The March issue of the Journal of Hospital Medicine represents a landmark for pediatric hospital medicine (PHM), with 100% of the original research content devoted to pediatrics. Since the days of the National Association of Inpatient Physicians, pediatric hospitalists have consistently constituted 8% to 10% of the membership of the Society of Hospital Medicine (SHM). SHM has always welcomed pediatrics and pediatricians into the community of hospital medicine. A pediatrician has sat on the board since the founding of the National Association of Inpatient Physicians, and for the past 3 years, there has been a formal pediatric board seat. The Hospitalist has consistently included pediatric content with program descriptions and literature reviews. This past July, more than 325 pediatric hospitalists gathered in Denver for the largest PHM meeting ever, a 4‐day event trisponsored by SHM, the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA).

As pediatric hospitalists, we have prospered by following the successes of adult hospitalists. We have flattered/emmitated our adult colleagues with pediatric voluntary referral policies, core competencies, salary surveys, fellowship programs, and quality improvement projects. In other areas, pediatrics has set trends for (adult) hospital medicine. Pediatrics developed the medical home concept. We zealously advocate for family‐centered rounds. (Imagine actually rounding in the room with the patient, family, nurse, and physician. It certainly beats flipping cards in the conference room)! Pediatricians have developed global fee codes for evaluation and management services (albeit limited to neonatal and pediatric critical care). As evidenced by the trisponsored meeting mentioned previously and the Pediatric Research in Inpatient Settings Network, we have created collaborative relationships among the pediatric academic (APA), professional (AAP), and hospitalist organizations (SHM) that serve as models for other disciplines and their respective sandboxes.

Research and publications are where we most lag behind our adult colleagues and where the most work needs to be done for us to achieve legitimacy as practitioners and as a discipline. This issue of the Journal of Hospital Medicine is a harbinger of more pediatric content to come, with topics that run the gamut of PHM. Woolford et al.1 highlight clinical, public health, and public policy issues with their analysis of the increased costs and morbidity associated with obesity and inpatient hospitalizations. Wilkes et al.2 explore the logistic issues surrounding influenza testing. As is frequently true for hospitalists, our expertise is not purely clinical: Is oseltamvir effective and, if so, in what age groups? That question is probably best left to the infectious disease community. Rather, Wilkes et al. highlight both the provider and system issues involved in reliably and expeditiously obtaining, reporting, and communicating flu antigen test results so that clinicians and families have the opportunity to consider oseltamvir use within the first 48 hours of disease. Odetola et al.'s3 analysis of a Michigan administrative data set suggests that morbidity, length of stay, and resource utilization are decreased for patients who ultimately require pediatric critical care when these patients are directly transferred from the emergency room to a facility with a pediatric intensive care unit (PICU) in comparison with the morbidity, length of stay, and resource utilization of patients who are initially admitted to the ward from the emergency room and then transferred to a facility with a PICU. This study lacks the rigor of prospectively collected physiological data and would probably never receive institutional review board approval for randomization, but it certainly raises key questions about appropriate transfer criteria for patients cared for in hospitals without a PICU. This is a key quality concern for pediatric hospitalists practicing in smaller, community hospital settings.

The 2 most controversial articles in this pediatric inpatient potpourri are the studies conducted by Freed and Kelly examining pediatric hospitalist training, practice, and career goals4 and PHM fellowship programs.5 These studies are part of a 6‐perspective analysis of pediatric hospitalists/PHM requested by the American Board of Pediatrics (ABP) to provide background to the ABP as it begins to grapple with its role in certifying pediatricians whose primary practice is inpatient pediatrics. A previously published study analyzed the perspective of PHM group leaders.6 The remaining studies assess the perspectives of residency program directors, department chairs, and hospital leaders.

Not surprisingly, these 3 articles46 tend to be more critical of the PHM movement and its current state than are articles and commentaries written by those of us who are practicing hospitalists. As a hospitalist, my initial reaction was to focus on the studies' shortcomings. The methods seemed flawed, the criticisms seemed unwarranted, and the study limitations seemed underappreciated. Aside from the fellowship study, which surveyed the entire n = 8 universe of PHM fellowship programs, the group leader and hospitalist surveys suffer from a selection bias. Sampling for these studies was based on hospital size and type. Although this sampling strategy is appropriate for comparing programs across hospitals, it fails to account for programs of different sizes in different settings. It is not the best sampling strategy for a denominator of all pediatric hospitalists. For example, community hospital programs without residents are often much bigger than academic programs with residents. Community pediatric hospitalists are likely underrepresented in Freed's survey.4 From a study design standpoint, it does not appear that specific a priori hypotheses were generated when subgroups were compared. Rather, one suspects that every possible comparison was analyzed. Thus, the percent differences from one group to another are best considered descriptive rather than rigorously statistically significant at a p < 0.05 level. Some criticisms addressed to hospitalists apply to all pediatricians. Given the current emphasis on quality assessment, wouldn't most office‐based pediatricians (and particularly group leaders) believe that they need extra training in this field? When less than 50% of hospitals require practitioners in established subboarded specialties to be board‐certified to maintain hospital privileges,7 is it surprising to see that privileging standards vary for pediatric hospitalists?

However, nitpicking these studies is a defensive response that does a disservice both to the reports and more importantly to the PHM community as a whole and to the children, parents, and colleagues that we serve. There is no denying that we are a young, evolving field with significant inter‐institutional and at times intra‐institutional variability. All of us in the PHM community, leaders and lurkers, need to rise to the challenges offered by comprehensive analysis. Freed's sample of 431 hospitalists4 is significantly larger than the sample of 265 hospitalist participants in the latest Pediatric Research in Inpatient Settings survey.8 The perceptions of external observers are crucial; it would be a mistake to dismiss their findings or to ignore their interpretations and criticisms.

Certainly none would challenge the variability of practice revealed in Freed's analyses.46 Remember, if you've seen one pediatric hospital medicine program, you've seen ONE pediatric hospital medicine program. Some may see this variability as a weakness; others may see it as a strength. We must be equally receptive to other less‐flattering observations, data, and conclusions included in these reports to the ABP. All programs target seamless communication with referring physicians, but hospitalists and referring physicians alike agree that we do not achieve it, as evidenced by the work of Harlan et al.9 in this issue. SHM is taking the lead in developing performance standards for transitions of care and has created best discharge practices for the geriatric population.10 Similarly, we in the PHM community would do well to ramp up our self‐assessment and quality improvement activities. Our recusal from Centers for Medicare and Medicaid Services reporting requirements for (adult) inpatient quality metrics does not excuse us from pursuing voluntary, rigorous, transparent, public reporting on pediatric quality indicators. As Freed et al.6 clearly implied, the public and payers expect this of us. No doubt, if we do not first propose and implement our own standards, external standards will be imposed upon us.

Aside from the question of mandatory fellowship training for hospitalists, does the vision implied in the studies commissioned by the ABP vary significantly from the challenges to PHM that Sandy Melzer11 presented at his keynote address at the Denver meeting? Melzer used strategic planning principles to outline a future vision for PHM, including the following:

• 1

  Harm is eliminated from the inpatient setting.

• 2

  Inpatient care is evidence‐based for all conditions treated.

• 3

  Hospital care is highly coordinated, especially for children with chronic conditions.

• 4

  A robust research agenda supports all aspects of inpatient care.

Is not the work done by the SHM and APA to develop core competencies for PHM an effort to define our field and identify (uniform) expectations? Do not the criteria for designation as a fellow of hospital medicine (5 years as a practicing hospitalist; 2 national meetings; and a minimum combination of leadership, teamwork, and quality improvement activities)12 serve to recognize the commitment and accomplishments that distinguish a true hospitalist practicing systems‐based hospital medicine from a physician who simply works in the hospital?

There is no need for pediatric hospitalists to respond defensively to the hospitalist studies commissioned by the ABP. In fact, Freed46 has done us a favor by adding dimension and texture to the preliminary outlines of what it means for PHM to be ultimately successful. Both Freed and Melzer11 are describing the same path. As hospitalists, we tend to take pride in how far we have already come along this adventure. External observers such as Freed remind of us of how far we still need to go. Either way, Dorothy Gale, MD, pediatric hospitalist, has a relatively well‐identified yellow brick road to follow with specific challenges and charges to meet. What is unclear is whether formal acknowledgment will be awarded at the end of this journey and, if so, what form it will take. Options include (1) recognition of focused practice in hospital medicine with maintenance of certification, (2) SHM fellowship, (3) a traditionally boarded subspecialty, or (4) all of the above.

Any formal designation will be of secondary importance. Remember, the wizard did not change anything when he bestowed the diploma, the heart‐shaped testimonial, and the medal of valor. Like the scarecrow, tin man, and lion, all the qualities that we need for success as pediatric hospitalists are already within us. No wizard's pronouncements will help us provide better care to our patients. Change will come from working together on shared goals with mutual support along our common path. Look to the Journal of Hospital Medicine for frequent updates on the journey. See you in the Emerald City.

The March issue of the Journal of Hospital Medicine represents a landmark for pediatric hospital medicine (PHM), with 100% of the original research content devoted to pediatrics. Since the days of the National Association of Inpatient Physicians, pediatric hospitalists have consistently constituted 8% to 10% of the membership of the Society of Hospital Medicine (SHM). SHM has always welcomed pediatrics and pediatricians into the community of hospital medicine. A pediatrician has sat on the board since the founding of the National Association of Inpatient Physicians, and for the past 3 years, there has been a formal pediatric board seat. The Hospitalist has consistently included pediatric content with program descriptions and literature reviews. This past July, more than 325 pediatric hospitalists gathered in Denver for the largest PHM meeting ever, a 4‐day event trisponsored by SHM, the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA).

As pediatric hospitalists, we have prospered by following the successes of adult hospitalists. We have flattered/emmitated our adult colleagues with pediatric voluntary referral policies, core competencies, salary surveys, fellowship programs, and quality improvement projects. In other areas, pediatrics has set trends for (adult) hospital medicine. Pediatrics developed the medical home concept. We zealously advocate for family‐centered rounds. (Imagine actually rounding in the room with the patient, family, nurse, and physician. It certainly beats flipping cards in the conference room)! Pediatricians have developed global fee codes for evaluation and management services (albeit limited to neonatal and pediatric critical care). As evidenced by the trisponsored meeting mentioned previously and the Pediatric Research in Inpatient Settings Network, we have created collaborative relationships among the pediatric academic (APA), professional (AAP), and hospitalist organizations (SHM) that serve as models for other disciplines and their respective sandboxes.

Research and publications are where we most lag behind our adult colleagues and where the most work needs to be done for us to achieve legitimacy as practitioners and as a discipline. This issue of the Journal of Hospital Medicine is a harbinger of more pediatric content to come, with topics that run the gamut of PHM. Woolford et al.1 highlight clinical, public health, and public policy issues with their analysis of the increased costs and morbidity associated with obesity and inpatient hospitalizations. Wilkes et al.2 explore the logistic issues surrounding influenza testing. As is frequently true for hospitalists, our expertise is not purely clinical: Is oseltamvir effective and, if so, in what age groups? That question is probably best left to the infectious disease community. Rather, Wilkes et al. highlight both the provider and system issues involved in reliably and expeditiously obtaining, reporting, and communicating flu antigen test results so that clinicians and families have the opportunity to consider oseltamvir use within the first 48 hours of disease. Odetola et al.'s3 analysis of a Michigan administrative data set suggests that morbidity, length of stay, and resource utilization are decreased for patients who ultimately require pediatric critical care when these patients are directly transferred from the emergency room to a facility with a pediatric intensive care unit (PICU) in comparison with the morbidity, length of stay, and resource utilization of patients who are initially admitted to the ward from the emergency room and then transferred to a facility with a PICU. This study lacks the rigor of prospectively collected physiological data and would probably never receive institutional review board approval for randomization, but it certainly raises key questions about appropriate transfer criteria for patients cared for in hospitals without a PICU. This is a key quality concern for pediatric hospitalists practicing in smaller, community hospital settings.

The 2 most controversial articles in this pediatric inpatient potpourri are the studies conducted by Freed and Kelly examining pediatric hospitalist training, practice, and career goals4 and PHM fellowship programs.5 These studies are part of a 6‐perspective analysis of pediatric hospitalists/PHM requested by the American Board of Pediatrics (ABP) to provide background to the ABP as it begins to grapple with its role in certifying pediatricians whose primary practice is inpatient pediatrics. A previously published study analyzed the perspective of PHM group leaders.6 The remaining studies assess the perspectives of residency program directors, department chairs, and hospital leaders.

Not surprisingly, these 3 articles46 tend to be more critical of the PHM movement and its current state than are articles and commentaries written by those of us who are practicing hospitalists. As a hospitalist, my initial reaction was to focus on the studies' shortcomings. The methods seemed flawed, the criticisms seemed unwarranted, and the study limitations seemed underappreciated. Aside from the fellowship study, which surveyed the entire n = 8 universe of PHM fellowship programs, the group leader and hospitalist surveys suffer from a selection bias. Sampling for these studies was based on hospital size and type. Although this sampling strategy is appropriate for comparing programs across hospitals, it fails to account for programs of different sizes in different settings. It is not the best sampling strategy for a denominator of all pediatric hospitalists. For example, community hospital programs without residents are often much bigger than academic programs with residents. Community pediatric hospitalists are likely underrepresented in Freed's survey.4 From a study design standpoint, it does not appear that specific a priori hypotheses were generated when subgroups were compared. Rather, one suspects that every possible comparison was analyzed. Thus, the percent differences from one group to another are best considered descriptive rather than rigorously statistically significant at a p < 0.05 level. Some criticisms addressed to hospitalists apply to all pediatricians. Given the current emphasis on quality assessment, wouldn't most office‐based pediatricians (and particularly group leaders) believe that they need extra training in this field? When less than 50% of hospitals require practitioners in established subboarded specialties to be board‐certified to maintain hospital privileges,7 is it surprising to see that privileging standards vary for pediatric hospitalists?

However, nitpicking these studies is a defensive response that does a disservice both to the reports and more importantly to the PHM community as a whole and to the children, parents, and colleagues that we serve. There is no denying that we are a young, evolving field with significant inter‐institutional and at times intra‐institutional variability. All of us in the PHM community, leaders and lurkers, need to rise to the challenges offered by comprehensive analysis. Freed's sample of 431 hospitalists4 is significantly larger than the sample of 265 hospitalist participants in the latest Pediatric Research in Inpatient Settings survey.8 The perceptions of external observers are crucial; it would be a mistake to dismiss their findings or to ignore their interpretations and criticisms.

Certainly none would challenge the variability of practice revealed in Freed's analyses.46 Remember, if you've seen one pediatric hospital medicine program, you've seen ONE pediatric hospital medicine program. Some may see this variability as a weakness; others may see it as a strength. We must be equally receptive to other less‐flattering observations, data, and conclusions included in these reports to the ABP. All programs target seamless communication with referring physicians, but hospitalists and referring physicians alike agree that we do not achieve it, as evidenced by the work of Harlan et al.9 in this issue. SHM is taking the lead in developing performance standards for transitions of care and has created best discharge practices for the geriatric population.10 Similarly, we in the PHM community would do well to ramp up our self‐assessment and quality improvement activities. Our recusal from Centers for Medicare and Medicaid Services reporting requirements for (adult) inpatient quality metrics does not excuse us from pursuing voluntary, rigorous, transparent, public reporting on pediatric quality indicators. As Freed et al.6 clearly implied, the public and payers expect this of us. No doubt, if we do not first propose and implement our own standards, external standards will be imposed upon us.

Aside from the question of mandatory fellowship training for hospitalists, does the vision implied in the studies commissioned by the ABP vary significantly from the challenges to PHM that Sandy Melzer11 presented at his keynote address at the Denver meeting? Melzer used strategic planning principles to outline a future vision for PHM, including the following:

• 1

  Harm is eliminated from the inpatient setting.

• 2

  Inpatient care is evidence‐based for all conditions treated.

• 3

  Hospital care is highly coordinated, especially for children with chronic conditions.

• 4

  A robust research agenda supports all aspects of inpatient care.

Is not the work done by the SHM and APA to develop core competencies for PHM an effort to define our field and identify (uniform) expectations? Do not the criteria for designation as a fellow of hospital medicine (5 years as a practicing hospitalist; 2 national meetings; and a minimum combination of leadership, teamwork, and quality improvement activities)12 serve to recognize the commitment and accomplishments that distinguish a true hospitalist practicing systems‐based hospital medicine from a physician who simply works in the hospital?

There is no need for pediatric hospitalists to respond defensively to the hospitalist studies commissioned by the ABP. In fact, Freed46 has done us a favor by adding dimension and texture to the preliminary outlines of what it means for PHM to be ultimately successful. Both Freed and Melzer11 are describing the same path. As hospitalists, we tend to take pride in how far we have already come along this adventure. External observers such as Freed remind of us of how far we still need to go. Either way, Dorothy Gale, MD, pediatric hospitalist, has a relatively well‐identified yellow brick road to follow with specific challenges and charges to meet. What is unclear is whether formal acknowledgment will be awarded at the end of this journey and, if so, what form it will take. Options include (1) recognition of focused practice in hospital medicine with maintenance of certification, (2) SHM fellowship, (3) a traditionally boarded subspecialty, or (4) all of the above.

Any formal designation will be of secondary importance. Remember, the wizard did not change anything when he bestowed the diploma, the heart‐shaped testimonial, and the medal of valor. Like the scarecrow, tin man, and lion, all the qualities that we need for success as pediatric hospitalists are already within us. No wizard's pronouncements will help us provide better care to our patients. Change will come from working together on shared goals with mutual support along our common path. Look to the Journal of Hospital Medicine for frequent updates on the journey. See you in the Emerald City.

The March issue of the Journal of Hospital Medicine represents a landmark for pediatric hospital medicine (PHM), with 100% of the original research content devoted to pediatrics. Since the days of the National Association of Inpatient Physicians, pediatric hospitalists have consistently constituted 8% to 10% of the membership of the Society of Hospital Medicine (SHM). SHM has always welcomed pediatrics and pediatricians into the community of hospital medicine. A pediatrician has sat on the board since the founding of the National Association of Inpatient Physicians, and for the past 3 years, there has been a formal pediatric board seat. The Hospitalist has consistently included pediatric content with program descriptions and literature reviews. This past July, more than 325 pediatric hospitalists gathered in Denver for the largest PHM meeting ever, a 4‐day event trisponsored by SHM, the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA).

As pediatric hospitalists, we have prospered by following the successes of adult hospitalists. We have flattered/emmitated our adult colleagues with pediatric voluntary referral policies, core competencies, salary surveys, fellowship programs, and quality improvement projects. In other areas, pediatrics has set trends for (adult) hospital medicine. Pediatrics developed the medical home concept. We zealously advocate for family‐centered rounds. (Imagine actually rounding in the room with the patient, family, nurse, and physician. It certainly beats flipping cards in the conference room)! Pediatricians have developed global fee codes for evaluation and management services (albeit limited to neonatal and pediatric critical care). As evidenced by the trisponsored meeting mentioned previously and the Pediatric Research in Inpatient Settings Network, we have created collaborative relationships among the pediatric academic (APA), professional (AAP), and hospitalist organizations (SHM) that serve as models for other disciplines and their respective sandboxes.

Research and publications are where we most lag behind our adult colleagues and where the most work needs to be done for us to achieve legitimacy as practitioners and as a discipline. This issue of the Journal of Hospital Medicine is a harbinger of more pediatric content to come, with topics that run the gamut of PHM. Woolford et al.1 highlight clinical, public health, and public policy issues with their analysis of the increased costs and morbidity associated with obesity and inpatient hospitalizations. Wilkes et al.2 explore the logistic issues surrounding influenza testing. As is frequently true for hospitalists, our expertise is not purely clinical: Is oseltamvir effective and, if so, in what age groups? That question is probably best left to the infectious disease community. Rather, Wilkes et al. highlight both the provider and system issues involved in reliably and expeditiously obtaining, reporting, and communicating flu antigen test results so that clinicians and families have the opportunity to consider oseltamvir use within the first 48 hours of disease. Odetola et al.'s3 analysis of a Michigan administrative data set suggests that morbidity, length of stay, and resource utilization are decreased for patients who ultimately require pediatric critical care when these patients are directly transferred from the emergency room to a facility with a pediatric intensive care unit (PICU) in comparison with the morbidity, length of stay, and resource utilization of patients who are initially admitted to the ward from the emergency room and then transferred to a facility with a PICU. This study lacks the rigor of prospectively collected physiological data and would probably never receive institutional review board approval for randomization, but it certainly raises key questions about appropriate transfer criteria for patients cared for in hospitals without a PICU. This is a key quality concern for pediatric hospitalists practicing in smaller, community hospital settings.

The 2 most controversial articles in this pediatric inpatient potpourri are the studies conducted by Freed and Kelly examining pediatric hospitalist training, practice, and career goals4 and PHM fellowship programs.5 These studies are part of a 6‐perspective analysis of pediatric hospitalists/PHM requested by the American Board of Pediatrics (ABP) to provide background to the ABP as it begins to grapple with its role in certifying pediatricians whose primary practice is inpatient pediatrics. A previously published study analyzed the perspective of PHM group leaders.6 The remaining studies assess the perspectives of residency program directors, department chairs, and hospital leaders.

Not surprisingly, these 3 articles46 tend to be more critical of the PHM movement and its current state than are articles and commentaries written by those of us who are practicing hospitalists. As a hospitalist, my initial reaction was to focus on the studies' shortcomings. The methods seemed flawed, the criticisms seemed unwarranted, and the study limitations seemed underappreciated. Aside from the fellowship study, which surveyed the entire n = 8 universe of PHM fellowship programs, the group leader and hospitalist surveys suffer from a selection bias. Sampling for these studies was based on hospital size and type. Although this sampling strategy is appropriate for comparing programs across hospitals, it fails to account for programs of different sizes in different settings. It is not the best sampling strategy for a denominator of all pediatric hospitalists. For example, community hospital programs without residents are often much bigger than academic programs with residents. Community pediatric hospitalists are likely underrepresented in Freed's survey.4 From a study design standpoint, it does not appear that specific a priori hypotheses were generated when subgroups were compared. Rather, one suspects that every possible comparison was analyzed. Thus, the percent differences from one group to another are best considered descriptive rather than rigorously statistically significant at a p < 0.05 level. Some criticisms addressed to hospitalists apply to all pediatricians. Given the current emphasis on quality assessment, wouldn't most office‐based pediatricians (and particularly group leaders) believe that they need extra training in this field? When less than 50% of hospitals require practitioners in established subboarded specialties to be board‐certified to maintain hospital privileges,7 is it surprising to see that privileging standards vary for pediatric hospitalists?

However, nitpicking these studies is a defensive response that does a disservice both to the reports and more importantly to the PHM community as a whole and to the children, parents, and colleagues that we serve. There is no denying that we are a young, evolving field with significant inter‐institutional and at times intra‐institutional variability. All of us in the PHM community, leaders and lurkers, need to rise to the challenges offered by comprehensive analysis. Freed's sample of 431 hospitalists4 is significantly larger than the sample of 265 hospitalist participants in the latest Pediatric Research in Inpatient Settings survey.8 The perceptions of external observers are crucial; it would be a mistake to dismiss their findings or to ignore their interpretations and criticisms.

Certainly none would challenge the variability of practice revealed in Freed's analyses.46 Remember, if you've seen one pediatric hospital medicine program, you've seen ONE pediatric hospital medicine program. Some may see this variability as a weakness; others may see it as a strength. We must be equally receptive to other less‐flattering observations, data, and conclusions included in these reports to the ABP. All programs target seamless communication with referring physicians, but hospitalists and referring physicians alike agree that we do not achieve it, as evidenced by the work of Harlan et al.9 in this issue. SHM is taking the lead in developing performance standards for transitions of care and has created best discharge practices for the geriatric population.10 Similarly, we in the PHM community would do well to ramp up our self‐assessment and quality improvement activities. Our recusal from Centers for Medicare and Medicaid Services reporting requirements for (adult) inpatient quality metrics does not excuse us from pursuing voluntary, rigorous, transparent, public reporting on pediatric quality indicators. As Freed et al.6 clearly implied, the public and payers expect this of us. No doubt, if we do not first propose and implement our own standards, external standards will be imposed upon us.

Aside from the question of mandatory fellowship training for hospitalists, does the vision implied in the studies commissioned by the ABP vary significantly from the challenges to PHM that Sandy Melzer11 presented at his keynote address at the Denver meeting? Melzer used strategic planning principles to outline a future vision for PHM, including the following:

• 1

  Harm is eliminated from the inpatient setting.

• 2

  Inpatient care is evidence‐based for all conditions treated.

• 3

  Hospital care is highly coordinated, especially for children with chronic conditions.

• 4

  A robust research agenda supports all aspects of inpatient care.

Is not the work done by the SHM and APA to develop core competencies for PHM an effort to define our field and identify (uniform) expectations? Do not the criteria for designation as a fellow of hospital medicine (5 years as a practicing hospitalist; 2 national meetings; and a minimum combination of leadership, teamwork, and quality improvement activities)12 serve to recognize the commitment and accomplishments that distinguish a true hospitalist practicing systems‐based hospital medicine from a physician who simply works in the hospital?

There is no need for pediatric hospitalists to respond defensively to the hospitalist studies commissioned by the ABP. In fact, Freed46 has done us a favor by adding dimension and texture to the preliminary outlines of what it means for PHM to be ultimately successful. Both Freed and Melzer11 are describing the same path. As hospitalists, we tend to take pride in how far we have already come along this adventure. External observers such as Freed remind of us of how far we still need to go. Either way, Dorothy Gale, MD, pediatric hospitalist, has a relatively well‐identified yellow brick road to follow with specific challenges and charges to meet. What is unclear is whether formal acknowledgment will be awarded at the end of this journey and, if so, what form it will take. Options include (1) recognition of focused practice in hospital medicine with maintenance of certification, (2) SHM fellowship, (3) a traditionally boarded subspecialty, or (4) all of the above.

Any formal designation will be of secondary importance. Remember, the wizard did not change anything when he bestowed the diploma, the heart‐shaped testimonial, and the medal of valor. Like the scarecrow, tin man, and lion, all the qualities that we need for success as pediatric hospitalists are already within us. No wizard's pronouncements will help us provide better care to our patients. Change will come from working together on shared goals with mutual support along our common path. Look to the Journal of Hospital Medicine for frequent updates on the journey. See you in the Emerald City.

Tobacco use in the United States is the chief avoidable cause of death in the United States.1 The health benefits of smoking cessation are widely known, including reductions in the risk for lung cancer, chronic obstructive pulmonary disease, and heart disease.2, 3 Particularly for patients with symptomatic coronary artery disease, smoking cessation reduces the risk of mortality by 30% to 50%.4, 5

Being hospitalized for a major cardiac event spurs many smokers to stop smoking. Acute and chronic health events are associated with a much lower likelihood of continued smoking, both immediately and over time. Cessation rates among smokers hospitalized for a cardiac condition, such as acute coronary syndrome (ACS), range from 31% without intervention to 60% with sustained intervention posthospitalization, at 1‐year follow‐up.610

Various studies have examined predictors of continued smoking among patients with heart disease. However, few studies have focused on prognostic factors in patients hospitalized for their heart condition, illustrating a gap in the literature. Factors found to affect smoking cessation rates have included: mood disorders, such as current or history of depression,6, 1113 a high level of state‐anxiety,13 and hostility or tensions;12 severity of disease, such as history of previous cardiac event,6, 9 history of smoking‐related pulmonary disease,6 severity of the cardiac disease,6, 12 having 1 or more risk factors for coronary artery disease other than smoking,14 or unstable angina;14 greater nicotine dependence or heavy smoking at index hospitalization;6, 9, 14, 15 and the presence of other smokers in the home/work environment.16

Data from a recently completed randomized controlled trial of a health behavior intervention within the context of hospital quality improvement provided the opportunity to study factors predictive of successfully quitting smoking in hospitalized cardiac patients. The description and results of that trial, called the Heart After Hospitalization Recovery Program (HARP), are reported elsewhere.17, 18 In summary, the health behavior intervention program studied in the trial was not successful in improving the smoking cessation rates above the control group receiving only the hospital quality improvement (QI) approach. Results of the QI intervention, the ACS Guidelines Applied to Practice (GAP) program, showed gains in survival that appeared to be due to better adherence to guidelines, which included a patient contract for behavior change.19, 20 Therefore, the purpose of this work is to describe all the preadmission smoking patients in the study, regardless of trial group assignment, and examine predictive factors for smoking cessation and relapse to smoking after their hospital discharge for ACS.

PATIENTS AND METHODS

The institutional review boards of the authors' university and each of the 5 participating hospitals approved the HARP study.

RESULTS

DISCUSSION

The smoking cessation rate of 56.8% (n = 111; only those with 8‐month follow‐up) in this study population at 8 months compares favorably with the range of 31% to 60% shown in earlier studies of cardiac populations.610, 27 Assuming more conservatively that the survey nonresponders were all smokers yields a 46.3% quit rate (n = 136; all those with at least 1 follow‐up), which is within the range reported in the literature.

The intervention program was not a factor predicting cessation. Most posthospital follow‐up counseling is associated with increased smoking abstinence at follow‐up.28, 29 It is possible that the GAP in‐hospital QI initiative in these hospitals contributed to improving the cessation of smokers in both trial arms, thereby negating the effect of the counseling‐only option, although we did not specifically study the effect of the GAP intervention. It is also possible that we were underpowered to detect a statistically significant difference given our sample size of smokers.

Several characteristics were associated with successful smoking cessation in posthospitalized ACS patients. These included higher incomes, no other smokers in the household, and being a lighter smoker. We also found, however, that those with a history of depression, and heavier smokers also had higher rates of relapsing. As with previous research, our results support the evidence that heavier smokers have greater difficulty quitting smoking.6, 9, 14, 15 Heavier smoking indicates a greater nicotine addiction.27 However, 1 study of smoking cessation of smokers at a tertiary referral, cardiothoracic hospital found that smokers with greater pack years (eg, number of years smoked at an equivalent of 1 pack per day), had a higher likelihood of abstinence at a 12‐month follow‐up.30 More intense efforts are likely needed to assist smokers with a more significant addiction. Perhaps studies are needed to better understand the physiological and genetic mechanisms of nicotine addiction and effective treatment options for this group.

Our results also demonstrate that those with a history of depression were more likely to relapse. Several researchers have demonstrated that in patients with a history of depression, return of depressive symptoms upon a cessation attempt may precipitate relapse.28, 29 Current depressive symptoms, as measured by the CES‐D, were not associated with decreased rates of quitting or relapsing. After controlling for history of depression, the CES‐D score was no longer a predictor of quitting or relapsing in our data.

Similar to other studies, smokers in this study who reported having other smokers in the household had a more difficult time both quitting and remaining abstinent.16, 31 A related controversy concerns the efficacy of including (smoking and nonsmoking) family members in interventions to sustain longer‐term abstinence. Including family members has demonstrated efficacy in some research,3234 although the optimal means of involving family members in smoking cessation interventions has not yet been identified. Severity of cardiac disease (as measured by ejection fraction) and the presence of comorbid conditions were not found to be associated with smoking continuation or cessation. We did not find in this sample of ACS patients that smoking cessation rates increased with age during the follow‐up survey time points.

There are several limitations to our study. First, we did not biochemically validate self‐reported smoking cessation rates. However, it is generally found that self‐reports of cessation are accurate in research studies.35 Also participants may have incorrectly stated their quit rates due to recall bias. We were unable to fully capture use of smoking cessation pharmacotherapy (such as bupropion or nicotine replacement), which may have better explained success with cessation. Unfortunately, this is also not usually captured in the literature on studies of this nature. Last, since this study enrolled only cardiac patients in 2 similar community populations, these results may not be fully generalizable to other communities.

For smokers suffering from cardiac disease, there are few better ways to prevent a second heart event than quitting smoking. Judging from these results, there still remain a great number of hospitalized smokers who either choose to, or are unable to, successfully quit smoking, even after hospitalization for a serious cardiac event. Further research is needed to understand what individual motivating or household mechanisms may be best considered when encouraging this group of smokers to quit permanently.

Tobacco use in the United States is the chief avoidable cause of death in the United States.1 The health benefits of smoking cessation are widely known, including reductions in the risk for lung cancer, chronic obstructive pulmonary disease, and heart disease.2, 3 Particularly for patients with symptomatic coronary artery disease, smoking cessation reduces the risk of mortality by 30% to 50%.4, 5

Being hospitalized for a major cardiac event spurs many smokers to stop smoking. Acute and chronic health events are associated with a much lower likelihood of continued smoking, both immediately and over time. Cessation rates among smokers hospitalized for a cardiac condition, such as acute coronary syndrome (ACS), range from 31% without intervention to 60% with sustained intervention posthospitalization, at 1‐year follow‐up.610

Various studies have examined predictors of continued smoking among patients with heart disease. However, few studies have focused on prognostic factors in patients hospitalized for their heart condition, illustrating a gap in the literature. Factors found to affect smoking cessation rates have included: mood disorders, such as current or history of depression,6, 1113 a high level of state‐anxiety,13 and hostility or tensions;12 severity of disease, such as history of previous cardiac event,6, 9 history of smoking‐related pulmonary disease,6 severity of the cardiac disease,6, 12 having 1 or more risk factors for coronary artery disease other than smoking,14 or unstable angina;14 greater nicotine dependence or heavy smoking at index hospitalization;6, 9, 14, 15 and the presence of other smokers in the home/work environment.16

Data from a recently completed randomized controlled trial of a health behavior intervention within the context of hospital quality improvement provided the opportunity to study factors predictive of successfully quitting smoking in hospitalized cardiac patients. The description and results of that trial, called the Heart After Hospitalization Recovery Program (HARP), are reported elsewhere.17, 18 In summary, the health behavior intervention program studied in the trial was not successful in improving the smoking cessation rates above the control group receiving only the hospital quality improvement (QI) approach. Results of the QI intervention, the ACS Guidelines Applied to Practice (GAP) program, showed gains in survival that appeared to be due to better adherence to guidelines, which included a patient contract for behavior change.19, 20 Therefore, the purpose of this work is to describe all the preadmission smoking patients in the study, regardless of trial group assignment, and examine predictive factors for smoking cessation and relapse to smoking after their hospital discharge for ACS.

PATIENTS AND METHODS

The institutional review boards of the authors' university and each of the 5 participating hospitals approved the HARP study.

RESULTS

DISCUSSION

The smoking cessation rate of 56.8% (n = 111; only those with 8‐month follow‐up) in this study population at 8 months compares favorably with the range of 31% to 60% shown in earlier studies of cardiac populations.610, 27 Assuming more conservatively that the survey nonresponders were all smokers yields a 46.3% quit rate (n = 136; all those with at least 1 follow‐up), which is within the range reported in the literature.

The intervention program was not a factor predicting cessation. Most posthospital follow‐up counseling is associated with increased smoking abstinence at follow‐up.28, 29 It is possible that the GAP in‐hospital QI initiative in these hospitals contributed to improving the cessation of smokers in both trial arms, thereby negating the effect of the counseling‐only option, although we did not specifically study the effect of the GAP intervention. It is also possible that we were underpowered to detect a statistically significant difference given our sample size of smokers.

Several characteristics were associated with successful smoking cessation in posthospitalized ACS patients. These included higher incomes, no other smokers in the household, and being a lighter smoker. We also found, however, that those with a history of depression, and heavier smokers also had higher rates of relapsing. As with previous research, our results support the evidence that heavier smokers have greater difficulty quitting smoking.6, 9, 14, 15 Heavier smoking indicates a greater nicotine addiction.27 However, 1 study of smoking cessation of smokers at a tertiary referral, cardiothoracic hospital found that smokers with greater pack years (eg, number of years smoked at an equivalent of 1 pack per day), had a higher likelihood of abstinence at a 12‐month follow‐up.30 More intense efforts are likely needed to assist smokers with a more significant addiction. Perhaps studies are needed to better understand the physiological and genetic mechanisms of nicotine addiction and effective treatment options for this group.

Our results also demonstrate that those with a history of depression were more likely to relapse. Several researchers have demonstrated that in patients with a history of depression, return of depressive symptoms upon a cessation attempt may precipitate relapse.28, 29 Current depressive symptoms, as measured by the CES‐D, were not associated with decreased rates of quitting or relapsing. After controlling for history of depression, the CES‐D score was no longer a predictor of quitting or relapsing in our data.

Similar to other studies, smokers in this study who reported having other smokers in the household had a more difficult time both quitting and remaining abstinent.16, 31 A related controversy concerns the efficacy of including (smoking and nonsmoking) family members in interventions to sustain longer‐term abstinence. Including family members has demonstrated efficacy in some research,3234 although the optimal means of involving family members in smoking cessation interventions has not yet been identified. Severity of cardiac disease (as measured by ejection fraction) and the presence of comorbid conditions were not found to be associated with smoking continuation or cessation. We did not find in this sample of ACS patients that smoking cessation rates increased with age during the follow‐up survey time points.

There are several limitations to our study. First, we did not biochemically validate self‐reported smoking cessation rates. However, it is generally found that self‐reports of cessation are accurate in research studies.35 Also participants may have incorrectly stated their quit rates due to recall bias. We were unable to fully capture use of smoking cessation pharmacotherapy (such as bupropion or nicotine replacement), which may have better explained success with cessation. Unfortunately, this is also not usually captured in the literature on studies of this nature. Last, since this study enrolled only cardiac patients in 2 similar community populations, these results may not be fully generalizable to other communities.

For smokers suffering from cardiac disease, there are few better ways to prevent a second heart event than quitting smoking. Judging from these results, there still remain a great number of hospitalized smokers who either choose to, or are unable to, successfully quit smoking, even after hospitalization for a serious cardiac event. Further research is needed to understand what individual motivating or household mechanisms may be best considered when encouraging this group of smokers to quit permanently.

Tobacco use in the United States is the chief avoidable cause of death in the United States.1 The health benefits of smoking cessation are widely known, including reductions in the risk for lung cancer, chronic obstructive pulmonary disease, and heart disease.2, 3 Particularly for patients with symptomatic coronary artery disease, smoking cessation reduces the risk of mortality by 30% to 50%.4, 5

Being hospitalized for a major cardiac event spurs many smokers to stop smoking. Acute and chronic health events are associated with a much lower likelihood of continued smoking, both immediately and over time. Cessation rates among smokers hospitalized for a cardiac condition, such as acute coronary syndrome (ACS), range from 31% without intervention to 60% with sustained intervention posthospitalization, at 1‐year follow‐up.610

Various studies have examined predictors of continued smoking among patients with heart disease. However, few studies have focused on prognostic factors in patients hospitalized for their heart condition, illustrating a gap in the literature. Factors found to affect smoking cessation rates have included: mood disorders, such as current or history of depression,6, 1113 a high level of state‐anxiety,13 and hostility or tensions;12 severity of disease, such as history of previous cardiac event,6, 9 history of smoking‐related pulmonary disease,6 severity of the cardiac disease,6, 12 having 1 or more risk factors for coronary artery disease other than smoking,14 or unstable angina;14 greater nicotine dependence or heavy smoking at index hospitalization;6, 9, 14, 15 and the presence of other smokers in the home/work environment.16

Data from a recently completed randomized controlled trial of a health behavior intervention within the context of hospital quality improvement provided the opportunity to study factors predictive of successfully quitting smoking in hospitalized cardiac patients. The description and results of that trial, called the Heart After Hospitalization Recovery Program (HARP), are reported elsewhere.17, 18 In summary, the health behavior intervention program studied in the trial was not successful in improving the smoking cessation rates above the control group receiving only the hospital quality improvement (QI) approach. Results of the QI intervention, the ACS Guidelines Applied to Practice (GAP) program, showed gains in survival that appeared to be due to better adherence to guidelines, which included a patient contract for behavior change.19, 20 Therefore, the purpose of this work is to describe all the preadmission smoking patients in the study, regardless of trial group assignment, and examine predictive factors for smoking cessation and relapse to smoking after their hospital discharge for ACS.

PATIENTS AND METHODS

The institutional review boards of the authors' university and each of the 5 participating hospitals approved the HARP study.

RESULTS

DISCUSSION

The smoking cessation rate of 56.8% (n = 111; only those with 8‐month follow‐up) in this study population at 8 months compares favorably with the range of 31% to 60% shown in earlier studies of cardiac populations.610, 27 Assuming more conservatively that the survey nonresponders were all smokers yields a 46.3% quit rate (n = 136; all those with at least 1 follow‐up), which is within the range reported in the literature.

The intervention program was not a factor predicting cessation. Most posthospital follow‐up counseling is associated with increased smoking abstinence at follow‐up.28, 29 It is possible that the GAP in‐hospital QI initiative in these hospitals contributed to improving the cessation of smokers in both trial arms, thereby negating the effect of the counseling‐only option, although we did not specifically study the effect of the GAP intervention. It is also possible that we were underpowered to detect a statistically significant difference given our sample size of smokers.

Several characteristics were associated with successful smoking cessation in posthospitalized ACS patients. These included higher incomes, no other smokers in the household, and being a lighter smoker. We also found, however, that those with a history of depression, and heavier smokers also had higher rates of relapsing. As with previous research, our results support the evidence that heavier smokers have greater difficulty quitting smoking.6, 9, 14, 15 Heavier smoking indicates a greater nicotine addiction.27 However, 1 study of smoking cessation of smokers at a tertiary referral, cardiothoracic hospital found that smokers with greater pack years (eg, number of years smoked at an equivalent of 1 pack per day), had a higher likelihood of abstinence at a 12‐month follow‐up.30 More intense efforts are likely needed to assist smokers with a more significant addiction. Perhaps studies are needed to better understand the physiological and genetic mechanisms of nicotine addiction and effective treatment options for this group.

Our results also demonstrate that those with a history of depression were more likely to relapse. Several researchers have demonstrated that in patients with a history of depression, return of depressive symptoms upon a cessation attempt may precipitate relapse.28, 29 Current depressive symptoms, as measured by the CES‐D, were not associated with decreased rates of quitting or relapsing. After controlling for history of depression, the CES‐D score was no longer a predictor of quitting or relapsing in our data.

Similar to other studies, smokers in this study who reported having other smokers in the household had a more difficult time both quitting and remaining abstinent.16, 31 A related controversy concerns the efficacy of including (smoking and nonsmoking) family members in interventions to sustain longer‐term abstinence. Including family members has demonstrated efficacy in some research,3234 although the optimal means of involving family members in smoking cessation interventions has not yet been identified. Severity of cardiac disease (as measured by ejection fraction) and the presence of comorbid conditions were not found to be associated with smoking continuation or cessation. We did not find in this sample of ACS patients that smoking cessation rates increased with age during the follow‐up survey time points.

There are several limitations to our study. First, we did not biochemically validate self‐reported smoking cessation rates. However, it is generally found that self‐reports of cessation are accurate in research studies.35 Also participants may have incorrectly stated their quit rates due to recall bias. We were unable to fully capture use of smoking cessation pharmacotherapy (such as bupropion or nicotine replacement), which may have better explained success with cessation. Unfortunately, this is also not usually captured in the literature on studies of this nature. Last, since this study enrolled only cardiac patients in 2 similar community populations, these results may not be fully generalizable to other communities.

For smokers suffering from cardiac disease, there are few better ways to prevent a second heart event than quitting smoking. Judging from these results, there still remain a great number of hospitalized smokers who either choose to, or are unable to, successfully quit smoking, even after hospitalization for a serious cardiac event. Further research is needed to understand what individual motivating or household mechanisms may be best considered when encouraging this group of smokers to quit permanently.

With increases in the prevalence of obesity among children and adults over the past 3 decades in the United States,13 healthcare expenditures attributed to obesity have climbed steadily, to over $100 billion in excess expenditures annually.4 Several studies have examined healthcare costs associated with obesity in adults,48 but these studies have not attempted to distinguish between excess expenditures in inpatient versus outpatient settings. In contrast, the only 2 national economic analyses of childhood obesity have focused exclusively on the inpatient setting, because the health and economic consequences of obesity among children may be most apparent in cases in which obesity is causally linked to other diagnoses (eg, type 2 diabetes mellitus, gall bladder disease) or is a comorbidity that complicates hospitalizations.9, 10

In our previous study of obesity as a comorbidity for hospitalized children, we examined the incremental charges and length‐of‐stay (LOS) for hospitalizations for the most common nonpregnancy/nonchildbirth pediatric diagnoses, comparing those coded with obesity as a secondary diagnosis versus those without.10 Using data from the Agency for Healthcare Research and Quality (AHRQ) Kid's Inpatient Database (KID) for the year 2000, we found that obesity was associated with higher charges and longer LOS for all 4 of the conditions studied (asthma, pneumonia, affective disorders, and appendicitis). Our findings regarding asthma and affective disorders echoed earlier analyses of hospitalizations for conditions clinically linked to obesity.9 However, our study was the first to demonstrate that childhood obesity is a clinically and economically significant complicating factor for conditions not thought to be linked to obesity (pneumonia, appendicitis).

For this current study, our objective was to use more recent child hospitalization data from 2003 to determine whether our prior findings of incremental charges and LOS associated with hospitalizations where obesity was coded as a secondary diagnosis compared to those where it was not, were stable over time, and whether the magnitude of differences was consistent over a period of 4 years. We hypothesized that incremental differences in hospital charges and LOS between discharges with and without obesity would be seen in the 2003 data and that the magnitude of these differences in 2003 would be similar to those in 2000. Because obesity prevalence among children increased from 2000 to 2003,11 we also hypothesized that there would be a corresponding increase in the proportion of hospitalizations with obesity as a comorbidity.

METHODS

RESULTS

Sample Characteristics

The characteristics of the study population are presented in Table 1. In 2003, the overall proportion of nonpregnancy‐related discharges for children 2‐18 years old coded with obesity as a secondary diagnosis was 1.6%, an increase from 1.1% in 2000. Within the 4 most common nonpregnancy‐related CCS category diagnoses (asthma, pneumonia, affective disorders, and appendicitis) the proportion of discharges with obesity coded as a secondary diagnosis increased from 2000 to 2003 (Figure 1)

Figure 1

Table 1.Characteristics of the Study Subpopulation from the 2000 and 2003 KID

Variables	Discharges
	With Obesity as Secondary Diagnosis		Without Obesity
2000	2003	2000	2003
Unweighted, n	8,696	15,546	762,407	943,182
Weighted population size	17,672	25,709	1,509,637	1,587,549
Age
2‐5 years (%)	4.8	4.8	27.4	29.0
6‐10 years (%)	14.7	15.9	22.4	22.3
11‐14 years (%)	34.4	34.1	20.9	20.9
15‐18 years (%)	46.1	45.2	29.3	27.8
Sex
Male (%)	45.5	46.8	53.8	53.4
Race/Ethnicity
White (%)	46.8	32.2	50.9	39.3
Black (%)	20.7	20.4	14.3	12.6
Hispanic (%)	14.9	16.8	14.3	14.4
Other (%)	4.8	5.0	5.6	5.6
Unreported (%)	12.8	25.6	14.9	28.1
Payer
Medicaid (%)	42.6	46.5	32.1	36.9
Private (%)	47.1	42.6	58.0	53.3
Other (%)	9.4	10.6	9.4	9.6
Unreported (%)	0.9	0.3	0.5	0.2
Hospital Region
Northeast (%)	17.3	15.9	21.7	18.7
Midwest (%)	24.6	24.8	20.0	23.3
South (%)	37.6	38.4	36.3	37.0
West (%)	20.5	20.9	22.0	21.0
Hospital type
General hospital (%)	68.2	61.4	61.0	57.1
Children's unit in general hospital (%)	15.2	17.8	18.6	19.2
Children's hospitals (%)	14.3	14.9	17.9	17.6
Unreported (%)	2.3%	5.9	2.5	6.1

Incremental Differences in Mean Charges Associated with Obesity

In Table 2, we present results for analyses of mean charges. Following the pattern in 2000 for all 4 of these common conditions, in 2003 the adjusted mean total hospital charges were statistically significantly higher for discharges in which obesity was listed as a secondary diagnosis, compared with those in which it was not. Moreover, the magnitude of these differences was somewhat greater in 2003 than in 2000, although it did not achieve statistical significance (P > 0.05) (Figure 2). Specifically, the difference in charges among asthma discharges with and without obesity as a comorbidity was 9% greater in 2003 than in 2000, 17% greater among pneumonia discharges, 121% greater among affective disorders, and 3% greater among appendicitis discharges.

Figure 2

Table 2.Adjusted Mean Charges for Discharges Coded with and Without Obesity as a Secondary Diagnosis in 2000 and 2003

	Adjusted Mean Charges ($)
	2000			2003
With Obesity	Without Obesity	Difference	With Obesity	Without Obesity	Difference
NOTE: Values are given in 2003 dollars. All models adjusted for sex, age, race/ethnicity, region, hospital type, and expected primary payer. * <0.05. <0.01.
Asthma	8,847	6,884	1,963*	10,589	8,444	2,145
Pneumonia	13,930	11,036	2,894*	16,609	13,219	3,390
Affective disorders	9,446	8,850	596	11,942	10,619	1,323
Appendicitis	16,101	12,587	3,514	19,213	15,586	3,627

DISCUSSION

Prior studies have explored the resource utilization and expenditures associated with obesity in adult populations and among obese children in the outpatient setting.48, 21 Few, however, have examined charges related to inpatient care of obese children. Our studies are the first to utilize actual charge data from a nationally representative sample to explore the economic implications of obesity among children hospitalized for common pediatric illnesses.

Our findings from this national analysis support the hypothesis that, for the 4 conditions studied, statistically significantly higher mean total hospital charges and longer mean LOS for those discharges with obesity coded as a secondary diagnosis versus those without obesity coded occurred for both 2000 and 2003, even when controlling for sex, age, race/ethnicity, region, payer, and hospital type. Our analyses also suggested that the magnitude of the incremental differences in charges from 2000 to 2003 increased somewhat, and the magnitude of the incremental differences in LOS for all of these common conditions (except asthma) is also increasing.

While these findings serve to confirm higher incremental charges and LOS associated with obesity for hospitalized children, they raise the question of why charges and LOS for children with obesity might increase at a greater rate than for those without obesity. Higher hospital charges and LOS for children with obesity coded as a secondary diagnosis may be explained by greater resource utilization due to obesity that: 1) increases the technical complexity of procedures such as surgical interventions or intravenous catheter (IV) placement;22 2) leads to greater illness severity, as has been suggested in studies of adult patients;23, 24 or 3) leads to more complications such as secondary infections.22 One explanation for the possible widening of the gap in charges during the time period studied might be that discharges coded with obesity in 2003 reflect children who were more severely obese and had a greater severity of illness, leading to higher resource utilization than those with obesity in the 2000 dataset. However, the ICD‐9‐CM code for morbid obesity (278.02) was not used more often in 2003 than in 2000. Alternatively, we suspect that between 2000 and 2003, due to an increasing awareness of the problem of childhood obesity, physicians may have become more likely to order tests or consultations specifically related to the treatment or evaluation of obesity. Other than the increase in the proportion of discharges with obesity as a comorbidity from 2000 to 2003, we were unable to explore these possible explanations with the KID datasets.

In this sample of discharges, with only 1.1% and 1.6% coded with obesity as a secondary diagnosis in 2000 and 2003, respectively, it is important to note that these discharges should not be interpreted as the prevalence of obesity in hospitalized children. Indeed, in a recent study of children hospitalized for surgical procedures at a large Midwestern tertiary care hospital, 31.6% were found to be overweight or obese.25 However, we posit that the cases coded with obesity as a secondary diagnosis in this sample represent the cases in which obesity presents a recognized factor that complicated the clinical course. Further work should explore the mechanisms by which obesity impacts the care of children hospitalized for common conditions. For example, children with obesity may require more procedures and may experience more treatment complications. These specific interventions should be the target of clinically focused analyses.

CONCLUSIONS

These results extend our earlier findings of higher charges and longer LOS for pediatric discharges coded with obesity versus those without. In addition, this analysis suggests a widening gap of incremental hospital charges and LOS associated with obesity as a comorbidity for common pediatric conditions. These findings present a heightening financial imperative for further research to evaluate factors associated with greater resource utilization among obese pediatric patients.

With increases in the prevalence of obesity among children and adults over the past 3 decades in the United States,13 healthcare expenditures attributed to obesity have climbed steadily, to over $100 billion in excess expenditures annually.4 Several studies have examined healthcare costs associated with obesity in adults,48 but these studies have not attempted to distinguish between excess expenditures in inpatient versus outpatient settings. In contrast, the only 2 national economic analyses of childhood obesity have focused exclusively on the inpatient setting, because the health and economic consequences of obesity among children may be most apparent in cases in which obesity is causally linked to other diagnoses (eg, type 2 diabetes mellitus, gall bladder disease) or is a comorbidity that complicates hospitalizations.9, 10

In our previous study of obesity as a comorbidity for hospitalized children, we examined the incremental charges and length‐of‐stay (LOS) for hospitalizations for the most common nonpregnancy/nonchildbirth pediatric diagnoses, comparing those coded with obesity as a secondary diagnosis versus those without.10 Using data from the Agency for Healthcare Research and Quality (AHRQ) Kid's Inpatient Database (KID) for the year 2000, we found that obesity was associated with higher charges and longer LOS for all 4 of the conditions studied (asthma, pneumonia, affective disorders, and appendicitis). Our findings regarding asthma and affective disorders echoed earlier analyses of hospitalizations for conditions clinically linked to obesity.9 However, our study was the first to demonstrate that childhood obesity is a clinically and economically significant complicating factor for conditions not thought to be linked to obesity (pneumonia, appendicitis).

For this current study, our objective was to use more recent child hospitalization data from 2003 to determine whether our prior findings of incremental charges and LOS associated with hospitalizations where obesity was coded as a secondary diagnosis compared to those where it was not, were stable over time, and whether the magnitude of differences was consistent over a period of 4 years. We hypothesized that incremental differences in hospital charges and LOS between discharges with and without obesity would be seen in the 2003 data and that the magnitude of these differences in 2003 would be similar to those in 2000. Because obesity prevalence among children increased from 2000 to 2003,11 we also hypothesized that there would be a corresponding increase in the proportion of hospitalizations with obesity as a comorbidity.

METHODS

RESULTS

Sample Characteristics

The characteristics of the study population are presented in Table 1. In 2003, the overall proportion of nonpregnancy‐related discharges for children 2‐18 years old coded with obesity as a secondary diagnosis was 1.6%, an increase from 1.1% in 2000. Within the 4 most common nonpregnancy‐related CCS category diagnoses (asthma, pneumonia, affective disorders, and appendicitis) the proportion of discharges with obesity coded as a secondary diagnosis increased from 2000 to 2003 (Figure 1)

Figure 1

Table 1.Characteristics of the Study Subpopulation from the 2000 and 2003 KID

Variables	Discharges
	With Obesity as Secondary Diagnosis		Without Obesity
2000	2003	2000	2003
Unweighted, n	8,696	15,546	762,407	943,182
Weighted population size	17,672	25,709	1,509,637	1,587,549
Age
2‐5 years (%)	4.8	4.8	27.4	29.0
6‐10 years (%)	14.7	15.9	22.4	22.3
11‐14 years (%)	34.4	34.1	20.9	20.9
15‐18 years (%)	46.1	45.2	29.3	27.8
Sex
Male (%)	45.5	46.8	53.8	53.4
Race/Ethnicity
White (%)	46.8	32.2	50.9	39.3
Black (%)	20.7	20.4	14.3	12.6
Hispanic (%)	14.9	16.8	14.3	14.4
Other (%)	4.8	5.0	5.6	5.6
Unreported (%)	12.8	25.6	14.9	28.1
Payer
Medicaid (%)	42.6	46.5	32.1	36.9
Private (%)	47.1	42.6	58.0	53.3
Other (%)	9.4	10.6	9.4	9.6
Unreported (%)	0.9	0.3	0.5	0.2
Hospital Region
Northeast (%)	17.3	15.9	21.7	18.7
Midwest (%)	24.6	24.8	20.0	23.3
South (%)	37.6	38.4	36.3	37.0
West (%)	20.5	20.9	22.0	21.0
Hospital type
General hospital (%)	68.2	61.4	61.0	57.1
Children's unit in general hospital (%)	15.2	17.8	18.6	19.2
Children's hospitals (%)	14.3	14.9	17.9	17.6
Unreported (%)	2.3%	5.9	2.5	6.1

Incremental Differences in Mean Charges Associated with Obesity

In Table 2, we present results for analyses of mean charges. Following the pattern in 2000 for all 4 of these common conditions, in 2003 the adjusted mean total hospital charges were statistically significantly higher for discharges in which obesity was listed as a secondary diagnosis, compared with those in which it was not. Moreover, the magnitude of these differences was somewhat greater in 2003 than in 2000, although it did not achieve statistical significance (P > 0.05) (Figure 2). Specifically, the difference in charges among asthma discharges with and without obesity as a comorbidity was 9% greater in 2003 than in 2000, 17% greater among pneumonia discharges, 121% greater among affective disorders, and 3% greater among appendicitis discharges.

Figure 2

Table 2.Adjusted Mean Charges for Discharges Coded with and Without Obesity as a Secondary Diagnosis in 2000 and 2003

	Adjusted Mean Charges ($)
	2000			2003
With Obesity	Without Obesity	Difference	With Obesity	Without Obesity	Difference
NOTE: Values are given in 2003 dollars. All models adjusted for sex, age, race/ethnicity, region, hospital type, and expected primary payer. * <0.05. <0.01.
Asthma	8,847	6,884	1,963*	10,589	8,444	2,145
Pneumonia	13,930	11,036	2,894*	16,609	13,219	3,390
Affective disorders	9,446	8,850	596	11,942	10,619	1,323
Appendicitis	16,101	12,587	3,514	19,213	15,586	3,627

DISCUSSION

Prior studies have explored the resource utilization and expenditures associated with obesity in adult populations and among obese children in the outpatient setting.48, 21 Few, however, have examined charges related to inpatient care of obese children. Our studies are the first to utilize actual charge data from a nationally representative sample to explore the economic implications of obesity among children hospitalized for common pediatric illnesses.

Our findings from this national analysis support the hypothesis that, for the 4 conditions studied, statistically significantly higher mean total hospital charges and longer mean LOS for those discharges with obesity coded as a secondary diagnosis versus those without obesity coded occurred for both 2000 and 2003, even when controlling for sex, age, race/ethnicity, region, payer, and hospital type. Our analyses also suggested that the magnitude of the incremental differences in charges from 2000 to 2003 increased somewhat, and the magnitude of the incremental differences in LOS for all of these common conditions (except asthma) is also increasing.

While these findings serve to confirm higher incremental charges and LOS associated with obesity for hospitalized children, they raise the question of why charges and LOS for children with obesity might increase at a greater rate than for those without obesity. Higher hospital charges and LOS for children with obesity coded as a secondary diagnosis may be explained by greater resource utilization due to obesity that: 1) increases the technical complexity of procedures such as surgical interventions or intravenous catheter (IV) placement;22 2) leads to greater illness severity, as has been suggested in studies of adult patients;23, 24 or 3) leads to more complications such as secondary infections.22 One explanation for the possible widening of the gap in charges during the time period studied might be that discharges coded with obesity in 2003 reflect children who were more severely obese and had a greater severity of illness, leading to higher resource utilization than those with obesity in the 2000 dataset. However, the ICD‐9‐CM code for morbid obesity (278.02) was not used more often in 2003 than in 2000. Alternatively, we suspect that between 2000 and 2003, due to an increasing awareness of the problem of childhood obesity, physicians may have become more likely to order tests or consultations specifically related to the treatment or evaluation of obesity. Other than the increase in the proportion of discharges with obesity as a comorbidity from 2000 to 2003, we were unable to explore these possible explanations with the KID datasets.

In this sample of discharges, with only 1.1% and 1.6% coded with obesity as a secondary diagnosis in 2000 and 2003, respectively, it is important to note that these discharges should not be interpreted as the prevalence of obesity in hospitalized children. Indeed, in a recent study of children hospitalized for surgical procedures at a large Midwestern tertiary care hospital, 31.6% were found to be overweight or obese.25 However, we posit that the cases coded with obesity as a secondary diagnosis in this sample represent the cases in which obesity presents a recognized factor that complicated the clinical course. Further work should explore the mechanisms by which obesity impacts the care of children hospitalized for common conditions. For example, children with obesity may require more procedures and may experience more treatment complications. These specific interventions should be the target of clinically focused analyses.

CONCLUSIONS

These results extend our earlier findings of higher charges and longer LOS for pediatric discharges coded with obesity versus those without. In addition, this analysis suggests a widening gap of incremental hospital charges and LOS associated with obesity as a comorbidity for common pediatric conditions. These findings present a heightening financial imperative for further research to evaluate factors associated with greater resource utilization among obese pediatric patients.

With increases in the prevalence of obesity among children and adults over the past 3 decades in the United States,13 healthcare expenditures attributed to obesity have climbed steadily, to over $100 billion in excess expenditures annually.4 Several studies have examined healthcare costs associated with obesity in adults,48 but these studies have not attempted to distinguish between excess expenditures in inpatient versus outpatient settings. In contrast, the only 2 national economic analyses of childhood obesity have focused exclusively on the inpatient setting, because the health and economic consequences of obesity among children may be most apparent in cases in which obesity is causally linked to other diagnoses (eg, type 2 diabetes mellitus, gall bladder disease) or is a comorbidity that complicates hospitalizations.9, 10

In our previous study of obesity as a comorbidity for hospitalized children, we examined the incremental charges and length‐of‐stay (LOS) for hospitalizations for the most common nonpregnancy/nonchildbirth pediatric diagnoses, comparing those coded with obesity as a secondary diagnosis versus those without.10 Using data from the Agency for Healthcare Research and Quality (AHRQ) Kid's Inpatient Database (KID) for the year 2000, we found that obesity was associated with higher charges and longer LOS for all 4 of the conditions studied (asthma, pneumonia, affective disorders, and appendicitis). Our findings regarding asthma and affective disorders echoed earlier analyses of hospitalizations for conditions clinically linked to obesity.9 However, our study was the first to demonstrate that childhood obesity is a clinically and economically significant complicating factor for conditions not thought to be linked to obesity (pneumonia, appendicitis).

For this current study, our objective was to use more recent child hospitalization data from 2003 to determine whether our prior findings of incremental charges and LOS associated with hospitalizations where obesity was coded as a secondary diagnosis compared to those where it was not, were stable over time, and whether the magnitude of differences was consistent over a period of 4 years. We hypothesized that incremental differences in hospital charges and LOS between discharges with and without obesity would be seen in the 2003 data and that the magnitude of these differences in 2003 would be similar to those in 2000. Because obesity prevalence among children increased from 2000 to 2003,11 we also hypothesized that there would be a corresponding increase in the proportion of hospitalizations with obesity as a comorbidity.

METHODS

RESULTS

Sample Characteristics

The characteristics of the study population are presented in Table 1. In 2003, the overall proportion of nonpregnancy‐related discharges for children 2‐18 years old coded with obesity as a secondary diagnosis was 1.6%, an increase from 1.1% in 2000. Within the 4 most common nonpregnancy‐related CCS category diagnoses (asthma, pneumonia, affective disorders, and appendicitis) the proportion of discharges with obesity coded as a secondary diagnosis increased from 2000 to 2003 (Figure 1)

Figure 1

Table 1.Characteristics of the Study Subpopulation from the 2000 and 2003 KID

Variables	Discharges
	With Obesity as Secondary Diagnosis		Without Obesity
2000	2003	2000	2003
Unweighted, n	8,696	15,546	762,407	943,182
Weighted population size	17,672	25,709	1,509,637	1,587,549
Age
2‐5 years (%)	4.8	4.8	27.4	29.0
6‐10 years (%)	14.7	15.9	22.4	22.3
11‐14 years (%)	34.4	34.1	20.9	20.9
15‐18 years (%)	46.1	45.2	29.3	27.8
Sex
Male (%)	45.5	46.8	53.8	53.4
Race/Ethnicity
White (%)	46.8	32.2	50.9	39.3
Black (%)	20.7	20.4	14.3	12.6
Hispanic (%)	14.9	16.8	14.3	14.4
Other (%)	4.8	5.0	5.6	5.6
Unreported (%)	12.8	25.6	14.9	28.1
Payer
Medicaid (%)	42.6	46.5	32.1	36.9
Private (%)	47.1	42.6	58.0	53.3
Other (%)	9.4	10.6	9.4	9.6
Unreported (%)	0.9	0.3	0.5	0.2
Hospital Region
Northeast (%)	17.3	15.9	21.7	18.7
Midwest (%)	24.6	24.8	20.0	23.3
South (%)	37.6	38.4	36.3	37.0
West (%)	20.5	20.9	22.0	21.0
Hospital type
General hospital (%)	68.2	61.4	61.0	57.1
Children's unit in general hospital (%)	15.2	17.8	18.6	19.2
Children's hospitals (%)	14.3	14.9	17.9	17.6
Unreported (%)	2.3%	5.9	2.5	6.1

Incremental Differences in Mean Charges Associated with Obesity

In Table 2, we present results for analyses of mean charges. Following the pattern in 2000 for all 4 of these common conditions, in 2003 the adjusted mean total hospital charges were statistically significantly higher for discharges in which obesity was listed as a secondary diagnosis, compared with those in which it was not. Moreover, the magnitude of these differences was somewhat greater in 2003 than in 2000, although it did not achieve statistical significance (P > 0.05) (Figure 2). Specifically, the difference in charges among asthma discharges with and without obesity as a comorbidity was 9% greater in 2003 than in 2000, 17% greater among pneumonia discharges, 121% greater among affective disorders, and 3% greater among appendicitis discharges.

Figure 2

Table 2.Adjusted Mean Charges for Discharges Coded with and Without Obesity as a Secondary Diagnosis in 2000 and 2003

	Adjusted Mean Charges ($)
	2000			2003
With Obesity	Without Obesity	Difference	With Obesity	Without Obesity	Difference
NOTE: Values are given in 2003 dollars. All models adjusted for sex, age, race/ethnicity, region, hospital type, and expected primary payer. * <0.05. <0.01.
Asthma	8,847	6,884	1,963*	10,589	8,444	2,145
Pneumonia	13,930	11,036	2,894*	16,609	13,219	3,390
Affective disorders	9,446	8,850	596	11,942	10,619	1,323
Appendicitis	16,101	12,587	3,514	19,213	15,586	3,627

DISCUSSION

Prior studies have explored the resource utilization and expenditures associated with obesity in adult populations and among obese children in the outpatient setting.48, 21 Few, however, have examined charges related to inpatient care of obese children. Our studies are the first to utilize actual charge data from a nationally representative sample to explore the economic implications of obesity among children hospitalized for common pediatric illnesses.

Our findings from this national analysis support the hypothesis that, for the 4 conditions studied, statistically significantly higher mean total hospital charges and longer mean LOS for those discharges with obesity coded as a secondary diagnosis versus those without obesity coded occurred for both 2000 and 2003, even when controlling for sex, age, race/ethnicity, region, payer, and hospital type. Our analyses also suggested that the magnitude of the incremental differences in charges from 2000 to 2003 increased somewhat, and the magnitude of the incremental differences in LOS for all of these common conditions (except asthma) is also increasing.

While these findings serve to confirm higher incremental charges and LOS associated with obesity for hospitalized children, they raise the question of why charges and LOS for children with obesity might increase at a greater rate than for those without obesity. Higher hospital charges and LOS for children with obesity coded as a secondary diagnosis may be explained by greater resource utilization due to obesity that: 1) increases the technical complexity of procedures such as surgical interventions or intravenous catheter (IV) placement;22 2) leads to greater illness severity, as has been suggested in studies of adult patients;23, 24 or 3) leads to more complications such as secondary infections.22 One explanation for the possible widening of the gap in charges during the time period studied might be that discharges coded with obesity in 2003 reflect children who were more severely obese and had a greater severity of illness, leading to higher resource utilization than those with obesity in the 2000 dataset. However, the ICD‐9‐CM code for morbid obesity (278.02) was not used more often in 2003 than in 2000. Alternatively, we suspect that between 2000 and 2003, due to an increasing awareness of the problem of childhood obesity, physicians may have become more likely to order tests or consultations specifically related to the treatment or evaluation of obesity. Other than the increase in the proportion of discharges with obesity as a comorbidity from 2000 to 2003, we were unable to explore these possible explanations with the KID datasets.

In this sample of discharges, with only 1.1% and 1.6% coded with obesity as a secondary diagnosis in 2000 and 2003, respectively, it is important to note that these discharges should not be interpreted as the prevalence of obesity in hospitalized children. Indeed, in a recent study of children hospitalized for surgical procedures at a large Midwestern tertiary care hospital, 31.6% were found to be overweight or obese.25 However, we posit that the cases coded with obesity as a secondary diagnosis in this sample represent the cases in which obesity presents a recognized factor that complicated the clinical course. Further work should explore the mechanisms by which obesity impacts the care of children hospitalized for common conditions. For example, children with obesity may require more procedures and may experience more treatment complications. These specific interventions should be the target of clinically focused analyses.

CONCLUSIONS

These results extend our earlier findings of higher charges and longer LOS for pediatric discharges coded with obesity versus those without. In addition, this analysis suggests a widening gap of incremental hospital charges and LOS associated with obesity as a comorbidity for common pediatric conditions. These findings present a heightening financial imperative for further research to evaluate factors associated with greater resource utilization among obese pediatric patients.

A 57‐year‐old woman developed a pruritic rash 6 hours after undergoing coronary angiography. On exam, symmetrical, eczematous plaques were noted in her bilateral groin (Figure 1), buttocks, axillae (Figure 2), and the intertriginous folds of her breasts. No palmar, plantar, or mucosal lesions were noted and laboratory tests were normal. This patient presents with symmetrical drug‐related intertriginous and flexural exanthema (SDRIFE) secondary to iodine‐based contrast dye. It is a type IV hypersensitivity reaction most often reported to nickel, mercury, and systemic antibiotics, although previous sensitization is often unknown. Also called baboon syndrome because its distribution mimics the pink bottom of a baboon, SDRIFE appears hours to days after exposure to the offending agent. The unusual distribution may be explained by high concentrations of the allergen in sweat. Resolution is typical with discontinuation of the offending drug, although antihistamines, topical steroids, and possibly oral steroids may be useful adjuncts.

Figure 1

Figure 2

A 57‐year‐old woman developed a pruritic rash 6 hours after undergoing coronary angiography. On exam, symmetrical, eczematous plaques were noted in her bilateral groin (Figure 1), buttocks, axillae (Figure 2), and the intertriginous folds of her breasts. No palmar, plantar, or mucosal lesions were noted and laboratory tests were normal. This patient presents with symmetrical drug‐related intertriginous and flexural exanthema (SDRIFE) secondary to iodine‐based contrast dye. It is a type IV hypersensitivity reaction most often reported to nickel, mercury, and systemic antibiotics, although previous sensitization is often unknown. Also called baboon syndrome because its distribution mimics the pink bottom of a baboon, SDRIFE appears hours to days after exposure to the offending agent. The unusual distribution may be explained by high concentrations of the allergen in sweat. Resolution is typical with discontinuation of the offending drug, although antihistamines, topical steroids, and possibly oral steroids may be useful adjuncts.

Figure 1

Figure 2

A 57‐year‐old woman developed a pruritic rash 6 hours after undergoing coronary angiography. On exam, symmetrical, eczematous plaques were noted in her bilateral groin (Figure 1), buttocks, axillae (Figure 2), and the intertriginous folds of her breasts. No palmar, plantar, or mucosal lesions were noted and laboratory tests were normal. This patient presents with symmetrical drug‐related intertriginous and flexural exanthema (SDRIFE) secondary to iodine‐based contrast dye. It is a type IV hypersensitivity reaction most often reported to nickel, mercury, and systemic antibiotics, although previous sensitization is often unknown. Also called baboon syndrome because its distribution mimics the pink bottom of a baboon, SDRIFE appears hours to days after exposure to the offending agent. The unusual distribution may be explained by high concentrations of the allergen in sweat. Resolution is typical with discontinuation of the offending drug, although antihistamines, topical steroids, and possibly oral steroids may be useful adjuncts.

Figure 1

Figure 2

I knew that he was going to die. I do not remember when it became evident to me, and I was not sure how to tell the family. I thought that I could arrange a family meeting and inform them of the sad reality in a calm, sympathetic manner. The patient had chronic lymphocytic leukemia, and his case was advanced. The only medication available to him was chlorambucil. As the days passed, I could not bring myself to call the family meeting because they had so much hope. Every day as we got results and I shared them, I would sandwich the bad news with some optimism to ease their pain. Well, his white blood cell count has come down, but his platelet count and red blood cell counts are very low, and this puts him in danger of bleeding. The medicine is bringing the white cell count down but has not yet brought the other cell counts up. What we can do is give him some blood. I tried not to allow despair to creep into my thoughts or my voice. I knew that the blood bank had no platelets or packed red blood cells. He was not eating or drinking, and we had placed a nasogastric tube through which his family fed him wheat or millet porridge (manufactured tube feeds are not widely available in Uganda). I tried not to think about the time that he had almost died a few weeks before.

I had been called to the bedside because the patient was in respiratory distress. The doctor on call was in his office when I arrived, and I wondered why he was not at the bedside. I took one look at the patient and had to step away for a moment to compose myself. I felt the tears threatening to come, but I had to stop them. This was not the time for emotions. I had to assess the patient and make some quick decisions. The doctor on call seemed to have given up. He was a young trainee in a system in which you treat when you can and, if the situation is hopeless, you move on to the next patient. There are no resources for perpetuating hope. This is so different from my practice in the United States, where if a patient wants everything done, we will do it. We are not taught when to give up hope, and futility does not figure into the allocation of resources. I looked at the patient struggling to breathe and felt that I had to do all that I could for him. I asked the doctor on call to place the patient on oxygen and hoped that the tanks were not empty. I was worried about a lot of things, such as pulmonary embolus, myocardial infarction, and pneumonia. Diagnosing any of these would not be easy (the hospital did not have a computed tomography scanner, and obtaining cardiac enzymes was not as simple as clicking a button on a computer). First things first: the chest X‐ray. I thanked God that we were in a private hospital, one of the best in the city of Kampala, so we were able to get a chest X‐ray right away. As we transported the patient (portable X‐rays are nonexistent), the resident told me that he had called the consultant (the equivalent of an attending physician in the United States), who happened to be out of town. The consultant instructed us to transfer the patient to Mulago Hospital (the largest tertiary center in Uganda with well over 1000 beds and some of the equipment that you might find in an American hospital). I wondered how an attending physician could be out of town and leave a resident in charge. The thought was disturbing, but I had no time to ponder it. I later learned that physicians are so poorly paid that many have their own private clinics. My patient got the X‐ray, and I reviewed it with the resident. Tuberculosis, he said. Tuberculosis was this resident's reality. Many patients who need chest X‐rays in Uganda have tuberculosis. As I reviewed the X‐ray, though, I was certain that this was congestive heart failure. However, in Uganda, congestive heart failure is rarely diagnosed in the hospital. Patients with an ejection fraction low enough to cause congestion generally die before they get to a hospital. I knew that some furosemide would work for this patient, but I could not get the resident to listen to me. He had orders from the consultant to transfer the patient immediately, and the ambulance was ready. I tried to convince the resident to administer furosemide before transferring the patient, but he feared administering a drug not approved by his superior. As the patient was loaded onto the ambulance, I reflected for a second on how different things would be if we were in the United States. We arrived at Mulago in record time, and I tried to get the intake doctors to understand what the problem was; however, they did not want to hear from the US doctor. I stared in frustration as they wasted valuable time. I wondered how long the patient would survive in respiratory distress with nothing being done. I called the patient's son and asked him to come to Mulago immediately. Miraculously, he had already been on his way. As I held the patient's hand, sure that he would die right then and there in a waiting area as nobody did anything, I saw the patient's son. I knew that he was a pharmacist, and I asked him to go to the pharmacy and buy furosemide and some syringes. In Uganda, one can buy any medication without a prescription. Luckily, the hospital pharmacy had the drug. We treated the patient, and in no time, his breathing had returned to normal.

I was jolted back to reality. He was dying, and I knew it. He had had many close calls. There was the time that he got the wrong blood during a blood transfusion. I informed the doctor on call as the blood was being administered that I thought the patient was getting a transfusion reaction because he had rigors. The physician on call suggested covering him in blankets, and I suggested stopping the infusion and administering steroids. The pack of blood showed that he was getting his blood type. The patient was typed and crossed again, and to our surprise, we got a different result. I went to the laboratory to perform a third, tie‐breaking cross match and was surprised to note that the reagents had passed their expiration date. However, I knew that these were small battles we were winning and that there was no winning the war.

I recognized that the challenges of practicing medicine in the developing world were many. I wondered how the patients of families with fewer resources survived. The answer was obvious: they didn't. I personally picked up blood when it was available from the blood bank and vividly remember walking from the blood bank at night to the private hospital with units of blood in each hand. Once we arrived at the hospital, I had to warm the blood to room temperature by holding it close to my own skin. Many tests that we perform routinely on a hospitalized patient in the United States are not available.

There was still the problem of breaking the news to the family. Despite everything that had been done and the many near misses that the patient had survived, he was still going to die. It turns out that the family was more intuitive than I thought. One day, the son came to me and asked how long his dad had. Not long, I said quietly. I thought about all that I could potentially do if I had the patient in the hospital at which I worked in the United States. Would it have made a difference? I do not know. It was impossible doctoring this patient, and I suspect doing it in a resource‐rich environment would not have made it any easier. You see this patient, perhaps the most important patient of my life, certainly a patient that I will never forget, was my father.

It had been 15 years since I had traveled to the United States for an education. I knew that my father was so incredibly proud of me. I think that he was the happiest I had ever seen him when he attended my graduation from medical school in Minnesota. I had been looking forward to this visit back home because it had been 3 years since I had last seen my family. I was somewhat concerned because my father had told me a week before I traveled that he was not feeling well. When I arrived, there seemed to be relief on my brother's face when he met me at the airport. We drove straight to the hospital, and along with the joy of seeing me, I could sense that my father was glad that I was home at this particular point in time. They had just received the diagnosis. He had leukemia, and they were glad that their doctor was home. They had particular faith in the daughter (sister) sent abroad for an education. Things would now be okay. Initially, I never got to choose the role of doctor that I played in the final chapter of my father's life. The decision was made for me out of my family's desperation to make sure that they had left no stone unturned to help my father, and I accepted it out of necessity. As my father became my father when I entered this world, I became his doctor when he was leaving it; there was never any question in my mind, as there never was in his. As it became clear that my father would not survive, I chose to continue the role of doctor. I have watched many patients die as a physician and have done my best to make sure that their passing is comfortable, peaceful, and dignified. The doctor could help this patient die, but the daughter could not watch her father go. When it was evident that he had only days to live and did not need this doctor or know his daughter, I flew back to the United States. Three days later my father died. I was not physically at his bedside, but my spirit was. I have no regrets. Although the head knows that he passed on, in my mind's eye, he is laughing and has a twinkle in his eye. I could not bear to see him without life. A piece of my heart is buried with him, and for this reason, I will never be out of Africa.

I knew that he was going to die. I do not remember when it became evident to me, and I was not sure how to tell the family. I thought that I could arrange a family meeting and inform them of the sad reality in a calm, sympathetic manner. The patient had chronic lymphocytic leukemia, and his case was advanced. The only medication available to him was chlorambucil. As the days passed, I could not bring myself to call the family meeting because they had so much hope. Every day as we got results and I shared them, I would sandwich the bad news with some optimism to ease their pain. Well, his white blood cell count has come down, but his platelet count and red blood cell counts are very low, and this puts him in danger of bleeding. The medicine is bringing the white cell count down but has not yet brought the other cell counts up. What we can do is give him some blood. I tried not to allow despair to creep into my thoughts or my voice. I knew that the blood bank had no platelets or packed red blood cells. He was not eating or drinking, and we had placed a nasogastric tube through which his family fed him wheat or millet porridge (manufactured tube feeds are not widely available in Uganda). I tried not to think about the time that he had almost died a few weeks before.

I had been called to the bedside because the patient was in respiratory distress. The doctor on call was in his office when I arrived, and I wondered why he was not at the bedside. I took one look at the patient and had to step away for a moment to compose myself. I felt the tears threatening to come, but I had to stop them. This was not the time for emotions. I had to assess the patient and make some quick decisions. The doctor on call seemed to have given up. He was a young trainee in a system in which you treat when you can and, if the situation is hopeless, you move on to the next patient. There are no resources for perpetuating hope. This is so different from my practice in the United States, where if a patient wants everything done, we will do it. We are not taught when to give up hope, and futility does not figure into the allocation of resources. I looked at the patient struggling to breathe and felt that I had to do all that I could for him. I asked the doctor on call to place the patient on oxygen and hoped that the tanks were not empty. I was worried about a lot of things, such as pulmonary embolus, myocardial infarction, and pneumonia. Diagnosing any of these would not be easy (the hospital did not have a computed tomography scanner, and obtaining cardiac enzymes was not as simple as clicking a button on a computer). First things first: the chest X‐ray. I thanked God that we were in a private hospital, one of the best in the city of Kampala, so we were able to get a chest X‐ray right away. As we transported the patient (portable X‐rays are nonexistent), the resident told me that he had called the consultant (the equivalent of an attending physician in the United States), who happened to be out of town. The consultant instructed us to transfer the patient to Mulago Hospital (the largest tertiary center in Uganda with well over 1000 beds and some of the equipment that you might find in an American hospital). I wondered how an attending physician could be out of town and leave a resident in charge. The thought was disturbing, but I had no time to ponder it. I later learned that physicians are so poorly paid that many have their own private clinics. My patient got the X‐ray, and I reviewed it with the resident. Tuberculosis, he said. Tuberculosis was this resident's reality. Many patients who need chest X‐rays in Uganda have tuberculosis. As I reviewed the X‐ray, though, I was certain that this was congestive heart failure. However, in Uganda, congestive heart failure is rarely diagnosed in the hospital. Patients with an ejection fraction low enough to cause congestion generally die before they get to a hospital. I knew that some furosemide would work for this patient, but I could not get the resident to listen to me. He had orders from the consultant to transfer the patient immediately, and the ambulance was ready. I tried to convince the resident to administer furosemide before transferring the patient, but he feared administering a drug not approved by his superior. As the patient was loaded onto the ambulance, I reflected for a second on how different things would be if we were in the United States. We arrived at Mulago in record time, and I tried to get the intake doctors to understand what the problem was; however, they did not want to hear from the US doctor. I stared in frustration as they wasted valuable time. I wondered how long the patient would survive in respiratory distress with nothing being done. I called the patient's son and asked him to come to Mulago immediately. Miraculously, he had already been on his way. As I held the patient's hand, sure that he would die right then and there in a waiting area as nobody did anything, I saw the patient's son. I knew that he was a pharmacist, and I asked him to go to the pharmacy and buy furosemide and some syringes. In Uganda, one can buy any medication without a prescription. Luckily, the hospital pharmacy had the drug. We treated the patient, and in no time, his breathing had returned to normal.

I was jolted back to reality. He was dying, and I knew it. He had had many close calls. There was the time that he got the wrong blood during a blood transfusion. I informed the doctor on call as the blood was being administered that I thought the patient was getting a transfusion reaction because he had rigors. The physician on call suggested covering him in blankets, and I suggested stopping the infusion and administering steroids. The pack of blood showed that he was getting his blood type. The patient was typed and crossed again, and to our surprise, we got a different result. I went to the laboratory to perform a third, tie‐breaking cross match and was surprised to note that the reagents had passed their expiration date. However, I knew that these were small battles we were winning and that there was no winning the war.

I recognized that the challenges of practicing medicine in the developing world were many. I wondered how the patients of families with fewer resources survived. The answer was obvious: they didn't. I personally picked up blood when it was available from the blood bank and vividly remember walking from the blood bank at night to the private hospital with units of blood in each hand. Once we arrived at the hospital, I had to warm the blood to room temperature by holding it close to my own skin. Many tests that we perform routinely on a hospitalized patient in the United States are not available.

There was still the problem of breaking the news to the family. Despite everything that had been done and the many near misses that the patient had survived, he was still going to die. It turns out that the family was more intuitive than I thought. One day, the son came to me and asked how long his dad had. Not long, I said quietly. I thought about all that I could potentially do if I had the patient in the hospital at which I worked in the United States. Would it have made a difference? I do not know. It was impossible doctoring this patient, and I suspect doing it in a resource‐rich environment would not have made it any easier. You see this patient, perhaps the most important patient of my life, certainly a patient that I will never forget, was my father.

It had been 15 years since I had traveled to the United States for an education. I knew that my father was so incredibly proud of me. I think that he was the happiest I had ever seen him when he attended my graduation from medical school in Minnesota. I had been looking forward to this visit back home because it had been 3 years since I had last seen my family. I was somewhat concerned because my father had told me a week before I traveled that he was not feeling well. When I arrived, there seemed to be relief on my brother's face when he met me at the airport. We drove straight to the hospital, and along with the joy of seeing me, I could sense that my father was glad that I was home at this particular point in time. They had just received the diagnosis. He had leukemia, and they were glad that their doctor was home. They had particular faith in the daughter (sister) sent abroad for an education. Things would now be okay. Initially, I never got to choose the role of doctor that I played in the final chapter of my father's life. The decision was made for me out of my family's desperation to make sure that they had left no stone unturned to help my father, and I accepted it out of necessity. As my father became my father when I entered this world, I became his doctor when he was leaving it; there was never any question in my mind, as there never was in his. As it became clear that my father would not survive, I chose to continue the role of doctor. I have watched many patients die as a physician and have done my best to make sure that their passing is comfortable, peaceful, and dignified. The doctor could help this patient die, but the daughter could not watch her father go. When it was evident that he had only days to live and did not need this doctor or know his daughter, I flew back to the United States. Three days later my father died. I was not physically at his bedside, but my spirit was. I have no regrets. Although the head knows that he passed on, in my mind's eye, he is laughing and has a twinkle in his eye. I could not bear to see him without life. A piece of my heart is buried with him, and for this reason, I will never be out of Africa.

I knew that he was going to die. I do not remember when it became evident to me, and I was not sure how to tell the family. I thought that I could arrange a family meeting and inform them of the sad reality in a calm, sympathetic manner. The patient had chronic lymphocytic leukemia, and his case was advanced. The only medication available to him was chlorambucil. As the days passed, I could not bring myself to call the family meeting because they had so much hope. Every day as we got results and I shared them, I would sandwich the bad news with some optimism to ease their pain. Well, his white blood cell count has come down, but his platelet count and red blood cell counts are very low, and this puts him in danger of bleeding. The medicine is bringing the white cell count down but has not yet brought the other cell counts up. What we can do is give him some blood. I tried not to allow despair to creep into my thoughts or my voice. I knew that the blood bank had no platelets or packed red blood cells. He was not eating or drinking, and we had placed a nasogastric tube through which his family fed him wheat or millet porridge (manufactured tube feeds are not widely available in Uganda). I tried not to think about the time that he had almost died a few weeks before.

I had been called to the bedside because the patient was in respiratory distress. The doctor on call was in his office when I arrived, and I wondered why he was not at the bedside. I took one look at the patient and had to step away for a moment to compose myself. I felt the tears threatening to come, but I had to stop them. This was not the time for emotions. I had to assess the patient and make some quick decisions. The doctor on call seemed to have given up. He was a young trainee in a system in which you treat when you can and, if the situation is hopeless, you move on to the next patient. There are no resources for perpetuating hope. This is so different from my practice in the United States, where if a patient wants everything done, we will do it. We are not taught when to give up hope, and futility does not figure into the allocation of resources. I looked at the patient struggling to breathe and felt that I had to do all that I could for him. I asked the doctor on call to place the patient on oxygen and hoped that the tanks were not empty. I was worried about a lot of things, such as pulmonary embolus, myocardial infarction, and pneumonia. Diagnosing any of these would not be easy (the hospital did not have a computed tomography scanner, and obtaining cardiac enzymes was not as simple as clicking a button on a computer). First things first: the chest X‐ray. I thanked God that we were in a private hospital, one of the best in the city of Kampala, so we were able to get a chest X‐ray right away. As we transported the patient (portable X‐rays are nonexistent), the resident told me that he had called the consultant (the equivalent of an attending physician in the United States), who happened to be out of town. The consultant instructed us to transfer the patient to Mulago Hospital (the largest tertiary center in Uganda with well over 1000 beds and some of the equipment that you might find in an American hospital). I wondered how an attending physician could be out of town and leave a resident in charge. The thought was disturbing, but I had no time to ponder it. I later learned that physicians are so poorly paid that many have their own private clinics. My patient got the X‐ray, and I reviewed it with the resident. Tuberculosis, he said. Tuberculosis was this resident's reality. Many patients who need chest X‐rays in Uganda have tuberculosis. As I reviewed the X‐ray, though, I was certain that this was congestive heart failure. However, in Uganda, congestive heart failure is rarely diagnosed in the hospital. Patients with an ejection fraction low enough to cause congestion generally die before they get to a hospital. I knew that some furosemide would work for this patient, but I could not get the resident to listen to me. He had orders from the consultant to transfer the patient immediately, and the ambulance was ready. I tried to convince the resident to administer furosemide before transferring the patient, but he feared administering a drug not approved by his superior. As the patient was loaded onto the ambulance, I reflected for a second on how different things would be if we were in the United States. We arrived at Mulago in record time, and I tried to get the intake doctors to understand what the problem was; however, they did not want to hear from the US doctor. I stared in frustration as they wasted valuable time. I wondered how long the patient would survive in respiratory distress with nothing being done. I called the patient's son and asked him to come to Mulago immediately. Miraculously, he had already been on his way. As I held the patient's hand, sure that he would die right then and there in a waiting area as nobody did anything, I saw the patient's son. I knew that he was a pharmacist, and I asked him to go to the pharmacy and buy furosemide and some syringes. In Uganda, one can buy any medication without a prescription. Luckily, the hospital pharmacy had the drug. We treated the patient, and in no time, his breathing had returned to normal.

I was jolted back to reality. He was dying, and I knew it. He had had many close calls. There was the time that he got the wrong blood during a blood transfusion. I informed the doctor on call as the blood was being administered that I thought the patient was getting a transfusion reaction because he had rigors. The physician on call suggested covering him in blankets, and I suggested stopping the infusion and administering steroids. The pack of blood showed that he was getting his blood type. The patient was typed and crossed again, and to our surprise, we got a different result. I went to the laboratory to perform a third, tie‐breaking cross match and was surprised to note that the reagents had passed their expiration date. However, I knew that these were small battles we were winning and that there was no winning the war.

I recognized that the challenges of practicing medicine in the developing world were many. I wondered how the patients of families with fewer resources survived. The answer was obvious: they didn't. I personally picked up blood when it was available from the blood bank and vividly remember walking from the blood bank at night to the private hospital with units of blood in each hand. Once we arrived at the hospital, I had to warm the blood to room temperature by holding it close to my own skin. Many tests that we perform routinely on a hospitalized patient in the United States are not available.

There was still the problem of breaking the news to the family. Despite everything that had been done and the many near misses that the patient had survived, he was still going to die. It turns out that the family was more intuitive than I thought. One day, the son came to me and asked how long his dad had. Not long, I said quietly. I thought about all that I could potentially do if I had the patient in the hospital at which I worked in the United States. Would it have made a difference? I do not know. It was impossible doctoring this patient, and I suspect doing it in a resource‐rich environment would not have made it any easier. You see this patient, perhaps the most important patient of my life, certainly a patient that I will never forget, was my father.

It had been 15 years since I had traveled to the United States for an education. I knew that my father was so incredibly proud of me. I think that he was the happiest I had ever seen him when he attended my graduation from medical school in Minnesota. I had been looking forward to this visit back home because it had been 3 years since I had last seen my family. I was somewhat concerned because my father had told me a week before I traveled that he was not feeling well. When I arrived, there seemed to be relief on my brother's face when he met me at the airport. We drove straight to the hospital, and along with the joy of seeing me, I could sense that my father was glad that I was home at this particular point in time. They had just received the diagnosis. He had leukemia, and they were glad that their doctor was home. They had particular faith in the daughter (sister) sent abroad for an education. Things would now be okay. Initially, I never got to choose the role of doctor that I played in the final chapter of my father's life. The decision was made for me out of my family's desperation to make sure that they had left no stone unturned to help my father, and I accepted it out of necessity. As my father became my father when I entered this world, I became his doctor when he was leaving it; there was never any question in my mind, as there never was in his. As it became clear that my father would not survive, I chose to continue the role of doctor. I have watched many patients die as a physician and have done my best to make sure that their passing is comfortable, peaceful, and dignified. The doctor could help this patient die, but the daughter could not watch her father go. When it was evident that he had only days to live and did not need this doctor or know his daughter, I flew back to the United States. Three days later my father died. I was not physically at his bedside, but my spirit was. I have no regrets. Although the head knows that he passed on, in my mind's eye, he is laughing and has a twinkle in his eye. I could not bear to see him without life. A piece of my heart is buried with him, and for this reason, I will never be out of Africa.

There has been marked recent growth in the employment and utilization of both pediatric and adult hospitalists. Recent data demonstrate that approximately 25% of current pediatric hospitalist programs are less than 2 years old.1 Some have posited that this growth is due to increasing pressure from the public and payors to deliver cost‐effective and high‐quality care.2 However, little is known about the mechanisms by which those who deliver care in this framework are trained, nor the scope of clinical practice they provide.37 One study has shown that among those who direct pediatric hospitalist services there is a great degree of variability in the description of the roles, work patterns, and employment characteristics of hospitalists.1 That study provided only 1 perspective on the roles and career trajectories of those in the field. To better understand both the range and frequency of experiences, clinical and nonclinical roles, training, work expectations, and career plans, we conducted a national survey study of practicing pediatric hospitalists.

METHODS

RESULTS

RESULTS BY ACADEMIC STATUS

Only significant differences between academic and nonacademic hospitalists are presented.

RESULTS BY HOSPITAL CHARACTERISTICS

For each hospital characteristic, only significant differences between dichotomized groups are presented.

DISCUSSION

This study provides the most comprehensive information available regarding the clinical and nonclinical roles, training, work expectations, and career plans of pediatric hospitalists. Among the most important of our findings is the distribution of the length of time that pediatric hospitalists had served in their roles. While over one‐third (37%) reported having been practicing as hospitalists for over 5 years, 45% of our respondents had been in practice for fewer than 3 years. This is consistent with both the perceptions of rapid growth of the field and with significant turnover of hospitalists.1, 8 It is important to note that our findings may actually overestimate the proportion of hospitalists with longer durations of employment as our sampling strategy would have been less likely to include those who left the field within the first 12 to 18 months of practice. Nevertheless, over half (61%) of our respondents expected to remain a hospitalist for the duration of their career and few reported choosing to become a hospitalist as a short‐term employment option. This finding has important implications for the future stability of the hospitalist workforce and the potential development of specific expertise among this cadre of clinicians.6

The demographic profile of pediatric hospitalists was also consistent with these findings. The mean age of 39 years for our respondents is indicative of a significant proportion of this group of physicians recently having completed their residency training. Further, the gender distribution approximates that of current pediatric residency graduates, thus indicating that that this is not a clinical choice for which there would be a skewed distribution as is the case in some pediatric subspecialties.9

Our findings were similar to the 2004 Ottolini et al.10 findings on the roles of pediatric hospitalists. Respondents in our study reported spending less time providing inpatient care (61% versus 75%), providing clinical teaching or supervising residents (16% versus 26%), performing administrative duties (8% versus 19%), and conducting research (3% versus 9%) compared with the respondents in the Ottolini et al.10 survey.

At this point in time, fewer than half of our respondents reported any hospitalist‐specific training, including workshops at professional meetings or CME coursework. As there are a paucity of fellowships offering postresidency training in pediatric hospital medicine, and most of the existing programs are newly established, few in practice have completed such programs.11 In addition, most respondents reported that current CME offerings do not meet their needs, and that they could have used additional QI training to prepare them for their role as pediatric hospitalists. However, almost three‐quarters of respondents (73%) do not believe any additional training beyond residency should be required. As such, it is unclear if a defined, unique body of knowledge specific to hospitalists is either needed or desired by those currently in the field.

Although there are a broad range of potential clinical roles within hospital medicine, and this clinical variety influenced most respondents' decisions to become hospitalists, the current scope of an individual hospitalist tends to become somewhat focused.12, 13 While we found almost all provided service on the pediatric inpatient unit, many fewer provided inpatient consultation and normal newborn care, or were involved in interhospital transport or as part of an emergency response team. There is also wide variation in the types of procedures performed or supervised by hospitalists at different institutions. More than half never perform or supervise infusion services, PICC or central line placement, or circumcision. The variation seen among hospitalists practicing in different hospital settings likely is a result, at least in part, of different needs in teaching hospitals for both service and for clinical experience of trainees. For example, our results demonstrate that pediatric hospitalists in nonteaching and non‐children's hospitals are more likely to have a broader scope of clinical care provision. Another potential issue is that some hospitalists may be employed by institutions which have no pediatric ICU, neonatal ICU, or other specialty unit. As such, these hospitalists would not have the opportunity to work in such settings.

Further, those without academic appointments are also more likely to have expanded clinical roles compared with their academic counterparts. This may be due to the fact that there is likely a greater number of subspecialty‐trained pediatric providers in academic centers and thus the need for hospitalists to cover specific services or perform specific procedures is lessened. There may also be a desire to prevent competition among care providers within the same institution. In contrast, hospitalists with academic appointments are more likely (though still uncommonly) to have taken leadership roles in hospital administration and QI initiatives. Thus, the nature of their efforts appears to expand into nonclinical delivery areas.

Clearly, hospitalists report they have assumed a significant role in the clinical teaching of trainees at all levels, with 94% of our respondents maintaining at least some involvement in education. On average, they spend 16% of their time in educational efforts. However, there are few data on the impact of their work in this area.5, 13 Studies in pediatrics to date have been limited to a few institutions,3, 5 and have not addressed the issue from the perspective of residency program directors or those who are in charge of inpatient curricula.

This study, like the majority of studies related to pediatric hospitalists, is hampered by the difficulty of identifying pediatric hospitalists. Rather than utilizing a hospital medicine membership list, which would be potentially biased by self‐selection, we attempted to obtain a more representative sample through utilization of the AHA database.

CONCLUSIONS

Findings from this study provide an additional perspective regarding pediatric hospitalists to add to our previous study of hospitalist program directors.1 However, the field is currently a moving target. Our data demonstrate that there is significant flux in the hospitalist workforce, uncertainty regarding turnover, and variation in the roles of these professionals in their clinical and nonclinical work environment. Moreover, additional studies of the educational impact of hospitalists on residency and medical student education are needed. Questions regarding the nature and degree of resident autonomy and experience conducting procedures in the hospitalist environment have been raised. These must be assessed through studies of residency program directors, their expectations of residents, and the curricula they have developed.

As with any new phenomenon, it will take time to understand the impact of hospitalists in a variety of domains. Additional research will be helpful in following the development of this field and the manner in which it will interface with existing medical practice and educational programs.

There has been marked recent growth in the employment and utilization of both pediatric and adult hospitalists. Recent data demonstrate that approximately 25% of current pediatric hospitalist programs are less than 2 years old.1 Some have posited that this growth is due to increasing pressure from the public and payors to deliver cost‐effective and high‐quality care.2 However, little is known about the mechanisms by which those who deliver care in this framework are trained, nor the scope of clinical practice they provide.37 One study has shown that among those who direct pediatric hospitalist services there is a great degree of variability in the description of the roles, work patterns, and employment characteristics of hospitalists.1 That study provided only 1 perspective on the roles and career trajectories of those in the field. To better understand both the range and frequency of experiences, clinical and nonclinical roles, training, work expectations, and career plans, we conducted a national survey study of practicing pediatric hospitalists.

METHODS

RESULTS

RESULTS BY ACADEMIC STATUS

Only significant differences between academic and nonacademic hospitalists are presented.

RESULTS BY HOSPITAL CHARACTERISTICS

For each hospital characteristic, only significant differences between dichotomized groups are presented.

DISCUSSION

This study provides the most comprehensive information available regarding the clinical and nonclinical roles, training, work expectations, and career plans of pediatric hospitalists. Among the most important of our findings is the distribution of the length of time that pediatric hospitalists had served in their roles. While over one‐third (37%) reported having been practicing as hospitalists for over 5 years, 45% of our respondents had been in practice for fewer than 3 years. This is consistent with both the perceptions of rapid growth of the field and with significant turnover of hospitalists.1, 8 It is important to note that our findings may actually overestimate the proportion of hospitalists with longer durations of employment as our sampling strategy would have been less likely to include those who left the field within the first 12 to 18 months of practice. Nevertheless, over half (61%) of our respondents expected to remain a hospitalist for the duration of their career and few reported choosing to become a hospitalist as a short‐term employment option. This finding has important implications for the future stability of the hospitalist workforce and the potential development of specific expertise among this cadre of clinicians.6

The demographic profile of pediatric hospitalists was also consistent with these findings. The mean age of 39 years for our respondents is indicative of a significant proportion of this group of physicians recently having completed their residency training. Further, the gender distribution approximates that of current pediatric residency graduates, thus indicating that that this is not a clinical choice for which there would be a skewed distribution as is the case in some pediatric subspecialties.9

Our findings were similar to the 2004 Ottolini et al.10 findings on the roles of pediatric hospitalists. Respondents in our study reported spending less time providing inpatient care (61% versus 75%), providing clinical teaching or supervising residents (16% versus 26%), performing administrative duties (8% versus 19%), and conducting research (3% versus 9%) compared with the respondents in the Ottolini et al.10 survey.

At this point in time, fewer than half of our respondents reported any hospitalist‐specific training, including workshops at professional meetings or CME coursework. As there are a paucity of fellowships offering postresidency training in pediatric hospital medicine, and most of the existing programs are newly established, few in practice have completed such programs.11 In addition, most respondents reported that current CME offerings do not meet their needs, and that they could have used additional QI training to prepare them for their role as pediatric hospitalists. However, almost three‐quarters of respondents (73%) do not believe any additional training beyond residency should be required. As such, it is unclear if a defined, unique body of knowledge specific to hospitalists is either needed or desired by those currently in the field.

Although there are a broad range of potential clinical roles within hospital medicine, and this clinical variety influenced most respondents' decisions to become hospitalists, the current scope of an individual hospitalist tends to become somewhat focused.12, 13 While we found almost all provided service on the pediatric inpatient unit, many fewer provided inpatient consultation and normal newborn care, or were involved in interhospital transport or as part of an emergency response team. There is also wide variation in the types of procedures performed or supervised by hospitalists at different institutions. More than half never perform or supervise infusion services, PICC or central line placement, or circumcision. The variation seen among hospitalists practicing in different hospital settings likely is a result, at least in part, of different needs in teaching hospitals for both service and for clinical experience of trainees. For example, our results demonstrate that pediatric hospitalists in nonteaching and non‐children's hospitals are more likely to have a broader scope of clinical care provision. Another potential issue is that some hospitalists may be employed by institutions which have no pediatric ICU, neonatal ICU, or other specialty unit. As such, these hospitalists would not have the opportunity to work in such settings.

Further, those without academic appointments are also more likely to have expanded clinical roles compared with their academic counterparts. This may be due to the fact that there is likely a greater number of subspecialty‐trained pediatric providers in academic centers and thus the need for hospitalists to cover specific services or perform specific procedures is lessened. There may also be a desire to prevent competition among care providers within the same institution. In contrast, hospitalists with academic appointments are more likely (though still uncommonly) to have taken leadership roles in hospital administration and QI initiatives. Thus, the nature of their efforts appears to expand into nonclinical delivery areas.

Clearly, hospitalists report they have assumed a significant role in the clinical teaching of trainees at all levels, with 94% of our respondents maintaining at least some involvement in education. On average, they spend 16% of their time in educational efforts. However, there are few data on the impact of their work in this area.5, 13 Studies in pediatrics to date have been limited to a few institutions,3, 5 and have not addressed the issue from the perspective of residency program directors or those who are in charge of inpatient curricula.

This study, like the majority of studies related to pediatric hospitalists, is hampered by the difficulty of identifying pediatric hospitalists. Rather than utilizing a hospital medicine membership list, which would be potentially biased by self‐selection, we attempted to obtain a more representative sample through utilization of the AHA database.

CONCLUSIONS

Findings from this study provide an additional perspective regarding pediatric hospitalists to add to our previous study of hospitalist program directors.1 However, the field is currently a moving target. Our data demonstrate that there is significant flux in the hospitalist workforce, uncertainty regarding turnover, and variation in the roles of these professionals in their clinical and nonclinical work environment. Moreover, additional studies of the educational impact of hospitalists on residency and medical student education are needed. Questions regarding the nature and degree of resident autonomy and experience conducting procedures in the hospitalist environment have been raised. These must be assessed through studies of residency program directors, their expectations of residents, and the curricula they have developed.

As with any new phenomenon, it will take time to understand the impact of hospitalists in a variety of domains. Additional research will be helpful in following the development of this field and the manner in which it will interface with existing medical practice and educational programs.

There has been marked recent growth in the employment and utilization of both pediatric and adult hospitalists. Recent data demonstrate that approximately 25% of current pediatric hospitalist programs are less than 2 years old.1 Some have posited that this growth is due to increasing pressure from the public and payors to deliver cost‐effective and high‐quality care.2 However, little is known about the mechanisms by which those who deliver care in this framework are trained, nor the scope of clinical practice they provide.37 One study has shown that among those who direct pediatric hospitalist services there is a great degree of variability in the description of the roles, work patterns, and employment characteristics of hospitalists.1 That study provided only 1 perspective on the roles and career trajectories of those in the field. To better understand both the range and frequency of experiences, clinical and nonclinical roles, training, work expectations, and career plans, we conducted a national survey study of practicing pediatric hospitalists.

METHODS

RESULTS

RESULTS BY ACADEMIC STATUS

Only significant differences between academic and nonacademic hospitalists are presented.

RESULTS BY HOSPITAL CHARACTERISTICS

For each hospital characteristic, only significant differences between dichotomized groups are presented.