JoAnna Leyenaar
1. As a member of The Dartmouth Institute faculty, you co-direct the capstone course. Can you tell us more about this?
I’m grateful for my faculty appointment at The Dartmouth Institute, where we have MPH, MS, and PhD programs. The Capstone course primarily focuses on teaching scientific manuscript and grant writing, which are two areas of focus in my own day to day work. I really enjoy mentoring students as they learn these rewarding (with perseverance) skills.
2. In your article “Foster Caregiver Experience of Pediatric Hospital-to-Home Transitions: A Qualitative Analysis” in Academic Pediatrics, you talk about how foster care caregivers face unique challenges at discharge from the hospital. In addition to recognizing this, how can we as pediatric hospitalists smooth over this transition period?
In pediatric hospital medicine we have increasingly recognized the role of social determinants of health in our patients’ disease presentations and post-discharge health outcomes. This study sheds light on the tremendous challenges that foster caregivers can face when they leave the hospital with a child for the first time. Understanding these challenges is an important first step towards addressing them. I’m aware of a number of hospital medicine programs that are now strongly encouraging foster caregivers to spend one night with their child in the hospital before discharge, even if this results in “discharge delay.” Given our field’s focus on throughput and timely discharge, the fact that some programs are delaying discharge to support transitional care for this vulnerable population is a departure from our usual approach to enhance patient-centered care.
3. For those looking to become more involved in qualitative and health services research, can you suggest ways for young hospitalists to get their feet wet?
Joining an ongoing project at your own hospital, or participating in a multi-site collaborative can be a great way to get your feet wet. The Academic Pediatric Program’s research scholars, QI scholars, and educational scholars programs also provide a great introduction to research and peer support.
4. You currently are studying the safety and effectiveness of direct admission to hospital as an alternative to admission through emergency departments with funding from the Patient Centered Outcomes Research Institute. You also published “Multi-Stakeholder Informed Guidelines for Direct Admission of Children to Hospital” in the Journal of Pediatrics in July 2018. Are you able to share any preliminary findings? Do you see direct admissions increasing in the future?
We know from our research that many families whose child needs admission would choose direct admission in order to avoid long waits in the ED. However, not all hospital medicine programs are set up to facilitate direct admissions safely. The article, “Multi-Stakeholder Informed Guidelines for Direct Admission of Children to Hospital” provides recommendations for hospital medicine programs interesting in setting up, and evaluating, their own direct admission programs. These recommendations come from the many stakeholders who play a role in the direct admission process, including families, nurses, ED physicians, and hospitalists, among others. COVID-19 may motivate more programs to develop direct admission programs, allowing children and their caregivers, particularly those with chronic diseases, to avoid the ED.
5. You published “Factors Influencing Career Longevity in Pediatric Hospital Medicine” in Hospital Pediatrics in December 2019. What are the important factors for hospitalist retention? And with pediatric hospital medicine as a new subspecialty, do you see that changing in the next 5-10 years?
This study found that two-thirds of early- to mid-career pediatric hospitalists remained in PHM five years later. This is a higher retention rate than has been observed previously, and an indicator of the stability of our specialty. This study also found that hospitalists earning higher salaries and with greater job satisfaction were more likely to stay in the field. In contrast, those more concerned about educational debt were more likely to leave PHM. This speaks to the large role that financial compensation, and financial stressors, may have in workforce development. With PHM now a board-certified subspecialty, I expect we’ll see greater career longevity in the future.
6. Reading your commentary “Child Mortality in the United States: Bridging Palliative Care and Public Health Perspectives“ in Pediatrics in October 2018, I was shocked to learn that in 2015, 1 out of every 270 infants in the United States died before their first birthday. U.S. mortality rates remain much higher than our peer countries. As pediatric hospitalists, what can and should we be doing differently?
This is a great question. The United States has a higher infant mortality rate than many economically-comparable countries, with substantial geographic variation and disparities across racial-ethnic groups. As hospitalists, we generally don’t think of this outcome as being one that we can influence. But I think we do have a responsibility to identify and address the social determinants of health that may exacerbate disparities in care and in health outcomes for children. Reinforcing safe sleep practices and facilitating social supports for families may be particularly high-impact areas to focus on.
7. In your editorial “Are Pediatric Readmission Reduction Efforts Falling Flat?” in the Journal of Hospital Medicine in October 2019, you discuss pediatric readmission rates and specifically mention children with chronic illnesses. What are your thoughts about trying to reduce pediatric readmission rates, and what do you think we should be focusing on when discharging patients?
In this editorial we discuss the findings published by Kathy Auger and colleagues that, from 2010 to 2016, the average 7-day readmission rate across 66 children’s hospitals was unchanged, despite many of the hospitals participating in a national learning collaborative focused on readmission reduction. While hospital readmission is an attractive outcome measure given its wide applicability and ease of measurement, I would recommend that we shift our focus to provide high quality transitional care that meets the diverse needs of our patients, with less focus on whether we’re moving the readmission needle.
8. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
This is an exciting time of growth and development of pediatric hospital medicine. Huge kudos to all of the pediatric hospitalists providing front line pediatric care and addressing head-on the multifaceted challenges brought by COVID.
I’m grateful for my faculty appointment at The Dartmouth Institute, where we have MPH, MS, and PhD programs. The Capstone course primarily focuses on teaching scientific manuscript and grant writing, which are two areas of focus in my own day to day work. I really enjoy mentoring students as they learn these rewarding (with perseverance) skills.
2. In your article “Foster Caregiver Experience of Pediatric Hospital-to-Home Transitions: A Qualitative Analysis” in Academic Pediatrics, you talk about how foster care caregivers face unique challenges at discharge from the hospital. In addition to recognizing this, how can we as pediatric hospitalists smooth over this transition period?
In pediatric hospital medicine we have increasingly recognized the role of social determinants of health in our patients’ disease presentations and post-discharge health outcomes. This study sheds light on the tremendous challenges that foster caregivers can face when they leave the hospital with a child for the first time. Understanding these challenges is an important first step towards addressing them. I’m aware of a number of hospital medicine programs that are now strongly encouraging foster caregivers to spend one night with their child in the hospital before discharge, even if this results in “discharge delay.” Given our field’s focus on throughput and timely discharge, the fact that some programs are delaying discharge to support transitional care for this vulnerable population is a departure from our usual approach to enhance patient-centered care.
3. For those looking to become more involved in qualitative and health services research, can you suggest ways for young hospitalists to get their feet wet?
Joining an ongoing project at your own hospital, or participating in a multi-site collaborative can be a great way to get your feet wet. The Academic Pediatric Program’s research scholars, QI scholars, and educational scholars programs also provide a great introduction to research and peer support.
4. You currently are studying the safety and effectiveness of direct admission to hospital as an alternative to admission through emergency departments with funding from the Patient Centered Outcomes Research Institute. You also published “Multi-Stakeholder Informed Guidelines for Direct Admission of Children to Hospital” in the Journal of Pediatrics in July 2018. Are you able to share any preliminary findings? Do you see direct admissions increasing in the future?
We know from our research that many families whose child needs admission would choose direct admission in order to avoid long waits in the ED. However, not all hospital medicine programs are set up to facilitate direct admissions safely. The article, “Multi-Stakeholder Informed Guidelines for Direct Admission of Children to Hospital” provides recommendations for hospital medicine programs interesting in setting up, and evaluating, their own direct admission programs. These recommendations come from the many stakeholders who play a role in the direct admission process, including families, nurses, ED physicians, and hospitalists, among others. COVID-19 may motivate more programs to develop direct admission programs, allowing children and their caregivers, particularly those with chronic diseases, to avoid the ED.
5. You published “Factors Influencing Career Longevity in Pediatric Hospital Medicine” in Hospital Pediatrics in December 2019. What are the important factors for hospitalist retention? And with pediatric hospital medicine as a new subspecialty, do you see that changing in the next 5-10 years?
This study found that two-thirds of early- to mid-career pediatric hospitalists remained in PHM five years later. This is a higher retention rate than has been observed previously, and an indicator of the stability of our specialty. This study also found that hospitalists earning higher salaries and with greater job satisfaction were more likely to stay in the field. In contrast, those more concerned about educational debt were more likely to leave PHM. This speaks to the large role that financial compensation, and financial stressors, may have in workforce development. With PHM now a board-certified subspecialty, I expect we’ll see greater career longevity in the future.
6. Reading your commentary “Child Mortality in the United States: Bridging Palliative Care and Public Health Perspectives“ in Pediatrics in October 2018, I was shocked to learn that in 2015, 1 out of every 270 infants in the United States died before their first birthday. U.S. mortality rates remain much higher than our peer countries. As pediatric hospitalists, what can and should we be doing differently?
This is a great question. The United States has a higher infant mortality rate than many economically-comparable countries, with substantial geographic variation and disparities across racial-ethnic groups. As hospitalists, we generally don’t think of this outcome as being one that we can influence. But I think we do have a responsibility to identify and address the social determinants of health that may exacerbate disparities in care and in health outcomes for children. Reinforcing safe sleep practices and facilitating social supports for families may be particularly high-impact areas to focus on.
7. In your editorial “Are Pediatric Readmission Reduction Efforts Falling Flat?” in the Journal of Hospital Medicine in October 2019, you discuss pediatric readmission rates and specifically mention children with chronic illnesses. What are your thoughts about trying to reduce pediatric readmission rates, and what do you think we should be focusing on when discharging patients?
In this editorial we discuss the findings published by Kathy Auger and colleagues that, from 2010 to 2016, the average 7-day readmission rate across 66 children’s hospitals was unchanged, despite many of the hospitals participating in a national learning collaborative focused on readmission reduction. While hospital readmission is an attractive outcome measure given its wide applicability and ease of measurement, I would recommend that we shift our focus to provide high quality transitional care that meets the diverse needs of our patients, with less focus on whether we’re moving the readmission needle.
8. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
This is an exciting time of growth and development of pediatric hospital medicine. Huge kudos to all of the pediatric hospitalists providing front line pediatric care and addressing head-on the multifaceted challenges brought by COVID.