Interhospital transfer of critically ill and injured children is necessitated by variation in resource availability between hospitals. Critically ill children judged in need of clinical services or expertise not locally available undergo transfer to hospitals with more appropriate resource capabilities and expertise, with the expectation that clinical outcomes of transfer will be better than nontransfer.

Significant variation both in the availability of pediatric critical care services across US hospitals1 and in child mortality among hospitals without pediatric critical care services2 suggests that interhospital transfer will remain an integral part of healthcare delivery for critically ill and injured children. Timely provision of definitive care for acute life‐threatening disease is associated with good clinical outcomes.3, 4 While prior studies have examined clinical outcomes and resource consumption among critically ill adults who underwent interhospital transfer for intensive care,59 there is scarce information regarding clinical characteristics and outcomes of interhospital transfer for critically ill and injured children.

This study was conducted to test the hypothesis that, among critically ill and injured children who undergo interhospital transfer for intensive care, children transferred after an initial hospitalization at the referring facility will have higher mortality, longer length of stay (LOS), and higher resource consumption than children transferred directly from the emergency department (ED) of the referring hospitals.

METHODS

RESULTS

DISCUSSION

This study is the first to highlight significant variation in clinical outcomes and resource consumption after interhospital transfer of critically ill and injured children, depending on the source of transfer. In comparison with children transferred directly from the referring hospitals' ED settings, children transferred from the referring hospitals' wards had higher mortality, while those who underwent inter‐ICU transfer had significantly higher resource consumption. In addition, ward transfers had the highest proportion of children who underwent CPR on the date of interhospital transfer, highlighting elevated severity of disease prior to transfer and an urgent need for improved understanding of pretransfer clinical care and medical decision‐making. The findings raise the possibility that more timely transfer of some patients directly from community hospital EDs to regional ICUs might improve survival and reduce resource consumption.

Although interhospital transfers are common in everyday clinical practice, there has been a knowledge gap in pediatric acute and critical care medicine regarding the clinical outcomes and resource consumption among children who undergo such transfers. Findings from the current study narrow this gap by relating triage at the referring hospitals to clinical outcomes and resource utilization at the receiving hospitals.

Certain distinct transfer patterns were observed. Most children with burn injury underwent direct transfer from the ED to the ICU; this transfer pattern may be related both to the limited availability of ICUs with burn care capability in Michigan and to the acuity of burn injuries, which often mandates immediate triage to hospitals with intensive burn care facilities. Conversely, while the majority of children with traumatic injuries were directly transferred from emergency to intensive care, over one‐fifth were transferred after initial care delivered on the ward or ICU settings prior to interhospital transfer for definitive intensive trauma care. Such imperfect regionalization of trauma care suggests further study of clinical outcomes and resource utilization among injured children is warranted. Likewise, cardiovascular disease was prominent among the inter‐ICU transfers, suggesting a clinical practice pattern of stabilization and resuscitation at the initial ICU prior to interhospital vertical or uptransfer for definitive cardiac care at the receiving hospitals.

It remains unknown whether the timing of interhospital transfer of critically ill children is a determinant of clinical outcomes. Prior studies among adults have reported higher mortality with prolonged duration of pre‐ICU care on the ward.4, 17 In the current study, ward and inter‐ICU transfers were initially hospitalized for a median of 1 and 3 days, respectively, prior to transfer. While we could not determine from administrative data what the precise triggers for interhospital transfer in this study were, it is instructive to note that ward transfers comprised more than one‐half of all children who received CPR on the date of transfer. For children who received CPR, severe clinical deterioration likely triggered transfer to hospitals with ICU facilities, but because only a minority of children received CPR overall, other triggers of transfer warrant investigation. For most of the children transferred, it seems plausible that the precipitant of transfer was likely a mismatch of their clinical status with the clinical capacities of the facilities where they were initially hospitalized. Future work should investigate if there is an association between clinical outcomes at the receiving hospitals, and both the timing of interhospital transfer and the clinical status of patients at transfer.

Importantly, compared with ED transfers, ward transfers demonstrated elevated odds of mortality after adjustment for coexisting comorbid illness, patient age, and pretransfer organ dysfunction at the referring hospital. Some possible explanations for this finding include the progression of disease while receiving care on the ward, or suboptimal access to ICU facilities due to barriers to transfer at either the referring or receiving hospitals. Importantly, progression of disease in ward settings may be detected by early identification of children at high risk of clinical deterioration on the wards of hospitals without ICU facilities, prior to cardiopulmonary arrest, because death after CPR may not be averted with subsequent ICU care.18

Various approaches to facilitate rapid and appropriate triage and reassessment of children in hospitals without ICU facilities, prior to severe clinical deterioration or need for CPR, must be investigated. These approaches might include in‐hospital measures such as the establishment of medical emergency teams to respond to clinical deterioration on the wards19 or collaborative interhospital measures such as the use of telemedicine20 or similar remote communication/triage systems to enhance communication between clinical caregivers at hospitals with ICU facilities and those in hospitals without ICU facilities. Furthermore, interhospital transfer agreements may facilitate expeditious and appropriate transfer of severely ill patients to hospitals with ICU facilities.

Access to hospitals with ICU facilities might also influence outcomes for critically ill children admitted initially to wards of hospitals without ICU facilities. Kanter2 reported significant variation in mortality among children who received care at New York hospitals without ICU facilities. Of note, 27% of statewide pediatric inpatient deaths occurred in those hospitals without ICU facilities. It appeared that, while some pediatric deaths in hospitals without ICU facilities were expected, regional variation in such mortality might have been associated with reduced access to, or poor utilization of, hospitals with ICU facilities. Barriers to interhospital transfers might include underrecognition of mismatch between patient illness severity and hospital capability at referring hospitals, or lack of capacity to accept transfers at the receiving hospitals. Further study is warranted to investigate clinical decision‐making underlying the initiation of the interhospital transfer processes, and procedural or institutional barriers that might hinder the transfer of critically ill children from hospitals without ICU facilities.

Resource consumption at the receiving hospitals, measured by hospital LOS and receipt of medical‐surgical procedures, was highest among the inter‐ICU transfers. This was an expected finding, given the high frequency of organ dysfunction among the inter‐ICU transfers, before and after interhospital transfer. These patients had the highest use of advanced and resource‐intensive technology, including continuous renal replacement therapy, extracorporeal membrane oxygenation, and cardiovascular procedures such as open‐heart surgery. In addition, the duration of hospitalization at the receiving hospital was 2 weeks longer among the inter‐ICU transfers when compared with the ED transfers. Such prolonged hospitalization has been previously associated with significantly increased resource consumption.4, 6 In the absence of physiologic data pertaining to illness severity, however, it is unknown whether this observed differential LOS by source of interhospital transfer might be attributable to both unobserved illness severity and/or extensive in‐hospital post‐ICU multidisciplinary rehabilitative care for inter‐ICU transfer patients, compared with ED transfer patients.

Our study findings need to be interpreted in light of certain limitations. Administrative claims data do not allow for assessment of the quality of hospital care, a factor that might play an important role in patient clinical outcomes. The data lacked any physiologic information that might enhance the ability to estimate patient severity of illness; the analysis used the presence of organ dysfunction at the referring hospitals as a proxy for illness severity. The use of diagnosis codebased measures of severity adjustment, as employed in the current study, however, has been reported to be comparable with clinical severity measures because of the relatively complete capture of diagnosis codes for life‐threatening conditions occurring late in the hospitalization, such as prior to interhospital transfer in the current study.2123

The absence of clinical information prevented assessment of the likelihood of in‐hospital morbidity, transport complications, and need for various therapeutic interventions after ICU care, which are also highly relevant outcomes of interhospital transfers. It is unknown if the small sample size among inter‐ICU transfers limited the ability to demonstrate a statistically significant difference in odds of mortality among inter‐ICU transfers compared with ED transfers.

Also, the identification of diagnoses and procedures was made using multiple coding instruments and is therefore susceptible to inaccuracies of detection and attribution that may have biased the findings. Study findings did not include cost, because cost data were not available for children enrolled in Medicaid managed care plans under capitated arrangements. Finally, it is unknown how generalizable the current study findings might be to children with private insurance, or to children who are uninsured.

The study findings highlight potential opportunities for future research. Further studies are warranted to identify key characteristics that differentiate children admitted to nonpediatric hospitals who are subsequently transferred to pediatric hospitals with ICU facilities versus the children who are not transferred. Also, in‐depth study of the decision‐making that underlies interhospital transfer of critically ill or injured children to hospitals with ICU facilities for advanced care after initial hospitalization is vital to improved understanding of factors that might contribute to the extensive resource consumption and mortality burden borne by these children. The existence and effectiveness of interhospital transfer agreements at the state level needs to be examined specifically as it relates to patterns and clinical outcomes of interhospital transfer of critically ill and injured children in the US.

In conclusion, in this multiyear, statewide sample among critically ill and injured children enrolled by a statewide public payer, clinical outcomes were worse and resource consumption higher, among children who underwent interhospital transfer after initial hospitalization compared with those transferred directly from referring EDs. The findings raise the possibility that more timely transfer of some patients directly from community hospital EDs to regional ICUs might improve survival and reduce resource consumption.

Efforts to improve the care of critically ill and injured children may be enhanced by improved understanding of the medical decision‐making underlying interhospital transfer; application of innovative methods to identify and ensure rapid access to clinical expertise for children initially admitted to hospitals without pediatric intensive care facilities who might subsequently require intensive care; and routine reassessment of hospitalized children to ensure effective and efficient triage and re‐triage at the ED, ward, and ICU levels of referring hospitals.

Interhospital transfer of critically ill and injured children is necessitated by variation in resource availability between hospitals. Critically ill children judged in need of clinical services or expertise not locally available undergo transfer to hospitals with more appropriate resource capabilities and expertise, with the expectation that clinical outcomes of transfer will be better than nontransfer.

Significant variation both in the availability of pediatric critical care services across US hospitals1 and in child mortality among hospitals without pediatric critical care services2 suggests that interhospital transfer will remain an integral part of healthcare delivery for critically ill and injured children. Timely provision of definitive care for acute life‐threatening disease is associated with good clinical outcomes.3, 4 While prior studies have examined clinical outcomes and resource consumption among critically ill adults who underwent interhospital transfer for intensive care,59 there is scarce information regarding clinical characteristics and outcomes of interhospital transfer for critically ill and injured children.

This study was conducted to test the hypothesis that, among critically ill and injured children who undergo interhospital transfer for intensive care, children transferred after an initial hospitalization at the referring facility will have higher mortality, longer length of stay (LOS), and higher resource consumption than children transferred directly from the emergency department (ED) of the referring hospitals.

METHODS

RESULTS

DISCUSSION

This study is the first to highlight significant variation in clinical outcomes and resource consumption after interhospital transfer of critically ill and injured children, depending on the source of transfer. In comparison with children transferred directly from the referring hospitals' ED settings, children transferred from the referring hospitals' wards had higher mortality, while those who underwent inter‐ICU transfer had significantly higher resource consumption. In addition, ward transfers had the highest proportion of children who underwent CPR on the date of interhospital transfer, highlighting elevated severity of disease prior to transfer and an urgent need for improved understanding of pretransfer clinical care and medical decision‐making. The findings raise the possibility that more timely transfer of some patients directly from community hospital EDs to regional ICUs might improve survival and reduce resource consumption.

Although interhospital transfers are common in everyday clinical practice, there has been a knowledge gap in pediatric acute and critical care medicine regarding the clinical outcomes and resource consumption among children who undergo such transfers. Findings from the current study narrow this gap by relating triage at the referring hospitals to clinical outcomes and resource utilization at the receiving hospitals.

Certain distinct transfer patterns were observed. Most children with burn injury underwent direct transfer from the ED to the ICU; this transfer pattern may be related both to the limited availability of ICUs with burn care capability in Michigan and to the acuity of burn injuries, which often mandates immediate triage to hospitals with intensive burn care facilities. Conversely, while the majority of children with traumatic injuries were directly transferred from emergency to intensive care, over one‐fifth were transferred after initial care delivered on the ward or ICU settings prior to interhospital transfer for definitive intensive trauma care. Such imperfect regionalization of trauma care suggests further study of clinical outcomes and resource utilization among injured children is warranted. Likewise, cardiovascular disease was prominent among the inter‐ICU transfers, suggesting a clinical practice pattern of stabilization and resuscitation at the initial ICU prior to interhospital vertical or uptransfer for definitive cardiac care at the receiving hospitals.

It remains unknown whether the timing of interhospital transfer of critically ill children is a determinant of clinical outcomes. Prior studies among adults have reported higher mortality with prolonged duration of pre‐ICU care on the ward.4, 17 In the current study, ward and inter‐ICU transfers were initially hospitalized for a median of 1 and 3 days, respectively, prior to transfer. While we could not determine from administrative data what the precise triggers for interhospital transfer in this study were, it is instructive to note that ward transfers comprised more than one‐half of all children who received CPR on the date of transfer. For children who received CPR, severe clinical deterioration likely triggered transfer to hospitals with ICU facilities, but because only a minority of children received CPR overall, other triggers of transfer warrant investigation. For most of the children transferred, it seems plausible that the precipitant of transfer was likely a mismatch of their clinical status with the clinical capacities of the facilities where they were initially hospitalized. Future work should investigate if there is an association between clinical outcomes at the receiving hospitals, and both the timing of interhospital transfer and the clinical status of patients at transfer.

Importantly, compared with ED transfers, ward transfers demonstrated elevated odds of mortality after adjustment for coexisting comorbid illness, patient age, and pretransfer organ dysfunction at the referring hospital. Some possible explanations for this finding include the progression of disease while receiving care on the ward, or suboptimal access to ICU facilities due to barriers to transfer at either the referring or receiving hospitals. Importantly, progression of disease in ward settings may be detected by early identification of children at high risk of clinical deterioration on the wards of hospitals without ICU facilities, prior to cardiopulmonary arrest, because death after CPR may not be averted with subsequent ICU care.18

Various approaches to facilitate rapid and appropriate triage and reassessment of children in hospitals without ICU facilities, prior to severe clinical deterioration or need for CPR, must be investigated. These approaches might include in‐hospital measures such as the establishment of medical emergency teams to respond to clinical deterioration on the wards19 or collaborative interhospital measures such as the use of telemedicine20 or similar remote communication/triage systems to enhance communication between clinical caregivers at hospitals with ICU facilities and those in hospitals without ICU facilities. Furthermore, interhospital transfer agreements may facilitate expeditious and appropriate transfer of severely ill patients to hospitals with ICU facilities.

Access to hospitals with ICU facilities might also influence outcomes for critically ill children admitted initially to wards of hospitals without ICU facilities. Kanter2 reported significant variation in mortality among children who received care at New York hospitals without ICU facilities. Of note, 27% of statewide pediatric inpatient deaths occurred in those hospitals without ICU facilities. It appeared that, while some pediatric deaths in hospitals without ICU facilities were expected, regional variation in such mortality might have been associated with reduced access to, or poor utilization of, hospitals with ICU facilities. Barriers to interhospital transfers might include underrecognition of mismatch between patient illness severity and hospital capability at referring hospitals, or lack of capacity to accept transfers at the receiving hospitals. Further study is warranted to investigate clinical decision‐making underlying the initiation of the interhospital transfer processes, and procedural or institutional barriers that might hinder the transfer of critically ill children from hospitals without ICU facilities.

Resource consumption at the receiving hospitals, measured by hospital LOS and receipt of medical‐surgical procedures, was highest among the inter‐ICU transfers. This was an expected finding, given the high frequency of organ dysfunction among the inter‐ICU transfers, before and after interhospital transfer. These patients had the highest use of advanced and resource‐intensive technology, including continuous renal replacement therapy, extracorporeal membrane oxygenation, and cardiovascular procedures such as open‐heart surgery. In addition, the duration of hospitalization at the receiving hospital was 2 weeks longer among the inter‐ICU transfers when compared with the ED transfers. Such prolonged hospitalization has been previously associated with significantly increased resource consumption.4, 6 In the absence of physiologic data pertaining to illness severity, however, it is unknown whether this observed differential LOS by source of interhospital transfer might be attributable to both unobserved illness severity and/or extensive in‐hospital post‐ICU multidisciplinary rehabilitative care for inter‐ICU transfer patients, compared with ED transfer patients.

Our study findings need to be interpreted in light of certain limitations. Administrative claims data do not allow for assessment of the quality of hospital care, a factor that might play an important role in patient clinical outcomes. The data lacked any physiologic information that might enhance the ability to estimate patient severity of illness; the analysis used the presence of organ dysfunction at the referring hospitals as a proxy for illness severity. The use of diagnosis codebased measures of severity adjustment, as employed in the current study, however, has been reported to be comparable with clinical severity measures because of the relatively complete capture of diagnosis codes for life‐threatening conditions occurring late in the hospitalization, such as prior to interhospital transfer in the current study.2123

The absence of clinical information prevented assessment of the likelihood of in‐hospital morbidity, transport complications, and need for various therapeutic interventions after ICU care, which are also highly relevant outcomes of interhospital transfers. It is unknown if the small sample size among inter‐ICU transfers limited the ability to demonstrate a statistically significant difference in odds of mortality among inter‐ICU transfers compared with ED transfers.

Also, the identification of diagnoses and procedures was made using multiple coding instruments and is therefore susceptible to inaccuracies of detection and attribution that may have biased the findings. Study findings did not include cost, because cost data were not available for children enrolled in Medicaid managed care plans under capitated arrangements. Finally, it is unknown how generalizable the current study findings might be to children with private insurance, or to children who are uninsured.

The study findings highlight potential opportunities for future research. Further studies are warranted to identify key characteristics that differentiate children admitted to nonpediatric hospitals who are subsequently transferred to pediatric hospitals with ICU facilities versus the children who are not transferred. Also, in‐depth study of the decision‐making that underlies interhospital transfer of critically ill or injured children to hospitals with ICU facilities for advanced care after initial hospitalization is vital to improved understanding of factors that might contribute to the extensive resource consumption and mortality burden borne by these children. The existence and effectiveness of interhospital transfer agreements at the state level needs to be examined specifically as it relates to patterns and clinical outcomes of interhospital transfer of critically ill and injured children in the US.

In conclusion, in this multiyear, statewide sample among critically ill and injured children enrolled by a statewide public payer, clinical outcomes were worse and resource consumption higher, among children who underwent interhospital transfer after initial hospitalization compared with those transferred directly from referring EDs. The findings raise the possibility that more timely transfer of some patients directly from community hospital EDs to regional ICUs might improve survival and reduce resource consumption.

Efforts to improve the care of critically ill and injured children may be enhanced by improved understanding of the medical decision‐making underlying interhospital transfer; application of innovative methods to identify and ensure rapid access to clinical expertise for children initially admitted to hospitals without pediatric intensive care facilities who might subsequently require intensive care; and routine reassessment of hospitalized children to ensure effective and efficient triage and re‐triage at the ED, ward, and ICU levels of referring hospitals.

Interhospital transfer of critically ill and injured children is necessitated by variation in resource availability between hospitals. Critically ill children judged in need of clinical services or expertise not locally available undergo transfer to hospitals with more appropriate resource capabilities and expertise, with the expectation that clinical outcomes of transfer will be better than nontransfer.

Significant variation both in the availability of pediatric critical care services across US hospitals1 and in child mortality among hospitals without pediatric critical care services2 suggests that interhospital transfer will remain an integral part of healthcare delivery for critically ill and injured children. Timely provision of definitive care for acute life‐threatening disease is associated with good clinical outcomes.3, 4 While prior studies have examined clinical outcomes and resource consumption among critically ill adults who underwent interhospital transfer for intensive care,59 there is scarce information regarding clinical characteristics and outcomes of interhospital transfer for critically ill and injured children.

This study was conducted to test the hypothesis that, among critically ill and injured children who undergo interhospital transfer for intensive care, children transferred after an initial hospitalization at the referring facility will have higher mortality, longer length of stay (LOS), and higher resource consumption than children transferred directly from the emergency department (ED) of the referring hospitals.

METHODS

RESULTS

DISCUSSION

This study is the first to highlight significant variation in clinical outcomes and resource consumption after interhospital transfer of critically ill and injured children, depending on the source of transfer. In comparison with children transferred directly from the referring hospitals' ED settings, children transferred from the referring hospitals' wards had higher mortality, while those who underwent inter‐ICU transfer had significantly higher resource consumption. In addition, ward transfers had the highest proportion of children who underwent CPR on the date of interhospital transfer, highlighting elevated severity of disease prior to transfer and an urgent need for improved understanding of pretransfer clinical care and medical decision‐making. The findings raise the possibility that more timely transfer of some patients directly from community hospital EDs to regional ICUs might improve survival and reduce resource consumption.

Although interhospital transfers are common in everyday clinical practice, there has been a knowledge gap in pediatric acute and critical care medicine regarding the clinical outcomes and resource consumption among children who undergo such transfers. Findings from the current study narrow this gap by relating triage at the referring hospitals to clinical outcomes and resource utilization at the receiving hospitals.

Certain distinct transfer patterns were observed. Most children with burn injury underwent direct transfer from the ED to the ICU; this transfer pattern may be related both to the limited availability of ICUs with burn care capability in Michigan and to the acuity of burn injuries, which often mandates immediate triage to hospitals with intensive burn care facilities. Conversely, while the majority of children with traumatic injuries were directly transferred from emergency to intensive care, over one‐fifth were transferred after initial care delivered on the ward or ICU settings prior to interhospital transfer for definitive intensive trauma care. Such imperfect regionalization of trauma care suggests further study of clinical outcomes and resource utilization among injured children is warranted. Likewise, cardiovascular disease was prominent among the inter‐ICU transfers, suggesting a clinical practice pattern of stabilization and resuscitation at the initial ICU prior to interhospital vertical or uptransfer for definitive cardiac care at the receiving hospitals.

It remains unknown whether the timing of interhospital transfer of critically ill children is a determinant of clinical outcomes. Prior studies among adults have reported higher mortality with prolonged duration of pre‐ICU care on the ward.4, 17 In the current study, ward and inter‐ICU transfers were initially hospitalized for a median of 1 and 3 days, respectively, prior to transfer. While we could not determine from administrative data what the precise triggers for interhospital transfer in this study were, it is instructive to note that ward transfers comprised more than one‐half of all children who received CPR on the date of transfer. For children who received CPR, severe clinical deterioration likely triggered transfer to hospitals with ICU facilities, but because only a minority of children received CPR overall, other triggers of transfer warrant investigation. For most of the children transferred, it seems plausible that the precipitant of transfer was likely a mismatch of their clinical status with the clinical capacities of the facilities where they were initially hospitalized. Future work should investigate if there is an association between clinical outcomes at the receiving hospitals, and both the timing of interhospital transfer and the clinical status of patients at transfer.

Importantly, compared with ED transfers, ward transfers demonstrated elevated odds of mortality after adjustment for coexisting comorbid illness, patient age, and pretransfer organ dysfunction at the referring hospital. Some possible explanations for this finding include the progression of disease while receiving care on the ward, or suboptimal access to ICU facilities due to barriers to transfer at either the referring or receiving hospitals. Importantly, progression of disease in ward settings may be detected by early identification of children at high risk of clinical deterioration on the wards of hospitals without ICU facilities, prior to cardiopulmonary arrest, because death after CPR may not be averted with subsequent ICU care.18

Various approaches to facilitate rapid and appropriate triage and reassessment of children in hospitals without ICU facilities, prior to severe clinical deterioration or need for CPR, must be investigated. These approaches might include in‐hospital measures such as the establishment of medical emergency teams to respond to clinical deterioration on the wards19 or collaborative interhospital measures such as the use of telemedicine20 or similar remote communication/triage systems to enhance communication between clinical caregivers at hospitals with ICU facilities and those in hospitals without ICU facilities. Furthermore, interhospital transfer agreements may facilitate expeditious and appropriate transfer of severely ill patients to hospitals with ICU facilities.

Access to hospitals with ICU facilities might also influence outcomes for critically ill children admitted initially to wards of hospitals without ICU facilities. Kanter2 reported significant variation in mortality among children who received care at New York hospitals without ICU facilities. Of note, 27% of statewide pediatric inpatient deaths occurred in those hospitals without ICU facilities. It appeared that, while some pediatric deaths in hospitals without ICU facilities were expected, regional variation in such mortality might have been associated with reduced access to, or poor utilization of, hospitals with ICU facilities. Barriers to interhospital transfers might include underrecognition of mismatch between patient illness severity and hospital capability at referring hospitals, or lack of capacity to accept transfers at the receiving hospitals. Further study is warranted to investigate clinical decision‐making underlying the initiation of the interhospital transfer processes, and procedural or institutional barriers that might hinder the transfer of critically ill children from hospitals without ICU facilities.

Resource consumption at the receiving hospitals, measured by hospital LOS and receipt of medical‐surgical procedures, was highest among the inter‐ICU transfers. This was an expected finding, given the high frequency of organ dysfunction among the inter‐ICU transfers, before and after interhospital transfer. These patients had the highest use of advanced and resource‐intensive technology, including continuous renal replacement therapy, extracorporeal membrane oxygenation, and cardiovascular procedures such as open‐heart surgery. In addition, the duration of hospitalization at the receiving hospital was 2 weeks longer among the inter‐ICU transfers when compared with the ED transfers. Such prolonged hospitalization has been previously associated with significantly increased resource consumption.4, 6 In the absence of physiologic data pertaining to illness severity, however, it is unknown whether this observed differential LOS by source of interhospital transfer might be attributable to both unobserved illness severity and/or extensive in‐hospital post‐ICU multidisciplinary rehabilitative care for inter‐ICU transfer patients, compared with ED transfer patients.

Our study findings need to be interpreted in light of certain limitations. Administrative claims data do not allow for assessment of the quality of hospital care, a factor that might play an important role in patient clinical outcomes. The data lacked any physiologic information that might enhance the ability to estimate patient severity of illness; the analysis used the presence of organ dysfunction at the referring hospitals as a proxy for illness severity. The use of diagnosis codebased measures of severity adjustment, as employed in the current study, however, has been reported to be comparable with clinical severity measures because of the relatively complete capture of diagnosis codes for life‐threatening conditions occurring late in the hospitalization, such as prior to interhospital transfer in the current study.2123

The absence of clinical information prevented assessment of the likelihood of in‐hospital morbidity, transport complications, and need for various therapeutic interventions after ICU care, which are also highly relevant outcomes of interhospital transfers. It is unknown if the small sample size among inter‐ICU transfers limited the ability to demonstrate a statistically significant difference in odds of mortality among inter‐ICU transfers compared with ED transfers.

Also, the identification of diagnoses and procedures was made using multiple coding instruments and is therefore susceptible to inaccuracies of detection and attribution that may have biased the findings. Study findings did not include cost, because cost data were not available for children enrolled in Medicaid managed care plans under capitated arrangements. Finally, it is unknown how generalizable the current study findings might be to children with private insurance, or to children who are uninsured.

The study findings highlight potential opportunities for future research. Further studies are warranted to identify key characteristics that differentiate children admitted to nonpediatric hospitals who are subsequently transferred to pediatric hospitals with ICU facilities versus the children who are not transferred. Also, in‐depth study of the decision‐making that underlies interhospital transfer of critically ill or injured children to hospitals with ICU facilities for advanced care after initial hospitalization is vital to improved understanding of factors that might contribute to the extensive resource consumption and mortality burden borne by these children. The existence and effectiveness of interhospital transfer agreements at the state level needs to be examined specifically as it relates to patterns and clinical outcomes of interhospital transfer of critically ill and injured children in the US.

In conclusion, in this multiyear, statewide sample among critically ill and injured children enrolled by a statewide public payer, clinical outcomes were worse and resource consumption higher, among children who underwent interhospital transfer after initial hospitalization compared with those transferred directly from referring EDs. The findings raise the possibility that more timely transfer of some patients directly from community hospital EDs to regional ICUs might improve survival and reduce resource consumption.

Efforts to improve the care of critically ill and injured children may be enhanced by improved understanding of the medical decision‐making underlying interhospital transfer; application of innovative methods to identify and ensure rapid access to clinical expertise for children initially admitted to hospitals without pediatric intensive care facilities who might subsequently require intensive care; and routine reassessment of hospitalized children to ensure effective and efficient triage and re‐triage at the ED, ward, and ICU levels of referring hospitals.

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

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

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

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

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

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

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

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

• 1

  Harm is eliminated from the inpatient setting.

• 2

  Inpatient care is evidence‐based for all conditions treated.

• 3

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

• 4

  A robust research agenda supports all aspects of inpatient care.

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

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

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

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

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

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

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

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

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

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

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

• 1

  Harm is eliminated from the inpatient setting.

• 2

  Inpatient care is evidence‐based for all conditions treated.

• 3

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

• 4

  A robust research agenda supports all aspects of inpatient care.

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

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

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

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

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

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

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

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

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

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

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

• 1

  Harm is eliminated from the inpatient setting.

• 2

  Inpatient care is evidence‐based for all conditions treated.

• 3

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

• 4

  A robust research agenda supports all aspects of inpatient care.

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

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

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

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

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

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

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

PATIENTS AND METHODS

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

RESULTS

DISCUSSION

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

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

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

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

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

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

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

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

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

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

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

PATIENTS AND METHODS

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

RESULTS

DISCUSSION

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

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

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

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

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

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

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

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

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

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

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

PATIENTS AND METHODS

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

RESULTS

DISCUSSION

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

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

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

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

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

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

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