Bridging the Gap: Med-Peds Hospitalists Supporting Adult Patients in Children’s Hospitals Free

More than 90% of patients with a childhood-onset chronic illness will live to adulthood. Such patients tend to have high utilization of health care services, including both elective and acute care hospitalizations.¹  Many adult-aged patients with chronic diseases of childhood continue to receive acute care within children’s hospitals, whether because they are receiving ongoing care from pediatric-trained providers or because treatment protocols favor treatment in a pediatric setting.²  As this vulnerable population ages, they inevitably experience additional health issues and concerns that are more common in adulthood. This could include the development of common adult conditions, such as hypertension and gout, substance use and abuse, or patient concerns regarding medication impacts on reproduction and managing health-related issues while raising a family or holding a job. Providers trained in combined internal medicine-pediatrics (Med-Peds) offer expertise and experience surrounding the unique health care challenges faced by adults with childhood-onset diseases. When such patients are admitted to pediatric hospitals, the experience of Med-Peds providers cannot only benefit inpatient medical decisions but can also directly impact hospital care guidelines and processes, discharge planning, patient safety, and patient and provider satisfaction.

In the current study, Peterson et al describe the prevalence and roles of adult-medicine consult services within children’s hospitals in the United States.³  Such services are designed to support pediatric providers who are caring for adult-aged patients with childhood-onset chronic disease in the pediatric inpatient setting. Using a layered sampling process, the study team identified 10 institutions with adult-medicine consult services, 9 of which were actively seeing patients. All programs included Med-Peds trained providers. Through qualitative and quantitative analyses, the authors highlighted the common conditions managed and clinical areas utilizing the service, as well as facilitators and barriers to initiating and maintaining these services. The consult teams reflected that facilitators included addressing gaps in care and safety concerns related to caring for adults in a pediatric facility. This allowed pediatric providers more adaptability in caring for adult patients and presented opportunities to create centers of excellence for certain conditions. Primary barriers included funding and consistent stakeholder investment. Additionally, although these consult teams supported efforts in the transition from pediatric to adult health care, that was not their full intent, and limitations in facilitating outpatient transitional care were noted. Although single-institution adult-medicine consult services have been previously described, as well as similar consult services for young adults in adult hospitals, this is the first to provide a more comprehensive look at adult-medicine consult services nationwide.^4,5 

Although the small number of services identified by the authors could be considered a major limitation to generalizability, the authors’ comprehensive sampling process likely uncovered all available services of this type. The findings are, therefore, expected to be representative of the general state of adult-medicine consult services nationally. In fact, the small number of services identified is relatively unsurprising considering the limitations and barriers noted by the authors, including the challenge of establishing sustainable funding in the face of leadership and stakeholder changes. For adult-medicine consult programs, such as those described in the paper, that may not be financially solvent, the demonstration of outcomes must be independent of the financial bottom line. The authors report that adult-medicine consult services contributed to high-value areas, such as safety, satisfaction, and clinical excellence. Other advantages may also exist. For instance, although supporting pediatric colleagues is crucial, making such services available to pediatric surgical colleagues who continue to care for adult-aged patients could be particularly beneficial. Adult-medicine consult services could support surgeons through the control of pain after surgical procedures, management of chronic adult-onset conditions in the perioperative period, weight-based dosing of medications for smaller adult patients, and coordination of care for patients at the time of discharge. The adult consult programs could also reveal their benefit to the health care system and get buy-in from leadership by providing surge capacity during high census times to offload adult patients into children’s hospitals without compromising the quality of care.⁶  Finally, an adult-medicine consult service can provide support in managing issues related to substance use disorders. Patients at risk for alcohol or benzodiazepine withdrawal need specialized care to prevent complications, a common practice for inpatient adult medicine providers. The findings of Peterson highlight the importance of identifying and measuring unique outcomes that can reveal the critical value added by adult-medicine consult services aside from just bottom-line financials.

Also unsurprising is that the champions of these services are Med-Peds-trained providers. Med-Peds trainees gain experience in all acute, ambulatory, and specialty areas in both pediatrics and internal medicine.⁷  They gain comfort with highly complex patients of all ages, including those who are technology dependent (ie, ventilators, feeding tubes, etc). Med-Peds providers can see the advantages of applying family-centered care to the adult setting while also recognizing the importance for adolescents and young adults to have agency and gain health care independence. However, the reliance on Med-Peds providers to develop and maintain services that can support adult patients in children’s hospitals may limit the availability of such services in hospitals that do not have a robust Med-Peds presence. Additionally, if these services are primarily managed by a small cohort of Med-Peds providers at a given institution, the sustainability of such programs may be compromised if those providers change roles. It is also important to note that the adult-medicine consult programs described in the current report may be most relevant in large, well-funded, stand-alone children’s hospitals in which clinicians practicing only adult medicine may not be readily available or credentialed to see patients in the pediatric hospital. In an institution in which the care of pediatric and adult patients is provided within an integrated health system, even if pediatric care is provided in a distinct facility, it may simply be easier and more cost-efficient to consult adult medicine hospitalists or specialists to assist with the care of adult-aged patients. The current paper supports the important role of providing age-appropriate services to adult patients in children’s hospitals, particularly as the population of adults with childhood-onset disease continues to grow. As such, institutions could benefit from supporting these services whether dual-trained providers are available or not.

Additional reflection on the role of adult-medicine services in facilitating transitions of care is valuable. In this report, it was noted that the adult-medicine consult services often served to support transitional care services, but these efforts were not the primary goal. Although the transition from pediatric to adult care is primarily considered to be a longitudinal, outpatient process,⁸  inpatient consult teams that specifically address transitional care needs have noted the ability to dispel myths about adult services, advise patients on navigating the health care system, and use interdisciplinary inpatient teams, including social work, care coordination managers, and pharmacists.^9,10  The authors of other literature have described the efforts of specific transitional care consult teams or explored the feasibility of inpatient transitional care.^9,11  During an acute care hospitalization, discussions around transition timing, medication education, insurance concerns, and plans to transition to an adult inpatient setting can be provided and add value to the outpatient transition process. Med-Peds-trained providers on adult-medicine consult services may be uniquely poised to provide this transitional support.¹² 

As the care of the pediatric patient with a chronic disease of childhood continues to improve and prolong life, the management of these patients as they enter adulthood will grow increasingly complex. For some, all care should transition to adult medical services, an ongoing process that can be facilitated during inpatient stays. For others, some care may continue to be best provided in a pediatric setting. For them, and for the pediatric providers caring for them, adult-medicine consult services can be immensely beneficial by ensuring that patients receive the care they need for their chronic disease, as well as issues that arise as they progress through adulthood. Supporting and sustaining such programs, whether led by Med-Peds-trained providers or other adult medicine-trained providers, should be an important goal for children’s hospitals looking to provide the highest-quality care to some of their most complex and vulnerable patients.