Hand hygiene (HH) is believed to be one of the single most important interventions to prevent healthcare‐associated infection, yet physicians are notorious for their poor compliance.[1, 2, 3] At our 800‐bed acute care academic hospital, we implemented a multifaceted HH program[4] in 2007, which was associated with improved HH compliance rates from 43% to 87%. Despite this improvement, HH compliance among physicians remained suboptimal, with rates below 60% in some patient areas. A targeted campaign focused on recruitment of physician champions, resulted in some improvement, but physician compliance has consistently remained below performance of nurses (70%75% for physicians vs 85%90% for nurses).

Our experience parallels the results seen in multinational surveys demonstrating consistently lower physician HH compliance.[5] Given the multiple improvement efforts directed at physicians and the apparent ceiling observed in HH performance, we wanted to confirm whether physicians are truly recalcitrant to cleaning their hands, or whether lower compliance among physicians reflected a differential in the Hawthorne effect inherent to direct observation methods. Specifically, we wondered if nurses tend to recognize auditors more readily than physicians and therefore show higher apparent HH compliance when auditors are present. We also wanted to verify whether the behavior of attending physicians influenced compliance of their physician trainees. To test these hypotheses, we trained 2 clinical observers to covertly measure HH compliance of nurses and physicians on 3 different clinical services.

METHODS

Between May 27, 2015 and July 31, 2015, 2 student observers joined clinical rotations on physician and nursing teams, respectively. Healthcare teams were unaware that the student observers were measuring HH compliance during their clinical rotation. Students rotated in the emergency department, general medical and surgical wards for no more than 1 week at a time to increase exposure to different providers and minimize risk of exposing the covert observation.

Prior to the study period, the students underwent training and validation with a hospital HH auditor at another clinical setting offsite to avoid any recognition of these students by healthcare providers as observers of HH at the main hospital. Training with the auditors occurred until interobserver agreement between all HH opportunities reached 100% agreement for 2 consecutive observation days.

During their rotations, students covertly recorded HH compliance based on moments of hand hygiene[4] and also noted location, presence, and compliance of the attending physician, team size during patient encounter, and isolation requirements. Both students measured HH compliance of nurses and physicians around them. Although students spent the majority of their time with their assigned physician or nurse teams, they did not limit their observations to these individuals only, but recorded compliance of any nurse or physician on the ward as long as they were within sight during an HH opportunity. To limit clustering of observations of the same healthcare worker, up to a maximum of 2 observations per healthcare worker per day was recorded.

We compared covertly measured HH compliance with data from overt observation by hospital auditors during the same time period. Differences in proportion of HH compliance were compared with hospital audits during the same period with a ² test. Difference between differences in overtly and covertly measured HH compliance for nurses and physicians was compared using Breslow day test.

The study was approved by the hospital's research ethics board. Although deception was used in this study,[2, 6] all data were collected for quality improvement purposes, and the aggregate results were disclosed to hospital staff following the study.

RESULTS

Covertly observed HH compliance was 50.0% (799/1597) compared with 83.7% (2769/3309) recorded by hospital auditors during the same time period (P < 0.0002) (Table 1). There was no significant difference in the compliance measured by each student (50.1%, 473/928 vs 48.7%, 326/669) (P = 0.3), and their results were combined for the rest of the analysis. Compliance before contact with the patient or patient environment was 43.1% (344/798), 74.3% (26/35) before clean/aseptic procedures, 34.8% (8/23) after potential body fluid exposure, and 56.8% (483/851) after contact with the patient or patient environment. Healthcare providers examining patients with isolation precautions were found to have a HH compliance of 74.8% (101/135) compared to 47.0% (385/820) when isolation precautions were not required (P < 0.0002).

Hospital auditor data showed that surgery and medicine had similarly high rates of compliance (91.0% and 85.0%, respectively), whereas the emergency department had a notably lower rate of 73.8%. Covert observation confirmed a lower rate in the emergency department (43.9%), but showed a higher compliance on general medicine than on surgery (58.9% vs 45.7%; P = 0.02). The difference in physician compliance between hospital auditors and covert observers was 19.0% (73.2%, 175/239 vs. 54.2%, 469/865); for nurses this difference was much higher at 40.7% (85.8%, 754/879 vs. 45.1%, 330/732) (P < 0.0001) (Table 1).

In terms of physician compliance, primary teams tended to have lower HH compliance of 50.4% (323/641) compared with consulting services at 57.0% (158/277) (P = 0.06). Team rounds of 3 members were associated with higher compliance compared with encounters involving <3 members (62.1%, 282/454 vs. 42.0%, 128/308) (P < 0.0002). Presence of attending physician did not affect trainee HH compliance (55.5%, 201/362 when attending present vs. 56.8%, 133/234 when attending absent; P = 0.79). However, trainee HH compliance improved markedly when attending staff cleaned their hands and decreased markedly when they did not (79.5%, 174/219 vs. 18.9%, 27/143; P < 0.0002).

DISCUSSION

We introduced covert HH observers at our hospital to determine whether differences in Hawthorne effect accounted for measured disparity between physician HH compliance, and to gain further insights into the barriers and enablers of physician HH compliance. We discovered that performance differences between physicians and nurses decreased when neither group was aware that HH was being measured, suggesting that healthcare professions are differentially affected by the Hawthorne effect. This difference may be explained by the continuity of nurses on the ward that makes them more aware of visitors like HH auditors,[7] compared with physicians who rotate periodically on the ward.

Although hospital auditors play a central role in HH education through in‐the‐moment feedback, use of these data to benchmark performance can lead to inappropriate inferences about HH compliance. Prior studies using automated HH surveillance have suggested that the magnitude of the Hawthorne effect varies based on baseline HH rates,[8] whereas our study suggests a differential Hawthorne effect between professions and clinical services. If we relied only on auditor data, we would have continued to believe that only physicians in our organization had poor HH compliance, and we would not be aware of the global nature of the HH problem.

Our results are similar to that of Pan et al., who used covert medical students to measure HH and found compliance of 44.1% compared with 94.1% by unit auditors.[2] Because their study involved an active feedback intervention, the differential in Hawthorne effect between professions could not be reliably assessed. However, they observed a progressive increase in nurse HH compliance using covert observation methods, suggesting improvement in HH performance independent of observer bias.[7]

Covert observation in our study also provided important insights regarding barriers and enablers of HH compliance. Self‐preservation behaviors were common among both nurses and physicians, as HH compliance was consistently higher after patient contact compared to before or when seeing patients who required additional precautions. This finding confirms that the perceived risk of transmission seems to be a powerful motivating factor for HH.[9] Larger groups of trainees were more likely to clean their hands, likely due to peer effects.[10] The strong impact of role modeling on HH was also noted as previously suggested in the literature,[3, 6] but our study captures the magnitude of this effect. Whether or not the attending physician cleaned their hands during rounds either positively or negatively influenced HH compliance of the rest of the physician team (80% when compliant vs 20% when noncompliant).

Our study has several important limitations. The differential Hawthorne effect seen at our center may not reflect other institutions that have numerous HH auditors or high staff turnover resulting in lower ability to recognize auditors. We cannot exclude the possibility of Hawthorne effect using covert methods that could have affected nurse and physician performance differently, but frequent rotation of the students helped maintain covertness of observations. Finally, due to the nature of the covert student observers, a longer observation time frame could not be sustained.

Our experience using covert HH auditors suggests that traditional HH audits not only overstate HH performance overall, but can lead to inaccurate inferences regarding HH performance due to relative differences in Hawthorne effect. The answer to the question regarding whether physicians clean their hands appears to be that they do just as often as nurses, but that all healthcare workers have tremendous room for improvement. We suggest that future improvement efforts will rely on more accurate HH monitoring systems and strong attending physician leadership to set an example for trainees.

Hand hygiene (HH) is believed to be one of the single most important interventions to prevent healthcare‐associated infection, yet physicians are notorious for their poor compliance.[1, 2, 3] At our 800‐bed acute care academic hospital, we implemented a multifaceted HH program[4] in 2007, which was associated with improved HH compliance rates from 43% to 87%. Despite this improvement, HH compliance among physicians remained suboptimal, with rates below 60% in some patient areas. A targeted campaign focused on recruitment of physician champions, resulted in some improvement, but physician compliance has consistently remained below performance of nurses (70%75% for physicians vs 85%90% for nurses).

Our experience parallels the results seen in multinational surveys demonstrating consistently lower physician HH compliance.[5] Given the multiple improvement efforts directed at physicians and the apparent ceiling observed in HH performance, we wanted to confirm whether physicians are truly recalcitrant to cleaning their hands, or whether lower compliance among physicians reflected a differential in the Hawthorne effect inherent to direct observation methods. Specifically, we wondered if nurses tend to recognize auditors more readily than physicians and therefore show higher apparent HH compliance when auditors are present. We also wanted to verify whether the behavior of attending physicians influenced compliance of their physician trainees. To test these hypotheses, we trained 2 clinical observers to covertly measure HH compliance of nurses and physicians on 3 different clinical services.

METHODS

Between May 27, 2015 and July 31, 2015, 2 student observers joined clinical rotations on physician and nursing teams, respectively. Healthcare teams were unaware that the student observers were measuring HH compliance during their clinical rotation. Students rotated in the emergency department, general medical and surgical wards for no more than 1 week at a time to increase exposure to different providers and minimize risk of exposing the covert observation.

Prior to the study period, the students underwent training and validation with a hospital HH auditor at another clinical setting offsite to avoid any recognition of these students by healthcare providers as observers of HH at the main hospital. Training with the auditors occurred until interobserver agreement between all HH opportunities reached 100% agreement for 2 consecutive observation days.

During their rotations, students covertly recorded HH compliance based on moments of hand hygiene[4] and also noted location, presence, and compliance of the attending physician, team size during patient encounter, and isolation requirements. Both students measured HH compliance of nurses and physicians around them. Although students spent the majority of their time with their assigned physician or nurse teams, they did not limit their observations to these individuals only, but recorded compliance of any nurse or physician on the ward as long as they were within sight during an HH opportunity. To limit clustering of observations of the same healthcare worker, up to a maximum of 2 observations per healthcare worker per day was recorded.

We compared covertly measured HH compliance with data from overt observation by hospital auditors during the same time period. Differences in proportion of HH compliance were compared with hospital audits during the same period with a ² test. Difference between differences in overtly and covertly measured HH compliance for nurses and physicians was compared using Breslow day test.

The study was approved by the hospital's research ethics board. Although deception was used in this study,[2, 6] all data were collected for quality improvement purposes, and the aggregate results were disclosed to hospital staff following the study.

RESULTS

Covertly observed HH compliance was 50.0% (799/1597) compared with 83.7% (2769/3309) recorded by hospital auditors during the same time period (P < 0.0002) (Table 1). There was no significant difference in the compliance measured by each student (50.1%, 473/928 vs 48.7%, 326/669) (P = 0.3), and their results were combined for the rest of the analysis. Compliance before contact with the patient or patient environment was 43.1% (344/798), 74.3% (26/35) before clean/aseptic procedures, 34.8% (8/23) after potential body fluid exposure, and 56.8% (483/851) after contact with the patient or patient environment. Healthcare providers examining patients with isolation precautions were found to have a HH compliance of 74.8% (101/135) compared to 47.0% (385/820) when isolation precautions were not required (P < 0.0002).

Hospital auditor data showed that surgery and medicine had similarly high rates of compliance (91.0% and 85.0%, respectively), whereas the emergency department had a notably lower rate of 73.8%. Covert observation confirmed a lower rate in the emergency department (43.9%), but showed a higher compliance on general medicine than on surgery (58.9% vs 45.7%; P = 0.02). The difference in physician compliance between hospital auditors and covert observers was 19.0% (73.2%, 175/239 vs. 54.2%, 469/865); for nurses this difference was much higher at 40.7% (85.8%, 754/879 vs. 45.1%, 330/732) (P < 0.0001) (Table 1).

In terms of physician compliance, primary teams tended to have lower HH compliance of 50.4% (323/641) compared with consulting services at 57.0% (158/277) (P = 0.06). Team rounds of 3 members were associated with higher compliance compared with encounters involving <3 members (62.1%, 282/454 vs. 42.0%, 128/308) (P < 0.0002). Presence of attending physician did not affect trainee HH compliance (55.5%, 201/362 when attending present vs. 56.8%, 133/234 when attending absent; P = 0.79). However, trainee HH compliance improved markedly when attending staff cleaned their hands and decreased markedly when they did not (79.5%, 174/219 vs. 18.9%, 27/143; P < 0.0002).

DISCUSSION

We introduced covert HH observers at our hospital to determine whether differences in Hawthorne effect accounted for measured disparity between physician HH compliance, and to gain further insights into the barriers and enablers of physician HH compliance. We discovered that performance differences between physicians and nurses decreased when neither group was aware that HH was being measured, suggesting that healthcare professions are differentially affected by the Hawthorne effect. This difference may be explained by the continuity of nurses on the ward that makes them more aware of visitors like HH auditors,[7] compared with physicians who rotate periodically on the ward.

Although hospital auditors play a central role in HH education through in‐the‐moment feedback, use of these data to benchmark performance can lead to inappropriate inferences about HH compliance. Prior studies using automated HH surveillance have suggested that the magnitude of the Hawthorne effect varies based on baseline HH rates,[8] whereas our study suggests a differential Hawthorne effect between professions and clinical services. If we relied only on auditor data, we would have continued to believe that only physicians in our organization had poor HH compliance, and we would not be aware of the global nature of the HH problem.

Our results are similar to that of Pan et al., who used covert medical students to measure HH and found compliance of 44.1% compared with 94.1% by unit auditors.[2] Because their study involved an active feedback intervention, the differential in Hawthorne effect between professions could not be reliably assessed. However, they observed a progressive increase in nurse HH compliance using covert observation methods, suggesting improvement in HH performance independent of observer bias.[7]

Covert observation in our study also provided important insights regarding barriers and enablers of HH compliance. Self‐preservation behaviors were common among both nurses and physicians, as HH compliance was consistently higher after patient contact compared to before or when seeing patients who required additional precautions. This finding confirms that the perceived risk of transmission seems to be a powerful motivating factor for HH.[9] Larger groups of trainees were more likely to clean their hands, likely due to peer effects.[10] The strong impact of role modeling on HH was also noted as previously suggested in the literature,[3, 6] but our study captures the magnitude of this effect. Whether or not the attending physician cleaned their hands during rounds either positively or negatively influenced HH compliance of the rest of the physician team (80% when compliant vs 20% when noncompliant).

Our study has several important limitations. The differential Hawthorne effect seen at our center may not reflect other institutions that have numerous HH auditors or high staff turnover resulting in lower ability to recognize auditors. We cannot exclude the possibility of Hawthorne effect using covert methods that could have affected nurse and physician performance differently, but frequent rotation of the students helped maintain covertness of observations. Finally, due to the nature of the covert student observers, a longer observation time frame could not be sustained.

Our experience using covert HH auditors suggests that traditional HH audits not only overstate HH performance overall, but can lead to inaccurate inferences regarding HH performance due to relative differences in Hawthorne effect. The answer to the question regarding whether physicians clean their hands appears to be that they do just as often as nurses, but that all healthcare workers have tremendous room for improvement. We suggest that future improvement efforts will rely on more accurate HH monitoring systems and strong attending physician leadership to set an example for trainees.

Hand hygiene (HH) is believed to be one of the single most important interventions to prevent healthcare‐associated infection, yet physicians are notorious for their poor compliance.[1, 2, 3] At our 800‐bed acute care academic hospital, we implemented a multifaceted HH program[4] in 2007, which was associated with improved HH compliance rates from 43% to 87%. Despite this improvement, HH compliance among physicians remained suboptimal, with rates below 60% in some patient areas. A targeted campaign focused on recruitment of physician champions, resulted in some improvement, but physician compliance has consistently remained below performance of nurses (70%75% for physicians vs 85%90% for nurses).

Our experience parallels the results seen in multinational surveys demonstrating consistently lower physician HH compliance.[5] Given the multiple improvement efforts directed at physicians and the apparent ceiling observed in HH performance, we wanted to confirm whether physicians are truly recalcitrant to cleaning their hands, or whether lower compliance among physicians reflected a differential in the Hawthorne effect inherent to direct observation methods. Specifically, we wondered if nurses tend to recognize auditors more readily than physicians and therefore show higher apparent HH compliance when auditors are present. We also wanted to verify whether the behavior of attending physicians influenced compliance of their physician trainees. To test these hypotheses, we trained 2 clinical observers to covertly measure HH compliance of nurses and physicians on 3 different clinical services.

METHODS

Between May 27, 2015 and July 31, 2015, 2 student observers joined clinical rotations on physician and nursing teams, respectively. Healthcare teams were unaware that the student observers were measuring HH compliance during their clinical rotation. Students rotated in the emergency department, general medical and surgical wards for no more than 1 week at a time to increase exposure to different providers and minimize risk of exposing the covert observation.

Prior to the study period, the students underwent training and validation with a hospital HH auditor at another clinical setting offsite to avoid any recognition of these students by healthcare providers as observers of HH at the main hospital. Training with the auditors occurred until interobserver agreement between all HH opportunities reached 100% agreement for 2 consecutive observation days.

During their rotations, students covertly recorded HH compliance based on moments of hand hygiene[4] and also noted location, presence, and compliance of the attending physician, team size during patient encounter, and isolation requirements. Both students measured HH compliance of nurses and physicians around them. Although students spent the majority of their time with their assigned physician or nurse teams, they did not limit their observations to these individuals only, but recorded compliance of any nurse or physician on the ward as long as they were within sight during an HH opportunity. To limit clustering of observations of the same healthcare worker, up to a maximum of 2 observations per healthcare worker per day was recorded.

We compared covertly measured HH compliance with data from overt observation by hospital auditors during the same time period. Differences in proportion of HH compliance were compared with hospital audits during the same period with a ² test. Difference between differences in overtly and covertly measured HH compliance for nurses and physicians was compared using Breslow day test.

The study was approved by the hospital's research ethics board. Although deception was used in this study,[2, 6] all data were collected for quality improvement purposes, and the aggregate results were disclosed to hospital staff following the study.

RESULTS

Covertly observed HH compliance was 50.0% (799/1597) compared with 83.7% (2769/3309) recorded by hospital auditors during the same time period (P < 0.0002) (Table 1). There was no significant difference in the compliance measured by each student (50.1%, 473/928 vs 48.7%, 326/669) (P = 0.3), and their results were combined for the rest of the analysis. Compliance before contact with the patient or patient environment was 43.1% (344/798), 74.3% (26/35) before clean/aseptic procedures, 34.8% (8/23) after potential body fluid exposure, and 56.8% (483/851) after contact with the patient or patient environment. Healthcare providers examining patients with isolation precautions were found to have a HH compliance of 74.8% (101/135) compared to 47.0% (385/820) when isolation precautions were not required (P < 0.0002).

Hospital auditor data showed that surgery and medicine had similarly high rates of compliance (91.0% and 85.0%, respectively), whereas the emergency department had a notably lower rate of 73.8%. Covert observation confirmed a lower rate in the emergency department (43.9%), but showed a higher compliance on general medicine than on surgery (58.9% vs 45.7%; P = 0.02). The difference in physician compliance between hospital auditors and covert observers was 19.0% (73.2%, 175/239 vs. 54.2%, 469/865); for nurses this difference was much higher at 40.7% (85.8%, 754/879 vs. 45.1%, 330/732) (P < 0.0001) (Table 1).

In terms of physician compliance, primary teams tended to have lower HH compliance of 50.4% (323/641) compared with consulting services at 57.0% (158/277) (P = 0.06). Team rounds of 3 members were associated with higher compliance compared with encounters involving <3 members (62.1%, 282/454 vs. 42.0%, 128/308) (P < 0.0002). Presence of attending physician did not affect trainee HH compliance (55.5%, 201/362 when attending present vs. 56.8%, 133/234 when attending absent; P = 0.79). However, trainee HH compliance improved markedly when attending staff cleaned their hands and decreased markedly when they did not (79.5%, 174/219 vs. 18.9%, 27/143; P < 0.0002).

DISCUSSION

We introduced covert HH observers at our hospital to determine whether differences in Hawthorne effect accounted for measured disparity between physician HH compliance, and to gain further insights into the barriers and enablers of physician HH compliance. We discovered that performance differences between physicians and nurses decreased when neither group was aware that HH was being measured, suggesting that healthcare professions are differentially affected by the Hawthorne effect. This difference may be explained by the continuity of nurses on the ward that makes them more aware of visitors like HH auditors,[7] compared with physicians who rotate periodically on the ward.

Although hospital auditors play a central role in HH education through in‐the‐moment feedback, use of these data to benchmark performance can lead to inappropriate inferences about HH compliance. Prior studies using automated HH surveillance have suggested that the magnitude of the Hawthorne effect varies based on baseline HH rates,[8] whereas our study suggests a differential Hawthorne effect between professions and clinical services. If we relied only on auditor data, we would have continued to believe that only physicians in our organization had poor HH compliance, and we would not be aware of the global nature of the HH problem.

Our results are similar to that of Pan et al., who used covert medical students to measure HH and found compliance of 44.1% compared with 94.1% by unit auditors.[2] Because their study involved an active feedback intervention, the differential in Hawthorne effect between professions could not be reliably assessed. However, they observed a progressive increase in nurse HH compliance using covert observation methods, suggesting improvement in HH performance independent of observer bias.[7]

Covert observation in our study also provided important insights regarding barriers and enablers of HH compliance. Self‐preservation behaviors were common among both nurses and physicians, as HH compliance was consistently higher after patient contact compared to before or when seeing patients who required additional precautions. This finding confirms that the perceived risk of transmission seems to be a powerful motivating factor for HH.[9] Larger groups of trainees were more likely to clean their hands, likely due to peer effects.[10] The strong impact of role modeling on HH was also noted as previously suggested in the literature,[3, 6] but our study captures the magnitude of this effect. Whether or not the attending physician cleaned their hands during rounds either positively or negatively influenced HH compliance of the rest of the physician team (80% when compliant vs 20% when noncompliant).

Our study has several important limitations. The differential Hawthorne effect seen at our center may not reflect other institutions that have numerous HH auditors or high staff turnover resulting in lower ability to recognize auditors. We cannot exclude the possibility of Hawthorne effect using covert methods that could have affected nurse and physician performance differently, but frequent rotation of the students helped maintain covertness of observations. Finally, due to the nature of the covert student observers, a longer observation time frame could not be sustained.

Our experience using covert HH auditors suggests that traditional HH audits not only overstate HH performance overall, but can lead to inaccurate inferences regarding HH performance due to relative differences in Hawthorne effect. The answer to the question regarding whether physicians clean their hands appears to be that they do just as often as nurses, but that all healthcare workers have tremendous room for improvement. We suggest that future improvement efforts will rely on more accurate HH monitoring systems and strong attending physician leadership to set an example for trainees.

Children with medical complexity (CMC) have complex and chronic health conditions that often involve multiple organ systems and severely affect cognitive and physical functioning. Although the prevalence of CMC is low (1% of all children), they account for nearly one‐fifth of all pediatric admissions and one‐half of all hospital days and charges in the United States.[1] Over the last decade, CMC have had a particularly large and increasing impact in tertiary‐care children's hospitals.[1, 2] The Institute of Medicine has identified CMC as a priority population for a revised healthcare system.[3]

Medical homes, hospitals, health plans, states, federal agencies, and others are striving to reduce excessive hospital use in CMC because of its high cost.[4, 5, 6] Containing length of stay (LOS)an increasingly used indicator of the time sensitiveness and efficiency of hospital careis a common aim across these initiatives. CMC have longer hospitalizations than children without medical complexity. Speculated reasons for this are that CMC tend to have (1) higher severity of acute illnesses (eg, pneumonia, cellulitis), (2) prolonged recovery time in the hospital, and (3) higher risk of adverse events in the hospital. Moreover, hospital clinicians caring for CMC often find it difficult to determine discharge readiness, given that many CMC do not return to a completely healthy baseline.[7]

Little is known about long LOS in CMC, including which CMC have the highest risk of experiencing such stays and which stays might have the greatest opportunity to be shortened. Patient characteristics associated with prolonged length of stay have been studied extensively for many pediatric conditions (eg, asthma).[8, 9, 10, 11, 12, 13, 14] However, most of these studies excluded CMC. Therefore, the objectives of this study were to examine (1) the prevalence of long LOS in CMC, (2) patient characteristics associated with long LOS, and (3) hospital‐to‐hospital variation in prevalence of long LOS hospitalizations.

METHODS

RESULTS

Study Population

There were 954,018 hospitalizations of 217,163 CMC at 44 children's hospitals included for analysis. Forty‐seven percent of hospitalizations were for females, 49.4% for non‐Hispanic whites, and 61.1% for children with government insurance. Fifteen percent (n = 142,082) had a long LOS of 10 days. The median (IQR) LOS of hospitalizations <10 days versus 10 days were 2 (IQR, 14) and 16 days (IQR, 1226), respectively. Long LOS hospitalizations accounted for 61.1% (3.7 million) hospital days and 61.8% ($13.7 billion) of total hospitalization costs for all CMC in the cohort (Table 1).

Table 1.Demographic, Clinical, and Hospitalization Characteristics of Hospitalized Children With Medical Complexity by Length of Stay*

Characteristic	Overall (n = 954,018)	Length of Stay
		<10 Days (n = 811,936)	10 Days (n = 142,082)
NOTE: Abbreviations: IQR, interquartile range. *All comparisons were significant at the P < 0.001 level.
Age at admission, y, %
<1	14.6	12.7	25.7
14	27.1	27.9	22.4
59	20.1	21.0	14.9
1018	33.6	34.0	31.7
18+	4.6	4.4	5.4
Gender, %
Female	47.0	46.9	47.5
Race/ethnicity, %
Non‐Hispanic white	49.4	49.4	49.4
Non‐Hispanic black	23.1	23.8	19.3
Hispanic	18.2	17.8	20.4
Asian	2.0	1.9	2.3
Other	7.4	7.1	8.6
Complex chronic condition, %
Any	79.5	77.3	91.8
Technology assistance	37.1	34.1	54.2
Gastrointestinal	30.0	27.2	45.9
Neuromuscular	28.2	27.7	30.9
Cardiovascular	16.8	14.5	29.9
Respiratory	14.1	11.5	29.4
Congenital/genetic defect	17.2	16.7	20.2
Metabolic	9.9	8.9	15.4
Renal	10.1	9.5	13.8
Hematology/emmmunodeficiency	11.7	12.0	10.0
Neonatal	3.8	3.1	7.7
Transplantation	4.5	4.2	6.7
Clinical risk group, %
Chronic condition in 2 systems	68.4	71.2	53.9
Catastrophic chronic condition	31.4	28.8	46.1
Distance from hospital to home residence in miles, median [IQR]	16.2 [7.440.4]	15.8 [7.338.7]	19.1 [8.552.6]
Transferred from outside hospital (%)	6.5	5.3	13.6
Admitted for surgery, %	23.4	20.7	38.7
Use of intensive care, %	19.6	14.9	46.5
Discharge disposition, %
Home	91.2	92.9	81.4
Home healthcare	4.5	3.5	9.9
Other	2.9	2.6	4.5
Postacute care facility	1.1	0.8	3.1
Died	0.4	0.3	1.1
Payor, %
Government	61.1	60.6	63.5
Private	33.2	33.6	30.9
Other	5.7	5.7	5.7
Hospital resource use
Median length of stay [IQR]	3 [16]	2 [14]	16 [1226]
Median hospital cost [IQR]	$8,144 [$4,122$18,447]	$6,689 [$3,685$12,395]	$49,207 [$29,444$95,738]
Total hospital cost, $, billions	$22.2	$8.5	$13.7

Demographics and Clinical Characteristics of Children With and Without Long LOS

Compared with hospitalized CMC with LOS <10 days, a higher percentage of hospitalizations with LOS 10 days were CMC age <1 year (25.7% vs 12.7%, P < 0.001) and Hispanic (20.4% vs 17.8%, P < 0.001). CMC hospitalizations with a long LOS had a higher percentage of any CCC (91.8% vs 77.3%, P < 0.001); the most common CCCs were gastrointestinal (45.9%), neuromuscular (30.9%), and cardiovascular (29.9%). Hospitalizations of CMC with a long LOS had a higher percentage of a catastrophic chronic condition (46.1% vs 28.8%, P < 0.001) and technology dependence (46.1% vs 28.8%, P < 0.001) (Table 1).

Hospitalization Characteristics of Children With and Without Long LOS

Compared with hospitalizations of CMC with LOS <10 days, hospitalizations of CMC with a long LOS more often involved transfer in from another hospital at admission (13.6% vs 5.3%, P < 0.001). CMC hospital stays with a long LOS more often involved surgery (38.7% vs 20.7%, P < 0.001) and use of intensive care (46.5% vs 14.9%; P < 0.001). A higher percentage of CMC with long LOS were discharged with home health services (9.9% vs 3.5%; P < 0.001) (Table 1).

The most common admitting diagnoses and CCCs for hospitalizations of CMC with long LOS are presented in Table 2. The two most prevalent APR‐DRGs in CMC hospitalizations lasting 10 days or longer were cystic fibrosis (10.7%) and respiratory system disease with ventilator support (5.5%). The two most common chronic condition characteristics represented among long CMC hospitalizations were gastrointestinal devices (eg, gastrostomy tube) (39.7%) and heart and great vessel malformations (eg, tetralogy of Fallot) (12.8%). The 5 most common CCC subcategories, as listed in Table 2, account for nearly 100% of the patients with long LOS hospitalizations.

Table 2.Most Common Reasons for Admission and Specific Complex Chronic Conditions for Hospitalized Children With Medical Complexity Who Had Length of Stay 10 Days

NOTE: *Reason for admission identified using All‐Patient Refined Diagnosis‐Related Groups. Complex chronic conditions identified using Feudtner and colleagues set of International Classification of Diseases, 9th Revision, Clinical Modification codes. Gastrointestinal devices include gastrostomy, gastrojejunostomy, colostomy. Respiratory devices include tracheostomy, noninvasive positive pressure, ventilator.
Most common reason for admission*
Cystic fibrosis	10.7%
Respiratory system diagnosis with ventilator support 96+ hours	5.5%
Malfunction, reaction, and complication of cardiac or vascular device or procedure	2.8%
Craniotomy except for trauma	2.6%
Major small and large bowel procedures	2.3%
Most common complex chronic condition
Gastrointestinal devices	39.7%
Heart and great vessel malformations	12.8%
Cystic fibrosis	12.5%
Dysrhythmias	11.0%
Respiratory devices	10.7%

Multivariable Analysis of Characteristics Associated With Long LOS

In multivariable analysis, the highest likelihood of long LOS was experienced by children who received care in the ICU (odds ratio [OR]: 3.5, 95% confidence interval [CI]: 3.43.5), who had a respiratory CCC (OR: 2.7, 95% CI: 2.62.7), and who were transferred from another acute care hospital at admission (OR: 2.1, 95% CI: 2.0, 2.1). The likelihood of long LOS was also higher in children <1 year of age (OR: 1.2, 95% CI: 1.21.3), and Hispanic children (OR: 1.1, 95% CI 1.0‐1.10) (Table 3). Similar multivariable findings were observed in sensitivity analysis using the 75th percentile of LOS (4 days) as the model outcome.

Table 3.Multivariable Analysis of the Likelihood of Long Length of Stay 10 Days

Characteristic	Odds Ratio (95% CI) of LOS 10 Days	P Value
NOTE: Abbreviations: CI, confidence interval; LOS, length of stay.
Use of intensive care	3.5 (3.4‐3.5)	<0.001
Transfer from another acute‐care hospital	2.1 (2.0‐2.1)	<0.001
Procedure/surgery	1.8 (1.8‐1.9)	<0.001
Complex chronic condition
Respiratory	2.7 (2.6‐2.7)	<0.001
Gastrointestinal	1.8 (1.8‐1.8)	<0.001
Metabolic	1.7 (1.7‐1.7)	<0.001
Cardiovascular	1.6 (1.5‐1.6)	<0.001
Neonatal	1.5 (1.5‐1.5)	<0.001
Renal	1.4 (1.4‐1.4)	<0.001
Transplant	1.4 (1.4‐1.4)	<0.001
Hematology and immunodeficiency	1.3 (1.3‐1.3)	<0.001
Technology assistance	1.1 (1.1, 1.1)	<0.001
Neuromuscular	0.9 (0.9‐0.9)	<0.001
Congenital or genetic defect	0.8 (0.8‐0.8)	<0.001
Age at admission, y
<1	1.2 (1.2‐1.3)	<0.001
14	0.5 (0.5‐0.5)	<0.001
59	0.6 (0.6‐0.6)	<0.001
1018	0.9 (0.9‐0.9)	<0.001
18+	Reference
Male	0.9 (0.9‐0.9)	<0.001
Race/ethnicity
Non‐Hispanic black	0.9 (0.9‐0.9)	<0.001
Hispanic	1.1 (1.0‐1.1)	<0.001
Asian	1.0 (1.0‐1.1)	0.3
Other	1.1 (1.1‐1.1)	<0.001
Non‐Hispanic white	Reference
Payor
Private	0.9 (0.8 0.9)	<0.001
Other	1.0 (1.0‐1.0)	0.4
Government	Reference
Season
Spring	1.0 (1.0 1.0)	<0.001
Summer	0.9 (0.9‐0.9)	<0.001
Fall	1.0 (0.9‐1.0)	<0.001
Winter	Reference

Variation in the Prevalence of Long LOS Across Children's Hospitals

After controlling for demographic, clinical, and hospital characteristics associated with long LOS, there was significant (P < 0.001) variation in the prevalence of long LOS for CMC across children's hospitals in the cohort (range, 10.3%21.8%) (Figure 1). Twelve (27%) hospitals had a significantly (P < 0.001) higher prevalence of long LOS for their hospitalized CMC, compared to the mean. Eighteen (41%) had a significantly (P < 0.001) lower prevalence of long LOS for their hospitalized CMC. There was also significant variation across hospitals with respect to cost, with 49.7% to 73.7% of all hospital costs of CMC attributed to long LOS hospitalizations. Finally, there was indirect correlation with the prevalence of LOS across hospitals and the hospitals' 30‐day readmission rate ( = 0.3; P = 0.04). As the prevalence of long LOS increased, the readmission rate decreased.

Figure 1

DISCUSSION

The main findings from this study suggest that a small percentage of CMC experiencing long LOS account for the majority of hospital bed days and cost of all hospitalized CMC in children's hospitals. The likelihood of long LOS varies significantly by CMC's age, race/ethnicity, and payor as well as by type and number of chronic conditions. Among CMC with long LOS, the use of gastrointestinal devices such as gastrostomy tubes, as well as congenital heart disease, were highly prevalent. In multivariable analysis, the characteristics most strongly associated with LOS 10 days were use of the ICU, respiratory complex chronic condition, and transfer from another medical facility at admission. After adjusting for these factors, there was significant variation in the prevalence of LOS 10 days for CMC across children's hospitals.

Although it is well known that CMC as a whole have a major impact on resource use in children's hospitals, this study reveals that 15% of hospitalizations of CMC account for 62% of all hospital costs of CMC. That is, a small fraction of hospitalizations of CMC is largely responsible for the significant financial impact of hospital resource use. To date, most clinical efforts and policies striving to reduce hospital use in CMC have focused on avoiding readmissions or index hospital admissions entirely, rather than improving the efficiency of hospital care after admission occurs.[23, 24, 25, 26] In the adult population, the impact of long LOS on hospital costs has been recognized, and several Medicare incentive programs have focused on in‐hospital timeliness and efficiency. As a result, LOS in Medicare beneficiaries has decreased dramatically over the past 2 decades.[27, 28, 29, 30] Optimizing the efficiency of hospital care for CMC may be an important goal to pursue, especially with precedent set in the adult literature.

Perhaps the substantial variation across hospitals in the prevalence of long LOS in CMC indicates opportunity to improve the efficiency of their inpatient care. This variation was not due to differences across hospitals' case mix of CMC. Further investigation is needed to determine how much of it is due to differences in quality of care. Clinical practice guidelines for hospital treatment of common illnesses usually exclude CMC. In our clinical experience across 9 children's hospitals, we have experienced varying approaches to setting discharge goals (ie, parameters on how healthy the child needs to be to ensure a successful hospital discharge) for CMC.[31] When the goals are absent or not clearly articulated, they can contribute to a prolonged hospitalization. Some families of CMC report significant issues when working with pediatric hospital staff to assess their child's discharge readiness.[7, 32, 33] In addition, there is significant variation across states and regions in access to and quality of post‐discharge health services (eg, home nursing, postacute care, durable medical equipment).[34, 35] In some areas, many CMC are not actively involved with their primary care physician.[5] These issues might also influence the ability of some children's hospitals to efficiently discharge CMC to a safe and supportive post‐discharge environment. Further examination of hospital outliersthose with the lowest and highest percentage of CMC hospitalizations with long LOSmay reveal opportunities to identify and spread best practices.

The demographic and clinical factors associated with long LOS in the present study, including age, ICU use, and transfer from another hospital, might help hospitals target which CMC have the greatest risk for experiencing long LOS. We found that infants age <1 year had longer LOS when compared with older children. Similar to our findings, younger‐aged children hospitalized with bronchiolitis have longer LOS.[36] Certainly, infants with medical complexity, in general, are a high‐acuity population with the potential for rapid clinical deterioration during an acute illness. Prolonged hospitalization for treatment and stabilization may be expected for many of them. Additional investigation is warranted to examine ICU use in CMC, and whether ICU admission or duration can be safely prevented or abbreviated. Opportunities to assess the quality of transfers into children's hospitals of CMC admitted to outside hospitals may be necessary. A study of pediatric burn patients reported that patients initially stabilized at a facility that was not a burn center and subsequently transferred to a burn center had a longer LOS than patients solely treated at a designated burn center.[37] Furthermore, events during transport itself may adversely impact the stability of an already fragile patient. Interventions to optimize the quality of care provided by transport teams have resulted in decreased LOS at the receiving hospital.[38]

This study's findings should be considered in the context of several limitations. Absent a gold‐standard definition of long LOS, we used the distribution of LOS across patients to inform our methods; LOS at the 90th percentile was selected as long. Although our sensitivity analysis using LOS at the 75th percentile produced similar findings, other cut points in LOS might be associated with different results. The study is not positioned to determine how much of the reported LOS was excessive, unnecessary, or preventable. The study findings may not generalize to types of hospitals not contained in PHIS (eg, nonchildren's hospitals and community hospitals). We did not focus on the impact of a new diagnosis (eg, new chronic illness) or acute in‐hospital event (eg, nosocomial infection) on prolonged LOS; future studies should investigate these clinical events with LOS.

PHIS does not contain information regarding characteristics that could influence LOS, including the children's social and familial attributes, transportation availability, home equipment needs, and local availability of postacute care facilities. Moreover, PHIS does not contain information about the hospital discharge procedures, process, or personnel across hospitals, which could influence LOS. Future studies on prolonged LOS should consider assessing this information. Because of the large sample size of hospitalizations included, the statistical power for the analyses was strong, rendering it possible that some findings that were statistically significant might have modest clinical significance (eg, relationship of Hispanic ethnicity with prolonged LOS). We could not determine why a positive correlation was not observed between hospitals' long LOS prevalence and their percentage of cost associated with long LOS; future studies should investigate the reasons for this finding.

Despite these limitations, the findings of the present study highlight the significance of long LOS in hospitalized CMC. These long hospitalizations account for a significant proportion of all hospital costs for this important population of children. The prevalence of long LOS for CMC varies considerably across children's hospitals, even after accounting for the case mix. Efforts to curtail hospital resource use and costs for CMC may benefit from focus on long LOS.

Children with medical complexity (CMC) have complex and chronic health conditions that often involve multiple organ systems and severely affect cognitive and physical functioning. Although the prevalence of CMC is low (1% of all children), they account for nearly one‐fifth of all pediatric admissions and one‐half of all hospital days and charges in the United States.[1] Over the last decade, CMC have had a particularly large and increasing impact in tertiary‐care children's hospitals.[1, 2] The Institute of Medicine has identified CMC as a priority population for a revised healthcare system.[3]

Medical homes, hospitals, health plans, states, federal agencies, and others are striving to reduce excessive hospital use in CMC because of its high cost.[4, 5, 6] Containing length of stay (LOS)an increasingly used indicator of the time sensitiveness and efficiency of hospital careis a common aim across these initiatives. CMC have longer hospitalizations than children without medical complexity. Speculated reasons for this are that CMC tend to have (1) higher severity of acute illnesses (eg, pneumonia, cellulitis), (2) prolonged recovery time in the hospital, and (3) higher risk of adverse events in the hospital. Moreover, hospital clinicians caring for CMC often find it difficult to determine discharge readiness, given that many CMC do not return to a completely healthy baseline.[7]

Little is known about long LOS in CMC, including which CMC have the highest risk of experiencing such stays and which stays might have the greatest opportunity to be shortened. Patient characteristics associated with prolonged length of stay have been studied extensively for many pediatric conditions (eg, asthma).[8, 9, 10, 11, 12, 13, 14] However, most of these studies excluded CMC. Therefore, the objectives of this study were to examine (1) the prevalence of long LOS in CMC, (2) patient characteristics associated with long LOS, and (3) hospital‐to‐hospital variation in prevalence of long LOS hospitalizations.

METHODS

RESULTS

Study Population

There were 954,018 hospitalizations of 217,163 CMC at 44 children's hospitals included for analysis. Forty‐seven percent of hospitalizations were for females, 49.4% for non‐Hispanic whites, and 61.1% for children with government insurance. Fifteen percent (n = 142,082) had a long LOS of 10 days. The median (IQR) LOS of hospitalizations <10 days versus 10 days were 2 (IQR, 14) and 16 days (IQR, 1226), respectively. Long LOS hospitalizations accounted for 61.1% (3.7 million) hospital days and 61.8% ($13.7 billion) of total hospitalization costs for all CMC in the cohort (Table 1).

Table 1.Demographic, Clinical, and Hospitalization Characteristics of Hospitalized Children With Medical Complexity by Length of Stay*

Characteristic	Overall (n = 954,018)	Length of Stay
		<10 Days (n = 811,936)	10 Days (n = 142,082)
NOTE: Abbreviations: IQR, interquartile range. *All comparisons were significant at the P < 0.001 level.
Age at admission, y, %
<1	14.6	12.7	25.7
14	27.1	27.9	22.4
59	20.1	21.0	14.9
1018	33.6	34.0	31.7
18+	4.6	4.4	5.4
Gender, %
Female	47.0	46.9	47.5
Race/ethnicity, %
Non‐Hispanic white	49.4	49.4	49.4
Non‐Hispanic black	23.1	23.8	19.3
Hispanic	18.2	17.8	20.4
Asian	2.0	1.9	2.3
Other	7.4	7.1	8.6
Complex chronic condition, %
Any	79.5	77.3	91.8
Technology assistance	37.1	34.1	54.2
Gastrointestinal	30.0	27.2	45.9
Neuromuscular	28.2	27.7	30.9
Cardiovascular	16.8	14.5	29.9
Respiratory	14.1	11.5	29.4
Congenital/genetic defect	17.2	16.7	20.2
Metabolic	9.9	8.9	15.4
Renal	10.1	9.5	13.8
Hematology/emmmunodeficiency	11.7	12.0	10.0
Neonatal	3.8	3.1	7.7
Transplantation	4.5	4.2	6.7
Clinical risk group, %
Chronic condition in 2 systems	68.4	71.2	53.9
Catastrophic chronic condition	31.4	28.8	46.1
Distance from hospital to home residence in miles, median [IQR]	16.2 [7.440.4]	15.8 [7.338.7]	19.1 [8.552.6]
Transferred from outside hospital (%)	6.5	5.3	13.6
Admitted for surgery, %	23.4	20.7	38.7
Use of intensive care, %	19.6	14.9	46.5
Discharge disposition, %
Home	91.2	92.9	81.4
Home healthcare	4.5	3.5	9.9
Other	2.9	2.6	4.5
Postacute care facility	1.1	0.8	3.1
Died	0.4	0.3	1.1
Payor, %
Government	61.1	60.6	63.5
Private	33.2	33.6	30.9
Other	5.7	5.7	5.7
Hospital resource use
Median length of stay [IQR]	3 [16]	2 [14]	16 [1226]
Median hospital cost [IQR]	$8,144 [$4,122$18,447]	$6,689 [$3,685$12,395]	$49,207 [$29,444$95,738]
Total hospital cost, $, billions	$22.2	$8.5	$13.7

Demographics and Clinical Characteristics of Children With and Without Long LOS

Compared with hospitalized CMC with LOS <10 days, a higher percentage of hospitalizations with LOS 10 days were CMC age <1 year (25.7% vs 12.7%, P < 0.001) and Hispanic (20.4% vs 17.8%, P < 0.001). CMC hospitalizations with a long LOS had a higher percentage of any CCC (91.8% vs 77.3%, P < 0.001); the most common CCCs were gastrointestinal (45.9%), neuromuscular (30.9%), and cardiovascular (29.9%). Hospitalizations of CMC with a long LOS had a higher percentage of a catastrophic chronic condition (46.1% vs 28.8%, P < 0.001) and technology dependence (46.1% vs 28.8%, P < 0.001) (Table 1).

Hospitalization Characteristics of Children With and Without Long LOS

Compared with hospitalizations of CMC with LOS <10 days, hospitalizations of CMC with a long LOS more often involved transfer in from another hospital at admission (13.6% vs 5.3%, P < 0.001). CMC hospital stays with a long LOS more often involved surgery (38.7% vs 20.7%, P < 0.001) and use of intensive care (46.5% vs 14.9%; P < 0.001). A higher percentage of CMC with long LOS were discharged with home health services (9.9% vs 3.5%; P < 0.001) (Table 1).

The most common admitting diagnoses and CCCs for hospitalizations of CMC with long LOS are presented in Table 2. The two most prevalent APR‐DRGs in CMC hospitalizations lasting 10 days or longer were cystic fibrosis (10.7%) and respiratory system disease with ventilator support (5.5%). The two most common chronic condition characteristics represented among long CMC hospitalizations were gastrointestinal devices (eg, gastrostomy tube) (39.7%) and heart and great vessel malformations (eg, tetralogy of Fallot) (12.8%). The 5 most common CCC subcategories, as listed in Table 2, account for nearly 100% of the patients with long LOS hospitalizations.

Table 2.Most Common Reasons for Admission and Specific Complex Chronic Conditions for Hospitalized Children With Medical Complexity Who Had Length of Stay 10 Days

NOTE: *Reason for admission identified using All‐Patient Refined Diagnosis‐Related Groups. Complex chronic conditions identified using Feudtner and colleagues set of International Classification of Diseases, 9th Revision, Clinical Modification codes. Gastrointestinal devices include gastrostomy, gastrojejunostomy, colostomy. Respiratory devices include tracheostomy, noninvasive positive pressure, ventilator.
Most common reason for admission*
Cystic fibrosis	10.7%
Respiratory system diagnosis with ventilator support 96+ hours	5.5%
Malfunction, reaction, and complication of cardiac or vascular device or procedure	2.8%
Craniotomy except for trauma	2.6%
Major small and large bowel procedures	2.3%
Most common complex chronic condition
Gastrointestinal devices	39.7%
Heart and great vessel malformations	12.8%
Cystic fibrosis	12.5%
Dysrhythmias	11.0%
Respiratory devices	10.7%

Multivariable Analysis of Characteristics Associated With Long LOS

In multivariable analysis, the highest likelihood of long LOS was experienced by children who received care in the ICU (odds ratio [OR]: 3.5, 95% confidence interval [CI]: 3.43.5), who had a respiratory CCC (OR: 2.7, 95% CI: 2.62.7), and who were transferred from another acute care hospital at admission (OR: 2.1, 95% CI: 2.0, 2.1). The likelihood of long LOS was also higher in children <1 year of age (OR: 1.2, 95% CI: 1.21.3), and Hispanic children (OR: 1.1, 95% CI 1.0‐1.10) (Table 3). Similar multivariable findings were observed in sensitivity analysis using the 75th percentile of LOS (4 days) as the model outcome.

Table 3.Multivariable Analysis of the Likelihood of Long Length of Stay 10 Days

Characteristic	Odds Ratio (95% CI) of LOS 10 Days	P Value
NOTE: Abbreviations: CI, confidence interval; LOS, length of stay.
Use of intensive care	3.5 (3.4‐3.5)	<0.001
Transfer from another acute‐care hospital	2.1 (2.0‐2.1)	<0.001
Procedure/surgery	1.8 (1.8‐1.9)	<0.001
Complex chronic condition
Respiratory	2.7 (2.6‐2.7)	<0.001
Gastrointestinal	1.8 (1.8‐1.8)	<0.001
Metabolic	1.7 (1.7‐1.7)	<0.001
Cardiovascular	1.6 (1.5‐1.6)	<0.001
Neonatal	1.5 (1.5‐1.5)	<0.001
Renal	1.4 (1.4‐1.4)	<0.001
Transplant	1.4 (1.4‐1.4)	<0.001
Hematology and immunodeficiency	1.3 (1.3‐1.3)	<0.001
Technology assistance	1.1 (1.1, 1.1)	<0.001
Neuromuscular	0.9 (0.9‐0.9)	<0.001
Congenital or genetic defect	0.8 (0.8‐0.8)	<0.001
Age at admission, y
<1	1.2 (1.2‐1.3)	<0.001
14	0.5 (0.5‐0.5)	<0.001
59	0.6 (0.6‐0.6)	<0.001
1018	0.9 (0.9‐0.9)	<0.001
18+	Reference
Male	0.9 (0.9‐0.9)	<0.001
Race/ethnicity
Non‐Hispanic black	0.9 (0.9‐0.9)	<0.001
Hispanic	1.1 (1.0‐1.1)	<0.001
Asian	1.0 (1.0‐1.1)	0.3
Other	1.1 (1.1‐1.1)	<0.001
Non‐Hispanic white	Reference
Payor
Private	0.9 (0.8 0.9)	<0.001
Other	1.0 (1.0‐1.0)	0.4
Government	Reference
Season
Spring	1.0 (1.0 1.0)	<0.001
Summer	0.9 (0.9‐0.9)	<0.001
Fall	1.0 (0.9‐1.0)	<0.001
Winter	Reference

Variation in the Prevalence of Long LOS Across Children's Hospitals

After controlling for demographic, clinical, and hospital characteristics associated with long LOS, there was significant (P < 0.001) variation in the prevalence of long LOS for CMC across children's hospitals in the cohort (range, 10.3%21.8%) (Figure 1). Twelve (27%) hospitals had a significantly (P < 0.001) higher prevalence of long LOS for their hospitalized CMC, compared to the mean. Eighteen (41%) had a significantly (P < 0.001) lower prevalence of long LOS for their hospitalized CMC. There was also significant variation across hospitals with respect to cost, with 49.7% to 73.7% of all hospital costs of CMC attributed to long LOS hospitalizations. Finally, there was indirect correlation with the prevalence of LOS across hospitals and the hospitals' 30‐day readmission rate ( = 0.3; P = 0.04). As the prevalence of long LOS increased, the readmission rate decreased.

Figure 1

DISCUSSION

The main findings from this study suggest that a small percentage of CMC experiencing long LOS account for the majority of hospital bed days and cost of all hospitalized CMC in children's hospitals. The likelihood of long LOS varies significantly by CMC's age, race/ethnicity, and payor as well as by type and number of chronic conditions. Among CMC with long LOS, the use of gastrointestinal devices such as gastrostomy tubes, as well as congenital heart disease, were highly prevalent. In multivariable analysis, the characteristics most strongly associated with LOS 10 days were use of the ICU, respiratory complex chronic condition, and transfer from another medical facility at admission. After adjusting for these factors, there was significant variation in the prevalence of LOS 10 days for CMC across children's hospitals.

Although it is well known that CMC as a whole have a major impact on resource use in children's hospitals, this study reveals that 15% of hospitalizations of CMC account for 62% of all hospital costs of CMC. That is, a small fraction of hospitalizations of CMC is largely responsible for the significant financial impact of hospital resource use. To date, most clinical efforts and policies striving to reduce hospital use in CMC have focused on avoiding readmissions or index hospital admissions entirely, rather than improving the efficiency of hospital care after admission occurs.[23, 24, 25, 26] In the adult population, the impact of long LOS on hospital costs has been recognized, and several Medicare incentive programs have focused on in‐hospital timeliness and efficiency. As a result, LOS in Medicare beneficiaries has decreased dramatically over the past 2 decades.[27, 28, 29, 30] Optimizing the efficiency of hospital care for CMC may be an important goal to pursue, especially with precedent set in the adult literature.

Perhaps the substantial variation across hospitals in the prevalence of long LOS in CMC indicates opportunity to improve the efficiency of their inpatient care. This variation was not due to differences across hospitals' case mix of CMC. Further investigation is needed to determine how much of it is due to differences in quality of care. Clinical practice guidelines for hospital treatment of common illnesses usually exclude CMC. In our clinical experience across 9 children's hospitals, we have experienced varying approaches to setting discharge goals (ie, parameters on how healthy the child needs to be to ensure a successful hospital discharge) for CMC.[31] When the goals are absent or not clearly articulated, they can contribute to a prolonged hospitalization. Some families of CMC report significant issues when working with pediatric hospital staff to assess their child's discharge readiness.[7, 32, 33] In addition, there is significant variation across states and regions in access to and quality of post‐discharge health services (eg, home nursing, postacute care, durable medical equipment).[34, 35] In some areas, many CMC are not actively involved with their primary care physician.[5] These issues might also influence the ability of some children's hospitals to efficiently discharge CMC to a safe and supportive post‐discharge environment. Further examination of hospital outliersthose with the lowest and highest percentage of CMC hospitalizations with long LOSmay reveal opportunities to identify and spread best practices.

The demographic and clinical factors associated with long LOS in the present study, including age, ICU use, and transfer from another hospital, might help hospitals target which CMC have the greatest risk for experiencing long LOS. We found that infants age <1 year had longer LOS when compared with older children. Similar to our findings, younger‐aged children hospitalized with bronchiolitis have longer LOS.[36] Certainly, infants with medical complexity, in general, are a high‐acuity population with the potential for rapid clinical deterioration during an acute illness. Prolonged hospitalization for treatment and stabilization may be expected for many of them. Additional investigation is warranted to examine ICU use in CMC, and whether ICU admission or duration can be safely prevented or abbreviated. Opportunities to assess the quality of transfers into children's hospitals of CMC admitted to outside hospitals may be necessary. A study of pediatric burn patients reported that patients initially stabilized at a facility that was not a burn center and subsequently transferred to a burn center had a longer LOS than patients solely treated at a designated burn center.[37] Furthermore, events during transport itself may adversely impact the stability of an already fragile patient. Interventions to optimize the quality of care provided by transport teams have resulted in decreased LOS at the receiving hospital.[38]

This study's findings should be considered in the context of several limitations. Absent a gold‐standard definition of long LOS, we used the distribution of LOS across patients to inform our methods; LOS at the 90th percentile was selected as long. Although our sensitivity analysis using LOS at the 75th percentile produced similar findings, other cut points in LOS might be associated with different results. The study is not positioned to determine how much of the reported LOS was excessive, unnecessary, or preventable. The study findings may not generalize to types of hospitals not contained in PHIS (eg, nonchildren's hospitals and community hospitals). We did not focus on the impact of a new diagnosis (eg, new chronic illness) or acute in‐hospital event (eg, nosocomial infection) on prolonged LOS; future studies should investigate these clinical events with LOS.

PHIS does not contain information regarding characteristics that could influence LOS, including the children's social and familial attributes, transportation availability, home equipment needs, and local availability of postacute care facilities. Moreover, PHIS does not contain information about the hospital discharge procedures, process, or personnel across hospitals, which could influence LOS. Future studies on prolonged LOS should consider assessing this information. Because of the large sample size of hospitalizations included, the statistical power for the analyses was strong, rendering it possible that some findings that were statistically significant might have modest clinical significance (eg, relationship of Hispanic ethnicity with prolonged LOS). We could not determine why a positive correlation was not observed between hospitals' long LOS prevalence and their percentage of cost associated with long LOS; future studies should investigate the reasons for this finding.

Despite these limitations, the findings of the present study highlight the significance of long LOS in hospitalized CMC. These long hospitalizations account for a significant proportion of all hospital costs for this important population of children. The prevalence of long LOS for CMC varies considerably across children's hospitals, even after accounting for the case mix. Efforts to curtail hospital resource use and costs for CMC may benefit from focus on long LOS.

Children with medical complexity (CMC) have complex and chronic health conditions that often involve multiple organ systems and severely affect cognitive and physical functioning. Although the prevalence of CMC is low (1% of all children), they account for nearly one‐fifth of all pediatric admissions and one‐half of all hospital days and charges in the United States.[1] Over the last decade, CMC have had a particularly large and increasing impact in tertiary‐care children's hospitals.[1, 2] The Institute of Medicine has identified CMC as a priority population for a revised healthcare system.[3]

Medical homes, hospitals, health plans, states, federal agencies, and others are striving to reduce excessive hospital use in CMC because of its high cost.[4, 5, 6] Containing length of stay (LOS)an increasingly used indicator of the time sensitiveness and efficiency of hospital careis a common aim across these initiatives. CMC have longer hospitalizations than children without medical complexity. Speculated reasons for this are that CMC tend to have (1) higher severity of acute illnesses (eg, pneumonia, cellulitis), (2) prolonged recovery time in the hospital, and (3) higher risk of adverse events in the hospital. Moreover, hospital clinicians caring for CMC often find it difficult to determine discharge readiness, given that many CMC do not return to a completely healthy baseline.[7]

Little is known about long LOS in CMC, including which CMC have the highest risk of experiencing such stays and which stays might have the greatest opportunity to be shortened. Patient characteristics associated with prolonged length of stay have been studied extensively for many pediatric conditions (eg, asthma).[8, 9, 10, 11, 12, 13, 14] However, most of these studies excluded CMC. Therefore, the objectives of this study were to examine (1) the prevalence of long LOS in CMC, (2) patient characteristics associated with long LOS, and (3) hospital‐to‐hospital variation in prevalence of long LOS hospitalizations.

METHODS

RESULTS

Study Population

There were 954,018 hospitalizations of 217,163 CMC at 44 children's hospitals included for analysis. Forty‐seven percent of hospitalizations were for females, 49.4% for non‐Hispanic whites, and 61.1% for children with government insurance. Fifteen percent (n = 142,082) had a long LOS of 10 days. The median (IQR) LOS of hospitalizations <10 days versus 10 days were 2 (IQR, 14) and 16 days (IQR, 1226), respectively. Long LOS hospitalizations accounted for 61.1% (3.7 million) hospital days and 61.8% ($13.7 billion) of total hospitalization costs for all CMC in the cohort (Table 1).

Table 1.Demographic, Clinical, and Hospitalization Characteristics of Hospitalized Children With Medical Complexity by Length of Stay*

Characteristic	Overall (n = 954,018)	Length of Stay
		<10 Days (n = 811,936)	10 Days (n = 142,082)
NOTE: Abbreviations: IQR, interquartile range. *All comparisons were significant at the P < 0.001 level.
Age at admission, y, %
<1	14.6	12.7	25.7
14	27.1	27.9	22.4
59	20.1	21.0	14.9
1018	33.6	34.0	31.7
18+	4.6	4.4	5.4
Gender, %
Female	47.0	46.9	47.5
Race/ethnicity, %
Non‐Hispanic white	49.4	49.4	49.4
Non‐Hispanic black	23.1	23.8	19.3
Hispanic	18.2	17.8	20.4
Asian	2.0	1.9	2.3
Other	7.4	7.1	8.6
Complex chronic condition, %
Any	79.5	77.3	91.8
Technology assistance	37.1	34.1	54.2
Gastrointestinal	30.0	27.2	45.9
Neuromuscular	28.2	27.7	30.9
Cardiovascular	16.8	14.5	29.9
Respiratory	14.1	11.5	29.4
Congenital/genetic defect	17.2	16.7	20.2
Metabolic	9.9	8.9	15.4
Renal	10.1	9.5	13.8
Hematology/emmmunodeficiency	11.7	12.0	10.0
Neonatal	3.8	3.1	7.7
Transplantation	4.5	4.2	6.7
Clinical risk group, %
Chronic condition in 2 systems	68.4	71.2	53.9
Catastrophic chronic condition	31.4	28.8	46.1
Distance from hospital to home residence in miles, median [IQR]	16.2 [7.440.4]	15.8 [7.338.7]	19.1 [8.552.6]
Transferred from outside hospital (%)	6.5	5.3	13.6
Admitted for surgery, %	23.4	20.7	38.7
Use of intensive care, %	19.6	14.9	46.5
Discharge disposition, %
Home	91.2	92.9	81.4
Home healthcare	4.5	3.5	9.9
Other	2.9	2.6	4.5
Postacute care facility	1.1	0.8	3.1
Died	0.4	0.3	1.1
Payor, %
Government	61.1	60.6	63.5
Private	33.2	33.6	30.9
Other	5.7	5.7	5.7
Hospital resource use
Median length of stay [IQR]	3 [16]	2 [14]	16 [1226]
Median hospital cost [IQR]	$8,144 [$4,122$18,447]	$6,689 [$3,685$12,395]	$49,207 [$29,444$95,738]
Total hospital cost, $, billions	$22.2	$8.5	$13.7

Demographics and Clinical Characteristics of Children With and Without Long LOS

Compared with hospitalized CMC with LOS <10 days, a higher percentage of hospitalizations with LOS 10 days were CMC age <1 year (25.7% vs 12.7%, P < 0.001) and Hispanic (20.4% vs 17.8%, P < 0.001). CMC hospitalizations with a long LOS had a higher percentage of any CCC (91.8% vs 77.3%, P < 0.001); the most common CCCs were gastrointestinal (45.9%), neuromuscular (30.9%), and cardiovascular (29.9%). Hospitalizations of CMC with a long LOS had a higher percentage of a catastrophic chronic condition (46.1% vs 28.8%, P < 0.001) and technology dependence (46.1% vs 28.8%, P < 0.001) (Table 1).

Hospitalization Characteristics of Children With and Without Long LOS

Compared with hospitalizations of CMC with LOS <10 days, hospitalizations of CMC with a long LOS more often involved transfer in from another hospital at admission (13.6% vs 5.3%, P < 0.001). CMC hospital stays with a long LOS more often involved surgery (38.7% vs 20.7%, P < 0.001) and use of intensive care (46.5% vs 14.9%; P < 0.001). A higher percentage of CMC with long LOS were discharged with home health services (9.9% vs 3.5%; P < 0.001) (Table 1).

The most common admitting diagnoses and CCCs for hospitalizations of CMC with long LOS are presented in Table 2. The two most prevalent APR‐DRGs in CMC hospitalizations lasting 10 days or longer were cystic fibrosis (10.7%) and respiratory system disease with ventilator support (5.5%). The two most common chronic condition characteristics represented among long CMC hospitalizations were gastrointestinal devices (eg, gastrostomy tube) (39.7%) and heart and great vessel malformations (eg, tetralogy of Fallot) (12.8%). The 5 most common CCC subcategories, as listed in Table 2, account for nearly 100% of the patients with long LOS hospitalizations.

Table 2.Most Common Reasons for Admission and Specific Complex Chronic Conditions for Hospitalized Children With Medical Complexity Who Had Length of Stay 10 Days

NOTE: *Reason for admission identified using All‐Patient Refined Diagnosis‐Related Groups. Complex chronic conditions identified using Feudtner and colleagues set of International Classification of Diseases, 9th Revision, Clinical Modification codes. Gastrointestinal devices include gastrostomy, gastrojejunostomy, colostomy. Respiratory devices include tracheostomy, noninvasive positive pressure, ventilator.
Most common reason for admission*
Cystic fibrosis	10.7%
Respiratory system diagnosis with ventilator support 96+ hours	5.5%
Malfunction, reaction, and complication of cardiac or vascular device or procedure	2.8%
Craniotomy except for trauma	2.6%
Major small and large bowel procedures	2.3%
Most common complex chronic condition
Gastrointestinal devices	39.7%
Heart and great vessel malformations	12.8%
Cystic fibrosis	12.5%
Dysrhythmias	11.0%
Respiratory devices	10.7%

Multivariable Analysis of Characteristics Associated With Long LOS

In multivariable analysis, the highest likelihood of long LOS was experienced by children who received care in the ICU (odds ratio [OR]: 3.5, 95% confidence interval [CI]: 3.43.5), who had a respiratory CCC (OR: 2.7, 95% CI: 2.62.7), and who were transferred from another acute care hospital at admission (OR: 2.1, 95% CI: 2.0, 2.1). The likelihood of long LOS was also higher in children <1 year of age (OR: 1.2, 95% CI: 1.21.3), and Hispanic children (OR: 1.1, 95% CI 1.0‐1.10) (Table 3). Similar multivariable findings were observed in sensitivity analysis using the 75th percentile of LOS (4 days) as the model outcome.

Table 3.Multivariable Analysis of the Likelihood of Long Length of Stay 10 Days

Characteristic	Odds Ratio (95% CI) of LOS 10 Days	P Value
NOTE: Abbreviations: CI, confidence interval; LOS, length of stay.
Use of intensive care	3.5 (3.4‐3.5)	<0.001
Transfer from another acute‐care hospital	2.1 (2.0‐2.1)	<0.001
Procedure/surgery	1.8 (1.8‐1.9)	<0.001
Complex chronic condition
Respiratory	2.7 (2.6‐2.7)	<0.001
Gastrointestinal	1.8 (1.8‐1.8)	<0.001
Metabolic	1.7 (1.7‐1.7)	<0.001
Cardiovascular	1.6 (1.5‐1.6)	<0.001
Neonatal	1.5 (1.5‐1.5)	<0.001
Renal	1.4 (1.4‐1.4)	<0.001
Transplant	1.4 (1.4‐1.4)	<0.001
Hematology and immunodeficiency	1.3 (1.3‐1.3)	<0.001
Technology assistance	1.1 (1.1, 1.1)	<0.001
Neuromuscular	0.9 (0.9‐0.9)	<0.001
Congenital or genetic defect	0.8 (0.8‐0.8)	<0.001
Age at admission, y
<1	1.2 (1.2‐1.3)	<0.001
14	0.5 (0.5‐0.5)	<0.001
59	0.6 (0.6‐0.6)	<0.001
1018	0.9 (0.9‐0.9)	<0.001
18+	Reference
Male	0.9 (0.9‐0.9)	<0.001
Race/ethnicity
Non‐Hispanic black	0.9 (0.9‐0.9)	<0.001
Hispanic	1.1 (1.0‐1.1)	<0.001
Asian	1.0 (1.0‐1.1)	0.3
Other	1.1 (1.1‐1.1)	<0.001
Non‐Hispanic white	Reference
Payor
Private	0.9 (0.8 0.9)	<0.001
Other	1.0 (1.0‐1.0)	0.4
Government	Reference
Season
Spring	1.0 (1.0 1.0)	<0.001
Summer	0.9 (0.9‐0.9)	<0.001
Fall	1.0 (0.9‐1.0)	<0.001
Winter	Reference

Variation in the Prevalence of Long LOS Across Children's Hospitals

After controlling for demographic, clinical, and hospital characteristics associated with long LOS, there was significant (P < 0.001) variation in the prevalence of long LOS for CMC across children's hospitals in the cohort (range, 10.3%21.8%) (Figure 1). Twelve (27%) hospitals had a significantly (P < 0.001) higher prevalence of long LOS for their hospitalized CMC, compared to the mean. Eighteen (41%) had a significantly (P < 0.001) lower prevalence of long LOS for their hospitalized CMC. There was also significant variation across hospitals with respect to cost, with 49.7% to 73.7% of all hospital costs of CMC attributed to long LOS hospitalizations. Finally, there was indirect correlation with the prevalence of LOS across hospitals and the hospitals' 30‐day readmission rate ( = 0.3; P = 0.04). As the prevalence of long LOS increased, the readmission rate decreased.

Figure 1

DISCUSSION

The main findings from this study suggest that a small percentage of CMC experiencing long LOS account for the majority of hospital bed days and cost of all hospitalized CMC in children's hospitals. The likelihood of long LOS varies significantly by CMC's age, race/ethnicity, and payor as well as by type and number of chronic conditions. Among CMC with long LOS, the use of gastrointestinal devices such as gastrostomy tubes, as well as congenital heart disease, were highly prevalent. In multivariable analysis, the characteristics most strongly associated with LOS 10 days were use of the ICU, respiratory complex chronic condition, and transfer from another medical facility at admission. After adjusting for these factors, there was significant variation in the prevalence of LOS 10 days for CMC across children's hospitals.

Although it is well known that CMC as a whole have a major impact on resource use in children's hospitals, this study reveals that 15% of hospitalizations of CMC account for 62% of all hospital costs of CMC. That is, a small fraction of hospitalizations of CMC is largely responsible for the significant financial impact of hospital resource use. To date, most clinical efforts and policies striving to reduce hospital use in CMC have focused on avoiding readmissions or index hospital admissions entirely, rather than improving the efficiency of hospital care after admission occurs.[23, 24, 25, 26] In the adult population, the impact of long LOS on hospital costs has been recognized, and several Medicare incentive programs have focused on in‐hospital timeliness and efficiency. As a result, LOS in Medicare beneficiaries has decreased dramatically over the past 2 decades.[27, 28, 29, 30] Optimizing the efficiency of hospital care for CMC may be an important goal to pursue, especially with precedent set in the adult literature.

Perhaps the substantial variation across hospitals in the prevalence of long LOS in CMC indicates opportunity to improve the efficiency of their inpatient care. This variation was not due to differences across hospitals' case mix of CMC. Further investigation is needed to determine how much of it is due to differences in quality of care. Clinical practice guidelines for hospital treatment of common illnesses usually exclude CMC. In our clinical experience across 9 children's hospitals, we have experienced varying approaches to setting discharge goals (ie, parameters on how healthy the child needs to be to ensure a successful hospital discharge) for CMC.[31] When the goals are absent or not clearly articulated, they can contribute to a prolonged hospitalization. Some families of CMC report significant issues when working with pediatric hospital staff to assess their child's discharge readiness.[7, 32, 33] In addition, there is significant variation across states and regions in access to and quality of post‐discharge health services (eg, home nursing, postacute care, durable medical equipment).[34, 35] In some areas, many CMC are not actively involved with their primary care physician.[5] These issues might also influence the ability of some children's hospitals to efficiently discharge CMC to a safe and supportive post‐discharge environment. Further examination of hospital outliersthose with the lowest and highest percentage of CMC hospitalizations with long LOSmay reveal opportunities to identify and spread best practices.

The demographic and clinical factors associated with long LOS in the present study, including age, ICU use, and transfer from another hospital, might help hospitals target which CMC have the greatest risk for experiencing long LOS. We found that infants age <1 year had longer LOS when compared with older children. Similar to our findings, younger‐aged children hospitalized with bronchiolitis have longer LOS.[36] Certainly, infants with medical complexity, in general, are a high‐acuity population with the potential for rapid clinical deterioration during an acute illness. Prolonged hospitalization for treatment and stabilization may be expected for many of them. Additional investigation is warranted to examine ICU use in CMC, and whether ICU admission or duration can be safely prevented or abbreviated. Opportunities to assess the quality of transfers into children's hospitals of CMC admitted to outside hospitals may be necessary. A study of pediatric burn patients reported that patients initially stabilized at a facility that was not a burn center and subsequently transferred to a burn center had a longer LOS than patients solely treated at a designated burn center.[37] Furthermore, events during transport itself may adversely impact the stability of an already fragile patient. Interventions to optimize the quality of care provided by transport teams have resulted in decreased LOS at the receiving hospital.[38]

This study's findings should be considered in the context of several limitations. Absent a gold‐standard definition of long LOS, we used the distribution of LOS across patients to inform our methods; LOS at the 90th percentile was selected as long. Although our sensitivity analysis using LOS at the 75th percentile produced similar findings, other cut points in LOS might be associated with different results. The study is not positioned to determine how much of the reported LOS was excessive, unnecessary, or preventable. The study findings may not generalize to types of hospitals not contained in PHIS (eg, nonchildren's hospitals and community hospitals). We did not focus on the impact of a new diagnosis (eg, new chronic illness) or acute in‐hospital event (eg, nosocomial infection) on prolonged LOS; future studies should investigate these clinical events with LOS.

PHIS does not contain information regarding characteristics that could influence LOS, including the children's social and familial attributes, transportation availability, home equipment needs, and local availability of postacute care facilities. Moreover, PHIS does not contain information about the hospital discharge procedures, process, or personnel across hospitals, which could influence LOS. Future studies on prolonged LOS should consider assessing this information. Because of the large sample size of hospitalizations included, the statistical power for the analyses was strong, rendering it possible that some findings that were statistically significant might have modest clinical significance (eg, relationship of Hispanic ethnicity with prolonged LOS). We could not determine why a positive correlation was not observed between hospitals' long LOS prevalence and their percentage of cost associated with long LOS; future studies should investigate the reasons for this finding.

Despite these limitations, the findings of the present study highlight the significance of long LOS in hospitalized CMC. These long hospitalizations account for a significant proportion of all hospital costs for this important population of children. The prevalence of long LOS for CMC varies considerably across children's hospitals, even after accounting for the case mix. Efforts to curtail hospital resource use and costs for CMC may benefit from focus on long LOS.

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

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

BACKGROUND

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

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

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

WHY LONG‐TERM PARENTERAL ANTIBIOTICS MAY NOT BE SUPERIOR

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

WHEN TO CONSIDER PROLONGED PARENTERAL ANTIBIOTICS

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

WHAT YOU SHOULD DO INSTEAD

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

RECOMMENDATIONS

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

CONCLUSION

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

Disclosure: Nothing to report.

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

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

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

BACKGROUND

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

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

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

WHY LONG‐TERM PARENTERAL ANTIBIOTICS MAY NOT BE SUPERIOR

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

WHEN TO CONSIDER PROLONGED PARENTERAL ANTIBIOTICS

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

WHAT YOU SHOULD DO INSTEAD

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

RECOMMENDATIONS

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

CONCLUSION

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

Disclosure: Nothing to report.

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

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

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

BACKGROUND

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

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

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

WHY LONG‐TERM PARENTERAL ANTIBIOTICS MAY NOT BE SUPERIOR

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

WHEN TO CONSIDER PROLONGED PARENTERAL ANTIBIOTICS

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

WHAT YOU SHOULD DO INSTEAD

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

RECOMMENDATIONS

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

CONCLUSION

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

Disclosure: Nothing to report.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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