Editorial

Despite concerted national efforts to decrease pediatric readmissions, recent data suggest that preventable and all-cause readmission rates of hospitalized children remain unchanged.¹ Because some readmissions may be caused by inadequate postdischarge follow-up, nurse (RN) home visits offer the prospect of addressing unresolved clinical issues after discharge and ameliorating patient and family concerns that may otherwise prompt re-presentation for acute care. Yet a recent trial of this approach, the Hospital to Home Outcomes (H2O) trial,² found the opposite to be true: participants receiving home nurse visits had higher reutilization rates than did participants in the control group. This raises interesting questions: Is it time to revisit postdischarge outreach as an intervention to reduce pediatric readmissions—and even pediatric readmissions altogether as an outcome metric?

In this issue of the Journal of Hospital Medicine, Riddle et al³ explored the perspectives of key stakeholders to understand the factors driving increased reutilization after postdischarge home visits in the H2O trial and obtained feedback for improving potential interventions. The investigators used a qualitative approach that consisted of telephone interviews with 33 parents who were enrolled in the H2O trial and in-person focus groups with 10 home care RNs involved in the trial, 12 hospital medicine physicians, and 7 primary care physicians (PCPs). Inductive thematic analysis was used to analyze responses to open-ended questions through a rigorous, iterative and multidisciplinary process. Key themes elicited from stakeholders included questions about the clinical appropriateness of reutilization episodes; the influence of insufficiently contextualized “red flag,” or warning sign, instructions given to parents in facilitating reutilization; the potential for hospital-employed home care nurses to inadvertently promote emergency department rather than PCP follow-up; and escalation of care exceeding that expected in a PCP office. Stakeholders suggested the intervention could be improved by enhancing postdischarge communication between home care RNs, hospital medicine physicians, and PCPs; tailoring home visits to specific clinical, patient, and family scenarios; and more clearly framing “red flags.”

We welcome the work of Riddle and colleagues in exposing the elements of home visits that may have led to increased utilization, and their proposed next steps to improve the intervention—enhancing contact with PCP offices and focusing interventions on specific populations—unquestionably have merit. We agree that this may be particularly true in children with medical complexity (a population that was excluded from this study), who have unique discharge needs and account for over half of pediatric readmissions.⁴ However, we suggest that the instinct to refine the design of the study intervention should be weighed against alternative possibilities: that postdischarge interventions are simply not effective in decreasing reutilization or, at the very least, that the findings of the H2O trial should not lead us to invest the resources required to further discern the efficacy of postdischarge interventions.

This counter-intuitive possibility is only compounded by the fact that reutilization rates were not improved in the study group’s H2O II trial, a follow-up study that focused on postdischarge nurse telephone calls as the intervention of interest⁵; and indeed, the results of these two, well-designed negative trials have been previously cited to propose postdischarge nurse contact as a potential target of deimplementation efforts.⁶ In the pediatric population, in which caregivers rather than patients themselves are generally responsible for seeking out care, postdischarge outreach may inevitably escalate concerning findings that will result in reutilization. Instead, perhaps the H2O study findings should prompt a broader exploration for alternative solutions to pediatric readmission reduction. One such solution could build on the finding by Riddle et al that stakeholders perceive ambiguity in whether discharging physicians, or rather PCPs, have ownership of clinical issues after discharge. Rather than asking visiting RNs to triangulate between inpatient and outpatient physicians, developing systems to directly integrate PCPs in the hospital discharge process for select patients—for instance, through leveraging the rapid expansion of telemedicine services during the COVID-19 crisis—may promote shared understanding of a patient’s illness trajectory and follow-up needs.

Importantly, the authors also noted that despite the findings of increased reutilization, parents who received home visits expressed their wishes to receive home visits in the future. While not a central finding of the study, this validates a hypothesis expressed in prior work by the H2O study group: “Hospital quality readmission metrics may not be well aligned with family desires for improved postdischarge transitions.”⁵ Given that efforts to reduce pediatric readmission have been largely unsuccessful and that readmission events are relatively uncommon in the general pediatric population,⁴ the parental wishes resonate with existing calls in the literature to consider looking beyond readmissions reduction in isolation as a quality metric. In contrast to the increasing presence of hospital reimbursement penalties among state Medicaid agencies for readmissions, a shift in focus toward outcome measures that are patient- and family-centered is imperative.^1,7 If home visits are not ultimately a solution to pediatric reutilization reduction, they may nonetheless still enable families to effectively manage the concerns that families endorse following discharge, including medication safety and social hardships.⁸

In summary, Riddle et al not only provided important context for the unexpected outcome of a well-designed randomized clinical trial but also provided a rich source of qualitative data that furthers our understanding of a child’s discharge home from the hospital through the perspective of multiple stakeholders. While the authors offer well-reasoned next steps in narrowing the intervention population of interest and enhancing connections of families with PCP care, it may be time to broadly revisit postdischarge interventions and outcomes to identify new approaches and redefine quality measures for hospital-to-home transitions of children and their families.

Despite concerted national efforts to decrease pediatric readmissions, recent data suggest that preventable and all-cause readmission rates of hospitalized children remain unchanged.¹ Because some readmissions may be caused by inadequate postdischarge follow-up, nurse (RN) home visits offer the prospect of addressing unresolved clinical issues after discharge and ameliorating patient and family concerns that may otherwise prompt re-presentation for acute care. Yet a recent trial of this approach, the Hospital to Home Outcomes (H2O) trial,² found the opposite to be true: participants receiving home nurse visits had higher reutilization rates than did participants in the control group. This raises interesting questions: Is it time to revisit postdischarge outreach as an intervention to reduce pediatric readmissions—and even pediatric readmissions altogether as an outcome metric?

In this issue of the Journal of Hospital Medicine, Riddle et al³ explored the perspectives of key stakeholders to understand the factors driving increased reutilization after postdischarge home visits in the H2O trial and obtained feedback for improving potential interventions. The investigators used a qualitative approach that consisted of telephone interviews with 33 parents who were enrolled in the H2O trial and in-person focus groups with 10 home care RNs involved in the trial, 12 hospital medicine physicians, and 7 primary care physicians (PCPs). Inductive thematic analysis was used to analyze responses to open-ended questions through a rigorous, iterative and multidisciplinary process. Key themes elicited from stakeholders included questions about the clinical appropriateness of reutilization episodes; the influence of insufficiently contextualized “red flag,” or warning sign, instructions given to parents in facilitating reutilization; the potential for hospital-employed home care nurses to inadvertently promote emergency department rather than PCP follow-up; and escalation of care exceeding that expected in a PCP office. Stakeholders suggested the intervention could be improved by enhancing postdischarge communication between home care RNs, hospital medicine physicians, and PCPs; tailoring home visits to specific clinical, patient, and family scenarios; and more clearly framing “red flags.”

We welcome the work of Riddle and colleagues in exposing the elements of home visits that may have led to increased utilization, and their proposed next steps to improve the intervention—enhancing contact with PCP offices and focusing interventions on specific populations—unquestionably have merit. We agree that this may be particularly true in children with medical complexity (a population that was excluded from this study), who have unique discharge needs and account for over half of pediatric readmissions.⁴ However, we suggest that the instinct to refine the design of the study intervention should be weighed against alternative possibilities: that postdischarge interventions are simply not effective in decreasing reutilization or, at the very least, that the findings of the H2O trial should not lead us to invest the resources required to further discern the efficacy of postdischarge interventions.

This counter-intuitive possibility is only compounded by the fact that reutilization rates were not improved in the study group’s H2O II trial, a follow-up study that focused on postdischarge nurse telephone calls as the intervention of interest⁵; and indeed, the results of these two, well-designed negative trials have been previously cited to propose postdischarge nurse contact as a potential target of deimplementation efforts.⁶ In the pediatric population, in which caregivers rather than patients themselves are generally responsible for seeking out care, postdischarge outreach may inevitably escalate concerning findings that will result in reutilization. Instead, perhaps the H2O study findings should prompt a broader exploration for alternative solutions to pediatric readmission reduction. One such solution could build on the finding by Riddle et al that stakeholders perceive ambiguity in whether discharging physicians, or rather PCPs, have ownership of clinical issues after discharge. Rather than asking visiting RNs to triangulate between inpatient and outpatient physicians, developing systems to directly integrate PCPs in the hospital discharge process for select patients—for instance, through leveraging the rapid expansion of telemedicine services during the COVID-19 crisis—may promote shared understanding of a patient’s illness trajectory and follow-up needs.

Importantly, the authors also noted that despite the findings of increased reutilization, parents who received home visits expressed their wishes to receive home visits in the future. While not a central finding of the study, this validates a hypothesis expressed in prior work by the H2O study group: “Hospital quality readmission metrics may not be well aligned with family desires for improved postdischarge transitions.”⁵ Given that efforts to reduce pediatric readmission have been largely unsuccessful and that readmission events are relatively uncommon in the general pediatric population,⁴ the parental wishes resonate with existing calls in the literature to consider looking beyond readmissions reduction in isolation as a quality metric. In contrast to the increasing presence of hospital reimbursement penalties among state Medicaid agencies for readmissions, a shift in focus toward outcome measures that are patient- and family-centered is imperative.^1,7 If home visits are not ultimately a solution to pediatric reutilization reduction, they may nonetheless still enable families to effectively manage the concerns that families endorse following discharge, including medication safety and social hardships.⁸

In summary, Riddle et al not only provided important context for the unexpected outcome of a well-designed randomized clinical trial but also provided a rich source of qualitative data that furthers our understanding of a child’s discharge home from the hospital through the perspective of multiple stakeholders. While the authors offer well-reasoned next steps in narrowing the intervention population of interest and enhancing connections of families with PCP care, it may be time to broadly revisit postdischarge interventions and outcomes to identify new approaches and redefine quality measures for hospital-to-home transitions of children and their families.

Despite concerted national efforts to decrease pediatric readmissions, recent data suggest that preventable and all-cause readmission rates of hospitalized children remain unchanged.¹ Because some readmissions may be caused by inadequate postdischarge follow-up, nurse (RN) home visits offer the prospect of addressing unresolved clinical issues after discharge and ameliorating patient and family concerns that may otherwise prompt re-presentation for acute care. Yet a recent trial of this approach, the Hospital to Home Outcomes (H2O) trial,² found the opposite to be true: participants receiving home nurse visits had higher reutilization rates than did participants in the control group. This raises interesting questions: Is it time to revisit postdischarge outreach as an intervention to reduce pediatric readmissions—and even pediatric readmissions altogether as an outcome metric?

In this issue of the Journal of Hospital Medicine, Riddle et al³ explored the perspectives of key stakeholders to understand the factors driving increased reutilization after postdischarge home visits in the H2O trial and obtained feedback for improving potential interventions. The investigators used a qualitative approach that consisted of telephone interviews with 33 parents who were enrolled in the H2O trial and in-person focus groups with 10 home care RNs involved in the trial, 12 hospital medicine physicians, and 7 primary care physicians (PCPs). Inductive thematic analysis was used to analyze responses to open-ended questions through a rigorous, iterative and multidisciplinary process. Key themes elicited from stakeholders included questions about the clinical appropriateness of reutilization episodes; the influence of insufficiently contextualized “red flag,” or warning sign, instructions given to parents in facilitating reutilization; the potential for hospital-employed home care nurses to inadvertently promote emergency department rather than PCP follow-up; and escalation of care exceeding that expected in a PCP office. Stakeholders suggested the intervention could be improved by enhancing postdischarge communication between home care RNs, hospital medicine physicians, and PCPs; tailoring home visits to specific clinical, patient, and family scenarios; and more clearly framing “red flags.”

We welcome the work of Riddle and colleagues in exposing the elements of home visits that may have led to increased utilization, and their proposed next steps to improve the intervention—enhancing contact with PCP offices and focusing interventions on specific populations—unquestionably have merit. We agree that this may be particularly true in children with medical complexity (a population that was excluded from this study), who have unique discharge needs and account for over half of pediatric readmissions.⁴ However, we suggest that the instinct to refine the design of the study intervention should be weighed against alternative possibilities: that postdischarge interventions are simply not effective in decreasing reutilization or, at the very least, that the findings of the H2O trial should not lead us to invest the resources required to further discern the efficacy of postdischarge interventions.

This counter-intuitive possibility is only compounded by the fact that reutilization rates were not improved in the study group’s H2O II trial, a follow-up study that focused on postdischarge nurse telephone calls as the intervention of interest⁵; and indeed, the results of these two, well-designed negative trials have been previously cited to propose postdischarge nurse contact as a potential target of deimplementation efforts.⁶ In the pediatric population, in which caregivers rather than patients themselves are generally responsible for seeking out care, postdischarge outreach may inevitably escalate concerning findings that will result in reutilization. Instead, perhaps the H2O study findings should prompt a broader exploration for alternative solutions to pediatric readmission reduction. One such solution could build on the finding by Riddle et al that stakeholders perceive ambiguity in whether discharging physicians, or rather PCPs, have ownership of clinical issues after discharge. Rather than asking visiting RNs to triangulate between inpatient and outpatient physicians, developing systems to directly integrate PCPs in the hospital discharge process for select patients—for instance, through leveraging the rapid expansion of telemedicine services during the COVID-19 crisis—may promote shared understanding of a patient’s illness trajectory and follow-up needs.

Importantly, the authors also noted that despite the findings of increased reutilization, parents who received home visits expressed their wishes to receive home visits in the future. While not a central finding of the study, this validates a hypothesis expressed in prior work by the H2O study group: “Hospital quality readmission metrics may not be well aligned with family desires for improved postdischarge transitions.”⁵ Given that efforts to reduce pediatric readmission have been largely unsuccessful and that readmission events are relatively uncommon in the general pediatric population,⁴ the parental wishes resonate with existing calls in the literature to consider looking beyond readmissions reduction in isolation as a quality metric. In contrast to the increasing presence of hospital reimbursement penalties among state Medicaid agencies for readmissions, a shift in focus toward outcome measures that are patient- and family-centered is imperative.^1,7 If home visits are not ultimately a solution to pediatric reutilization reduction, they may nonetheless still enable families to effectively manage the concerns that families endorse following discharge, including medication safety and social hardships.⁸

In summary, Riddle et al not only provided important context for the unexpected outcome of a well-designed randomized clinical trial but also provided a rich source of qualitative data that furthers our understanding of a child’s discharge home from the hospital through the perspective of multiple stakeholders. While the authors offer well-reasoned next steps in narrowing the intervention population of interest and enhancing connections of families with PCP care, it may be time to broadly revisit postdischarge interventions and outcomes to identify new approaches and redefine quality measures for hospital-to-home transitions of children and their families.

Let me start with these 3 words that really should never have to be said: Black Lives Matter.

It was hard to sit down to write this piece—not just because it’s a sunny Sunday morning, but because I’m still afraid I’ll get it wrong, show my white privilege, offend someone. George Floyd’s murder has been a reckoning for Black Americans, for the police, for the nation (maybe the world), and for me. I live in a multi-racial household, and we have redoubled our efforts to talk about racism and bias and question our assumptions as part of our daily conversations. After Mr. Floyd was killed, I decided that I would try to be less afraid of getting it wrong and be more outspoken about my support for Black Lives Matter and for the work that we need to do in this country, and in ourselves, to become more antiracist.

Here are some things that I know: I know that study after study has shown that health care and health outcomes are worse for Black people than for White people. I know that people of color are sickening and dying with COVID-19 before our eyes, just as other pandemics, such as HIV, differentially affect communities of color. I know, too, that a Black physician executive who lives around the corner from me has been stopped by our local police more than 10 times; I have been stopped by our local police exactly once.

I don’t know how to fix it. But I do know that my silence won’t help. Here are some things I am trying to do at home and at work: I am educating myself about race and racism. I’m not asking my Black peers, patients, or colleagues to teach me, but I am listening to what they tell me, when they want to tell me. I am reading books like Ibram Kendi’s How to Be Antiracist and Bernadine Evaristo’s Girl, Woman, Other. I challenge myself to read articles that I might have skipped over—because they were simply too painful. People of color don’t have a choice about facing their pain. I have that choice—it’s a privilege—and I choose to be an ally.

I’m speaking up even when I’m afraid that I might say the wrong thing. This can take several forms—questioning assumptions about race and racism when it comes up, which is often, in medicine. It also means amplifying the voices that don’t always get heard—asking a young person of color her opinion in a meeting, retweeting the thoughts of a Black colleague, thanking someone publicly or personally for a comment, an idea, or the kernel of something important. I ask people to correct me, and I try to be humble in accepting criticism or correction.

Being a better ally also means putting our money where our mouth is, supporting Black-owned businesses and restaurants, and donating to causes that support equality and justice. We can diversify our social media feeds. We have to be willing to be excluded from the conversation—if you’re white or straight or cis-gendered, it’s not about you—and be ready to feel uncomfortable. We can encourage our organizations to do better. I’m proud of my organization, which had already started working to make our organizational culture even more inclusive.

Black Lives Matter. I’m looking forward to a day when that is so obvious that we don’t have to say it. Until then, I’m going to be hard at work with my head, my ears, and my whole heart.

Let me start with these 3 words that really should never have to be said: Black Lives Matter.

It was hard to sit down to write this piece—not just because it’s a sunny Sunday morning, but because I’m still afraid I’ll get it wrong, show my white privilege, offend someone. George Floyd’s murder has been a reckoning for Black Americans, for the police, for the nation (maybe the world), and for me. I live in a multi-racial household, and we have redoubled our efforts to talk about racism and bias and question our assumptions as part of our daily conversations. After Mr. Floyd was killed, I decided that I would try to be less afraid of getting it wrong and be more outspoken about my support for Black Lives Matter and for the work that we need to do in this country, and in ourselves, to become more antiracist.

Here are some things that I know: I know that study after study has shown that health care and health outcomes are worse for Black people than for White people. I know that people of color are sickening and dying with COVID-19 before our eyes, just as other pandemics, such as HIV, differentially affect communities of color. I know, too, that a Black physician executive who lives around the corner from me has been stopped by our local police more than 10 times; I have been stopped by our local police exactly once.

I don’t know how to fix it. But I do know that my silence won’t help. Here are some things I am trying to do at home and at work: I am educating myself about race and racism. I’m not asking my Black peers, patients, or colleagues to teach me, but I am listening to what they tell me, when they want to tell me. I am reading books like Ibram Kendi’s How to Be Antiracist and Bernadine Evaristo’s Girl, Woman, Other. I challenge myself to read articles that I might have skipped over—because they were simply too painful. People of color don’t have a choice about facing their pain. I have that choice—it’s a privilege—and I choose to be an ally.

I’m speaking up even when I’m afraid that I might say the wrong thing. This can take several forms—questioning assumptions about race and racism when it comes up, which is often, in medicine. It also means amplifying the voices that don’t always get heard—asking a young person of color her opinion in a meeting, retweeting the thoughts of a Black colleague, thanking someone publicly or personally for a comment, an idea, or the kernel of something important. I ask people to correct me, and I try to be humble in accepting criticism or correction.

Being a better ally also means putting our money where our mouth is, supporting Black-owned businesses and restaurants, and donating to causes that support equality and justice. We can diversify our social media feeds. We have to be willing to be excluded from the conversation—if you’re white or straight or cis-gendered, it’s not about you—and be ready to feel uncomfortable. We can encourage our organizations to do better. I’m proud of my organization, which had already started working to make our organizational culture even more inclusive.

Black Lives Matter. I’m looking forward to a day when that is so obvious that we don’t have to say it. Until then, I’m going to be hard at work with my head, my ears, and my whole heart.

Let me start with these 3 words that really should never have to be said: Black Lives Matter.

It was hard to sit down to write this piece—not just because it’s a sunny Sunday morning, but because I’m still afraid I’ll get it wrong, show my white privilege, offend someone. George Floyd’s murder has been a reckoning for Black Americans, for the police, for the nation (maybe the world), and for me. I live in a multi-racial household, and we have redoubled our efforts to talk about racism and bias and question our assumptions as part of our daily conversations. After Mr. Floyd was killed, I decided that I would try to be less afraid of getting it wrong and be more outspoken about my support for Black Lives Matter and for the work that we need to do in this country, and in ourselves, to become more antiracist.

Here are some things that I know: I know that study after study has shown that health care and health outcomes are worse for Black people than for White people. I know that people of color are sickening and dying with COVID-19 before our eyes, just as other pandemics, such as HIV, differentially affect communities of color. I know, too, that a Black physician executive who lives around the corner from me has been stopped by our local police more than 10 times; I have been stopped by our local police exactly once.

I don’t know how to fix it. But I do know that my silence won’t help. Here are some things I am trying to do at home and at work: I am educating myself about race and racism. I’m not asking my Black peers, patients, or colleagues to teach me, but I am listening to what they tell me, when they want to tell me. I am reading books like Ibram Kendi’s How to Be Antiracist and Bernadine Evaristo’s Girl, Woman, Other. I challenge myself to read articles that I might have skipped over—because they were simply too painful. People of color don’t have a choice about facing their pain. I have that choice—it’s a privilege—and I choose to be an ally.

I’m speaking up even when I’m afraid that I might say the wrong thing. This can take several forms—questioning assumptions about race and racism when it comes up, which is often, in medicine. It also means amplifying the voices that don’t always get heard—asking a young person of color her opinion in a meeting, retweeting the thoughts of a Black colleague, thanking someone publicly or personally for a comment, an idea, or the kernel of something important. I ask people to correct me, and I try to be humble in accepting criticism or correction.

Being a better ally also means putting our money where our mouth is, supporting Black-owned businesses and restaurants, and donating to causes that support equality and justice. We can diversify our social media feeds. We have to be willing to be excluded from the conversation—if you’re white or straight or cis-gendered, it’s not about you—and be ready to feel uncomfortable. We can encourage our organizations to do better. I’m proud of my organization, which had already started working to make our organizational culture even more inclusive.

Black Lives Matter. I’m looking forward to a day when that is so obvious that we don’t have to say it. Until then, I’m going to be hard at work with my head, my ears, and my whole heart.

The growth in the hospitalist workforce has been one of the major trends shaping US (and international) inpatient medicine over the last 25 years.¹ Hospitalists’ clinical work is typically split among serving as the primary attending for admitted patients (termed “most responsible physician,” or MRP, in Canada), outpatient clinics, medical consults, and comanagement.^2,3 Comanagement typically involves the cooperative efforts of hospitalists and subspecialists ranging from general surgery to orthopedics to medical oncology. Comanagement differs from typical medical consultation because comanaging hospitalists are commonly given broad discretion to directly write orders, manage intercurrent medical illness (eg, hyperglycemia), and even discharge patients from the hospital when appropriate. There can be significant heterogeneity in how comanagement is implemented across institutions.⁴

With respect to hip fractures, literature suggests that subspecialists value comanagement and that comanagement is associated with reductions in hospital length of stay, timelier surgical repair, and potential cost savings for hospitals.^5-7 Some studies have found reductions in in-hospital and 1-year mortality (including one meta-analysis on ortho-geriatric comanagement)⁸ and complications,⁹ but others have found no such benefits.^10,11

In the current issue of the Journal of Hospital Medicine, Maxwell and Mirza used data from the National Surgical Quality Improvement Program (NSQIP) Participant Use Data File (PUF)—specifically, from the Hip Fracture PUF—to investigate the relationship between comanagement and mortality and major morbidity among more than 15,000 patients hospitalized with hip fracture.¹² The investigators did not find that comanagement was associated with a reduction in either morbidity or mortality.

Several factors give gravitas to their analysis. First, the NSQIP PUF is an extremely rigorous data source for evaluating surgical outcomes. Originally developed in the US Veterans Health Administration in the 1980’s to standardize data elements needed for quality improvement and hospital benchmarking, today NSQIP involves more than 600 hospitals in 9 different countries submitting hundreds of thousands of cases annually.¹³ Second, the authors recognized that the comanagement and noncomanagement groups differed substantially and used propensity score matching in an effort to account for these differences. Surprisingly, they found that the comanagement had significantly higher mortality and morbidity than the noncomanagement group, even after propensity score matching.

These results are important in testing the assumption of the inherent “good” of comanagement. Does this study provide definitive evidence that surgical comanagement does not improve outcomes? We would suggest that this study be interpreted in light of certain considerations.

First, comanagement is a broad term including a variety of operationalizations, such as geriatrician vs hospitalist comanagement, involvement before vs after surgery, and varying divisions of responsibility between the surgical and medical services. Research indicates that successful comanagement models tend to incorporate multidisciplinary teams, embrace the “dual primary caregiver” nature of comanagement, and shared goals among primary caregivers, specifically anticipating prevention of complications.⁵ The NSQIP data do not provide sufficient granularity to allow for investigation of these crucial nuances that may ultimately determine whether comanagement programs are effective. Additionally, comanagement often (but not always) coexists with a care pathway, and so deficiencies in or absence of a care pathway add additional heterogeneity to the comanagement group which is not captured in the NSQIP PUF.

Second, it is important to consider the potential for unmeasured confounding. The propensity score matching did seem to achieve balance in the distribution of most baseline variables between the comanagement and noncomanagement groups, though differences remain for certain covariates. A key assumption in propensity score matching (and in observational research more broadly) is the principle of “no unmeasured confounders” (ie, the assumption that all variables that might influence treatment assignment and outcomes are measured).¹⁴ For the NSQIP PUF this absence of unmeasured confounders is clearly not the case because hospital and surgeon variables are omitted from the PUF for reasons of confidentiality. Inclusion of hospital and surgeon variables could well be important because outcomes may vary by hospital or by surgeon, and simultaneously, different hospitals and different surgeons will have different protocols and preferences regarding comanagement. Furthermore, confounding is virtually guaranteed to the extent that hospitals and surgeons do not randomly assign hip fracture patients to comanagement or usual care. The finding of higher mortality in the comanagement group, even after adjustment and matching, suggests the presence of residual confounding. Even if residual confounding is the explanation for the worse outcomes observed in the comanagement group, the finding of a lack of benefit of comanagement is noteworthy and should not be dismissed out of hand.

Limitations aside, these results suggest a need for humility among strong proponents of comanagement, at least in the hip fracture population. While it may still be reasonable to claim that comanagement improves efficiency and may enhance certain aspects of patient or physician satisfaction, the lack of an impact on mortality highlights a need to examine the benefits of these programs more carefully. From a clinical perspective, hospitalists and orthopedic surgeons should consider which hip fracture patients might be most likely to benefit from comanagement.⁴ From a research perspective, the current study highlights the pressing need for a randomized trial of comanagement to definitively address the effectiveness of these programs.

The growth in the hospitalist workforce has been one of the major trends shaping US (and international) inpatient medicine over the last 25 years.¹ Hospitalists’ clinical work is typically split among serving as the primary attending for admitted patients (termed “most responsible physician,” or MRP, in Canada), outpatient clinics, medical consults, and comanagement.^2,3 Comanagement typically involves the cooperative efforts of hospitalists and subspecialists ranging from general surgery to orthopedics to medical oncology. Comanagement differs from typical medical consultation because comanaging hospitalists are commonly given broad discretion to directly write orders, manage intercurrent medical illness (eg, hyperglycemia), and even discharge patients from the hospital when appropriate. There can be significant heterogeneity in how comanagement is implemented across institutions.⁴

With respect to hip fractures, literature suggests that subspecialists value comanagement and that comanagement is associated with reductions in hospital length of stay, timelier surgical repair, and potential cost savings for hospitals.^5-7 Some studies have found reductions in in-hospital and 1-year mortality (including one meta-analysis on ortho-geriatric comanagement)⁸ and complications,⁹ but others have found no such benefits.^10,11

In the current issue of the Journal of Hospital Medicine, Maxwell and Mirza used data from the National Surgical Quality Improvement Program (NSQIP) Participant Use Data File (PUF)—specifically, from the Hip Fracture PUF—to investigate the relationship between comanagement and mortality and major morbidity among more than 15,000 patients hospitalized with hip fracture.¹² The investigators did not find that comanagement was associated with a reduction in either morbidity or mortality.

Several factors give gravitas to their analysis. First, the NSQIP PUF is an extremely rigorous data source for evaluating surgical outcomes. Originally developed in the US Veterans Health Administration in the 1980’s to standardize data elements needed for quality improvement and hospital benchmarking, today NSQIP involves more than 600 hospitals in 9 different countries submitting hundreds of thousands of cases annually.¹³ Second, the authors recognized that the comanagement and noncomanagement groups differed substantially and used propensity score matching in an effort to account for these differences. Surprisingly, they found that the comanagement had significantly higher mortality and morbidity than the noncomanagement group, even after propensity score matching.

These results are important in testing the assumption of the inherent “good” of comanagement. Does this study provide definitive evidence that surgical comanagement does not improve outcomes? We would suggest that this study be interpreted in light of certain considerations.

First, comanagement is a broad term including a variety of operationalizations, such as geriatrician vs hospitalist comanagement, involvement before vs after surgery, and varying divisions of responsibility between the surgical and medical services. Research indicates that successful comanagement models tend to incorporate multidisciplinary teams, embrace the “dual primary caregiver” nature of comanagement, and shared goals among primary caregivers, specifically anticipating prevention of complications.⁵ The NSQIP data do not provide sufficient granularity to allow for investigation of these crucial nuances that may ultimately determine whether comanagement programs are effective. Additionally, comanagement often (but not always) coexists with a care pathway, and so deficiencies in or absence of a care pathway add additional heterogeneity to the comanagement group which is not captured in the NSQIP PUF.

Second, it is important to consider the potential for unmeasured confounding. The propensity score matching did seem to achieve balance in the distribution of most baseline variables between the comanagement and noncomanagement groups, though differences remain for certain covariates. A key assumption in propensity score matching (and in observational research more broadly) is the principle of “no unmeasured confounders” (ie, the assumption that all variables that might influence treatment assignment and outcomes are measured).¹⁴ For the NSQIP PUF this absence of unmeasured confounders is clearly not the case because hospital and surgeon variables are omitted from the PUF for reasons of confidentiality. Inclusion of hospital and surgeon variables could well be important because outcomes may vary by hospital or by surgeon, and simultaneously, different hospitals and different surgeons will have different protocols and preferences regarding comanagement. Furthermore, confounding is virtually guaranteed to the extent that hospitals and surgeons do not randomly assign hip fracture patients to comanagement or usual care. The finding of higher mortality in the comanagement group, even after adjustment and matching, suggests the presence of residual confounding. Even if residual confounding is the explanation for the worse outcomes observed in the comanagement group, the finding of a lack of benefit of comanagement is noteworthy and should not be dismissed out of hand.

Limitations aside, these results suggest a need for humility among strong proponents of comanagement, at least in the hip fracture population. While it may still be reasonable to claim that comanagement improves efficiency and may enhance certain aspects of patient or physician satisfaction, the lack of an impact on mortality highlights a need to examine the benefits of these programs more carefully. From a clinical perspective, hospitalists and orthopedic surgeons should consider which hip fracture patients might be most likely to benefit from comanagement.⁴ From a research perspective, the current study highlights the pressing need for a randomized trial of comanagement to definitively address the effectiveness of these programs.

The growth in the hospitalist workforce has been one of the major trends shaping US (and international) inpatient medicine over the last 25 years.¹ Hospitalists’ clinical work is typically split among serving as the primary attending for admitted patients (termed “most responsible physician,” or MRP, in Canada), outpatient clinics, medical consults, and comanagement.^2,3 Comanagement typically involves the cooperative efforts of hospitalists and subspecialists ranging from general surgery to orthopedics to medical oncology. Comanagement differs from typical medical consultation because comanaging hospitalists are commonly given broad discretion to directly write orders, manage intercurrent medical illness (eg, hyperglycemia), and even discharge patients from the hospital when appropriate. There can be significant heterogeneity in how comanagement is implemented across institutions.⁴

With respect to hip fractures, literature suggests that subspecialists value comanagement and that comanagement is associated with reductions in hospital length of stay, timelier surgical repair, and potential cost savings for hospitals.^5-7 Some studies have found reductions in in-hospital and 1-year mortality (including one meta-analysis on ortho-geriatric comanagement)⁸ and complications,⁹ but others have found no such benefits.^10,11

In the current issue of the Journal of Hospital Medicine, Maxwell and Mirza used data from the National Surgical Quality Improvement Program (NSQIP) Participant Use Data File (PUF)—specifically, from the Hip Fracture PUF—to investigate the relationship between comanagement and mortality and major morbidity among more than 15,000 patients hospitalized with hip fracture.¹² The investigators did not find that comanagement was associated with a reduction in either morbidity or mortality.

Several factors give gravitas to their analysis. First, the NSQIP PUF is an extremely rigorous data source for evaluating surgical outcomes. Originally developed in the US Veterans Health Administration in the 1980’s to standardize data elements needed for quality improvement and hospital benchmarking, today NSQIP involves more than 600 hospitals in 9 different countries submitting hundreds of thousands of cases annually.¹³ Second, the authors recognized that the comanagement and noncomanagement groups differed substantially and used propensity score matching in an effort to account for these differences. Surprisingly, they found that the comanagement had significantly higher mortality and morbidity than the noncomanagement group, even after propensity score matching.

These results are important in testing the assumption of the inherent “good” of comanagement. Does this study provide definitive evidence that surgical comanagement does not improve outcomes? We would suggest that this study be interpreted in light of certain considerations.

First, comanagement is a broad term including a variety of operationalizations, such as geriatrician vs hospitalist comanagement, involvement before vs after surgery, and varying divisions of responsibility between the surgical and medical services. Research indicates that successful comanagement models tend to incorporate multidisciplinary teams, embrace the “dual primary caregiver” nature of comanagement, and shared goals among primary caregivers, specifically anticipating prevention of complications.⁵ The NSQIP data do not provide sufficient granularity to allow for investigation of these crucial nuances that may ultimately determine whether comanagement programs are effective. Additionally, comanagement often (but not always) coexists with a care pathway, and so deficiencies in or absence of a care pathway add additional heterogeneity to the comanagement group which is not captured in the NSQIP PUF.

Second, it is important to consider the potential for unmeasured confounding. The propensity score matching did seem to achieve balance in the distribution of most baseline variables between the comanagement and noncomanagement groups, though differences remain for certain covariates. A key assumption in propensity score matching (and in observational research more broadly) is the principle of “no unmeasured confounders” (ie, the assumption that all variables that might influence treatment assignment and outcomes are measured).¹⁴ For the NSQIP PUF this absence of unmeasured confounders is clearly not the case because hospital and surgeon variables are omitted from the PUF for reasons of confidentiality. Inclusion of hospital and surgeon variables could well be important because outcomes may vary by hospital or by surgeon, and simultaneously, different hospitals and different surgeons will have different protocols and preferences regarding comanagement. Furthermore, confounding is virtually guaranteed to the extent that hospitals and surgeons do not randomly assign hip fracture patients to comanagement or usual care. The finding of higher mortality in the comanagement group, even after adjustment and matching, suggests the presence of residual confounding. Even if residual confounding is the explanation for the worse outcomes observed in the comanagement group, the finding of a lack of benefit of comanagement is noteworthy and should not be dismissed out of hand.

Limitations aside, these results suggest a need for humility among strong proponents of comanagement, at least in the hip fracture population. While it may still be reasonable to claim that comanagement improves efficiency and may enhance certain aspects of patient or physician satisfaction, the lack of an impact on mortality highlights a need to examine the benefits of these programs more carefully. From a clinical perspective, hospitalists and orthopedic surgeons should consider which hip fracture patients might be most likely to benefit from comanagement.⁴ From a research perspective, the current study highlights the pressing need for a randomized trial of comanagement to definitively address the effectiveness of these programs.

The ability to detect myocardial injury has never been more advanced. With the availability of high-­sensitivity troponin testing, microscopic evidence of myocyte death can now be detected, often within an hour or so of the inciting event. This, in turn, has facilitated quicker and more accurate identification and treatment of affected patients. However, these advances in detection have, in some cases, outstripped our understanding of the etiology and appropriate management of troponin elevation.

This dilemma is particularly apparent among patients undergoing noncardiac surgery. Annually, over 200 million of these surgeries occur worldwide, many in patients with elevated cardiac risk or overt cardiac disease. Naturally, physicians treating these patients are concerned that the stress of surgery will provoke myocardial injury. Since symptoms are often masked in the immediate postoperative period because of sedating or analgesic medications, many physicians rely on troponin testing to detect signs of myocardial injury. With the increased sensitivity of these assays, the prevalence of troponin elevation has increased, which currently affects nearly one in five postoperative patients. This knowledge, however, doesn’t lend itself to a clear management strategy, particularly in those patients with no other objective evidence of infarction. To paraphrase T.S. Eliot, have we lost the wisdom in our knowledge?

In this journal issue, Cohn and colleagues summarize the current information around this phenomenon of myocardial injury after noncardiac surgery, or MINS.¹ Consistent with the literature, they define MINS as an acute rise and/or fall in troponin (above the assay’s upper limit of normal) at any point in the 30 days following noncardiac surgery. Importantly, MINS is an umbrella term that can indicate either a myocardial infarction (MI) or nonischemic myocardial injury (NIMI). An MI exists if there are clinical signs of ischemia and/or objective evidence of infarction on imaging.

The authors found that MINS is highly prevalent (19.6%) and associated with both cardiac disease and perioperative hemodynamic stress. Between 2.9% and 13.5% of MINS patients experienced 30-day adverse cardiac events, with higher rates in patients with higher troponin elevations and/or accompanying ischemic symptoms. The authors suggested MINS management with standard cardio-protective medications, such as statins, beta-blockers, and angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers. For those patients at low bleeding risk, they also suggested dabigatran based on the recent MANAGE trial. Finally, they noted that US cardiac society guidelines suggested no screening for MINS, while the European and Canadian guidelines advocated for screening in patients at high risk for cardiac complications.

The authors are to be congratulated for highlighting an important and vexing area of postoperative management. To date, it has been difficult to chart the best path forward for these patients because we could “see” the issue, thanks to increasingly sensitive troponin assays, but we didn’t know what to do once we found it.

So what rationale exists to justify screening? Some advocate that the presence of MINS suggests a need for further imaging and closer monitoring of these patients to identify those with an MI. Indeed, several recent MINS registry studies have found that 20% to 40% of MINS patients had definitive evidence of MI.^2-4 But what about those patients with troponin elevation and no evidence of MI? A small, propensity-matched, observational study of MINS patients, including those without MI, noted positive associations between cardioprotective medications, such as aspirin and statins, and cardiac outcomes.⁵ In addition, the MANAGE trial suggested that MINS patients, with or without evidence of an MI, receiving dabigatran had reduced vascular events without increased bleeding complications.⁶ With this growing base of evidence, the rationale for systematic screening for MINS appears to be standing on stronger footing.

As noted by the authors, the recommendations for MINS screening differ across three major cardiovascular societies. How does the practicing clinician make sense of this discordant advice? Differences often occur when the evidence is of moderate or low quality, which means guideline committees must make their own interpretations of equivocal findings. Another driver of discordant recommendations is the timing of the guidelines. Both the US and European guidelines were published in 2014, while the Canadian guidelines were published in 2017. Over time, experience with postoperative troponin testing increased, which may have influenced the Canadian guidelines. Finally, many members of the Canadian guideline writing committee were the ones conducting the various studies identifying management options for MINS patients, which may have guided their ultimate recommendation. Regardless, practicing physicians should collectively view the guidelines as acceptable “guardrails” to guide their practice. Selection of the appropriate strategy can then be tailored to the individual patient’s risks and benefits, as well as available management options.

In this era of high-sensitivity troponin testing, we now possess an exquisite opportunity to “see” minute levels of myocardial injury among postoperative patients. Our growing ability to effectively act on this knowledge will enable us to make wise decisions with our patients to optimize their cardiac outcomes during the vulnerable postoperative period.

The ability to detect myocardial injury has never been more advanced. With the availability of high-­sensitivity troponin testing, microscopic evidence of myocyte death can now be detected, often within an hour or so of the inciting event. This, in turn, has facilitated quicker and more accurate identification and treatment of affected patients. However, these advances in detection have, in some cases, outstripped our understanding of the etiology and appropriate management of troponin elevation.

This dilemma is particularly apparent among patients undergoing noncardiac surgery. Annually, over 200 million of these surgeries occur worldwide, many in patients with elevated cardiac risk or overt cardiac disease. Naturally, physicians treating these patients are concerned that the stress of surgery will provoke myocardial injury. Since symptoms are often masked in the immediate postoperative period because of sedating or analgesic medications, many physicians rely on troponin testing to detect signs of myocardial injury. With the increased sensitivity of these assays, the prevalence of troponin elevation has increased, which currently affects nearly one in five postoperative patients. This knowledge, however, doesn’t lend itself to a clear management strategy, particularly in those patients with no other objective evidence of infarction. To paraphrase T.S. Eliot, have we lost the wisdom in our knowledge?

In this journal issue, Cohn and colleagues summarize the current information around this phenomenon of myocardial injury after noncardiac surgery, or MINS.¹ Consistent with the literature, they define MINS as an acute rise and/or fall in troponin (above the assay’s upper limit of normal) at any point in the 30 days following noncardiac surgery. Importantly, MINS is an umbrella term that can indicate either a myocardial infarction (MI) or nonischemic myocardial injury (NIMI). An MI exists if there are clinical signs of ischemia and/or objective evidence of infarction on imaging.

The authors found that MINS is highly prevalent (19.6%) and associated with both cardiac disease and perioperative hemodynamic stress. Between 2.9% and 13.5% of MINS patients experienced 30-day adverse cardiac events, with higher rates in patients with higher troponin elevations and/or accompanying ischemic symptoms. The authors suggested MINS management with standard cardio-protective medications, such as statins, beta-blockers, and angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers. For those patients at low bleeding risk, they also suggested dabigatran based on the recent MANAGE trial. Finally, they noted that US cardiac society guidelines suggested no screening for MINS, while the European and Canadian guidelines advocated for screening in patients at high risk for cardiac complications.

The authors are to be congratulated for highlighting an important and vexing area of postoperative management. To date, it has been difficult to chart the best path forward for these patients because we could “see” the issue, thanks to increasingly sensitive troponin assays, but we didn’t know what to do once we found it.

So what rationale exists to justify screening? Some advocate that the presence of MINS suggests a need for further imaging and closer monitoring of these patients to identify those with an MI. Indeed, several recent MINS registry studies have found that 20% to 40% of MINS patients had definitive evidence of MI.^2-4 But what about those patients with troponin elevation and no evidence of MI? A small, propensity-matched, observational study of MINS patients, including those without MI, noted positive associations between cardioprotective medications, such as aspirin and statins, and cardiac outcomes.⁵ In addition, the MANAGE trial suggested that MINS patients, with or without evidence of an MI, receiving dabigatran had reduced vascular events without increased bleeding complications.⁶ With this growing base of evidence, the rationale for systematic screening for MINS appears to be standing on stronger footing.

As noted by the authors, the recommendations for MINS screening differ across three major cardiovascular societies. How does the practicing clinician make sense of this discordant advice? Differences often occur when the evidence is of moderate or low quality, which means guideline committees must make their own interpretations of equivocal findings. Another driver of discordant recommendations is the timing of the guidelines. Both the US and European guidelines were published in 2014, while the Canadian guidelines were published in 2017. Over time, experience with postoperative troponin testing increased, which may have influenced the Canadian guidelines. Finally, many members of the Canadian guideline writing committee were the ones conducting the various studies identifying management options for MINS patients, which may have guided their ultimate recommendation. Regardless, practicing physicians should collectively view the guidelines as acceptable “guardrails” to guide their practice. Selection of the appropriate strategy can then be tailored to the individual patient’s risks and benefits, as well as available management options.

In this era of high-sensitivity troponin testing, we now possess an exquisite opportunity to “see” minute levels of myocardial injury among postoperative patients. Our growing ability to effectively act on this knowledge will enable us to make wise decisions with our patients to optimize their cardiac outcomes during the vulnerable postoperative period.

The ability to detect myocardial injury has never been more advanced. With the availability of high-­sensitivity troponin testing, microscopic evidence of myocyte death can now be detected, often within an hour or so of the inciting event. This, in turn, has facilitated quicker and more accurate identification and treatment of affected patients. However, these advances in detection have, in some cases, outstripped our understanding of the etiology and appropriate management of troponin elevation.

This dilemma is particularly apparent among patients undergoing noncardiac surgery. Annually, over 200 million of these surgeries occur worldwide, many in patients with elevated cardiac risk or overt cardiac disease. Naturally, physicians treating these patients are concerned that the stress of surgery will provoke myocardial injury. Since symptoms are often masked in the immediate postoperative period because of sedating or analgesic medications, many physicians rely on troponin testing to detect signs of myocardial injury. With the increased sensitivity of these assays, the prevalence of troponin elevation has increased, which currently affects nearly one in five postoperative patients. This knowledge, however, doesn’t lend itself to a clear management strategy, particularly in those patients with no other objective evidence of infarction. To paraphrase T.S. Eliot, have we lost the wisdom in our knowledge?

In this journal issue, Cohn and colleagues summarize the current information around this phenomenon of myocardial injury after noncardiac surgery, or MINS.¹ Consistent with the literature, they define MINS as an acute rise and/or fall in troponin (above the assay’s upper limit of normal) at any point in the 30 days following noncardiac surgery. Importantly, MINS is an umbrella term that can indicate either a myocardial infarction (MI) or nonischemic myocardial injury (NIMI). An MI exists if there are clinical signs of ischemia and/or objective evidence of infarction on imaging.

The authors found that MINS is highly prevalent (19.6%) and associated with both cardiac disease and perioperative hemodynamic stress. Between 2.9% and 13.5% of MINS patients experienced 30-day adverse cardiac events, with higher rates in patients with higher troponin elevations and/or accompanying ischemic symptoms. The authors suggested MINS management with standard cardio-protective medications, such as statins, beta-blockers, and angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers. For those patients at low bleeding risk, they also suggested dabigatran based on the recent MANAGE trial. Finally, they noted that US cardiac society guidelines suggested no screening for MINS, while the European and Canadian guidelines advocated for screening in patients at high risk for cardiac complications.

The authors are to be congratulated for highlighting an important and vexing area of postoperative management. To date, it has been difficult to chart the best path forward for these patients because we could “see” the issue, thanks to increasingly sensitive troponin assays, but we didn’t know what to do once we found it.

So what rationale exists to justify screening? Some advocate that the presence of MINS suggests a need for further imaging and closer monitoring of these patients to identify those with an MI. Indeed, several recent MINS registry studies have found that 20% to 40% of MINS patients had definitive evidence of MI.^2-4 But what about those patients with troponin elevation and no evidence of MI? A small, propensity-matched, observational study of MINS patients, including those without MI, noted positive associations between cardioprotective medications, such as aspirin and statins, and cardiac outcomes.⁵ In addition, the MANAGE trial suggested that MINS patients, with or without evidence of an MI, receiving dabigatran had reduced vascular events without increased bleeding complications.⁶ With this growing base of evidence, the rationale for systematic screening for MINS appears to be standing on stronger footing.

As noted by the authors, the recommendations for MINS screening differ across three major cardiovascular societies. How does the practicing clinician make sense of this discordant advice? Differences often occur when the evidence is of moderate or low quality, which means guideline committees must make their own interpretations of equivocal findings. Another driver of discordant recommendations is the timing of the guidelines. Both the US and European guidelines were published in 2014, while the Canadian guidelines were published in 2017. Over time, experience with postoperative troponin testing increased, which may have influenced the Canadian guidelines. Finally, many members of the Canadian guideline writing committee were the ones conducting the various studies identifying management options for MINS patients, which may have guided their ultimate recommendation. Regardless, practicing physicians should collectively view the guidelines as acceptable “guardrails” to guide their practice. Selection of the appropriate strategy can then be tailored to the individual patient’s risks and benefits, as well as available management options.

In this era of high-sensitivity troponin testing, we now possess an exquisite opportunity to “see” minute levels of myocardial injury among postoperative patients. Our growing ability to effectively act on this knowledge will enable us to make wise decisions with our patients to optimize their cardiac outcomes during the vulnerable postoperative period.

In this issue of the Journal of Hospital Medicine, Dr. Thomson and colleagues present an analysis of 4,700 hospitalizations in the Pediatric Health Information System (PHIS) database to compare the effectiveness of different antibiotic regimens for children with neurological impairment and aspiration pneumonia.¹ After adjusting for potential confounders, including illness severity markers and demographic factors, they observed that receiving anaerobic coverage was associated with improvements in rates of acute respiratory failure, intensive care unit (ICU) transfer frequency, and length of stay. Given that the authors used an administrative database, several considerations limit the generalizability of the current study. These limitations include that only patients hospitalized at freestanding children’s hospitals were included, the incomplete ability to assess illness severity, and the absence of validated clinical criteria for the diagnosis of aspiration pneumonia. Despite the limitations of a retrospective study using administrative data, the authors should be commended for their rigorous analyses and for their important contribution to the care of this understudied population.

Optimizing appropriate antibiotic therapy for children with suspected aspiration pneumonia is challenging for several reasons. First, previous epidemiological studies demonstrated that viruses cause most pediatric community-acquired pneumonia²; however, we lack tools to identify patients who do not require antibiotic therapy. Second, current clinical guidelines on community-acquired pneumonia do not address aspiration pneumonia diagnosis and management.³ Similar to community-acquired pneumonia, aspiration pneumonia is a clinical diagnosis supported by patient history and laboratory and radiographic data. Given the lack of a gold standard, diagnosis of aspiration pneumonia is difficult to confirm. Previous studies using the PHIS database have demonstrated that, compared with children with nonaspiration pneumonia, those with aspiration pneumonia International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes feature higher rates of mortality, ICU-level care, and 30-day readmission rates.^4,5 However, in these studies, patients with an ICD-9-CM code for aspiration pneumonia were also more medically complex, with a higher number of complex chronic conditions and rates of technology use. Lastly, aspiration pneumonia is occasionally synonymous with pneumonia in medically complex patients, which leads to the increased exposure to broad-­spectrum antibiotics. The exposure to broad-spectrum antibiotics causes complications, such as Clostridioides difficile infection and potential antibiotic resistance in a patient population that already experiences significant antibiotic exposure.

Growing concerns about antibiotic overuse and the declining prevalence of anaerobic isolates among adult pneumonia patients recently prompted the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) to discourage routine anaerobic coverage among adults with suspected aspiration pneumonia and no abscess or empyema.⁶ These guidelines overturn years of habit for most adult hospitalists, although the IDSA and ATS acknowledge the extremely low quality of evidence informing the recommendation. Thus, the dilemma is whether the IDSA/ATS guidelines should be reconciled with the conclusions of Thomson et al. The answer is “not necessarily.” Fundamentally, different causes of neurological impairment, such as dementia and stroke, afflict elderly adults with aspiration pneumonia along with important differences in physiological and microbiological exposures. Instead, adult and pediatric hospitalists can find common ground around the shared uncertainty and variability in diagnosing aspiration pneumonia and the need for more credible evidence. Unfortunately, wide variation in diagnosis and coding practices might complicate the efforts to reproduce Thomson’s rigorous retrospective cohort study in large adult databases⁷ given that Medicare-quality comparison programs may have inadvertently encouraged changes in coding behaviors during the last decade. Attributing pneumonia cases to aspiration removed high-risk patients from reporting cohorts, thus improving a hospital’s apparent mortality rate for community-acquired pneumonia. Although the United States Centers for Medicare & Medicaid Services amended rules in 2017 to address this concern, years of overdiagnosis of aspiration pneumonia possibly biased adult administrative data sets.

Although the association between the use of anaerobic antibiotic coverage and improved pediatric outcomes is promising, these results also point out the need for rigorous prospective studies to improve the evidence base for the diagnosis and treatment of suspected aspiration pneumonia in hospitalized patients of all ages. Given the heterogeneity in the use of aspiration pneumonia diagnoses, foundational work might include assessing the factors that influence clinicians in deciding on the diagnosis of aspiration pneumonia (versus community-­acquired pneumonia). On the patient side, parallel trials may start with multicenter, prospective cohort studies to gain insights into the demographic, clinical, and laboratory factors that are associated with the diagnosis of aspiration pneumonia. This research direction may lead to the development and standardization of diagnostic criteria for aspiration pneumonia. Ultimately, prospective randomized controlled trials are needed to assess the comparative effectiveness of different antibiotic choices on clinical outcomes.

In this issue of the Journal of Hospital Medicine, Dr. Thomson and colleagues present an analysis of 4,700 hospitalizations in the Pediatric Health Information System (PHIS) database to compare the effectiveness of different antibiotic regimens for children with neurological impairment and aspiration pneumonia.¹ After adjusting for potential confounders, including illness severity markers and demographic factors, they observed that receiving anaerobic coverage was associated with improvements in rates of acute respiratory failure, intensive care unit (ICU) transfer frequency, and length of stay. Given that the authors used an administrative database, several considerations limit the generalizability of the current study. These limitations include that only patients hospitalized at freestanding children’s hospitals were included, the incomplete ability to assess illness severity, and the absence of validated clinical criteria for the diagnosis of aspiration pneumonia. Despite the limitations of a retrospective study using administrative data, the authors should be commended for their rigorous analyses and for their important contribution to the care of this understudied population.

Optimizing appropriate antibiotic therapy for children with suspected aspiration pneumonia is challenging for several reasons. First, previous epidemiological studies demonstrated that viruses cause most pediatric community-acquired pneumonia²; however, we lack tools to identify patients who do not require antibiotic therapy. Second, current clinical guidelines on community-acquired pneumonia do not address aspiration pneumonia diagnosis and management.³ Similar to community-acquired pneumonia, aspiration pneumonia is a clinical diagnosis supported by patient history and laboratory and radiographic data. Given the lack of a gold standard, diagnosis of aspiration pneumonia is difficult to confirm. Previous studies using the PHIS database have demonstrated that, compared with children with nonaspiration pneumonia, those with aspiration pneumonia International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes feature higher rates of mortality, ICU-level care, and 30-day readmission rates.^4,5 However, in these studies, patients with an ICD-9-CM code for aspiration pneumonia were also more medically complex, with a higher number of complex chronic conditions and rates of technology use. Lastly, aspiration pneumonia is occasionally synonymous with pneumonia in medically complex patients, which leads to the increased exposure to broad-­spectrum antibiotics. The exposure to broad-spectrum antibiotics causes complications, such as Clostridioides difficile infection and potential antibiotic resistance in a patient population that already experiences significant antibiotic exposure.

Growing concerns about antibiotic overuse and the declining prevalence of anaerobic isolates among adult pneumonia patients recently prompted the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) to discourage routine anaerobic coverage among adults with suspected aspiration pneumonia and no abscess or empyema.⁶ These guidelines overturn years of habit for most adult hospitalists, although the IDSA and ATS acknowledge the extremely low quality of evidence informing the recommendation. Thus, the dilemma is whether the IDSA/ATS guidelines should be reconciled with the conclusions of Thomson et al. The answer is “not necessarily.” Fundamentally, different causes of neurological impairment, such as dementia and stroke, afflict elderly adults with aspiration pneumonia along with important differences in physiological and microbiological exposures. Instead, adult and pediatric hospitalists can find common ground around the shared uncertainty and variability in diagnosing aspiration pneumonia and the need for more credible evidence. Unfortunately, wide variation in diagnosis and coding practices might complicate the efforts to reproduce Thomson’s rigorous retrospective cohort study in large adult databases⁷ given that Medicare-quality comparison programs may have inadvertently encouraged changes in coding behaviors during the last decade. Attributing pneumonia cases to aspiration removed high-risk patients from reporting cohorts, thus improving a hospital’s apparent mortality rate for community-acquired pneumonia. Although the United States Centers for Medicare & Medicaid Services amended rules in 2017 to address this concern, years of overdiagnosis of aspiration pneumonia possibly biased adult administrative data sets.

Although the association between the use of anaerobic antibiotic coverage and improved pediatric outcomes is promising, these results also point out the need for rigorous prospective studies to improve the evidence base for the diagnosis and treatment of suspected aspiration pneumonia in hospitalized patients of all ages. Given the heterogeneity in the use of aspiration pneumonia diagnoses, foundational work might include assessing the factors that influence clinicians in deciding on the diagnosis of aspiration pneumonia (versus community-­acquired pneumonia). On the patient side, parallel trials may start with multicenter, prospective cohort studies to gain insights into the demographic, clinical, and laboratory factors that are associated with the diagnosis of aspiration pneumonia. This research direction may lead to the development and standardization of diagnostic criteria for aspiration pneumonia. Ultimately, prospective randomized controlled trials are needed to assess the comparative effectiveness of different antibiotic choices on clinical outcomes.

In this issue of the Journal of Hospital Medicine, Dr. Thomson and colleagues present an analysis of 4,700 hospitalizations in the Pediatric Health Information System (PHIS) database to compare the effectiveness of different antibiotic regimens for children with neurological impairment and aspiration pneumonia.¹ After adjusting for potential confounders, including illness severity markers and demographic factors, they observed that receiving anaerobic coverage was associated with improvements in rates of acute respiratory failure, intensive care unit (ICU) transfer frequency, and length of stay. Given that the authors used an administrative database, several considerations limit the generalizability of the current study. These limitations include that only patients hospitalized at freestanding children’s hospitals were included, the incomplete ability to assess illness severity, and the absence of validated clinical criteria for the diagnosis of aspiration pneumonia. Despite the limitations of a retrospective study using administrative data, the authors should be commended for their rigorous analyses and for their important contribution to the care of this understudied population.

Optimizing appropriate antibiotic therapy for children with suspected aspiration pneumonia is challenging for several reasons. First, previous epidemiological studies demonstrated that viruses cause most pediatric community-acquired pneumonia²; however, we lack tools to identify patients who do not require antibiotic therapy. Second, current clinical guidelines on community-acquired pneumonia do not address aspiration pneumonia diagnosis and management.³ Similar to community-acquired pneumonia, aspiration pneumonia is a clinical diagnosis supported by patient history and laboratory and radiographic data. Given the lack of a gold standard, diagnosis of aspiration pneumonia is difficult to confirm. Previous studies using the PHIS database have demonstrated that, compared with children with nonaspiration pneumonia, those with aspiration pneumonia International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes feature higher rates of mortality, ICU-level care, and 30-day readmission rates.^4,5 However, in these studies, patients with an ICD-9-CM code for aspiration pneumonia were also more medically complex, with a higher number of complex chronic conditions and rates of technology use. Lastly, aspiration pneumonia is occasionally synonymous with pneumonia in medically complex patients, which leads to the increased exposure to broad-­spectrum antibiotics. The exposure to broad-spectrum antibiotics causes complications, such as Clostridioides difficile infection and potential antibiotic resistance in a patient population that already experiences significant antibiotic exposure.

Growing concerns about antibiotic overuse and the declining prevalence of anaerobic isolates among adult pneumonia patients recently prompted the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) to discourage routine anaerobic coverage among adults with suspected aspiration pneumonia and no abscess or empyema.⁶ These guidelines overturn years of habit for most adult hospitalists, although the IDSA and ATS acknowledge the extremely low quality of evidence informing the recommendation. Thus, the dilemma is whether the IDSA/ATS guidelines should be reconciled with the conclusions of Thomson et al. The answer is “not necessarily.” Fundamentally, different causes of neurological impairment, such as dementia and stroke, afflict elderly adults with aspiration pneumonia along with important differences in physiological and microbiological exposures. Instead, adult and pediatric hospitalists can find common ground around the shared uncertainty and variability in diagnosing aspiration pneumonia and the need for more credible evidence. Unfortunately, wide variation in diagnosis and coding practices might complicate the efforts to reproduce Thomson’s rigorous retrospective cohort study in large adult databases⁷ given that Medicare-quality comparison programs may have inadvertently encouraged changes in coding behaviors during the last decade. Attributing pneumonia cases to aspiration removed high-risk patients from reporting cohorts, thus improving a hospital’s apparent mortality rate for community-acquired pneumonia. Although the United States Centers for Medicare & Medicaid Services amended rules in 2017 to address this concern, years of overdiagnosis of aspiration pneumonia possibly biased adult administrative data sets.

Although the association between the use of anaerobic antibiotic coverage and improved pediatric outcomes is promising, these results also point out the need for rigorous prospective studies to improve the evidence base for the diagnosis and treatment of suspected aspiration pneumonia in hospitalized patients of all ages. Given the heterogeneity in the use of aspiration pneumonia diagnoses, foundational work might include assessing the factors that influence clinicians in deciding on the diagnosis of aspiration pneumonia (versus community-­acquired pneumonia). On the patient side, parallel trials may start with multicenter, prospective cohort studies to gain insights into the demographic, clinical, and laboratory factors that are associated with the diagnosis of aspiration pneumonia. This research direction may lead to the development and standardization of diagnostic criteria for aspiration pneumonia. Ultimately, prospective randomized controlled trials are needed to assess the comparative effectiveness of different antibiotic choices on clinical outcomes.

Core competencies are intended to provide defined expectations in a field of medicine. The newly published Pediatric Hospital Medicine (PHM) Core Competencies: 2020 Revision are an update of the original 2010 competencies¹ with added and restructured content based on relevance to current practice.^2,3 This is timely given the 2017 update to the Society of Hospital Medicine (SHM) core competencies⁴ and recent designation of PHM as a boarded subspecialty by the American Board of Pediatrics (ABP). The competencies help define the knowledge, skills, and attitudes of a pediatric hospital medicine specialist and inform curriculum development to achieve the determined expectations.

In this update to the PHM core competencies, key adjustments were made to the editorial process. Importantly, a community hospitalist was added to the editorial team; this change better reflects the proportion of care provided to hospitalized children at community sites nationwide.⁵ Content updates were considered using a two-pronged needs assessment: (1) review of recent PHM conference, textbook, and handbook content and (2) survey of the SHM, Academic Pediatric Association, and American Academy of Pediatrics stakeholder groups. These processes led to the addition of 12 chapters, the major revision of 7 chapters, and the addition of content to 29 of the original chapters.

The increased focus on mental health in the sections “Common Clinical Diagnoses and Conditions” and “Specialized Services” is a necessary update. Chapters on neonatal abstinence syndrome (NAS), substance abuse, and altered mental status were added to the “Common Clinical Diagnoses and Conditions” section. The increasing incidence of NAS has been well described, and the field of PHM has been instrumental in improving care for these patients.⁶ Children hospitalized with mental health diagnoses constitute a substantial portion of pediatric inpatient admissions,⁷ and we anticipate that it will be a continued area of need in PHM. Therefore, the addition of chapters on acute and chronic behavioral and psychiatric conditions in the “Specialized Services” section is noteworthy. In contrast, with the added chapters on constipation and gastrointestinal and digestive disorders, the gastrointestinal disorders may be disproportionately represented in the updated competencies and may be an area to streamline in future iterations.

Recognition of changing procedural needs in the inpatient pediatric setting, particularly with the growing population of children with medical complexity, resulted in removal of suprapubic bladder taps and addition of vesicostomy care to the “Core Skills” section. In future updates, it will be important to continue to remove practices that are no longer relevant or widespread and include advances in procedural skills applicable to PHM such as point-of-care ultrasound.⁸

The “Healthcare Systems” section highlights additional skills ranging from quality improvement and research to family-­centered care that PHM physicians bring to healthcare institutions. According to a recent survey of early-career hospitalists, skills in these areas are often not adequately developed during residency training.⁹ Therefore, the competencies outlined in this section are a key part of proposed PHM fellowship curricula¹⁰ and should be recognized as potential development opportunities for junior faculty in the field. This section also highlights the increasing medical complexity of patients and evolving role of PHM expertise in comanagement and consultation to improve quality and safety of care. Appreciating the unique needs of underserved communities is another important addition in the new chapter on family-centered care.

Looking ahead to future updates, we appreciate that the editors commented on diversity in both editorship and authorship. In line with the recent call for improved representation of women and racial and ethnic minorities in academic medicine by the Journal of Hospital Medicine,¹¹ future core competency publications should broadly consider diversity in editors, authors, and reviewers and more explicitly address methods for increasing diversity. We also anticipate that technological advances, such as telemedicine and remote patient monitoring, will be at the forefront in subsequent updates, which will allow higher levels of care to be provided outside of the traditional hospital structure. With the recent inauguration of the ABP PHM certification exam and the first cycle of Accreditation Council for Graduate Medical Education accreditation for PHM fellowships, these updated competencies are timely and relevant. The authors’ ongoing efforts are crucial for our young and evolving field as we strive to improve the health of all hospitalized children.

The authors have nothing to disclose.

Core competencies are intended to provide defined expectations in a field of medicine. The newly published Pediatric Hospital Medicine (PHM) Core Competencies: 2020 Revision are an update of the original 2010 competencies¹ with added and restructured content based on relevance to current practice.^2,3 This is timely given the 2017 update to the Society of Hospital Medicine (SHM) core competencies⁴ and recent designation of PHM as a boarded subspecialty by the American Board of Pediatrics (ABP). The competencies help define the knowledge, skills, and attitudes of a pediatric hospital medicine specialist and inform curriculum development to achieve the determined expectations.

In this update to the PHM core competencies, key adjustments were made to the editorial process. Importantly, a community hospitalist was added to the editorial team; this change better reflects the proportion of care provided to hospitalized children at community sites nationwide.⁵ Content updates were considered using a two-pronged needs assessment: (1) review of recent PHM conference, textbook, and handbook content and (2) survey of the SHM, Academic Pediatric Association, and American Academy of Pediatrics stakeholder groups. These processes led to the addition of 12 chapters, the major revision of 7 chapters, and the addition of content to 29 of the original chapters.

The increased focus on mental health in the sections “Common Clinical Diagnoses and Conditions” and “Specialized Services” is a necessary update. Chapters on neonatal abstinence syndrome (NAS), substance abuse, and altered mental status were added to the “Common Clinical Diagnoses and Conditions” section. The increasing incidence of NAS has been well described, and the field of PHM has been instrumental in improving care for these patients.⁶ Children hospitalized with mental health diagnoses constitute a substantial portion of pediatric inpatient admissions,⁷ and we anticipate that it will be a continued area of need in PHM. Therefore, the addition of chapters on acute and chronic behavioral and psychiatric conditions in the “Specialized Services” section is noteworthy. In contrast, with the added chapters on constipation and gastrointestinal and digestive disorders, the gastrointestinal disorders may be disproportionately represented in the updated competencies and may be an area to streamline in future iterations.

Recognition of changing procedural needs in the inpatient pediatric setting, particularly with the growing population of children with medical complexity, resulted in removal of suprapubic bladder taps and addition of vesicostomy care to the “Core Skills” section. In future updates, it will be important to continue to remove practices that are no longer relevant or widespread and include advances in procedural skills applicable to PHM such as point-of-care ultrasound.⁸

The “Healthcare Systems” section highlights additional skills ranging from quality improvement and research to family-­centered care that PHM physicians bring to healthcare institutions. According to a recent survey of early-career hospitalists, skills in these areas are often not adequately developed during residency training.⁹ Therefore, the competencies outlined in this section are a key part of proposed PHM fellowship curricula¹⁰ and should be recognized as potential development opportunities for junior faculty in the field. This section also highlights the increasing medical complexity of patients and evolving role of PHM expertise in comanagement and consultation to improve quality and safety of care. Appreciating the unique needs of underserved communities is another important addition in the new chapter on family-centered care.

Looking ahead to future updates, we appreciate that the editors commented on diversity in both editorship and authorship. In line with the recent call for improved representation of women and racial and ethnic minorities in academic medicine by the Journal of Hospital Medicine,¹¹ future core competency publications should broadly consider diversity in editors, authors, and reviewers and more explicitly address methods for increasing diversity. We also anticipate that technological advances, such as telemedicine and remote patient monitoring, will be at the forefront in subsequent updates, which will allow higher levels of care to be provided outside of the traditional hospital structure. With the recent inauguration of the ABP PHM certification exam and the first cycle of Accreditation Council for Graduate Medical Education accreditation for PHM fellowships, these updated competencies are timely and relevant. The authors’ ongoing efforts are crucial for our young and evolving field as we strive to improve the health of all hospitalized children.

The authors have nothing to disclose.

Core competencies are intended to provide defined expectations in a field of medicine. The newly published Pediatric Hospital Medicine (PHM) Core Competencies: 2020 Revision are an update of the original 2010 competencies¹ with added and restructured content based on relevance to current practice.^2,3 This is timely given the 2017 update to the Society of Hospital Medicine (SHM) core competencies⁴ and recent designation of PHM as a boarded subspecialty by the American Board of Pediatrics (ABP). The competencies help define the knowledge, skills, and attitudes of a pediatric hospital medicine specialist and inform curriculum development to achieve the determined expectations.

In this update to the PHM core competencies, key adjustments were made to the editorial process. Importantly, a community hospitalist was added to the editorial team; this change better reflects the proportion of care provided to hospitalized children at community sites nationwide.⁵ Content updates were considered using a two-pronged needs assessment: (1) review of recent PHM conference, textbook, and handbook content and (2) survey of the SHM, Academic Pediatric Association, and American Academy of Pediatrics stakeholder groups. These processes led to the addition of 12 chapters, the major revision of 7 chapters, and the addition of content to 29 of the original chapters.

The increased focus on mental health in the sections “Common Clinical Diagnoses and Conditions” and “Specialized Services” is a necessary update. Chapters on neonatal abstinence syndrome (NAS), substance abuse, and altered mental status were added to the “Common Clinical Diagnoses and Conditions” section. The increasing incidence of NAS has been well described, and the field of PHM has been instrumental in improving care for these patients.⁶ Children hospitalized with mental health diagnoses constitute a substantial portion of pediatric inpatient admissions,⁷ and we anticipate that it will be a continued area of need in PHM. Therefore, the addition of chapters on acute and chronic behavioral and psychiatric conditions in the “Specialized Services” section is noteworthy. In contrast, with the added chapters on constipation and gastrointestinal and digestive disorders, the gastrointestinal disorders may be disproportionately represented in the updated competencies and may be an area to streamline in future iterations.

Recognition of changing procedural needs in the inpatient pediatric setting, particularly with the growing population of children with medical complexity, resulted in removal of suprapubic bladder taps and addition of vesicostomy care to the “Core Skills” section. In future updates, it will be important to continue to remove practices that are no longer relevant or widespread and include advances in procedural skills applicable to PHM such as point-of-care ultrasound.⁸

The “Healthcare Systems” section highlights additional skills ranging from quality improvement and research to family-­centered care that PHM physicians bring to healthcare institutions. According to a recent survey of early-career hospitalists, skills in these areas are often not adequately developed during residency training.⁹ Therefore, the competencies outlined in this section are a key part of proposed PHM fellowship curricula¹⁰ and should be recognized as potential development opportunities for junior faculty in the field. This section also highlights the increasing medical complexity of patients and evolving role of PHM expertise in comanagement and consultation to improve quality and safety of care. Appreciating the unique needs of underserved communities is another important addition in the new chapter on family-centered care.

Looking ahead to future updates, we appreciate that the editors commented on diversity in both editorship and authorship. In line with the recent call for improved representation of women and racial and ethnic minorities in academic medicine by the Journal of Hospital Medicine,¹¹ future core competency publications should broadly consider diversity in editors, authors, and reviewers and more explicitly address methods for increasing diversity. We also anticipate that technological advances, such as telemedicine and remote patient monitoring, will be at the forefront in subsequent updates, which will allow higher levels of care to be provided outside of the traditional hospital structure. With the recent inauguration of the ABP PHM certification exam and the first cycle of Accreditation Council for Graduate Medical Education accreditation for PHM fellowships, these updated competencies are timely and relevant. The authors’ ongoing efforts are crucial for our young and evolving field as we strive to improve the health of all hospitalized children.

The authors have nothing to disclose.

As an appealing, physiologically plausible treatment, humidified oxygen delivery via high-flow nasal cannula (HFNC) has been rapidly adopted for the treatment of bronchiolitis despite weak evidence supporting its routine and early use in hypoxemic infants.¹ Although HFNC use has been associated with decreased work of breathing and lower rates of progression to invasive ventilation in some studies, the one large trial published on the topic found no difference between early HFNC and standard oxygen therapy on length of stay in hospital, duration of oxygen therapy, or rates of intubation.^2,3 No adequately powered studies have examined the effect of ward-based HFNC initiation on ICU transfer, an outcome that it is designed to prevent.

In this month’s issue of the Journal of Hospital Medicine, Coon et al examine the association between the implementation of ward-based HFNC initiation protocols and subsequent ICU transfer rates.⁴ Hospitals enrolled in the Pediatric Health Information System database were surveyed about their HFNC use and protocol implementation, with 41 (93% response rate) hospitals replying, 12 of which implemented ward-based HFNC initiation protocols during 2010 to 2016. Administrative data for bronchiolitis encounters were obtained with use of International Classification of Diseases, 9th and 10th Revisions, coding of children aged 3 to 24 months discharged during the respiratory seasons of the study period. The authors used an interrupted time series analysis to study the association between ward-based HFNC protocol initiation and several outcomes, revealing a small but significant increase in ICU transfers (absolute difference, 3.1%; 95% CI, 2.8%-3.4%) and ICU length of stay (absolute difference, 9.1 days per 100 patients; 95% CI 5.1-13.2), but not overall length of stay or use of mechanical ventilation. Modifications to the analysis that account for a learning period during the first season of implementation at each hospital, and for trends among nonadopting hospitals, did not substantially affect the findings.

The authors acknowledged many of the study’s limitations, including its retrospective design, presumption of bronchiolitis discharge code validity, restriction to tertiary care hospitals, and analysis of hospital-level rather than patient-level variables and outcomes. Because the data source does not capture patient-­level HFNC use, the number and characteristics of patients receiving HFNC at the centers are unknown. It is also important to note that the 12 included protocols are quite heterogeneous, with differing exclusion criteria, maximum flow rates, and indications for ICU transfer. Given the rapid evolution of ward-based HFNC use for bronchiolitis, these protocols from 2010 to 2016 are already out of date. All of the protocols allowed much lower maximum flow rates (4-10 L/min) than would typically be expected today (usually 2 L/kg per minute, which translates to 10 L/min of flow for a 5-kg child or 20 L/min for a 10-kg child). Many also had time-based criteria prompting ICU transfer (eg, 24 hours without improvement) that are not typically included in more recent protocols. Few had instructions for weaning or discontinuation of HFNC.

In spite of the above limitations, the results of this large, multicenter study advance our understanding of the consequences of ward-based protocols for HFNC initiation. However, it is important to contextualize this work as an examination of the implementation of a technology to a broad population in a specific era, not necessarily a study of the effectiveness of the technology itself.

The pediatric hospital medicine community has long recognized the need for more evidence regarding HFNC use.^5-7 Coon et al have highlighted possible unintended consequences, notably increased ICU use, that may be associated with ward-based HFNC implementation on a population basis. This finding mirrors evidence from a recent similarly designed study analyzing Canadian tertiary care centers implementing HFNC administration during 2009 to 2014, though not specifically limited to ward use.⁸

More recently there has been discussion of how we might deimplement ward-based HFNC protocols. Although it is increasingly clear that HFNC is not a panacea for bronchiolitis, there is not necessarily a problem with the technology; the problem that this study so clearly demonstrates is how we have applied it. We need pragmatic trials of HFNC protocols to understand what parameters should guide HFNC initiation as a rescue treatment; what oxygen and flow settings might prevent ICU transfer; how it should be used in populations that have been largely excluded from trials (ie, children with medical complexity); and how to optimally wean it. With that information we could construct evidence-based, utilitarian HFNC initiation and treatment protocols to maximize benefit and minimize harm and cost.

It is understandable that our desire to help patients has led us to hear the “siren’s call” for this therapy, and indeed we should work on putting some of the “horses back in the barn.”^5,6 Until new evidence guides how to best use this technology, institutional practice guidelines for HFNC initiation in ward settings should target children for whom ICU transfer seems very likely (eg, having oxygen saturations not maintained on maximum low-flow oxygen therapy) so that HFNC is not used routinely and that we maximize its cost to benefit ratio. It is important to approach this shift in a thoughtful manner to prevent a pendulum swing to premature universal deimplementation.

As an appealing, physiologically plausible treatment, humidified oxygen delivery via high-flow nasal cannula (HFNC) has been rapidly adopted for the treatment of bronchiolitis despite weak evidence supporting its routine and early use in hypoxemic infants.¹ Although HFNC use has been associated with decreased work of breathing and lower rates of progression to invasive ventilation in some studies, the one large trial published on the topic found no difference between early HFNC and standard oxygen therapy on length of stay in hospital, duration of oxygen therapy, or rates of intubation.^2,3 No adequately powered studies have examined the effect of ward-based HFNC initiation on ICU transfer, an outcome that it is designed to prevent.

In this month’s issue of the Journal of Hospital Medicine, Coon et al examine the association between the implementation of ward-based HFNC initiation protocols and subsequent ICU transfer rates.⁴ Hospitals enrolled in the Pediatric Health Information System database were surveyed about their HFNC use and protocol implementation, with 41 (93% response rate) hospitals replying, 12 of which implemented ward-based HFNC initiation protocols during 2010 to 2016. Administrative data for bronchiolitis encounters were obtained with use of International Classification of Diseases, 9th and 10th Revisions, coding of children aged 3 to 24 months discharged during the respiratory seasons of the study period. The authors used an interrupted time series analysis to study the association between ward-based HFNC protocol initiation and several outcomes, revealing a small but significant increase in ICU transfers (absolute difference, 3.1%; 95% CI, 2.8%-3.4%) and ICU length of stay (absolute difference, 9.1 days per 100 patients; 95% CI 5.1-13.2), but not overall length of stay or use of mechanical ventilation. Modifications to the analysis that account for a learning period during the first season of implementation at each hospital, and for trends among nonadopting hospitals, did not substantially affect the findings.

The authors acknowledged many of the study’s limitations, including its retrospective design, presumption of bronchiolitis discharge code validity, restriction to tertiary care hospitals, and analysis of hospital-level rather than patient-level variables and outcomes. Because the data source does not capture patient-­level HFNC use, the number and characteristics of patients receiving HFNC at the centers are unknown. It is also important to note that the 12 included protocols are quite heterogeneous, with differing exclusion criteria, maximum flow rates, and indications for ICU transfer. Given the rapid evolution of ward-based HFNC use for bronchiolitis, these protocols from 2010 to 2016 are already out of date. All of the protocols allowed much lower maximum flow rates (4-10 L/min) than would typically be expected today (usually 2 L/kg per minute, which translates to 10 L/min of flow for a 5-kg child or 20 L/min for a 10-kg child). Many also had time-based criteria prompting ICU transfer (eg, 24 hours without improvement) that are not typically included in more recent protocols. Few had instructions for weaning or discontinuation of HFNC.

In spite of the above limitations, the results of this large, multicenter study advance our understanding of the consequences of ward-based protocols for HFNC initiation. However, it is important to contextualize this work as an examination of the implementation of a technology to a broad population in a specific era, not necessarily a study of the effectiveness of the technology itself.

The pediatric hospital medicine community has long recognized the need for more evidence regarding HFNC use.^5-7 Coon et al have highlighted possible unintended consequences, notably increased ICU use, that may be associated with ward-based HFNC implementation on a population basis. This finding mirrors evidence from a recent similarly designed study analyzing Canadian tertiary care centers implementing HFNC administration during 2009 to 2014, though not specifically limited to ward use.⁸

More recently there has been discussion of how we might deimplement ward-based HFNC protocols. Although it is increasingly clear that HFNC is not a panacea for bronchiolitis, there is not necessarily a problem with the technology; the problem that this study so clearly demonstrates is how we have applied it. We need pragmatic trials of HFNC protocols to understand what parameters should guide HFNC initiation as a rescue treatment; what oxygen and flow settings might prevent ICU transfer; how it should be used in populations that have been largely excluded from trials (ie, children with medical complexity); and how to optimally wean it. With that information we could construct evidence-based, utilitarian HFNC initiation and treatment protocols to maximize benefit and minimize harm and cost.

It is understandable that our desire to help patients has led us to hear the “siren’s call” for this therapy, and indeed we should work on putting some of the “horses back in the barn.”^5,6 Until new evidence guides how to best use this technology, institutional practice guidelines for HFNC initiation in ward settings should target children for whom ICU transfer seems very likely (eg, having oxygen saturations not maintained on maximum low-flow oxygen therapy) so that HFNC is not used routinely and that we maximize its cost to benefit ratio. It is important to approach this shift in a thoughtful manner to prevent a pendulum swing to premature universal deimplementation.

As an appealing, physiologically plausible treatment, humidified oxygen delivery via high-flow nasal cannula (HFNC) has been rapidly adopted for the treatment of bronchiolitis despite weak evidence supporting its routine and early use in hypoxemic infants.¹ Although HFNC use has been associated with decreased work of breathing and lower rates of progression to invasive ventilation in some studies, the one large trial published on the topic found no difference between early HFNC and standard oxygen therapy on length of stay in hospital, duration of oxygen therapy, or rates of intubation.^2,3 No adequately powered studies have examined the effect of ward-based HFNC initiation on ICU transfer, an outcome that it is designed to prevent.

In this month’s issue of the Journal of Hospital Medicine, Coon et al examine the association between the implementation of ward-based HFNC initiation protocols and subsequent ICU transfer rates.⁴ Hospitals enrolled in the Pediatric Health Information System database were surveyed about their HFNC use and protocol implementation, with 41 (93% response rate) hospitals replying, 12 of which implemented ward-based HFNC initiation protocols during 2010 to 2016. Administrative data for bronchiolitis encounters were obtained with use of International Classification of Diseases, 9th and 10th Revisions, coding of children aged 3 to 24 months discharged during the respiratory seasons of the study period. The authors used an interrupted time series analysis to study the association between ward-based HFNC protocol initiation and several outcomes, revealing a small but significant increase in ICU transfers (absolute difference, 3.1%; 95% CI, 2.8%-3.4%) and ICU length of stay (absolute difference, 9.1 days per 100 patients; 95% CI 5.1-13.2), but not overall length of stay or use of mechanical ventilation. Modifications to the analysis that account for a learning period during the first season of implementation at each hospital, and for trends among nonadopting hospitals, did not substantially affect the findings.

The authors acknowledged many of the study’s limitations, including its retrospective design, presumption of bronchiolitis discharge code validity, restriction to tertiary care hospitals, and analysis of hospital-level rather than patient-level variables and outcomes. Because the data source does not capture patient-­level HFNC use, the number and characteristics of patients receiving HFNC at the centers are unknown. It is also important to note that the 12 included protocols are quite heterogeneous, with differing exclusion criteria, maximum flow rates, and indications for ICU transfer. Given the rapid evolution of ward-based HFNC use for bronchiolitis, these protocols from 2010 to 2016 are already out of date. All of the protocols allowed much lower maximum flow rates (4-10 L/min) than would typically be expected today (usually 2 L/kg per minute, which translates to 10 L/min of flow for a 5-kg child or 20 L/min for a 10-kg child). Many also had time-based criteria prompting ICU transfer (eg, 24 hours without improvement) that are not typically included in more recent protocols. Few had instructions for weaning or discontinuation of HFNC.

In spite of the above limitations, the results of this large, multicenter study advance our understanding of the consequences of ward-based protocols for HFNC initiation. However, it is important to contextualize this work as an examination of the implementation of a technology to a broad population in a specific era, not necessarily a study of the effectiveness of the technology itself.

The pediatric hospital medicine community has long recognized the need for more evidence regarding HFNC use.^5-7 Coon et al have highlighted possible unintended consequences, notably increased ICU use, that may be associated with ward-based HFNC implementation on a population basis. This finding mirrors evidence from a recent similarly designed study analyzing Canadian tertiary care centers implementing HFNC administration during 2009 to 2014, though not specifically limited to ward use.⁸

More recently there has been discussion of how we might deimplement ward-based HFNC protocols. Although it is increasingly clear that HFNC is not a panacea for bronchiolitis, there is not necessarily a problem with the technology; the problem that this study so clearly demonstrates is how we have applied it. We need pragmatic trials of HFNC protocols to understand what parameters should guide HFNC initiation as a rescue treatment; what oxygen and flow settings might prevent ICU transfer; how it should be used in populations that have been largely excluded from trials (ie, children with medical complexity); and how to optimally wean it. With that information we could construct evidence-based, utilitarian HFNC initiation and treatment protocols to maximize benefit and minimize harm and cost.

It is understandable that our desire to help patients has led us to hear the “siren’s call” for this therapy, and indeed we should work on putting some of the “horses back in the barn.”^5,6 Until new evidence guides how to best use this technology, institutional practice guidelines for HFNC initiation in ward settings should target children for whom ICU transfer seems very likely (eg, having oxygen saturations not maintained on maximum low-flow oxygen therapy) so that HFNC is not used routinely and that we maximize its cost to benefit ratio. It is important to approach this shift in a thoughtful manner to prevent a pendulum swing to premature universal deimplementation.