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Growth of hospital medicine, focus on population health among changes in inpatient pediatrics :

November 4, 2016

The AAP Task Force on Pediatric Practice Change continues to chart a future for pediatric practice. Recognizing the importance of attention to hospitalized children in planning for practice change, the task force’s diverse membership includes pediatric hospitalists.

Future of pediatric hospitalists

The practice of hospital medicine has undergone tremendous growth over the past decade. Dedicated pediatric hospitalists now provide much of the care for hospitalized children.

Hospitalists are highly committed to improving the system, patient experience and outcomes of hospitalized children, following a set of standards and guiding principles recently reaffirmed by the Academy (Pediatrics. 2013;132:782-786,

Chief among factors that will influence the future practice of pediatric hospitalists is formal recognition of the field with subspecialty certification. Recently, the American Board of Pediatrics (ABP) approved pediatric hospital medicine (PHM) as the next official pediatric subspecialty. While this petition still needs American Board of Medical Specialties approval, the ABP believes the field has evolved to become a distinct discipline with its own knowledge base and set of skills. Most importantly, PHM meets an ABP requirement that recognition of a field as a subspecialty should serve the best interests of children.

While many concerns remain, especially the impact of certification on workforce availability, the example of recent subspecialties such as child abuse pediatrics and pediatric emergency medicine should reassure that subspecialty status will enhance scholarly output and improve the care of hospitalized children.

Future of hospitals

Many factors will contribute to the changing practice of inpatient pediatrics, including how population health and payment models in the hospital setting align. The move toward value-based purchasing and pay-for-performance (PFP) models should lead hospitals to address care for patients outside their walls.

One particularly relevant example is the use of readmissions as a key metric in PFP models. While the role of readmissions as a pediatric quality indicator continues to be debated (see AAP News article “Hospital readmissions another area where children differ from adults,”, the reality is that for at least certain pediatric conditions, such as asthma, hospital-based models that address population health have demonstrated promising results.

In one program, a team at a satellite hospital without an onsite pharmacy partnered with community pharmacies to provide medications at discharge. This rapid cycle improvement project increased in-hand medications for discharged patients from 0%-82% and reduced readmissions from 18% to 11% (Sauers-Ford HS, et al. Pediatrics. 2016;137:e20150039, This project highlights the importance of a hospital going beyond its walls to address factors that contribute to pediatric readmissions.

Children with medical complexity also are particularly vulnerable to readmissions (Berry JG, et al. JAMA. 2011;305:682-690, Many programs around the country are trying to address readmissions among these children. A comprehensive literature review found that children who have home visits are less likely to be readmitted to the hospital. This finding may translate to other pediatric conditions (Tubbs-Cooley HL, et al. J Adv Nurs. 2016;72:915-925,

Many factors such as improvement in diagnostic and therapeutic technologies, improved electronic medical records, information-sharing platforms to improve transitions within and between hospital systems and telemedicine also will contribute to the practice of pediatrics in hospitals. However, hospitals that go beyond their walls to improve care and address population health likely will have the most meaningful impact.

Dr. Quinonez is a member of the AAP Task Force on Pediatric Practice Change and immediate past chair of the AAP Section on Hospital Medicine Executive Committee. 

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