Benefits and Cost-Effectiveness of a Pediatric Hospitalist Service : a Stepped Wedge Quality Improvement Trial

Background. Hospitalists predominantly engaged in inpatient care constitute a fundamental, poorly assessed change in medical care. The University of Texas Houston Pediatrics Department is developing a Hospitalist Division to staff Children's Memorial Hermann Hospital. Demonstration of its benefits and cost-effectiveness is important to secure adequate, sustained hospital or 3rd-party reimbursement. Design. Prospective step wedged quality improvement (QI) study with pediatric hospitalists sequentially assuming 24/7 responsibility for each of the 4 pediatric inpatient services over 2-3 years. This design allows within- and between-group analyses and is particularly desirable for evaluating interventions likely to be beneficial that will be given stepwise to an increasing % of patients. Intervention. Faculty of the new Pediatric Hospitalist Division will initially become responsible 24/7 for 1-2 of the 4 services now staffed by the General Pediatric Division. Currently, each pediatric service admits every other patient without regard to diagnosis, resulting in quasi-random patient assignment. Outcomes: Total hospital days (including 30-day readmissions); intubation; pediatric intensive care unit (ICU) admissions; parent, nurse, and resident satisfaction; and costs assessed using state-of-the-art methods and expressed from the health system, medical school, and hospital perspectives. Hypotheses. Hospitalists will improve clinical outcomes and parent, nurse, and resident satisfaction and be cost-effective (primary outcome), assessed by net cost or savings per hospital day prevented (health system perspective). Analyses. Frequentist and Bayesian analyses to assess the probability of benefit and of cost-effectiveness.