The Things We Do for No Reason (TWDFNR) series reviews practices which have become common parts of hospital care but which may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent black and white conclusions or clinical practice standards, but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion. https://www.choosingwisely.org/

A previously healthy 6‐year‐old boy presented to the emergency room with 3 days of right lower leg pain and fevers up to 102F. The leg pain had progressed until he refused to walk. The patient and family did not recall any trauma to the leg. In the emergency department, he had a blood culture drawn. Because he had elevated inflammatory markers and a negative x‐ray of his right leg, a magnetic resonance imaging scan of the right leg was obtained that revealed right tibial osteomyelitis. He was taken to the operating room for debridement. After obtaining blood and bone cultures, he was started on intravenous (IV) vancomycin. His blood and surgical cultures grew methicillin‐resistant Staphylococcus aureus, sensitive to clindamycin. Subsequent blood cultures were negative, and his inflammatory markers trended down shortly after starting therapy. As he clinically improved, a peripherally inserted central catheter (PICC) was placed, and he was discharged home to complete a 6‐week course of IV vancomycin.

BACKGROUND

Osteoarticular infections (osteomyelitis and septic arthritis) are common problems in the pediatric population, affecting 1/2000 children annually and accounting for approximately 1% of all pediatric hospitalizations.[1, 2] Osteomyelitis can occur in children of all ages and usually requires hospitalization for diagnosis and initial management. The most common mechanism of infection in children is hematogenous inoculation of the bone during an episode of bacteremia (acute hematogenous osteomyelitis), particularly in young children, due to the highly vascular nature of the developing bone. Long bones, such as the femur, tibia, and humerus, are most commonly involved. Treatment of acute osteomyelitis requires prolonged administration of antimicrobial agents. Inadequately treated osteomyelitis can result in progression to chronic infection and loss of function of the affected bone.[3]

WHY YOU MIGHT THINK PARENTERAL ANTIBIOTICS AT DISCHARGE IS SUPERIOR TO ENTERAL THERAPY

In the United States, a large proportion of children with hematogenous osteomyelitis are discharged from the hospital with long‐term parenteral intravenous antibiotics through a PICC line.[3] The medical community historically favored parenteral therapy for young children with serious bacterial infections given concerns regarding impaired enteral absorption. As a result, children with osteomyelitis were initially stabilized in the hospital and discharged with parenteral therapy through a PICC line to continue or complete care, even when the organism was susceptible to a viable oral alternative such as clindamycin or cephalexin. Recommendations regarding the safety and timing to transition to oral antibiotics have been lacking. There is also extreme variation in practice in route of administration (oral vs prolonged IV therapy) in patients being discharged from the hospital with osteomyelitis.[3, 4] The most recent Infectious Diseases Society of America (IDSA) guidelines do not clearly state when transition to oral antibiotics may be safe. Specifically, they state that if patients are stable and without ongoing bacteremia, they can transition to oral therapy to complete a 4‐ to 6‐week course.[5]

WHY LONG‐TERM PARENTERAL ANTIBIOTICS MAY NOT BE SUPERIOR

The use of PICC lines has increased substantially in recent years. This has led to an increasing awareness of complications associated with PICC lines. As a result, guidelines for the appropriate use of PICC lines have been established in adults by collaborators at the University of Michigan.[6] Mounting evidence has called into question whether longer parenteral therapy is truly a more conservative or safer approach for the treatment of osteomyelitis.[3, 4, 7, 8, 9] Providing antibiotics via a PICC line in both the inpatient and outpatient settings may not be as benign as once accepted and may not improve outcomes in osteomyelitis as expected.

WHEN TO CONSIDER PROLONGED PARENTERAL ANTIBIOTICS

The studies indicating the safe transition to oral antibiotics discussed above all excluded children with certain comorbid conditions. Although this varied from study to study, exclusions were as general in some as not previously healthy, and others were as specific as hematologic malignancies, immunocompromised states, sickle cell disease, malabsorption, and penetrating injuries. Also, although we know blood cultures obtained in children with osteomyelitis are positive in only approximately half of the patients,[19] the studies cited do not contain information for their study populations regarding the duration of bacteremia or endovascular complications, such as septic thrombophlebitis, which are well described in the literature.[20, 21] There are limited data on optimal treatment of children with prolonged bacteremia and endovascular complications. Because studies generally involved previously healthy children and do not specifically address these potential complications, the safety of early oral transition in complicated cases is not clear. The current IDSA and Red Book Committee on Infectious Diseases recommend intravenous therapy for bacteremia and endovascular infections with methicillin‐resistant S aureus.[5, 22] Clinical judgement should be used when treating children with comorbid illnesses who experience persistent bacteremia >48 hours, or who have endovascular complications.

WHAT YOU SHOULD DO INSTEAD

For children with acute hematogenous osteomyelitis who are either culture negative and improve on empiric therapy, or who have culture results (blood or tissue) that are susceptible to a reasonable oral antibiotic agent and who have clinical improvement on initial IV antibiotic therapy, a growing body of evidence indicates that the benefit of early transition to oral antibiotics outweighs the risks of continuing with parenteral therapy. Discharging children on oral antibiotics does not increase their risk of treatment failure but seems to decrease the risk of therapy‐associated complications, including increased healthcare utilization with return visits to the emergency department or the hospital. The possible exceptions to early transition to enteral antibiotics are prolonged bacteremia or endovascular infection, though there are insufficient data in the literature indicating benefits or risks of one administration route over the other.

RECOMMENDATIONS

1. Previously healthy children with acute hematogenous osteomyelitis, without endovascular complications, should be transitioned to enteral antibiotics when they are showing signs of clinical improvement, as defined by: resolution of fever, improving physical exam, ability to take oral medications, and decreasing C‐reactive protein.
2. The choice of oral antibiotics should be based on the organism's antibiotic susceptibility. If cultures are negative and the child has improved on empiric IV therapy, transition to an oral regimen with similar spectrum is acceptable.
3. Patients with acute osteomyelitis should have close follow‐up after discharge from the hospital, within 1 to 2 weeks, to ensure continued improvement on therapy.

CONCLUSION

Early transition to oral antibiotics should be used in children with acute, uncomplicated osteomyelitis. A growing body of evidence shows that early transition to oral antibiotics does not increase the risk of treatment failure and can obviate the need for an outpatient PICC line. Oral antibiotics do not carry the risk of potential complications and complexity that are inherent in outpatient parenteral therapy. The transition to oral therapy should occur prior to discharge from the hospital after clinical improvement. Close follow‐up is essential to ensure successful treatment in children with acute osteomyelitis.

Disclosure: Nothing to report.

Do you think this is a low‐value practice? Is this truly a Thing We Do for No Reason? Share what you do in your practice and join in the conversation online by retweeting it on Twitter (#TWDFNR) and liking it on Facebook. We invite you to propose ideas for other Things We Do for No Reason topics by emailing [email protected].

The Things We Do for No Reason (TWDFNR) series reviews practices which have become common parts of hospital care but which may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent black and white conclusions or clinical practice standards, but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion. https://www.choosingwisely.org/

A previously healthy 6‐year‐old boy presented to the emergency room with 3 days of right lower leg pain and fevers up to 102F. The leg pain had progressed until he refused to walk. The patient and family did not recall any trauma to the leg. In the emergency department, he had a blood culture drawn. Because he had elevated inflammatory markers and a negative x‐ray of his right leg, a magnetic resonance imaging scan of the right leg was obtained that revealed right tibial osteomyelitis. He was taken to the operating room for debridement. After obtaining blood and bone cultures, he was started on intravenous (IV) vancomycin. His blood and surgical cultures grew methicillin‐resistant Staphylococcus aureus, sensitive to clindamycin. Subsequent blood cultures were negative, and his inflammatory markers trended down shortly after starting therapy. As he clinically improved, a peripherally inserted central catheter (PICC) was placed, and he was discharged home to complete a 6‐week course of IV vancomycin.

BACKGROUND

Osteoarticular infections (osteomyelitis and septic arthritis) are common problems in the pediatric population, affecting 1/2000 children annually and accounting for approximately 1% of all pediatric hospitalizations.[1, 2] Osteomyelitis can occur in children of all ages and usually requires hospitalization for diagnosis and initial management. The most common mechanism of infection in children is hematogenous inoculation of the bone during an episode of bacteremia (acute hematogenous osteomyelitis), particularly in young children, due to the highly vascular nature of the developing bone. Long bones, such as the femur, tibia, and humerus, are most commonly involved. Treatment of acute osteomyelitis requires prolonged administration of antimicrobial agents. Inadequately treated osteomyelitis can result in progression to chronic infection and loss of function of the affected bone.[3]

WHY YOU MIGHT THINK PARENTERAL ANTIBIOTICS AT DISCHARGE IS SUPERIOR TO ENTERAL THERAPY

In the United States, a large proportion of children with hematogenous osteomyelitis are discharged from the hospital with long‐term parenteral intravenous antibiotics through a PICC line.[3] The medical community historically favored parenteral therapy for young children with serious bacterial infections given concerns regarding impaired enteral absorption. As a result, children with osteomyelitis were initially stabilized in the hospital and discharged with parenteral therapy through a PICC line to continue or complete care, even when the organism was susceptible to a viable oral alternative such as clindamycin or cephalexin. Recommendations regarding the safety and timing to transition to oral antibiotics have been lacking. There is also extreme variation in practice in route of administration (oral vs prolonged IV therapy) in patients being discharged from the hospital with osteomyelitis.[3, 4] The most recent Infectious Diseases Society of America (IDSA) guidelines do not clearly state when transition to oral antibiotics may be safe. Specifically, they state that if patients are stable and without ongoing bacteremia, they can transition to oral therapy to complete a 4‐ to 6‐week course.[5]

WHY LONG‐TERM PARENTERAL ANTIBIOTICS MAY NOT BE SUPERIOR

The use of PICC lines has increased substantially in recent years. This has led to an increasing awareness of complications associated with PICC lines. As a result, guidelines for the appropriate use of PICC lines have been established in adults by collaborators at the University of Michigan.[6] Mounting evidence has called into question whether longer parenteral therapy is truly a more conservative or safer approach for the treatment of osteomyelitis.[3, 4, 7, 8, 9] Providing antibiotics via a PICC line in both the inpatient and outpatient settings may not be as benign as once accepted and may not improve outcomes in osteomyelitis as expected.

WHEN TO CONSIDER PROLONGED PARENTERAL ANTIBIOTICS

The studies indicating the safe transition to oral antibiotics discussed above all excluded children with certain comorbid conditions. Although this varied from study to study, exclusions were as general in some as not previously healthy, and others were as specific as hematologic malignancies, immunocompromised states, sickle cell disease, malabsorption, and penetrating injuries. Also, although we know blood cultures obtained in children with osteomyelitis are positive in only approximately half of the patients,[19] the studies cited do not contain information for their study populations regarding the duration of bacteremia or endovascular complications, such as septic thrombophlebitis, which are well described in the literature.[20, 21] There are limited data on optimal treatment of children with prolonged bacteremia and endovascular complications. Because studies generally involved previously healthy children and do not specifically address these potential complications, the safety of early oral transition in complicated cases is not clear. The current IDSA and Red Book Committee on Infectious Diseases recommend intravenous therapy for bacteremia and endovascular infections with methicillin‐resistant S aureus.[5, 22] Clinical judgement should be used when treating children with comorbid illnesses who experience persistent bacteremia >48 hours, or who have endovascular complications.

WHAT YOU SHOULD DO INSTEAD

For children with acute hematogenous osteomyelitis who are either culture negative and improve on empiric therapy, or who have culture results (blood or tissue) that are susceptible to a reasonable oral antibiotic agent and who have clinical improvement on initial IV antibiotic therapy, a growing body of evidence indicates that the benefit of early transition to oral antibiotics outweighs the risks of continuing with parenteral therapy. Discharging children on oral antibiotics does not increase their risk of treatment failure but seems to decrease the risk of therapy‐associated complications, including increased healthcare utilization with return visits to the emergency department or the hospital. The possible exceptions to early transition to enteral antibiotics are prolonged bacteremia or endovascular infection, though there are insufficient data in the literature indicating benefits or risks of one administration route over the other.

RECOMMENDATIONS

1. Previously healthy children with acute hematogenous osteomyelitis, without endovascular complications, should be transitioned to enteral antibiotics when they are showing signs of clinical improvement, as defined by: resolution of fever, improving physical exam, ability to take oral medications, and decreasing C‐reactive protein.
2. The choice of oral antibiotics should be based on the organism's antibiotic susceptibility. If cultures are negative and the child has improved on empiric IV therapy, transition to an oral regimen with similar spectrum is acceptable.
3. Patients with acute osteomyelitis should have close follow‐up after discharge from the hospital, within 1 to 2 weeks, to ensure continued improvement on therapy.

CONCLUSION

Early transition to oral antibiotics should be used in children with acute, uncomplicated osteomyelitis. A growing body of evidence shows that early transition to oral antibiotics does not increase the risk of treatment failure and can obviate the need for an outpatient PICC line. Oral antibiotics do not carry the risk of potential complications and complexity that are inherent in outpatient parenteral therapy. The transition to oral therapy should occur prior to discharge from the hospital after clinical improvement. Close follow‐up is essential to ensure successful treatment in children with acute osteomyelitis.

Disclosure: Nothing to report.

Do you think this is a low‐value practice? Is this truly a Thing We Do for No Reason? Share what you do in your practice and join in the conversation online by retweeting it on Twitter (#TWDFNR) and liking it on Facebook. We invite you to propose ideas for other Things We Do for No Reason topics by emailing [email protected].

The Things We Do for No Reason (TWDFNR) series reviews practices which have become common parts of hospital care but which may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent black and white conclusions or clinical practice standards, but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion. https://www.choosingwisely.org/

A previously healthy 6‐year‐old boy presented to the emergency room with 3 days of right lower leg pain and fevers up to 102F. The leg pain had progressed until he refused to walk. The patient and family did not recall any trauma to the leg. In the emergency department, he had a blood culture drawn. Because he had elevated inflammatory markers and a negative x‐ray of his right leg, a magnetic resonance imaging scan of the right leg was obtained that revealed right tibial osteomyelitis. He was taken to the operating room for debridement. After obtaining blood and bone cultures, he was started on intravenous (IV) vancomycin. His blood and surgical cultures grew methicillin‐resistant Staphylococcus aureus, sensitive to clindamycin. Subsequent blood cultures were negative, and his inflammatory markers trended down shortly after starting therapy. As he clinically improved, a peripherally inserted central catheter (PICC) was placed, and he was discharged home to complete a 6‐week course of IV vancomycin.

BACKGROUND

Osteoarticular infections (osteomyelitis and septic arthritis) are common problems in the pediatric population, affecting 1/2000 children annually and accounting for approximately 1% of all pediatric hospitalizations.[1, 2] Osteomyelitis can occur in children of all ages and usually requires hospitalization for diagnosis and initial management. The most common mechanism of infection in children is hematogenous inoculation of the bone during an episode of bacteremia (acute hematogenous osteomyelitis), particularly in young children, due to the highly vascular nature of the developing bone. Long bones, such as the femur, tibia, and humerus, are most commonly involved. Treatment of acute osteomyelitis requires prolonged administration of antimicrobial agents. Inadequately treated osteomyelitis can result in progression to chronic infection and loss of function of the affected bone.[3]

WHY YOU MIGHT THINK PARENTERAL ANTIBIOTICS AT DISCHARGE IS SUPERIOR TO ENTERAL THERAPY

In the United States, a large proportion of children with hematogenous osteomyelitis are discharged from the hospital with long‐term parenteral intravenous antibiotics through a PICC line.[3] The medical community historically favored parenteral therapy for young children with serious bacterial infections given concerns regarding impaired enteral absorption. As a result, children with osteomyelitis were initially stabilized in the hospital and discharged with parenteral therapy through a PICC line to continue or complete care, even when the organism was susceptible to a viable oral alternative such as clindamycin or cephalexin. Recommendations regarding the safety and timing to transition to oral antibiotics have been lacking. There is also extreme variation in practice in route of administration (oral vs prolonged IV therapy) in patients being discharged from the hospital with osteomyelitis.[3, 4] The most recent Infectious Diseases Society of America (IDSA) guidelines do not clearly state when transition to oral antibiotics may be safe. Specifically, they state that if patients are stable and without ongoing bacteremia, they can transition to oral therapy to complete a 4‐ to 6‐week course.[5]

WHY LONG‐TERM PARENTERAL ANTIBIOTICS MAY NOT BE SUPERIOR

The use of PICC lines has increased substantially in recent years. This has led to an increasing awareness of complications associated with PICC lines. As a result, guidelines for the appropriate use of PICC lines have been established in adults by collaborators at the University of Michigan.[6] Mounting evidence has called into question whether longer parenteral therapy is truly a more conservative or safer approach for the treatment of osteomyelitis.[3, 4, 7, 8, 9] Providing antibiotics via a PICC line in both the inpatient and outpatient settings may not be as benign as once accepted and may not improve outcomes in osteomyelitis as expected.

WHEN TO CONSIDER PROLONGED PARENTERAL ANTIBIOTICS

The studies indicating the safe transition to oral antibiotics discussed above all excluded children with certain comorbid conditions. Although this varied from study to study, exclusions were as general in some as not previously healthy, and others were as specific as hematologic malignancies, immunocompromised states, sickle cell disease, malabsorption, and penetrating injuries. Also, although we know blood cultures obtained in children with osteomyelitis are positive in only approximately half of the patients,[19] the studies cited do not contain information for their study populations regarding the duration of bacteremia or endovascular complications, such as septic thrombophlebitis, which are well described in the literature.[20, 21] There are limited data on optimal treatment of children with prolonged bacteremia and endovascular complications. Because studies generally involved previously healthy children and do not specifically address these potential complications, the safety of early oral transition in complicated cases is not clear. The current IDSA and Red Book Committee on Infectious Diseases recommend intravenous therapy for bacteremia and endovascular infections with methicillin‐resistant S aureus.[5, 22] Clinical judgement should be used when treating children with comorbid illnesses who experience persistent bacteremia >48 hours, or who have endovascular complications.

WHAT YOU SHOULD DO INSTEAD

For children with acute hematogenous osteomyelitis who are either culture negative and improve on empiric therapy, or who have culture results (blood or tissue) that are susceptible to a reasonable oral antibiotic agent and who have clinical improvement on initial IV antibiotic therapy, a growing body of evidence indicates that the benefit of early transition to oral antibiotics outweighs the risks of continuing with parenteral therapy. Discharging children on oral antibiotics does not increase their risk of treatment failure but seems to decrease the risk of therapy‐associated complications, including increased healthcare utilization with return visits to the emergency department or the hospital. The possible exceptions to early transition to enteral antibiotics are prolonged bacteremia or endovascular infection, though there are insufficient data in the literature indicating benefits or risks of one administration route over the other.

RECOMMENDATIONS

1. Previously healthy children with acute hematogenous osteomyelitis, without endovascular complications, should be transitioned to enteral antibiotics when they are showing signs of clinical improvement, as defined by: resolution of fever, improving physical exam, ability to take oral medications, and decreasing C‐reactive protein.
2. The choice of oral antibiotics should be based on the organism's antibiotic susceptibility. If cultures are negative and the child has improved on empiric IV therapy, transition to an oral regimen with similar spectrum is acceptable.
3. Patients with acute osteomyelitis should have close follow‐up after discharge from the hospital, within 1 to 2 weeks, to ensure continued improvement on therapy.

CONCLUSION

Early transition to oral antibiotics should be used in children with acute, uncomplicated osteomyelitis. A growing body of evidence shows that early transition to oral antibiotics does not increase the risk of treatment failure and can obviate the need for an outpatient PICC line. Oral antibiotics do not carry the risk of potential complications and complexity that are inherent in outpatient parenteral therapy. The transition to oral therapy should occur prior to discharge from the hospital after clinical improvement. Close follow‐up is essential to ensure successful treatment in children with acute osteomyelitis.

Disclosure: Nothing to report.

Do you think this is a low‐value practice? Is this truly a Thing We Do for No Reason? Share what you do in your practice and join in the conversation online by retweeting it on Twitter (#TWDFNR) and liking it on Facebook. We invite you to propose ideas for other Things We Do for No Reason topics by emailing [email protected].

In 1995 I took my first job as a hospitalist at a community teaching hospital where hospitalists, though then known as medical directors, had been in place for 20 years. Soon afterward, our field gained a name, and my old job no longer was mistaken for a utilization review functionary or lead of a medical unit.

I have been lucky enough to have seen the field of hospital medicine grow rapidly in scope and importance. The growth of our specialty in mere numbers alone is a testament to the value we in hospital medicine (MDs, DOs, PAs, NPs) bring to the care of acutely ill patients. We are the front line caring for the elderly and vulnerable, the glue holding transdisciplinary care teams together, and lead hospitals, health systems, and governmental organizations. Hospitalists touch the lives of our patients, and shape the health systems' practices and health policy on a national and international scale. These are remarkable achievements for a field which, just a few years ago, was concerned about becoming a job equivalent to perpetual residency training (or worse) and gained only grudging acceptance.[1] There is no doubt that the roles of hospitalists will continue to evolve, and whereas hospitalists will be able to shape the debates and development of new programs solving the problems of our health systems, we must take time to foster the mind, heart, and soul of our field.

When I speak of the mind of hospital medicine, I am thinking of our field's contribution to the evidence for how to care for patients' illnesses, a different body of knowledge than our field's focus to date on hospitals and health systems. Hospital medicine has been growing research capacity at a rate that is slower than the field overall, a problem in part due to limitations in National Institutes of Health funding for fellowships and early‐career awards, which in turn has restricted the pipeline of young and innovative researchers. Slow growth may also be a result of an emphasis on health systems rather than diseases.[2] I and others have written about the need to create mentoring support for junior research faculty as a way to promote success and avoid burnout,[3, 4, 5, 6, 7] and while at least 1 hospital medicine research network exists,[8] there is room for many more. However, at its core, our specialty needs to devote more time and focus to becoming a full scientific partner with our colleagues in cardiology, pulmonary medicine, and critical care, among others. To develop the mind of hospital medicine we will also need to think about our contributions to useful clinical guidelines for care of diseases and patients. Developing trustworthy clinical guidelines can be time consuming[9] but is a key part of ensuring patients and families understand the rationale for changes in clinical care. Hospital medicine as a field has been a leader in programs that develop approaches to implementing evidence and stands in an excellent position toperhaps in collaboration with other specialtiescreate the next‐generation guidelines that are practically minded, evidence based, and end up being used.

The heart I speak of is how we can make sure that the field of hospital medicine is one that is attractive and sustainable as a career. Electronic health records' impact on day‐to‐day work is substantial and a large part of the problem, though a more fundamental problem we face is in how to create sustainable jobs at a time where we are going to need to deliver higher‐value care to more patients with the same number (or fewer) providers. This is an issue that means we need to settle many important aspects of our workpay, relationships with our peers, control over our work on a day‐to‐day basis, hospitalists' work schedules (such as the 7 days on/7 days off model)while we also grapple with how to work within a population‐health framework. I am not prescient enough to see all the solutions to burnout, but there are at least 2 opportunities hospitalists are perhaps best suited to develop and lead. The first is how we arrange our teams in the hospital and afterward. Recent articles have talked about how medicine needs to be open to Uber‐like disruptive models,[10] where labor is deployed in fundamentally different ways. Tools such as e‐consults, the application of population health tools to inpatient care, telemedicine, or some forms of predictive analytics may be examples of these tools, which are routes to allowing more care to be delivered more effectively and more efficiently. Another opportunity lies in how we adapt our electronic health records to our work (and vice versa). The perils of sloppy and paste documentation are indicative of the burden of busywork, the pressures of needing to focus on revenue rather than clinical utility, and exhaustion; hospitalists are well positioned to think about howas payment reform continues to evolvedocumentation can be less busywork and more clinically useful, patient oriented, and shareable across sites and phases of care.

Now to the soul of our field. Hospital medicine has rightly been considered a key partner in developing the solutions hospitals and health systems need to address gaps in quality, safety, value, and clinical outcomes. However, this self‐image of hospital medicine has the downside of being viewed as doctors for hospitals, rather than doctors for patients and families who are in hospitals. As we think about burnout and jobs that are fulfilling and meaningful over the long term, I increasingly return to the factors that motivated me and many others to become physicians: meaningful relationships with patients, being an excellent clinician, and making a lasting contribution to my community through my patient care, support of my colleagues, and teaching younger physicians. It is easy for the pressures of the hospital and need to fix problems rapidly to obscure these larger motivators, but our field will need to ensure that these elements remain how we prioritize and shape our field going forward. Hospital medicine is comprised of physicians who do clinical care and who in most cases entered the field for that reason alone. Using the true north of improving and innovating care in ways that impact patient livesnot just the needs of our hospitalsin meaningful ways will need to be the soul of our field, and will allow the mind and heart of hospitalists and hospital medicine to thrive.

In 1995 I took my first job as a hospitalist at a community teaching hospital where hospitalists, though then known as medical directors, had been in place for 20 years. Soon afterward, our field gained a name, and my old job no longer was mistaken for a utilization review functionary or lead of a medical unit.

I have been lucky enough to have seen the field of hospital medicine grow rapidly in scope and importance. The growth of our specialty in mere numbers alone is a testament to the value we in hospital medicine (MDs, DOs, PAs, NPs) bring to the care of acutely ill patients. We are the front line caring for the elderly and vulnerable, the glue holding transdisciplinary care teams together, and lead hospitals, health systems, and governmental organizations. Hospitalists touch the lives of our patients, and shape the health systems' practices and health policy on a national and international scale. These are remarkable achievements for a field which, just a few years ago, was concerned about becoming a job equivalent to perpetual residency training (or worse) and gained only grudging acceptance.[1] There is no doubt that the roles of hospitalists will continue to evolve, and whereas hospitalists will be able to shape the debates and development of new programs solving the problems of our health systems, we must take time to foster the mind, heart, and soul of our field.

When I speak of the mind of hospital medicine, I am thinking of our field's contribution to the evidence for how to care for patients' illnesses, a different body of knowledge than our field's focus to date on hospitals and health systems. Hospital medicine has been growing research capacity at a rate that is slower than the field overall, a problem in part due to limitations in National Institutes of Health funding for fellowships and early‐career awards, which in turn has restricted the pipeline of young and innovative researchers. Slow growth may also be a result of an emphasis on health systems rather than diseases.[2] I and others have written about the need to create mentoring support for junior research faculty as a way to promote success and avoid burnout,[3, 4, 5, 6, 7] and while at least 1 hospital medicine research network exists,[8] there is room for many more. However, at its core, our specialty needs to devote more time and focus to becoming a full scientific partner with our colleagues in cardiology, pulmonary medicine, and critical care, among others. To develop the mind of hospital medicine we will also need to think about our contributions to useful clinical guidelines for care of diseases and patients. Developing trustworthy clinical guidelines can be time consuming[9] but is a key part of ensuring patients and families understand the rationale for changes in clinical care. Hospital medicine as a field has been a leader in programs that develop approaches to implementing evidence and stands in an excellent position toperhaps in collaboration with other specialtiescreate the next‐generation guidelines that are practically minded, evidence based, and end up being used.

The heart I speak of is how we can make sure that the field of hospital medicine is one that is attractive and sustainable as a career. Electronic health records' impact on day‐to‐day work is substantial and a large part of the problem, though a more fundamental problem we face is in how to create sustainable jobs at a time where we are going to need to deliver higher‐value care to more patients with the same number (or fewer) providers. This is an issue that means we need to settle many important aspects of our workpay, relationships with our peers, control over our work on a day‐to‐day basis, hospitalists' work schedules (such as the 7 days on/7 days off model)while we also grapple with how to work within a population‐health framework. I am not prescient enough to see all the solutions to burnout, but there are at least 2 opportunities hospitalists are perhaps best suited to develop and lead. The first is how we arrange our teams in the hospital and afterward. Recent articles have talked about how medicine needs to be open to Uber‐like disruptive models,[10] where labor is deployed in fundamentally different ways. Tools such as e‐consults, the application of population health tools to inpatient care, telemedicine, or some forms of predictive analytics may be examples of these tools, which are routes to allowing more care to be delivered more effectively and more efficiently. Another opportunity lies in how we adapt our electronic health records to our work (and vice versa). The perils of sloppy and paste documentation are indicative of the burden of busywork, the pressures of needing to focus on revenue rather than clinical utility, and exhaustion; hospitalists are well positioned to think about howas payment reform continues to evolvedocumentation can be less busywork and more clinically useful, patient oriented, and shareable across sites and phases of care.

Now to the soul of our field. Hospital medicine has rightly been considered a key partner in developing the solutions hospitals and health systems need to address gaps in quality, safety, value, and clinical outcomes. However, this self‐image of hospital medicine has the downside of being viewed as doctors for hospitals, rather than doctors for patients and families who are in hospitals. As we think about burnout and jobs that are fulfilling and meaningful over the long term, I increasingly return to the factors that motivated me and many others to become physicians: meaningful relationships with patients, being an excellent clinician, and making a lasting contribution to my community through my patient care, support of my colleagues, and teaching younger physicians. It is easy for the pressures of the hospital and need to fix problems rapidly to obscure these larger motivators, but our field will need to ensure that these elements remain how we prioritize and shape our field going forward. Hospital medicine is comprised of physicians who do clinical care and who in most cases entered the field for that reason alone. Using the true north of improving and innovating care in ways that impact patient livesnot just the needs of our hospitalsin meaningful ways will need to be the soul of our field, and will allow the mind and heart of hospitalists and hospital medicine to thrive.

In 1995 I took my first job as a hospitalist at a community teaching hospital where hospitalists, though then known as medical directors, had been in place for 20 years. Soon afterward, our field gained a name, and my old job no longer was mistaken for a utilization review functionary or lead of a medical unit.

I have been lucky enough to have seen the field of hospital medicine grow rapidly in scope and importance. The growth of our specialty in mere numbers alone is a testament to the value we in hospital medicine (MDs, DOs, PAs, NPs) bring to the care of acutely ill patients. We are the front line caring for the elderly and vulnerable, the glue holding transdisciplinary care teams together, and lead hospitals, health systems, and governmental organizations. Hospitalists touch the lives of our patients, and shape the health systems' practices and health policy on a national and international scale. These are remarkable achievements for a field which, just a few years ago, was concerned about becoming a job equivalent to perpetual residency training (or worse) and gained only grudging acceptance.[1] There is no doubt that the roles of hospitalists will continue to evolve, and whereas hospitalists will be able to shape the debates and development of new programs solving the problems of our health systems, we must take time to foster the mind, heart, and soul of our field.

When I speak of the mind of hospital medicine, I am thinking of our field's contribution to the evidence for how to care for patients' illnesses, a different body of knowledge than our field's focus to date on hospitals and health systems. Hospital medicine has been growing research capacity at a rate that is slower than the field overall, a problem in part due to limitations in National Institutes of Health funding for fellowships and early‐career awards, which in turn has restricted the pipeline of young and innovative researchers. Slow growth may also be a result of an emphasis on health systems rather than diseases.[2] I and others have written about the need to create mentoring support for junior research faculty as a way to promote success and avoid burnout,[3, 4, 5, 6, 7] and while at least 1 hospital medicine research network exists,[8] there is room for many more. However, at its core, our specialty needs to devote more time and focus to becoming a full scientific partner with our colleagues in cardiology, pulmonary medicine, and critical care, among others. To develop the mind of hospital medicine we will also need to think about our contributions to useful clinical guidelines for care of diseases and patients. Developing trustworthy clinical guidelines can be time consuming[9] but is a key part of ensuring patients and families understand the rationale for changes in clinical care. Hospital medicine as a field has been a leader in programs that develop approaches to implementing evidence and stands in an excellent position toperhaps in collaboration with other specialtiescreate the next‐generation guidelines that are practically minded, evidence based, and end up being used.

The heart I speak of is how we can make sure that the field of hospital medicine is one that is attractive and sustainable as a career. Electronic health records' impact on day‐to‐day work is substantial and a large part of the problem, though a more fundamental problem we face is in how to create sustainable jobs at a time where we are going to need to deliver higher‐value care to more patients with the same number (or fewer) providers. This is an issue that means we need to settle many important aspects of our workpay, relationships with our peers, control over our work on a day‐to‐day basis, hospitalists' work schedules (such as the 7 days on/7 days off model)while we also grapple with how to work within a population‐health framework. I am not prescient enough to see all the solutions to burnout, but there are at least 2 opportunities hospitalists are perhaps best suited to develop and lead. The first is how we arrange our teams in the hospital and afterward. Recent articles have talked about how medicine needs to be open to Uber‐like disruptive models,[10] where labor is deployed in fundamentally different ways. Tools such as e‐consults, the application of population health tools to inpatient care, telemedicine, or some forms of predictive analytics may be examples of these tools, which are routes to allowing more care to be delivered more effectively and more efficiently. Another opportunity lies in how we adapt our electronic health records to our work (and vice versa). The perils of sloppy and paste documentation are indicative of the burden of busywork, the pressures of needing to focus on revenue rather than clinical utility, and exhaustion; hospitalists are well positioned to think about howas payment reform continues to evolvedocumentation can be less busywork and more clinically useful, patient oriented, and shareable across sites and phases of care.

Now to the soul of our field. Hospital medicine has rightly been considered a key partner in developing the solutions hospitals and health systems need to address gaps in quality, safety, value, and clinical outcomes. However, this self‐image of hospital medicine has the downside of being viewed as doctors for hospitals, rather than doctors for patients and families who are in hospitals. As we think about burnout and jobs that are fulfilling and meaningful over the long term, I increasingly return to the factors that motivated me and many others to become physicians: meaningful relationships with patients, being an excellent clinician, and making a lasting contribution to my community through my patient care, support of my colleagues, and teaching younger physicians. It is easy for the pressures of the hospital and need to fix problems rapidly to obscure these larger motivators, but our field will need to ensure that these elements remain how we prioritize and shape our field going forward. Hospital medicine is comprised of physicians who do clinical care and who in most cases entered the field for that reason alone. Using the true north of improving and innovating care in ways that impact patient livesnot just the needs of our hospitalsin meaningful ways will need to be the soul of our field, and will allow the mind and heart of hospitalists and hospital medicine to thrive.

When I was a resident, one common warning delivered to us by our putatively omniscient attendings was, Well you know, most children are not hospitalized at children's hospitals. This caution was likely meant to warn us future pediatricians that the supports and access to pediatric subspecialists we took for granted in a children's hospital would be different once we graduated and left for community settings. However, it is doubtful that any resident ever challenged the validity of that statement. Are most children hospitalized at general hospitals and is the availability of subspecialty services different between general and children's hospitals?

In this issue of the Journal of Hospital Medicine, Leyenaar et al.[1] set out to test that warning and to quantify where children in the United States are hospitalized. They investigated differences in the pediatric hospitalizations at general and freestanding children's hospitals. In doing so, their findings began to implicitly explore what is meant by the term children's hospital. The authors utilized the Agency for Healthcare Quality and Research's (AHQR) 2012 Kids Inpatient Database (KID), which after excluding in‐hospital births and pregnancy‐related admissions, captured nearly 4000 hospitals and 1.4 million acute care pediatric admissions across the United States.

Leyenaar et al. found that our attendings were correct, confirming a prior study on the subject[2]; close to three‐quarters of discharges were from general hospitals. However, although the most frequent reasons for hospitalization were similar between the 2 types of hospitals, that is where the similarities ended. They found that although the median annual number of discharges at the 50 freestanding children's hospitals was 12,000, it was only 56 at the nearly 4000 general hospitals. Approximately 80% of general hospitals (the equivalent of nearly 3000 hospitals) accounted for only 11% of all discharges and had less than 375 annual pediatric discharges, essentially 1 discharge per day or fewer. In addition, over one‐third of discharges at freestanding children's hospitals were for children with medical complexity, compared to 1 in 5 at general hospitals. Furthermore, one‐quarter of discharges at freestanding children's hospitals were of high or highest severity, compared with half that amount at general hospitals.

Although it is not possible to determine the quality of care from the KID, the authors insightfully discuss the implications these differences have on quality improvement and quality measurement. General hospitals with low volumes of pediatric inpatients may have difficulty providing condition‐specific quality metrics or implementing condition‐specific quality improvement processes. How can you compare quality across hospitals averaging only 56 pediatric admissions a year? If existing quality metrics are not meaningful for those hospitals, but the majority of children are admitted to them, the development of new, more useful, quality metrics is needed.

Perhaps the most interesting finding resulted from a new and unfortunate limitation in the KID database. Beginning in 2012, the AHQR began deidentifying all hospitals contributing data to the KID, leaving researchers reliant on KID's categorization of hospitals as either freestanding children's hospitals or general hospitals. The authors attempted to work around these limitations to identify those children's hospitals that were not freestanding but were located within general hospitals. They found that 36 general hospitals had patient volumes equivalent to freestanding children's hospitals, whereas 20 freestanding children's hospitals had very infrequent admissions for the most common discharge diagnoses. The authors are almost certainly correct in deeming the latter 20 hospitals to be subspecialty children's hospitals, such as those focused solely on orthopedic or oncologic conditions. Among the 36 high‐volume general hospitals, the authors found that patient complexity and severity was more similar to freestanding children's hospitals than to the low‐volume general hospitals. Length of stay (and therefore presumably costs as well) for high‐volume general hospitals was positioned between freestanding children's hospitals and low‐volume general hospitals.

Who are those high‐volume hospitals that appear to be general in name only? Because of KID's deidentification of hospitals, we do not know. It is possible that those hospitals self‐identify as being children's hospitals, but are not freestanding, meaning that they are located within a general hospital (hospitals within a hospital). If they are children's hospitals within general hospitals, it would provide a different perspective to the study's overall finding that 71% of hospitalizations, 64% of hospital days, and 50% of costs occur at general hospitals. As the authors allude to, some institutions may not call themselves freestanding children's hospitals but function that way; other institutions call themselves freestanding children's hospitals but offer very focused specialty services. Through this limitation in the KID database, the authors began the process of identifying hospitals that look like freestanding children's hospitals but are not called that. In other words, they began creating a more robust functional definition of which institutions are truly children's hospitals. Volume does not, of course, always equate into specialization, and much work needs to be done measuring the availability of subspecialty and critical care services before any functional definition of children's hospital can be made; the potential, however, is intriguing.

Does it matter which hospitals are deemed children's hospitals? Although a hospitalist may not place importance on the name over the hospital's entrance, the Centers for Medicare and Medicaid Services (CMS) and state insurance regulators may find the difference extremely important. CMS and state insurance regulators are increasingly focusing their attention on the adequacy of pediatric insurance networks.[3, 4, 5, 6] They are seeking to create rules that ensure health insurance plans have a broad range of pediatric subspecialists in close proximity to the great majority of children insured by the plan. For adult insurance, the adequacy of a plan's network is typically defined by the time and distance from a patient's home to a specialist. However, unlike in adult medicine, pediatric subspecialty care is becoming increasingly regionalized at academic medical centers, especially children's hospitals. Furthermore, unlike adult care, a wide range of pediatric subspecialists is unlikely to be found at the hospital closest to a patient's home. Therefore, time and distance rules for ensuring network adequacy may fail within pediatric care. Instead, inclusion of a hospital designatedby functional or other criteriaas a children's hospital may be the best way to ensure the adequate provision of pediatric specialty care within a network.

How policymakers define pediatric network adequacy will have important implications for ensuring that pediatric inpatient medicine achieves the goal of the right patient, the right place, the right time. Therefore, the attending from our residency may have been correct that most children are not hospitalized at children's hospitals. However, depending on how pediatric network adequacy rules are developed, that may not have to mean that these children (and their pediatricians) will be out there alone.

When I was a resident, one common warning delivered to us by our putatively omniscient attendings was, Well you know, most children are not hospitalized at children's hospitals. This caution was likely meant to warn us future pediatricians that the supports and access to pediatric subspecialists we took for granted in a children's hospital would be different once we graduated and left for community settings. However, it is doubtful that any resident ever challenged the validity of that statement. Are most children hospitalized at general hospitals and is the availability of subspecialty services different between general and children's hospitals?

In this issue of the Journal of Hospital Medicine, Leyenaar et al.[1] set out to test that warning and to quantify where children in the United States are hospitalized. They investigated differences in the pediatric hospitalizations at general and freestanding children's hospitals. In doing so, their findings began to implicitly explore what is meant by the term children's hospital. The authors utilized the Agency for Healthcare Quality and Research's (AHQR) 2012 Kids Inpatient Database (KID), which after excluding in‐hospital births and pregnancy‐related admissions, captured nearly 4000 hospitals and 1.4 million acute care pediatric admissions across the United States.

Leyenaar et al. found that our attendings were correct, confirming a prior study on the subject[2]; close to three‐quarters of discharges were from general hospitals. However, although the most frequent reasons for hospitalization were similar between the 2 types of hospitals, that is where the similarities ended. They found that although the median annual number of discharges at the 50 freestanding children's hospitals was 12,000, it was only 56 at the nearly 4000 general hospitals. Approximately 80% of general hospitals (the equivalent of nearly 3000 hospitals) accounted for only 11% of all discharges and had less than 375 annual pediatric discharges, essentially 1 discharge per day or fewer. In addition, over one‐third of discharges at freestanding children's hospitals were for children with medical complexity, compared to 1 in 5 at general hospitals. Furthermore, one‐quarter of discharges at freestanding children's hospitals were of high or highest severity, compared with half that amount at general hospitals.

Although it is not possible to determine the quality of care from the KID, the authors insightfully discuss the implications these differences have on quality improvement and quality measurement. General hospitals with low volumes of pediatric inpatients may have difficulty providing condition‐specific quality metrics or implementing condition‐specific quality improvement processes. How can you compare quality across hospitals averaging only 56 pediatric admissions a year? If existing quality metrics are not meaningful for those hospitals, but the majority of children are admitted to them, the development of new, more useful, quality metrics is needed.

Perhaps the most interesting finding resulted from a new and unfortunate limitation in the KID database. Beginning in 2012, the AHQR began deidentifying all hospitals contributing data to the KID, leaving researchers reliant on KID's categorization of hospitals as either freestanding children's hospitals or general hospitals. The authors attempted to work around these limitations to identify those children's hospitals that were not freestanding but were located within general hospitals. They found that 36 general hospitals had patient volumes equivalent to freestanding children's hospitals, whereas 20 freestanding children's hospitals had very infrequent admissions for the most common discharge diagnoses. The authors are almost certainly correct in deeming the latter 20 hospitals to be subspecialty children's hospitals, such as those focused solely on orthopedic or oncologic conditions. Among the 36 high‐volume general hospitals, the authors found that patient complexity and severity was more similar to freestanding children's hospitals than to the low‐volume general hospitals. Length of stay (and therefore presumably costs as well) for high‐volume general hospitals was positioned between freestanding children's hospitals and low‐volume general hospitals.

Who are those high‐volume hospitals that appear to be general in name only? Because of KID's deidentification of hospitals, we do not know. It is possible that those hospitals self‐identify as being children's hospitals, but are not freestanding, meaning that they are located within a general hospital (hospitals within a hospital). If they are children's hospitals within general hospitals, it would provide a different perspective to the study's overall finding that 71% of hospitalizations, 64% of hospital days, and 50% of costs occur at general hospitals. As the authors allude to, some institutions may not call themselves freestanding children's hospitals but function that way; other institutions call themselves freestanding children's hospitals but offer very focused specialty services. Through this limitation in the KID database, the authors began the process of identifying hospitals that look like freestanding children's hospitals but are not called that. In other words, they began creating a more robust functional definition of which institutions are truly children's hospitals. Volume does not, of course, always equate into specialization, and much work needs to be done measuring the availability of subspecialty and critical care services before any functional definition of children's hospital can be made; the potential, however, is intriguing.

Does it matter which hospitals are deemed children's hospitals? Although a hospitalist may not place importance on the name over the hospital's entrance, the Centers for Medicare and Medicaid Services (CMS) and state insurance regulators may find the difference extremely important. CMS and state insurance regulators are increasingly focusing their attention on the adequacy of pediatric insurance networks.[3, 4, 5, 6] They are seeking to create rules that ensure health insurance plans have a broad range of pediatric subspecialists in close proximity to the great majority of children insured by the plan. For adult insurance, the adequacy of a plan's network is typically defined by the time and distance from a patient's home to a specialist. However, unlike in adult medicine, pediatric subspecialty care is becoming increasingly regionalized at academic medical centers, especially children's hospitals. Furthermore, unlike adult care, a wide range of pediatric subspecialists is unlikely to be found at the hospital closest to a patient's home. Therefore, time and distance rules for ensuring network adequacy may fail within pediatric care. Instead, inclusion of a hospital designatedby functional or other criteriaas a children's hospital may be the best way to ensure the adequate provision of pediatric specialty care within a network.

How policymakers define pediatric network adequacy will have important implications for ensuring that pediatric inpatient medicine achieves the goal of the right patient, the right place, the right time. Therefore, the attending from our residency may have been correct that most children are not hospitalized at children's hospitals. However, depending on how pediatric network adequacy rules are developed, that may not have to mean that these children (and their pediatricians) will be out there alone.

When I was a resident, one common warning delivered to us by our putatively omniscient attendings was, Well you know, most children are not hospitalized at children's hospitals. This caution was likely meant to warn us future pediatricians that the supports and access to pediatric subspecialists we took for granted in a children's hospital would be different once we graduated and left for community settings. However, it is doubtful that any resident ever challenged the validity of that statement. Are most children hospitalized at general hospitals and is the availability of subspecialty services different between general and children's hospitals?

In this issue of the Journal of Hospital Medicine, Leyenaar et al.[1] set out to test that warning and to quantify where children in the United States are hospitalized. They investigated differences in the pediatric hospitalizations at general and freestanding children's hospitals. In doing so, their findings began to implicitly explore what is meant by the term children's hospital. The authors utilized the Agency for Healthcare Quality and Research's (AHQR) 2012 Kids Inpatient Database (KID), which after excluding in‐hospital births and pregnancy‐related admissions, captured nearly 4000 hospitals and 1.4 million acute care pediatric admissions across the United States.

Leyenaar et al. found that our attendings were correct, confirming a prior study on the subject[2]; close to three‐quarters of discharges were from general hospitals. However, although the most frequent reasons for hospitalization were similar between the 2 types of hospitals, that is where the similarities ended. They found that although the median annual number of discharges at the 50 freestanding children's hospitals was 12,000, it was only 56 at the nearly 4000 general hospitals. Approximately 80% of general hospitals (the equivalent of nearly 3000 hospitals) accounted for only 11% of all discharges and had less than 375 annual pediatric discharges, essentially 1 discharge per day or fewer. In addition, over one‐third of discharges at freestanding children's hospitals were for children with medical complexity, compared to 1 in 5 at general hospitals. Furthermore, one‐quarter of discharges at freestanding children's hospitals were of high or highest severity, compared with half that amount at general hospitals.

Although it is not possible to determine the quality of care from the KID, the authors insightfully discuss the implications these differences have on quality improvement and quality measurement. General hospitals with low volumes of pediatric inpatients may have difficulty providing condition‐specific quality metrics or implementing condition‐specific quality improvement processes. How can you compare quality across hospitals averaging only 56 pediatric admissions a year? If existing quality metrics are not meaningful for those hospitals, but the majority of children are admitted to them, the development of new, more useful, quality metrics is needed.

Perhaps the most interesting finding resulted from a new and unfortunate limitation in the KID database. Beginning in 2012, the AHQR began deidentifying all hospitals contributing data to the KID, leaving researchers reliant on KID's categorization of hospitals as either freestanding children's hospitals or general hospitals. The authors attempted to work around these limitations to identify those children's hospitals that were not freestanding but were located within general hospitals. They found that 36 general hospitals had patient volumes equivalent to freestanding children's hospitals, whereas 20 freestanding children's hospitals had very infrequent admissions for the most common discharge diagnoses. The authors are almost certainly correct in deeming the latter 20 hospitals to be subspecialty children's hospitals, such as those focused solely on orthopedic or oncologic conditions. Among the 36 high‐volume general hospitals, the authors found that patient complexity and severity was more similar to freestanding children's hospitals than to the low‐volume general hospitals. Length of stay (and therefore presumably costs as well) for high‐volume general hospitals was positioned between freestanding children's hospitals and low‐volume general hospitals.

Who are those high‐volume hospitals that appear to be general in name only? Because of KID's deidentification of hospitals, we do not know. It is possible that those hospitals self‐identify as being children's hospitals, but are not freestanding, meaning that they are located within a general hospital (hospitals within a hospital). If they are children's hospitals within general hospitals, it would provide a different perspective to the study's overall finding that 71% of hospitalizations, 64% of hospital days, and 50% of costs occur at general hospitals. As the authors allude to, some institutions may not call themselves freestanding children's hospitals but function that way; other institutions call themselves freestanding children's hospitals but offer very focused specialty services. Through this limitation in the KID database, the authors began the process of identifying hospitals that look like freestanding children's hospitals but are not called that. In other words, they began creating a more robust functional definition of which institutions are truly children's hospitals. Volume does not, of course, always equate into specialization, and much work needs to be done measuring the availability of subspecialty and critical care services before any functional definition of children's hospital can be made; the potential, however, is intriguing.

Does it matter which hospitals are deemed children's hospitals? Although a hospitalist may not place importance on the name over the hospital's entrance, the Centers for Medicare and Medicaid Services (CMS) and state insurance regulators may find the difference extremely important. CMS and state insurance regulators are increasingly focusing their attention on the adequacy of pediatric insurance networks.[3, 4, 5, 6] They are seeking to create rules that ensure health insurance plans have a broad range of pediatric subspecialists in close proximity to the great majority of children insured by the plan. For adult insurance, the adequacy of a plan's network is typically defined by the time and distance from a patient's home to a specialist. However, unlike in adult medicine, pediatric subspecialty care is becoming increasingly regionalized at academic medical centers, especially children's hospitals. Furthermore, unlike adult care, a wide range of pediatric subspecialists is unlikely to be found at the hospital closest to a patient's home. Therefore, time and distance rules for ensuring network adequacy may fail within pediatric care. Instead, inclusion of a hospital designatedby functional or other criteriaas a children's hospital may be the best way to ensure the adequate provision of pediatric specialty care within a network.

How policymakers define pediatric network adequacy will have important implications for ensuring that pediatric inpatient medicine achieves the goal of the right patient, the right place, the right time. Therefore, the attending from our residency may have been correct that most children are not hospitalized at children's hospitals. However, depending on how pediatric network adequacy rules are developed, that may not have to mean that these children (and their pediatricians) will be out there alone.

Improvement in the quality of hospital care in the United States is a national priority, both to advance patient safety and because our expenditures exceed any other nation's, but our health outcomes lag behind.[1, 2] Healthcare spending for children is growing at a faster rate than any other age group, with hospital care accounting for more than 40% of pediatric healthcare expenditures.[3] Inpatient healthcare comprises a greater proportion of healthcare costs for children than for adults, yet we have limited knowledge about where this care is provided.[4]

There is substantial variability in the settings in which children are hospitalized. Children may be hospitalized in freestanding children's hospitals, where all services are designed for children and which operate independently of adult‐focused institutions. They may also be hospitalized in general hospitals where care may be provided in a general inpatient bed, on a dedicated pediatric ward, or in a children's hospital nested within a hospital, which may have specialized nursing and physician care but often shares other resources such as laboratory and radiology with the primarily adult‐focused institution. Medical students and residents may be trained in all of these settings. We know little about how these hospital types differ with respect to patient populations, disease volumes, and resource utilization, and this knowledge is important to inform clinical programs, implementation research, and quality improvement (QI) priorities. To this end, we aimed to describe the volume and characteristics of pediatric hospitalizations at acute care general hospitals and freestanding children's hospitals in the United States.

METHODS

RESULTS

Overall, 3866 hospitals were categorized as a GH, whereas 70 hospitals were categorized as FCHs. Following exclusion of specialty hospitals, 3758 GHs and 50 FCHs were retained in this study. The geographic distribution of hospitals was similar, but although GHs included those in both urban and rural regions, all FCHs were located in urban regions (Table 1).

A total of 1,407,822 (SD 50,456) hospitalizations occurred at GHs, representing 71.7% of pediatric hospitalizations, whereas 554,458 (SD 45,046) hospitalizations occurred at FCHs. Hospitalizations at GHs accounted for 63.6% of days in hospital and 50.0% of pediatric inpatient healthcare costs. Eighty percent of the GHs had total pediatric patient volumes of less than 375 hospitalizations yearly; 11.1% of pediatric hospitalizations occurred at these lower‐volume centers. At FCHs, the median volume of pediatric hospitalizations was 12,001 (interquartile range [IQR]: 583815,448). A total of 36 GHs had pediatric hospitalization volumes in this IQR.

The median age for pediatric patients was slightly higher at GHs, whereas gender, race/ethnicity, primary payer, and median household income for zip code did not differ significantly between hospital types (Table 2). Medical complexity differed between hospital types: children with complex chronic diseases represented 20.2% of hospitalizations at GHs and 35.6% of hospitalizations at FCHs. Severity of illness differed between hospital types, with fewer hospitalizations categorized at the highest level of severity at GHs than FCHs. There were no significant differences between hospital types with respect to the proportion of hospitalizations categorized as neonatal hospitalizations or as elective hospitalizations. The median LOS was shorter at GHs than FCHs. Approximately 1 in 5 children hospitalized at GHs had LOS greater than 4 days, whereas almost 30% of children hospitalized at FCHs had LOS of this duration.

The most common pediatric medical, mental health, and surgical conditions are shown in Figure 1, together representing 32% of pediatric hospitalizations during the study period. For these medical conditions, 77.9% of hospitalizations occurred at GHs, ranging from 52.6% of chemotherapy hospitalizations to 89.0% of hospitalizations for neonatal hyperbilirubinemia. Sixty‐two percent of total hospital costs for these conditions were incurred at GHs. For the common mental health hospitalizations, 86% of hospitalizations occurred at GHs. The majority of hospitalizations and aggregate hospital costs for common surgical conditions also occurred at GHs.

Figure 1

Whereas pneumonia, asthma, and bronchiolitis were the most common reasons for hospitalization at both GHs and FCHs, the most costly conditions differed (see Supporting Table 1 in the online version of this article). At GHs, these respiratory diseases were responsible for the highest condition‐specific total hospital costs. At FCHs, the highest aggregate costs were due to respiratory distress syndrome and chemotherapy. Congenital heart diseases, including hypoplastic left heart syndrome, transposition of the great vessels, tetralogy of Fallot, endocardial cushion defects, coarctation of the aorta and ventricular septal defects accounted for 6 of the 20 most costly conditions at FCHs.

Figure 2 illustrates the volume of hospitalizations, per hospital, at GHs and FCHs for the most common medical hospitalizations. The median number of hospitalizations, per hospital, was consistently significantly lower at GHs than at FCHs (all P values <0.001). Similar results for surgical and mental health hospitalizations are shown as Supporting Figures 1 and 2 in the online version of this article. In our sensitivity analyses that included all hospitals classified as GH and FCH, all results were essentially unchanged.

Figure 2

Recognizing the wide range of pediatric volumes at GHs (Table 1) and our inability to differentiate children's hospitals nested within GHs from GHs with pediatric beds, we examined differences in patient and hospitalization characteristics at GHs with volumes 5838 hospitalizations (the 25th percentile for FCH volume) and GHs with pediatric volumes <5838/year (see Supporting Table 2 in the online version of this article). We also compared patient and hospitalization characteristics at FCHs and the higher‐volume GHs. A total of 36 GHs had pediatric volumes 5838, with hospitalizations at these sites together accounting for 15.4% of all pediatric hospitalizations. Characteristics of patients hospitalized at these higher‐volume GHs were similar to patients hospitalized at FCHs, but they had significantly lower disease severity, fewer neonatal hospitalizations, shorter LOS, and more high‐turnover hospitalizations than patients hospitalized at FCHs. We also observed several differences between children hospitalized at higher‐ and lower‐volume GHs (see Supporting Table 2 in the online version of this article). Children hospitalized at the lower‐volume GHs were more likely to have public health insurance and less likely to have complex chronic diseases, although overall, 39.0% of all hospitalizations for children with complex chronic diseases occurred at these lower‐volume GHs. Compared to children hospitalized at higher‐volume GHs, children hospitalized at the lower‐volume hospitals had significantly lower disease severity, shorter LOS, more direct admissions, and a greater proportion of routine discharges.

DISCUSSION

Of the 2 million pediatric hospitalizations in the United States in 2012, more than 70% occurred at GHs. We observed considerable heterogeneity in pediatric volumes across GHs, with 11% of pediatric hospitalizations occurring at hospitals with pediatric volumes of <375 hospitalizations annually, whereas 15% of pediatric hospitalizations occurred at GHs with volumes similar to those observed at FCHs. The remaining pediatric hospitalizations at GHs occurred at centers with intermediate volumes. The most common reasons for hospitalization were similar at GHs and FCHs, but the most costly conditions differed substantially. These findings have important implications for pediatric clinical care programs, research, and QI efforts.

Our finding that more than 70% of pediatric hospitalizations occurred at GHs speaks to the importance of quality measurement at these hospitals, whereas low per‐hospital pediatric volumes at the majority of GHs makes such measurement particularly challenging. Several previous studies have illustrated that volumes of pediatric hospitalizations are too small to detect meaningful differences in quality between hospitals using established condition‐specific metrics.[13, 14, 15] Our finding that more than 10% of pediatric hospitalizations occurred at GHs with pediatric volumes <375 year supports previous research suggesting that cross‐cutting, all‐condition quality metrics, composite measures, and/or multihospital reporting networks may be needed to enable quality measurement at these sites. In addition, the heterogeneity in patient volumes and characteristics across GHs raise questions about the applicability of quality metrics developed and validated at FCHs to the many GH settings. Field‐testing quality measures to ensure their validity at diverse GHs, particularly those with patient volumes and infrastructure different from FCHs, will be important to meaningful pediatric quality measurement.

Our results illustrating differences in the most common and costly conditions at GHs and FCHs have further implications for prioritization and implementation of research and QI efforts. Implementation research and QI efforts focused on cardiac and neurosurgical procedures, as well as neonatal intensive care, may have considerable impact on cost and quality at FCHs. At GHs, research and QI efforts focused on common conditions are needed to increase our knowledge of contextually relevant barriers to and facilitators of high‐quality pediatric care. This, however, can be made more difficult by small sample sizes, limited resources, and infrastructure, and competing priorities in adult‐focused GH settings.[16, 17, 18] Multihospital learning collaboratives and partnerships between FCHs and GHs can begin to address these challenges, but their success is contingent upon national advocacy and funding to support pediatric research and quality measures at GHs.

One of the most notable differences in the characteristics of pediatric hospitalizations at GHs and FCHs was the proportion of hospitalizations attributable to children with medical complexity (CMC); more than one‐third of hospitalizations at FCHs were for CMC compared to 1 in 5 at GHs. These findings align with the results of several previous studies describing the substantial resource utilization attributed to CMC, and with growing research, innovation, and quality metrics focused on improving both inpatient and outpatient care for these vulnerable children.[19, 20, 21, 22] Structured complex care programs, developed to improve care coordination and healthcare quality for CMC, are common at FCHs, and have been associated with decreased resource utilization and improved outcomes.[23, 24, 25] Notably, however, more than half of all hospitalizations for CMC, exceeding 250,000 annually, occurred at GHs, and almost 40% of hospitalizations for CMC occurred at the lower‐volume GHs. These findings speak to the importance of translating effective and innovative programs of care for CMC to GHs as resources allow, accompanied by robust evaluations of their effectiveness. Lower patient volume at most GHs, however, may be a barrier to dedicated CMC programs. As a result, decentralized community‐based programs of care for CMC, linking primary care programs with regional and tertiary care hospitals, warrant further consideration.[26, 27, 28]

This analysis should be interpreted in light of several limitations. First, we were unable to distinguish between GHs with scant pediatric‐specific resources from those with a large volume of dedicated pediatric resources, such as children's hospitals nested within GHs. We did identify 36 GHs with pediatric volumes similar to those observed at FCHs (see Supporting Table 2 in the online version of this article); patient and hospitalization characteristics at these higher‐volume GHs were similar in many ways to children hospitalized at FCHs. Several of these higher‐volume GHs may have considerable resources dedicated to the care of children, including subspecialty care, and may represent children's hospitals nested within GHs. Because nested children's hospitals are included in the GH categorization, our results may have underestimated the proportion of children cared for at children's hospitals. Further work is needed to identify the health systems challenges and opportunities that may be unique to these institutions. Second, because the 2012 KID does not include a specialty hospital indicator, we developed a proxy method for identifying these hospitals, which may have resulted in some misclassification. We are reassured that the results of our analyses did not change substantively when we included all hospitals. Similarly, although we are reassured that the number of hospitals classified in our analysis as acute care FCHs aligns, approximately, with the number of hospitals classified as such by the Children's Hospital Association, we were unable to assess the validity of this variable within the KID. Third, the KID does not link records at the patient level, so we are unable to report the number of unique children included in this analysis. In addition, the KID includes only inpatient stays with exclusion of observation status stays; potential differences between GH and FCH in the use of observation status could have biased our findings. Fifth, we used the PMCA to identify CMC; although this algorithm has been shown to have excellent sensitivity in identifying children with chronic diseases, using up to 3 years of Medicaid claims data, the sensitivity using the KID, where only 1 inpatient stay is available for assessment, is unknown.[8, 29] Similarly, use of Keren's pediatric diagnosis grouper to classify reasons for hospitalization may have resulted in misclassification, though there are few other nonproprietary pediatric‐specific diagnostic groupers available.

In 2012, more than 70% of pediatric hospitalizations occurred at GHs in the United States. The considerably higher pediatric volumes at FCHs makes these institutions well suited for research, innovation, and the development and application of disease‐specific QI initiatives. Recognizing that the majority of pediatric hospitalizations occurred at GHs, there is a clear need for implementation research, program development, and quality metrics that align with the characteristics of hospitalizations at these centers. National support for research and quality improvement that reflects the diverse hospital settings where children receive their hospital care is critical to further our nation's goal of improving hospital quality for children.

Improvement in the quality of hospital care in the United States is a national priority, both to advance patient safety and because our expenditures exceed any other nation's, but our health outcomes lag behind.[1, 2] Healthcare spending for children is growing at a faster rate than any other age group, with hospital care accounting for more than 40% of pediatric healthcare expenditures.[3] Inpatient healthcare comprises a greater proportion of healthcare costs for children than for adults, yet we have limited knowledge about where this care is provided.[4]

There is substantial variability in the settings in which children are hospitalized. Children may be hospitalized in freestanding children's hospitals, where all services are designed for children and which operate independently of adult‐focused institutions. They may also be hospitalized in general hospitals where care may be provided in a general inpatient bed, on a dedicated pediatric ward, or in a children's hospital nested within a hospital, which may have specialized nursing and physician care but often shares other resources such as laboratory and radiology with the primarily adult‐focused institution. Medical students and residents may be trained in all of these settings. We know little about how these hospital types differ with respect to patient populations, disease volumes, and resource utilization, and this knowledge is important to inform clinical programs, implementation research, and quality improvement (QI) priorities. To this end, we aimed to describe the volume and characteristics of pediatric hospitalizations at acute care general hospitals and freestanding children's hospitals in the United States.

METHODS

RESULTS

Overall, 3866 hospitals were categorized as a GH, whereas 70 hospitals were categorized as FCHs. Following exclusion of specialty hospitals, 3758 GHs and 50 FCHs were retained in this study. The geographic distribution of hospitals was similar, but although GHs included those in both urban and rural regions, all FCHs were located in urban regions (Table 1).

A total of 1,407,822 (SD 50,456) hospitalizations occurred at GHs, representing 71.7% of pediatric hospitalizations, whereas 554,458 (SD 45,046) hospitalizations occurred at FCHs. Hospitalizations at GHs accounted for 63.6% of days in hospital and 50.0% of pediatric inpatient healthcare costs. Eighty percent of the GHs had total pediatric patient volumes of less than 375 hospitalizations yearly; 11.1% of pediatric hospitalizations occurred at these lower‐volume centers. At FCHs, the median volume of pediatric hospitalizations was 12,001 (interquartile range [IQR]: 583815,448). A total of 36 GHs had pediatric hospitalization volumes in this IQR.

The median age for pediatric patients was slightly higher at GHs, whereas gender, race/ethnicity, primary payer, and median household income for zip code did not differ significantly between hospital types (Table 2). Medical complexity differed between hospital types: children with complex chronic diseases represented 20.2% of hospitalizations at GHs and 35.6% of hospitalizations at FCHs. Severity of illness differed between hospital types, with fewer hospitalizations categorized at the highest level of severity at GHs than FCHs. There were no significant differences between hospital types with respect to the proportion of hospitalizations categorized as neonatal hospitalizations or as elective hospitalizations. The median LOS was shorter at GHs than FCHs. Approximately 1 in 5 children hospitalized at GHs had LOS greater than 4 days, whereas almost 30% of children hospitalized at FCHs had LOS of this duration.

The most common pediatric medical, mental health, and surgical conditions are shown in Figure 1, together representing 32% of pediatric hospitalizations during the study period. For these medical conditions, 77.9% of hospitalizations occurred at GHs, ranging from 52.6% of chemotherapy hospitalizations to 89.0% of hospitalizations for neonatal hyperbilirubinemia. Sixty‐two percent of total hospital costs for these conditions were incurred at GHs. For the common mental health hospitalizations, 86% of hospitalizations occurred at GHs. The majority of hospitalizations and aggregate hospital costs for common surgical conditions also occurred at GHs.

Figure 1

Whereas pneumonia, asthma, and bronchiolitis were the most common reasons for hospitalization at both GHs and FCHs, the most costly conditions differed (see Supporting Table 1 in the online version of this article). At GHs, these respiratory diseases were responsible for the highest condition‐specific total hospital costs. At FCHs, the highest aggregate costs were due to respiratory distress syndrome and chemotherapy. Congenital heart diseases, including hypoplastic left heart syndrome, transposition of the great vessels, tetralogy of Fallot, endocardial cushion defects, coarctation of the aorta and ventricular septal defects accounted for 6 of the 20 most costly conditions at FCHs.

Figure 2 illustrates the volume of hospitalizations, per hospital, at GHs and FCHs for the most common medical hospitalizations. The median number of hospitalizations, per hospital, was consistently significantly lower at GHs than at FCHs (all P values <0.001). Similar results for surgical and mental health hospitalizations are shown as Supporting Figures 1 and 2 in the online version of this article. In our sensitivity analyses that included all hospitals classified as GH and FCH, all results were essentially unchanged.

Figure 2

Recognizing the wide range of pediatric volumes at GHs (Table 1) and our inability to differentiate children's hospitals nested within GHs from GHs with pediatric beds, we examined differences in patient and hospitalization characteristics at GHs with volumes 5838 hospitalizations (the 25th percentile for FCH volume) and GHs with pediatric volumes <5838/year (see Supporting Table 2 in the online version of this article). We also compared patient and hospitalization characteristics at FCHs and the higher‐volume GHs. A total of 36 GHs had pediatric volumes 5838, with hospitalizations at these sites together accounting for 15.4% of all pediatric hospitalizations. Characteristics of patients hospitalized at these higher‐volume GHs were similar to patients hospitalized at FCHs, but they had significantly lower disease severity, fewer neonatal hospitalizations, shorter LOS, and more high‐turnover hospitalizations than patients hospitalized at FCHs. We also observed several differences between children hospitalized at higher‐ and lower‐volume GHs (see Supporting Table 2 in the online version of this article). Children hospitalized at the lower‐volume GHs were more likely to have public health insurance and less likely to have complex chronic diseases, although overall, 39.0% of all hospitalizations for children with complex chronic diseases occurred at these lower‐volume GHs. Compared to children hospitalized at higher‐volume GHs, children hospitalized at the lower‐volume hospitals had significantly lower disease severity, shorter LOS, more direct admissions, and a greater proportion of routine discharges.

DISCUSSION

Of the 2 million pediatric hospitalizations in the United States in 2012, more than 70% occurred at GHs. We observed considerable heterogeneity in pediatric volumes across GHs, with 11% of pediatric hospitalizations occurring at hospitals with pediatric volumes of <375 hospitalizations annually, whereas 15% of pediatric hospitalizations occurred at GHs with volumes similar to those observed at FCHs. The remaining pediatric hospitalizations at GHs occurred at centers with intermediate volumes. The most common reasons for hospitalization were similar at GHs and FCHs, but the most costly conditions differed substantially. These findings have important implications for pediatric clinical care programs, research, and QI efforts.

Our finding that more than 70% of pediatric hospitalizations occurred at GHs speaks to the importance of quality measurement at these hospitals, whereas low per‐hospital pediatric volumes at the majority of GHs makes such measurement particularly challenging. Several previous studies have illustrated that volumes of pediatric hospitalizations are too small to detect meaningful differences in quality between hospitals using established condition‐specific metrics.[13, 14, 15] Our finding that more than 10% of pediatric hospitalizations occurred at GHs with pediatric volumes <375 year supports previous research suggesting that cross‐cutting, all‐condition quality metrics, composite measures, and/or multihospital reporting networks may be needed to enable quality measurement at these sites. In addition, the heterogeneity in patient volumes and characteristics across GHs raise questions about the applicability of quality metrics developed and validated at FCHs to the many GH settings. Field‐testing quality measures to ensure their validity at diverse GHs, particularly those with patient volumes and infrastructure different from FCHs, will be important to meaningful pediatric quality measurement.

Our results illustrating differences in the most common and costly conditions at GHs and FCHs have further implications for prioritization and implementation of research and QI efforts. Implementation research and QI efforts focused on cardiac and neurosurgical procedures, as well as neonatal intensive care, may have considerable impact on cost and quality at FCHs. At GHs, research and QI efforts focused on common conditions are needed to increase our knowledge of contextually relevant barriers to and facilitators of high‐quality pediatric care. This, however, can be made more difficult by small sample sizes, limited resources, and infrastructure, and competing priorities in adult‐focused GH settings.[16, 17, 18] Multihospital learning collaboratives and partnerships between FCHs and GHs can begin to address these challenges, but their success is contingent upon national advocacy and funding to support pediatric research and quality measures at GHs.

One of the most notable differences in the characteristics of pediatric hospitalizations at GHs and FCHs was the proportion of hospitalizations attributable to children with medical complexity (CMC); more than one‐third of hospitalizations at FCHs were for CMC compared to 1 in 5 at GHs. These findings align with the results of several previous studies describing the substantial resource utilization attributed to CMC, and with growing research, innovation, and quality metrics focused on improving both inpatient and outpatient care for these vulnerable children.[19, 20, 21, 22] Structured complex care programs, developed to improve care coordination and healthcare quality for CMC, are common at FCHs, and have been associated with decreased resource utilization and improved outcomes.[23, 24, 25] Notably, however, more than half of all hospitalizations for CMC, exceeding 250,000 annually, occurred at GHs, and almost 40% of hospitalizations for CMC occurred at the lower‐volume GHs. These findings speak to the importance of translating effective and innovative programs of care for CMC to GHs as resources allow, accompanied by robust evaluations of their effectiveness. Lower patient volume at most GHs, however, may be a barrier to dedicated CMC programs. As a result, decentralized community‐based programs of care for CMC, linking primary care programs with regional and tertiary care hospitals, warrant further consideration.[26, 27, 28]

This analysis should be interpreted in light of several limitations. First, we were unable to distinguish between GHs with scant pediatric‐specific resources from those with a large volume of dedicated pediatric resources, such as children's hospitals nested within GHs. We did identify 36 GHs with pediatric volumes similar to those observed at FCHs (see Supporting Table 2 in the online version of this article); patient and hospitalization characteristics at these higher‐volume GHs were similar in many ways to children hospitalized at FCHs. Several of these higher‐volume GHs may have considerable resources dedicated to the care of children, including subspecialty care, and may represent children's hospitals nested within GHs. Because nested children's hospitals are included in the GH categorization, our results may have underestimated the proportion of children cared for at children's hospitals. Further work is needed to identify the health systems challenges and opportunities that may be unique to these institutions. Second, because the 2012 KID does not include a specialty hospital indicator, we developed a proxy method for identifying these hospitals, which may have resulted in some misclassification. We are reassured that the results of our analyses did not change substantively when we included all hospitals. Similarly, although we are reassured that the number of hospitals classified in our analysis as acute care FCHs aligns, approximately, with the number of hospitals classified as such by the Children's Hospital Association, we were unable to assess the validity of this variable within the KID. Third, the KID does not link records at the patient level, so we are unable to report the number of unique children included in this analysis. In addition, the KID includes only inpatient stays with exclusion of observation status stays; potential differences between GH and FCH in the use of observation status could have biased our findings. Fifth, we used the PMCA to identify CMC; although this algorithm has been shown to have excellent sensitivity in identifying children with chronic diseases, using up to 3 years of Medicaid claims data, the sensitivity using the KID, where only 1 inpatient stay is available for assessment, is unknown.[8, 29] Similarly, use of Keren's pediatric diagnosis grouper to classify reasons for hospitalization may have resulted in misclassification, though there are few other nonproprietary pediatric‐specific diagnostic groupers available.

In 2012, more than 70% of pediatric hospitalizations occurred at GHs in the United States. The considerably higher pediatric volumes at FCHs makes these institutions well suited for research, innovation, and the development and application of disease‐specific QI initiatives. Recognizing that the majority of pediatric hospitalizations occurred at GHs, there is a clear need for implementation research, program development, and quality metrics that align with the characteristics of hospitalizations at these centers. National support for research and quality improvement that reflects the diverse hospital settings where children receive their hospital care is critical to further our nation's goal of improving hospital quality for children.

Improvement in the quality of hospital care in the United States is a national priority, both to advance patient safety and because our expenditures exceed any other nation's, but our health outcomes lag behind.[1, 2] Healthcare spending for children is growing at a faster rate than any other age group, with hospital care accounting for more than 40% of pediatric healthcare expenditures.[3] Inpatient healthcare comprises a greater proportion of healthcare costs for children than for adults, yet we have limited knowledge about where this care is provided.[4]

There is substantial variability in the settings in which children are hospitalized. Children may be hospitalized in freestanding children's hospitals, where all services are designed for children and which operate independently of adult‐focused institutions. They may also be hospitalized in general hospitals where care may be provided in a general inpatient bed, on a dedicated pediatric ward, or in a children's hospital nested within a hospital, which may have specialized nursing and physician care but often shares other resources such as laboratory and radiology with the primarily adult‐focused institution. Medical students and residents may be trained in all of these settings. We know little about how these hospital types differ with respect to patient populations, disease volumes, and resource utilization, and this knowledge is important to inform clinical programs, implementation research, and quality improvement (QI) priorities. To this end, we aimed to describe the volume and characteristics of pediatric hospitalizations at acute care general hospitals and freestanding children's hospitals in the United States.

METHODS

RESULTS

Overall, 3866 hospitals were categorized as a GH, whereas 70 hospitals were categorized as FCHs. Following exclusion of specialty hospitals, 3758 GHs and 50 FCHs were retained in this study. The geographic distribution of hospitals was similar, but although GHs included those in both urban and rural regions, all FCHs were located in urban regions (Table 1).

A total of 1,407,822 (SD 50,456) hospitalizations occurred at GHs, representing 71.7% of pediatric hospitalizations, whereas 554,458 (SD 45,046) hospitalizations occurred at FCHs. Hospitalizations at GHs accounted for 63.6% of days in hospital and 50.0% of pediatric inpatient healthcare costs. Eighty percent of the GHs had total pediatric patient volumes of less than 375 hospitalizations yearly; 11.1% of pediatric hospitalizations occurred at these lower‐volume centers. At FCHs, the median volume of pediatric hospitalizations was 12,001 (interquartile range [IQR]: 583815,448). A total of 36 GHs had pediatric hospitalization volumes in this IQR.

The median age for pediatric patients was slightly higher at GHs, whereas gender, race/ethnicity, primary payer, and median household income for zip code did not differ significantly between hospital types (Table 2). Medical complexity differed between hospital types: children with complex chronic diseases represented 20.2% of hospitalizations at GHs and 35.6% of hospitalizations at FCHs. Severity of illness differed between hospital types, with fewer hospitalizations categorized at the highest level of severity at GHs than FCHs. There were no significant differences between hospital types with respect to the proportion of hospitalizations categorized as neonatal hospitalizations or as elective hospitalizations. The median LOS was shorter at GHs than FCHs. Approximately 1 in 5 children hospitalized at GHs had LOS greater than 4 days, whereas almost 30% of children hospitalized at FCHs had LOS of this duration.

The most common pediatric medical, mental health, and surgical conditions are shown in Figure 1, together representing 32% of pediatric hospitalizations during the study period. For these medical conditions, 77.9% of hospitalizations occurred at GHs, ranging from 52.6% of chemotherapy hospitalizations to 89.0% of hospitalizations for neonatal hyperbilirubinemia. Sixty‐two percent of total hospital costs for these conditions were incurred at GHs. For the common mental health hospitalizations, 86% of hospitalizations occurred at GHs. The majority of hospitalizations and aggregate hospital costs for common surgical conditions also occurred at GHs.

Figure 1

Whereas pneumonia, asthma, and bronchiolitis were the most common reasons for hospitalization at both GHs and FCHs, the most costly conditions differed (see Supporting Table 1 in the online version of this article). At GHs, these respiratory diseases were responsible for the highest condition‐specific total hospital costs. At FCHs, the highest aggregate costs were due to respiratory distress syndrome and chemotherapy. Congenital heart diseases, including hypoplastic left heart syndrome, transposition of the great vessels, tetralogy of Fallot, endocardial cushion defects, coarctation of the aorta and ventricular septal defects accounted for 6 of the 20 most costly conditions at FCHs.

Figure 2 illustrates the volume of hospitalizations, per hospital, at GHs and FCHs for the most common medical hospitalizations. The median number of hospitalizations, per hospital, was consistently significantly lower at GHs than at FCHs (all P values <0.001). Similar results for surgical and mental health hospitalizations are shown as Supporting Figures 1 and 2 in the online version of this article. In our sensitivity analyses that included all hospitals classified as GH and FCH, all results were essentially unchanged.

Figure 2

Recognizing the wide range of pediatric volumes at GHs (Table 1) and our inability to differentiate children's hospitals nested within GHs from GHs with pediatric beds, we examined differences in patient and hospitalization characteristics at GHs with volumes 5838 hospitalizations (the 25th percentile for FCH volume) and GHs with pediatric volumes <5838/year (see Supporting Table 2 in the online version of this article). We also compared patient and hospitalization characteristics at FCHs and the higher‐volume GHs. A total of 36 GHs had pediatric volumes 5838, with hospitalizations at these sites together accounting for 15.4% of all pediatric hospitalizations. Characteristics of patients hospitalized at these higher‐volume GHs were similar to patients hospitalized at FCHs, but they had significantly lower disease severity, fewer neonatal hospitalizations, shorter LOS, and more high‐turnover hospitalizations than patients hospitalized at FCHs. We also observed several differences between children hospitalized at higher‐ and lower‐volume GHs (see Supporting Table 2 in the online version of this article). Children hospitalized at the lower‐volume GHs were more likely to have public health insurance and less likely to have complex chronic diseases, although overall, 39.0% of all hospitalizations for children with complex chronic diseases occurred at these lower‐volume GHs. Compared to children hospitalized at higher‐volume GHs, children hospitalized at the lower‐volume hospitals had significantly lower disease severity, shorter LOS, more direct admissions, and a greater proportion of routine discharges.

DISCUSSION

Of the 2 million pediatric hospitalizations in the United States in 2012, more than 70% occurred at GHs. We observed considerable heterogeneity in pediatric volumes across GHs, with 11% of pediatric hospitalizations occurring at hospitals with pediatric volumes of <375 hospitalizations annually, whereas 15% of pediatric hospitalizations occurred at GHs with volumes similar to those observed at FCHs. The remaining pediatric hospitalizations at GHs occurred at centers with intermediate volumes. The most common reasons for hospitalization were similar at GHs and FCHs, but the most costly conditions differed substantially. These findings have important implications for pediatric clinical care programs, research, and QI efforts.

Our finding that more than 70% of pediatric hospitalizations occurred at GHs speaks to the importance of quality measurement at these hospitals, whereas low per‐hospital pediatric volumes at the majority of GHs makes such measurement particularly challenging. Several previous studies have illustrated that volumes of pediatric hospitalizations are too small to detect meaningful differences in quality between hospitals using established condition‐specific metrics.[13, 14, 15] Our finding that more than 10% of pediatric hospitalizations occurred at GHs with pediatric volumes <375 year supports previous research suggesting that cross‐cutting, all‐condition quality metrics, composite measures, and/or multihospital reporting networks may be needed to enable quality measurement at these sites. In addition, the heterogeneity in patient volumes and characteristics across GHs raise questions about the applicability of quality metrics developed and validated at FCHs to the many GH settings. Field‐testing quality measures to ensure their validity at diverse GHs, particularly those with patient volumes and infrastructure different from FCHs, will be important to meaningful pediatric quality measurement.

Our results illustrating differences in the most common and costly conditions at GHs and FCHs have further implications for prioritization and implementation of research and QI efforts. Implementation research and QI efforts focused on cardiac and neurosurgical procedures, as well as neonatal intensive care, may have considerable impact on cost and quality at FCHs. At GHs, research and QI efforts focused on common conditions are needed to increase our knowledge of contextually relevant barriers to and facilitators of high‐quality pediatric care. This, however, can be made more difficult by small sample sizes, limited resources, and infrastructure, and competing priorities in adult‐focused GH settings.[16, 17, 18] Multihospital learning collaboratives and partnerships between FCHs and GHs can begin to address these challenges, but their success is contingent upon national advocacy and funding to support pediatric research and quality measures at GHs.

One of the most notable differences in the characteristics of pediatric hospitalizations at GHs and FCHs was the proportion of hospitalizations attributable to children with medical complexity (CMC); more than one‐third of hospitalizations at FCHs were for CMC compared to 1 in 5 at GHs. These findings align with the results of several previous studies describing the substantial resource utilization attributed to CMC, and with growing research, innovation, and quality metrics focused on improving both inpatient and outpatient care for these vulnerable children.[19, 20, 21, 22] Structured complex care programs, developed to improve care coordination and healthcare quality for CMC, are common at FCHs, and have been associated with decreased resource utilization and improved outcomes.[23, 24, 25] Notably, however, more than half of all hospitalizations for CMC, exceeding 250,000 annually, occurred at GHs, and almost 40% of hospitalizations for CMC occurred at the lower‐volume GHs. These findings speak to the importance of translating effective and innovative programs of care for CMC to GHs as resources allow, accompanied by robust evaluations of their effectiveness. Lower patient volume at most GHs, however, may be a barrier to dedicated CMC programs. As a result, decentralized community‐based programs of care for CMC, linking primary care programs with regional and tertiary care hospitals, warrant further consideration.[26, 27, 28]

This analysis should be interpreted in light of several limitations. First, we were unable to distinguish between GHs with scant pediatric‐specific resources from those with a large volume of dedicated pediatric resources, such as children's hospitals nested within GHs. We did identify 36 GHs with pediatric volumes similar to those observed at FCHs (see Supporting Table 2 in the online version of this article); patient and hospitalization characteristics at these higher‐volume GHs were similar in many ways to children hospitalized at FCHs. Several of these higher‐volume GHs may have considerable resources dedicated to the care of children, including subspecialty care, and may represent children's hospitals nested within GHs. Because nested children's hospitals are included in the GH categorization, our results may have underestimated the proportion of children cared for at children's hospitals. Further work is needed to identify the health systems challenges and opportunities that may be unique to these institutions. Second, because the 2012 KID does not include a specialty hospital indicator, we developed a proxy method for identifying these hospitals, which may have resulted in some misclassification. We are reassured that the results of our analyses did not change substantively when we included all hospitals. Similarly, although we are reassured that the number of hospitals classified in our analysis as acute care FCHs aligns, approximately, with the number of hospitals classified as such by the Children's Hospital Association, we were unable to assess the validity of this variable within the KID. Third, the KID does not link records at the patient level, so we are unable to report the number of unique children included in this analysis. In addition, the KID includes only inpatient stays with exclusion of observation status stays; potential differences between GH and FCH in the use of observation status could have biased our findings. Fifth, we used the PMCA to identify CMC; although this algorithm has been shown to have excellent sensitivity in identifying children with chronic diseases, using up to 3 years of Medicaid claims data, the sensitivity using the KID, where only 1 inpatient stay is available for assessment, is unknown.[8, 29] Similarly, use of Keren's pediatric diagnosis grouper to classify reasons for hospitalization may have resulted in misclassification, though there are few other nonproprietary pediatric‐specific diagnostic groupers available.

In 2012, more than 70% of pediatric hospitalizations occurred at GHs in the United States. The considerably higher pediatric volumes at FCHs makes these institutions well suited for research, innovation, and the development and application of disease‐specific QI initiatives. Recognizing that the majority of pediatric hospitalizations occurred at GHs, there is a clear need for implementation research, program development, and quality metrics that align with the characteristics of hospitalizations at these centers. National support for research and quality improvement that reflects the diverse hospital settings where children receive their hospital care is critical to further our nation's goal of improving hospital quality for children.