section. This did not alter the identified relationship between variability and the evidence base fundamentally; hospitalists' reported variation in use of therapies of unproven benefit in this sensitivity analysis was 44.6 21.7%, compared with 21.4 17.0% variation in reported use of proven therapies (p = 0.05).

DISCUSSION

Substantial variation exists in the inpatient management of common pediatric diseases. Although we have previously found less reported variability in pediatric hospitalists' practices than in those of community‐based pediatricians,20 the current study demonstrates a high degree of reported variation even among a cohort of inpatient specialists. Importantly, however, reported variation was found to be significantly less for those inpatient therapies supported by a robust evidence base.

Bronchiolitis, gastroenteritis, asthma, and GERD are extremely common causes of pediatric hospitalization throughout the developed world.2125 Our finding of high reported variability in the routine care of all of these conditions except asthma is concerning, as it suggests that experts do not agree on how to manage children hospitalized with even the most common childhood diseases. While we hypothesized that there would be some variation in the use of therapies whose benefit has not been well established, the high degree of variation observed is of concern because it indicates that an insufficient evidentiary base exists to support much of our day‐to‐day practice. Some variation in practice in response to differing clinical presentations is both expected and desirable, but it is remarkable that variance in practice was significantly less for the most evidence‐based therapies than for those grounded less firmly in science, suggesting that the variation identified here is not justifiable variation based on appropriate responses to atypical clinical presentations, but uncertainty in the absence of clear data. Such undesired variability may decrease system reliability (introducing avoidable opportunity for error),26 and lead to under‐use of needed therapies as well as overuse of unnecessary therapies.1

Our work extends prior research that has identified wide variation in patterns of hospital admission, use of hospital resources, and processes of inpatient care,2732 by documenting reported variation in the use of common inpatient therapies. Rates of hospital admission may vary by as much as 7‐fold across regions.33 Our study demonstrates that wide variation exists not only in admission rates, but in reported inpatient care processes for some of the most common diseases seen in pediatric hospitals. Our study also supports the hypothesis that variation in care may be driven by gaps in knowledge.32 Among hospitalists, we found the strength of the evidence base to be a major determinant of reported variability.

Our study has several limitations. First, the data presented here are derived from provider self‐reports, which may not fully reflect actual practice. In the case of the few proven therapies studied, reporting bias could lead to an over‐reporting of adherence to evidence‐based standards of care. Like our study, however, prior studies have found that hospital‐based providers fairly consistently comply with evidence‐based practice recommendations for acute asthma care,34, 35 supporting our finding that variation in acute asthma care (which represented 3 of our 4 proven therapies) is low in this setting.

Another limitation is that classifications of therapies as proven or unproven change as the evidence base evolves. Of particular relevance to this study, the use of thickened feeds as a therapy for GERD, originally classified as being of unknown effectiveness, was reclassified by Clinical Evidence during the course of the study as likely to be beneficial. The relationship we identified between proven therapies and degree of variability in care did not change when we conducted a sensitivity analysis re‐categorizing this therapy as proven, but precisely quantifying variation is complicated by continuous changes in the state of the evidence.

Pediatric hospitalist systems have been found consistently to improve the efficiency of care,9 yet this study suggests that considerable variation in hospitalists' management of key conditions remains. The Pediatric Research in Inpatient Settings (PRIS) Network was formed in 2002 to improve the care of hospitalized children and the quality of inpatient practice by developing an evidence base for inpatient pediatric care. Ongoing multi‐center research efforts through PRIS and other research networks are beginning to critically evaluate therapies used in the management of common pediatric conditions. Rigorous studies of the processes and outcomes of pediatric hospital care will inform inpatient pediatric practice, and ultimately improve the care of hospitalized children. The current study strongly affirms the urgent need to establish such an evidence base. Without data to inform optimal care, efforts to reduce undesirable variation in care and improve care quality cannot be fully realized.