Implementing Parental Tobacco Dependence Treatment Within Bronchiolitis QI Collaboratives.

BACKGROUND AND OBJECTIVES: We sought to implement systematic tobacco dependence interventions for parents and/or caregivers as secondary aims within 2 multisite quality improvement (QI) collaboratives for bronchiolitis. We hypothesized that iterative improvements in tobacco dependence intervention strategies would result in improvement in outcomes between collaboratives. METHODS: This study involved 2 separate yearlong, multisite QI collaboratives that were focused on care provided to inpatients with a primary diagnosis of bronchiolitis. In each collaborative, we provided tools and training in tobacco dependence treatment and expert coaching on interventions for parents as a secondary aim. Data were collected by chart review and results analyzed by using analysis of means and statistical process control analysis. Outcomes between collaboratives were compared by using relative risks. RESULTS: Between both collaboratives, 56 hospitals participated and 6258 inpatient charts were reviewed. In the first collaborative, 22% of identified parents who smoke received tobacco dependence interventions at baseline. This rate increased to 51% during the postintervention period, with special cause revealed by analysis of means. In the second collaborative, 31% of parents who smoke received baseline interventions. This rate increased to 53% by the conclusion of the collaborative, with special cause revealed by statistical process control analysis. The relative risk for providing any cessation intervention in 1 collaborative versus the other was 0.9 (confidence interval 0.8-1.1). CONCLUSIONS: Tobacco dependence treatment of parents and/or caregivers can be integrated into bronchiolitis QI by using relatively low-resource strategies. Using a more intensive QI intervention did not alter the rates of screening or intervention for caregivers who smoke.

Pediatric hospitalist systems versus traditional models of care: effect on quality and cost outcomes.

BACKGROUND: Pediatric hospitalist systems are increasing in popularity, but data regarding the effects of hospitalist systems on the quality of care has been sparse, in part because rigorous metrics for analysis have not yet been established. We conducted a literature review of studies comparing the performance of pediatric hospitalists and traditional attendings. OBJECTIVE: To determine the effect of pediatric hospitalists on quality and outcome metrics such as length of stay, cost, patient satisfaction, mortality, readmission rates, and use of evidence-based medicine during care. RESULTS: A Medline literature search identified 11 studies that met criteria for inclusion. Five previously reviewed studies reported lengths of stay between 6% and 14% shorter for hospitalists. Five of the new studies evaluated lengths of stay, with 1 showing significantly lower length of stay and cost for a faculty model, 1 showing lower length of stay for hospitalists for all conditions, 1 for certain conditions only, and 2 showing no statistical difference. Six studies reported on readmission rate, with 4 showing no difference, 1 showing decreased readmissions for hospitalists, and 1 showing decreased readmissions for a traditional faculty service. Hospitalists self-report higher use of evidence-based guidelines. Few differences in patient satisfaction were reported. Mortality on the pediatrics wards is rare, and no studies were adequately powered to evaluate mortality rate. CONCLUSION: Hospitalists can improve the quality and efficiency of inpatient care in the pediatric population, but the effect is not universal, and mechanisms underlying demonstrated improvements are poorly understood. We propose 4 components to improve quality and value in hospital medicine systems: investment in comparative effectiveness research involving delivery system interventions, development and implementation of pediatric quality measures, better understanding of improvement mechanisms for hospital medicine systems, and increased focus on quality and value delivered by hospital medicine groups and individuals.