Leaders: Pediatric Hospitalist Tackles Interhospital Variation

Dr. Raj Srivastava is leading the effort to find answers to the most pressing questions on quality, cost-effectiveness, and patient safety in the care of hospitalized children. Dr. Srivastava, of the department of pediatrics at the University of Utah, Salt Lake City, chairs Pediatric Research in Inpatient Settings (PRIS), a hospitalist-run research network. This network is a joint project of the Society of Hospital Medicine (SHM), the American Academy of Pediatrics, and the Academic Pediatric Association.

Dr. Srivastava has won several teaching awards, and recently SHM bestowed upon him its 2011 Excellence in Research Award. In an interview with Hospitalist News, he shared his thoughts on future directions for PRIS and pediatric hospital medicine.

HN: PRIS is working to identify conditions that are prevalent, costly, and show high interhospital variation. Why is this important?

DR. SRIVASTAVA: Unlike hospitalists who take care of adults, where essentially only a handful of conditions account for the majority of the costs, it’s very different in pediatrics, where a number of conditions are very prevalent but not very costly. But the reverse also can be true in pediatrics.

We believe that by prioritizing these conditions using prevalence, cost, and variation, we will be able to create a roadmap for pediatric inpatient medicine. If you go after condition X as opposed to condition Y, this is the potential return on investment you might get, for example. And I don’t just mean in terms of money, but in terms of the effort expended.

HN: How will this information be used?

DR. SRIVASTAVA: First, we’re going to identify drill-down conditions after the initial prioritization project. These drill downs will make up the next year and a half of work for the PRIS network, where we will study why there’s interhospital variation. Ultimately, we want to understand if there’s overutilization of resources for a particular condition. If we find that to be the case, we think we have two potential avenues to pursue. If there’s no evidence, maybe that’s why there’s overutilization. It’s a case of not knowing what to do. So then we can perform comparative effectiveness research. If the evidence is known, but not followed, then that’s the perfect avenue for quality improvement interventions.

HN: You have won several teaching awards; what do you find most rewarding about working with medical students and residents?

DR. SRIVASTAVA: I love seeing patients, and I love working with students. One of the huge joys I get comes from working through complex issues or teaching points on patients. I enjoy working with the house staff and the students to figure out how to pose the right questions and use the literature to try to figure out to the best of our ability what we should do. I think that sort of lifelong learning skill is really fun.

HN: How do you think the implementation of the Affordable Care Act will affect pediatric hospitalists?

DR. SRIVASTAVA: I think the potential for pediatric hospitalists could be similar to adult hospitalists in the sense of our being relied on to provide efficient care, streamline care, and study systems of care. The Accountable Care Organizations called for in the law are probably going to be utilized first in the adult world. I think if you were to look at pediatric ACOs, you would target the chronically ill pediatric patient (the 5% of kids that account for 50% of your costs). With the PRIS analysis of specific pediatric conditions, we will also have some cost data from hospitals that could aid with bundled payments. For example, we could provide very specific complication data based on many admissions for a condition, and this could be used by stakeholders to work with policy makers to determine the appropriate bundled payment for that condition.

Dr. Raj Srivastava is leading the effort to find answers to the most pressing questions on quality, cost-effectiveness, and patient safety in the care of hospitalized children. Dr. Srivastava, of the department of pediatrics at the University of Utah, Salt Lake City, chairs Pediatric Research in Inpatient Settings (PRIS), a hospitalist-run research network. This network is a joint project of the Society of Hospital Medicine (SHM), the American Academy of Pediatrics, and the Academic Pediatric Association.

Dr. Srivastava has won several teaching awards, and recently SHM bestowed upon him its 2011 Excellence in Research Award. In an interview with Hospitalist News, he shared his thoughts on future directions for PRIS and pediatric hospital medicine.

HN: PRIS is working to identify conditions that are prevalent, costly, and show high interhospital variation. Why is this important?

DR. SRIVASTAVA: Unlike hospitalists who take care of adults, where essentially only a handful of conditions account for the majority of the costs, it’s very different in pediatrics, where a number of conditions are very prevalent but not very costly. But the reverse also can be true in pediatrics.

We believe that by prioritizing these conditions using prevalence, cost, and variation, we will be able to create a roadmap for pediatric inpatient medicine. If you go after condition X as opposed to condition Y, this is the potential return on investment you might get, for example. And I don’t just mean in terms of money, but in terms of the effort expended.

HN: How will this information be used?

DR. SRIVASTAVA: First, we’re going to identify drill-down conditions after the initial prioritization project. These drill downs will make up the next year and a half of work for the PRIS network, where we will study why there’s interhospital variation. Ultimately, we want to understand if there’s overutilization of resources for a particular condition. If we find that to be the case, we think we have two potential avenues to pursue. If there’s no evidence, maybe that’s why there’s overutilization. It’s a case of not knowing what to do. So then we can perform comparative effectiveness research. If the evidence is known, but not followed, then that’s the perfect avenue for quality improvement interventions.

HN: You have won several teaching awards; what do you find most rewarding about working with medical students and residents?

DR. SRIVASTAVA: I love seeing patients, and I love working with students. One of the huge joys I get comes from working through complex issues or teaching points on patients. I enjoy working with the house staff and the students to figure out how to pose the right questions and use the literature to try to figure out to the best of our ability what we should do. I think that sort of lifelong learning skill is really fun.

HN: How do you think the implementation of the Affordable Care Act will affect pediatric hospitalists?

DR. SRIVASTAVA: I think the potential for pediatric hospitalists could be similar to adult hospitalists in the sense of our being relied on to provide efficient care, streamline care, and study systems of care. The Accountable Care Organizations called for in the law are probably going to be utilized first in the adult world. I think if you were to look at pediatric ACOs, you would target the chronically ill pediatric patient (the 5% of kids that account for 50% of your costs). With the PRIS analysis of specific pediatric conditions, we will also have some cost data from hospitals that could aid with bundled payments. For example, we could provide very specific complication data based on many admissions for a condition, and this could be used by stakeholders to work with policy makers to determine the appropriate bundled payment for that condition.

Dr. Raj Srivastava is leading the effort to find answers to the most pressing questions on quality, cost-effectiveness, and patient safety in the care of hospitalized children. Dr. Srivastava, of the department of pediatrics at the University of Utah, Salt Lake City, chairs Pediatric Research in Inpatient Settings (PRIS), a hospitalist-run research network. This network is a joint project of the Society of Hospital Medicine (SHM), the American Academy of Pediatrics, and the Academic Pediatric Association.

Dr. Srivastava has won several teaching awards, and recently SHM bestowed upon him its 2011 Excellence in Research Award. In an interview with Hospitalist News, he shared his thoughts on future directions for PRIS and pediatric hospital medicine.

HN: PRIS is working to identify conditions that are prevalent, costly, and show high interhospital variation. Why is this important?

DR. SRIVASTAVA: Unlike hospitalists who take care of adults, where essentially only a handful of conditions account for the majority of the costs, it’s very different in pediatrics, where a number of conditions are very prevalent but not very costly. But the reverse also can be true in pediatrics.

We believe that by prioritizing these conditions using prevalence, cost, and variation, we will be able to create a roadmap for pediatric inpatient medicine. If you go after condition X as opposed to condition Y, this is the potential return on investment you might get, for example. And I don’t just mean in terms of money, but in terms of the effort expended.

HN: How will this information be used?

DR. SRIVASTAVA: First, we’re going to identify drill-down conditions after the initial prioritization project. These drill downs will make up the next year and a half of work for the PRIS network, where we will study why there’s interhospital variation. Ultimately, we want to understand if there’s overutilization of resources for a particular condition. If we find that to be the case, we think we have two potential avenues to pursue. If there’s no evidence, maybe that’s why there’s overutilization. It’s a case of not knowing what to do. So then we can perform comparative effectiveness research. If the evidence is known, but not followed, then that’s the perfect avenue for quality improvement interventions.

HN: You have won several teaching awards; what do you find most rewarding about working with medical students and residents?

DR. SRIVASTAVA: I love seeing patients, and I love working with students. One of the huge joys I get comes from working through complex issues or teaching points on patients. I enjoy working with the house staff and the students to figure out how to pose the right questions and use the literature to try to figure out to the best of our ability what we should do. I think that sort of lifelong learning skill is really fun.

HN: How do you think the implementation of the Affordable Care Act will affect pediatric hospitalists?

DR. SRIVASTAVA: I think the potential for pediatric hospitalists could be similar to adult hospitalists in the sense of our being relied on to provide efficient care, streamline care, and study systems of care. The Accountable Care Organizations called for in the law are probably going to be utilized first in the adult world. I think if you were to look at pediatric ACOs, you would target the chronically ill pediatric patient (the 5% of kids that account for 50% of your costs). With the PRIS analysis of specific pediatric conditions, we will also have some cost data from hospitals that could aid with bundled payments. For example, we could provide very specific complication data based on many admissions for a condition, and this could be used by stakeholders to work with policy makers to determine the appropriate bundled payment for that condition.