RESEARCH ARTICLE

Toward High-Value Care: A Quality ImprovementInitiative to Reduce Unnecessary Repeat CompleteBlood Counts and Basic Metabolic Panels on aPediatric Hospitalist ServiceDavid P. Johnson, MD,a Carrie Lind, MD,a Sarah E.S. Parker, MD,a Christian Beuschel, MD,b Stacey VanVliet, MD,b James Nichols, PhD,c Carol A. Rauch, MD, PhD,c

Brenda Lee, BSIE,d Stephen E. Muething, MDd

A B S T R A C T OBJECTIVE: Achieving high-value health care is a goal of health care providers who strive to increasequality and decrease cost. Decreasing laboratory tests is a potential method to increase value. We usedquality improvement methodology to decrease the percentage of unnecessary complete blood counts (CBCs)and basic metabolic panels (BMPs) obtained on a pediatric hospital medicine service from 13.5% to ,5%.

METHODS: A pre- and postintervention design was conducted including all patients admitted to2 hospital medicine teams between May 2013 and December 2014. Multiple interventions linked to keydrivers were tested through rapid plan-do-study-act cycles. Primary and secondary outcome measures,percent reduction of unnecessary CBCs and BMPs, and consecutive day tests were analyzed usingstatistical process control. Total billed charges, laboratory charges, 7-day readmission rates, and length ofstay were compared pre- and postintervention.

RESULTS: Primary outcome of unnecessary CBCs and BMPs was reduced from a baseline of 13.5% to4.5%. Secondary outcome measure of consecutive day testing was reduced from 20.9% to 8.5%. Medianlaboratory charges decreased significantly ($842 [$256–$1863] vs $800 [$222–$1616], P 5 .002), with nosignificant differences in total billed charges, 7-day readmission rates, or length of stay.

CONCLUSIONS: Rapid cycle plan-do-study-act methodology, initially focusing on the inclusion of adaily laboratory plan in progress notes, was an effective means to improve laboratory utilization anddecrease laboratory charges without adversely affecting other quality measures. Spreading theseefforts to different patient populations and laboratory tests could have a demonstrable effect on thevalue of health care.

aDepartments ofPediatrics, Division ofHospital Medicine, and

bPediatric ResidencyProgram, Monroe CarellJr. Children’s Hospital at

Vanderbilt, Nashville,Tennessee; cDepartment

of Pathology,Microbiology, and

Immunology, VanderbiltUniversity School ofMedicine, Nashville,

Tennessee; anddCincinnati Children’s

Medical Center,Cincinnati, Ohio

www.hospitalpediatrics.orgDOI:10.1542/hpeds.2015-0099Copyright © 2016 by the American Academy of Pediatrics

Address correspondence to David P. Johnson, MD, 2200 Children’s Way, 8020 Vanderbilt Children’s Hospital, Nashville, TN 37232-9452.E-mail: david.p.johnson.1@vanderbilt.edu

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

FINANCIAL DISCLOSURE: James Nichols participates on IL and Siemens Scientific Advisory Boards; receives speaker travel funds andhonoraria from Abbott, Bio-Ra, and Roche; is on the Board of Directors for CLSI; and is the editor of Point of Care Testing journal.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Dr Johnson conceptualized and designed the study and drafted the initial manuscript; Drs Lind, Parker, Beuschel, VanVliet, Nichols, andRauch assisted with data collection and analysis and critically reviewed the manuscript; Ms Lee and Dr Muething assisted withconceptualizing the study and critically reviewed the manuscript; and all authors approved the final manuscript as submitted.

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The turn of the new millennium brought abouta rejuvenated interest in patient safety andquality,1,2 and more recently, attention hasbroadened to improve value in health care asinsurance payers, including the Centers forMedicare and Medicaid Services, have begunto base hospital payments on care value.3

Unnecessary services and waste in health carehave been identified as 2 potential sourcesthat decrease value, with waste constituting21% to 47% of health care expenditures.4,5 Ifvalue can be defined as quality or outcomes/cost,4,6 then targeting waste reduction ingeneral, and laboratory testing in particular,has the potential to increase value.

Repeat laboratory testing has untowardeffects on care quality. Previous literaturehas not only shown that laboratory testingis overused7 but also that many tests arerepeated within a time frame that provideslittle clinical information.8,9 Repeat tests aretaxing on laboratory personnel’s workloadand delay efficient reporting of otherstudies.10 Excessive phlebotomy can result iniatrogenic anemia in both neonates11 andadults.12 Spurious or unexpected resultshave downstream implications for furthertesting, increased resource utilization, andoverdiagnosis.13–15 Excessive phlebotomy isassociated with patient discomfort andsleep disruption and can lead to decreasedpatient satisfaction.

Because of these issues, multiple projectshave sought to reduce repeat testing.Many of these studies have used singleinformation technology interventionsincluding computerized reminders or hardstops regarding duplicate orders,16,17

“unbundling” of panels so physiciansare required to order each desiredcomponent,18,19 providing justification foreach test,20 and computerized decision-support tools.21 Other reports have shownmixed success in providing charge dataeither while ordering tests,22–24 or on aweekly basis for each patient.25 Aside from1 study reporting slightly higherunscheduled outpatient follow-up afteremergency department visits,23 thesestudies did not report any patient safetyconcerns, indicating that the reduction inlaboratory tests in these studies was likelyfrom reducing excessive testing.

We set forth to decrease the number ofunnecessary complete blood counts(CBCs) and basic metabolic panels (BMPs)on 2 pediatric hospital medicine (HM)teams using rapid cycle plan-do-study-act(PDSA) quality improvement methodology.We hypothesized that a successfulinitiative would improve value byeliminating waste and improving patientexperience. To our knowledge, this is thefirst report reducing laboratory utilizationthrough multiple interventions targetingprovider behavior.

METHODS

Monroe Carell Jr. Children’s Hospital atVanderbilt is a large, freestanding,academic children’s hospital with 271 bedsand 18 081 discharges in fiscal year 2014,with 2780 from the HM service. There are2 HM teams, each staffed weekly by 1 of10 HM faculty physicians, 2 pediatric ormedicine-pediatric residents, 4 or 5 interns,and medical students. An attending HMphysician is in-house daily to staffadmissions until midnight. Residents andinterns rotate on a 4-week schedule. The HMservice cares for a variety of generalpediatric issues and for many subspecialtypatients with consultant input. This studywas approved by the Vanderbilt UniversityInstitutional Review Board.

Planning the Intervention

A multidisciplinary team consisting of HMfaculty, pediatric residents, laboratoryfaculty members, nursing leadership, and aquality consultant mapped the laboratorytest ordering process,26 conducted amodified failure mode and effects analysis,and developed a key driver diagram relatedto theories for improvement and potentialinterventions (Fig 1).

The team worked together to define an“unnecessary” test. The team determinedthat a BMP obtained within 1 calendar dayof a previous BMP with #3 abnormalvalues and a CBC obtained within1 calendar day of a previous CBC with#1 abnormal value were “unnecessary”for this improvement project. The BMPincluded sodium, potassium, chloride,bicarbonate, blood urea nitrogen,creatinine, and glucose. The CBC included

white blood cell count, hemoglobin, andplatelets. Normal age-specific referenceranges for BMPs and CBCs were obtainedfrom the CALIPER study27 and NelsonTextbook of Pediatrics,28 respectively.

Improvement Activities

The interventions focused on 3 key drivers:(1) effective communication among theprimary team, (2) knowledge of laboratorycharges, and (3) providers understandingthe magnitude of the problem. The teamused a series of rapid-cycle PDSAinterventions to determine theireffectiveness.26

Effective Communication Among thePrimary Team Members

Before the intervention, there was nostandard practice of incorporatinglaboratory plans or interpretation into thenotes or the handover tools used byresidents. It was done on a case-by-casebasis and anecdotally almost never done ifthere were no laboratories planned. Webegan by asking 1 intern to document bothlaboratory result interpretation andanticipated laboratory plans for the next24 hours on a single patient, including if nolaboratory tests were planned. Feedbackrevealed documenting the previous day’slaboratory interpretation was arduousbecause results were autoimported into thenotes, but including a laboratory plan forthe next day did not disrupt intern workflow.Over 2 weeks, the initiative was slowlyexpanded until all 10 interns on the 2 HMteams were including laboratory plans intheir daily notes. This plan carried overfrom month to month as residents andinterns switched rotations, but occasionally,a member of the improvement project teamwould remind the residents to include alaboratory plan. Feedback early in theproject via REDcap29 also revealed that themost helpful aspect of the laboratory planwas when documentation confirmed nolaboratories were needed. This allowed thecovering night intern to field questions fromnursing and families overnight that they hadpreviously been unable to answer and oftenresulted in more testing.

For the first 2 months after the initialintervention, the majority of our

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unnecessary laboratories were obtainedwithin 1 calendar day of patient admission.HM faculty revealed that future laboratorystudies were only discussed when theythought studies were needed. If studieswere not discussed, the faculty’sassumption was that no laboratory studieswere needed, but the residents’understanding sometimes differed. Thislack of clarity resulted in laboratorystudies often being ordered the morningafter admission. Therefore, HM attendingphysicians were asked to initiate aconversation specifically addressingfuture laboratory testing during the initialadmission conversations.

Knowledge of Laboratory Charges

A common misconception of charges atour hospital was that a panel componentcarried the same charge as a completepanel. Hospital administration providedthe improvement team with the chargesfor BMPs, CBCs, and the individualcomponents of each panel and providedpermission to use them as educationalmaterials for this study. The charges wereplaced on small index cards and taped tocomputers in HM resident ward workareas. After receiving favorable feedbackabout the location, size, usability, andeffect on ordering habits, they were alsoposted in the main resident workroom.

Providers Understanding the Magnitudeof the Problem

In an effort to gain support from theresidents and attending physicians and toillustrate the magnitude of the problem, theteam began posting updated control charts inearly February in the resident work areas.Shortly thereafter, quality improvement teammembers began e-mailing each attendingabout the unnecessary laboratories obtainedduring their service week to inquire about therationale for the tests. This interventionlasted 1 month mainly because of its labor-intensive nature. Feedback from the attendingphysicians revealed these laboratory testswere often ordered without the attending’sexplicit knowledge. In late July 2014, datacollection was more timely because of thecreation of a weekly report, and we begane-mailing the HM teams the number ofunnecessary tests ordered from the previousweek, a control chart, and a short reminderto include a laboratory plan in the notes.

Measurement Plans

Laboratory data were collected from May2013 through December 2014 via billinginformation. All CBC and BMP laboratorydraws obtained by teams led by a HMattending were extracted. Laboratoriesdrawn immediately before admission in theemergency department or in the ICU within

1 calendar day of transfer to the HM servicewere included as initial laboratories. Dataregarding laboratories drawn at outsidehospitals before transfer were not availablefor review. All repeat laboratories within1 calendar day were reviewed to determineif they met “unnecessary” criteria. All repeatlaboratory tests drawn within 1 calendarday were a secondary measure. A processmeasure of laboratory plans in intern noteswas accomplished by doing a randomreview of 20 charts per week from billingdata to determine if there was a writtenfuture laboratory plan. Administrative datafrom the Pediatric Health InformationSystem (PHIS) was obtained to comparea 12-month preintervention period(December 2012–November 2013) withthe postintervention period (December2013–November 2014). PHIS data weremerged with administrative data to captureall patients discharged from the HM servicewithin the study period. Charges and lengthof stay (LOS) balancing measure wereanalyzed using this data. Our secondbalancing measure, 7-day readmissionrates, was obtained using our readmissiondashboard.

Analysis

Analysis of primary and secondary outcomemeasures was performed using statisticalprocess control p-charts with 8 points

FIGURE 1 Key driver diagram. An unnecessary test is defined as a second CBC ordered within 1 calendar day when the first test had #1 abnormalvalue or second BMP when the first test had #3 abnormal values.

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above or below the mean representingspecial cause variation. Seven-dayreadmission rates were compared in thepre- and postintervention time periodsusing 2-tailed t tests. Median LOS, totalbilled charges, and laboratory charges werecompared in the pre- and postperiod with aWilcoxon rank sum test using Stata13.0 software. Hospitalizations with totalbilled charges less than the fifth andgreater than the 95th percentiles wereexcluded from the charge and LOS analysesbecause those less than the fifth percentilewere thought to represent short admissionswith few opportunities for repeat laboratorytesting and those with total billed chargesgreater than the 95th percentile likely spentthe vast majority of time in the ICU or onsurgical services where the HM servicecontributed little to the overall charges.

RESULTS

The primary outcome measure, percentageof unnecessary BMPs and CBCs ordered,decreased from 13.5% at baseline to 4.5%(Fig 2). This outcome was sustained for42 weeks and the control limits narrowed,indicating a more stable panel orderingprocess on the HM service. The largestimprovement in our primary outcomemeasure was temporally related to thelaboratory plan intervention, decreasingunnecessary testing from 13.5% to 7.9%.Additionally, the sharing of the data withresidents and attending physicians andasking for direct feedback about failuresalso resulted in a second shift of the meanline to 4.5%, allowing us to attain our goal.

We also saw an improvement in oursecondary outcome, which was a reductionin the percentage of tests repeated within1 calendar day. Through the interventionperiod, the mean percentage of repeat testsdecreased initially from a baseline mean of20.9% to 13.2%, and then again to 8.5%.Similar to our primary outcome, theoriginal change also occurred in temporalrelation to the laboratory plan intervention(Fig 3).

The original observation of special causevariation in our primary and secondaryoutcomes coincides with special causevariation in our process measure afterinclusion of a laboratory plan in daily notes.

The percentage of notes including a planoriginally increased from a median of 30%to 80%, but degradation of the processoccurred in mid-May, and the median fell to50%. After the implementation of the finalintervention that included a reminder e-mail,this improved to our goal of 75% (Fig 4).

Exclusion of the top and bottom 5% of totalbilled charges resulted in 2926 and2922 patient discharges for 12 monthspre- and postimplementation, respectively.Comparisons pre- and postinterventionrevealed a significant difference in totallaboratory charges ($842, interquartilerange [IQR] $256–$1863 vs $800 IQR$222–$1616, P 5 .002) but not total billedcharges ($9822, IQR $6258–$17 265 vs$10 101 IQR $6578–$17351, P 5 .12).

LOS (1.56 [days], IQR 0.88–2.59 vs 1.59 IQR0.88–2.60, P 5 .68) and 7-day readmissionrates (3.4% vs 2.5%, P 5 .20) remainedunchanged as balancing measures.

DISCUSSION

We used improvement science to implementmultiple interventions that togetherachieved our primary goal of reducingunnecessary CBCs and BMPs while alsoreducing consecutive-day laboratorytests and total laboratory charges. Theimprovements in our outcomes had noadverse effects on LOS or readmissions. Wefocused on interventions to have an impacton 3 key drivers: effective laboratorycommunication among the primary team,knowledge of laboratory charges, andproviders understanding the magnitude ofthe problem.

Previous successful attempts to reducelaboratory tests have relied mainly onsingle interventions. Many of these focusedon order entry process, either throughalterations in the ordering process16–21

or providing charge data in electronicordering systems.23,24 Although feedback toteams regarding charges25 and educationalinitiatives30 have decreased costs, webelieve our report is the first to useimprovement science to combine multipleinterventions that have successfullyimproved and sustained physicianordering behavior without a technologysupport emphasis.

While developing this project, our team hadto define “unnecessary” laboratories toinvestigate failures and provide feedback.This definition helped us determine the vastmajority of our failures were occurringwithin 1 day of hospital admission, allowingus to tailor our next intervention to theadmission process. The definition alsoencouraged providers to be more focused intheir requisition of follow-up tests, onlyordering necessary components of a panel.This helps avoid spurious values not initiallyof clinical interest that subsequently drivefurther testing and resource utilization.Through our approach, we not only reducedlaboratory tests that met our definitionof unnecessary but also reduced thepercentage of consecutive day CBCs andBMPs, which is currently a Choosing WiselyCampaign initiative for adult hospitalmedicine.31

Our team also had to define a goal. Wechose a reduction to 5% to be bothaggressive in our primary aim and accountfor clinical scenarios in which a blanketdefinition may not address clinical nuance.We felt that a goal of zero unnecessary testswould not have been feasible for multiplereasons. We understood that our definitionof unnecessary would not fit every clinicalscenario. For example, serial laboratorymonitoring may be necessary in a child atrisk for hemolysis or a child with metabolicdisease at risk for severe electrolyteabnormalities even with minor illness. Inthese cases initial laboratory tests may benormal, but repeat monitoring is necessary.In fact, a cluster of such patientscontributed to the special cause variationseen in 3 of the 4 weeks betweenMay 12, 2014, and June 2, 2014. Conversely,a profoundly abnormal BMP in a child withstable contraction alkalosis on a diureticregimen may not warrant repeating despite.3 abnormal values. For such testing thatmay fall outside of the “unnecessary”definition but still provide little clinicalutility, our secondary outcome wasdeveloped to measure broader repeatlaboratory ordering behaviors.

Throughout our interventions, feedbackfrom key stakeholders proved pivotal.Feedback allowed us to adapt our initial

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intervention to include only a future

laboratory plan, which helped gain support

from the interns, solidified our choice ofplacement for laboratory charges, focused

the team laboratory discussions on

admission, and helped attending physicians

become more aware of the number of tests

being ordered during their time on service.Even interventions that were short andaborted, like the direct attending feedback,were important in improving the teams’understanding of the problems.

Initially, we saw significant improvement inprimary and secondary outcomes after

PDSA cycles targeted documenting

laboratory plans. As the project progressed,

we saw degradation in the process beforereturning to our goal, despite sustained

improvements in outcomes. This may reveal

that the laboratory plan process was

sufficient but not necessary to drive change

FIGURE 2 Percent unnecessary CBCs and BMPs on the HM service: control p-chart showing the primary outcome measure with annotations ofsmall tests of change. The x-axis is labeled with every other week, but data points are weekly.

FIGURE 3 Percent of repeat CBCs and BMPs within 1 calendar day on the HM service: control p-chart showing the secondary outcome measurewith annotations of small tests of change. The x-axis is labeled with every other week, but data points are weekly.

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and that the cumulative effect ofinterventions began to change the culture oflaboratory ordering.

Limitations

This study was performed at a single site.Given the known heterogeneity of HM services,our interventions may not be generalizable toother hospitals or patient populations.

We were also unable to measure many of thepotential benefits to the patients, theirfamilies, and the hospital as a whole. Ideally,refraining from laboratory testing reducesthe number of isolated phlebotomy draws,increases sleep for patients and families,increases patient satisfaction, and improveslaboratory turn-around time. Unfortunately,within our system, we did not have a way to

develop obtainable metrics for theseimportant suspected benefits. In addition,refraining from a BMP or CBC does notnecessarily mean that no laboratorieswere obtained because individual panelcomponents or other tests might beordered.

Our analysis of charges simply comparedcharges pre- and postimplementation. We

FIGURE 4 Percent of 20 random weekly charts with future laboratory plan in resident note: run chart after the process measure for the first smalltest of change with a goal of 75% indicated and annotations of small tests of change related to this process. The x-axis is labeled withevery other week, but data points are weekly.

TABLE 1 Project Measures and Definitions

Measurement Type Measure Definition

Primary outcome measure % of unnecessary BMPs and CBCs obtained on theHM service per total BMPs and CBCs ordered

A measure of the % of total BMPs and CBCsobtained that were “unnecessary” (Unnecessarywas defined as BMPs obtained within 1 calendarday of a previous BMP that had #3 abnormalvalues and CBCs obtained within 1 calendar dayof a previous CBC that had #1 abnormal value.)

Secondary outcome % of consecutive day BMPs and CBCs ordered pertotal CBCs and BMPs

A measure of the % of BMPs and CBCs obtainedwithin 1 calendar day of the same test

Process measure Laboratory plans % of 20 random weekly charts having a plan forfuture laboratories in the resident note

Charge outcomes Median total billed charges Median total billed charges per discharged patientobtained from administrative data set

Median total laboratory charges Median value of the total laboratory charges perdischarged patient obtained from administrativedata set

Balancing measures Median LOS A measure of the LOS in days of each patientdischarged from the HM service (includesinpatient and observation stays)

7-d readmission rate A measure of the rate of unplanned readmissionswithin 7 d for all patients discharged from theHM service (includes inpatient and observationstays)

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did not take into account the effects ofinflation or any potential chargemasterchanges. In addition, the data extractedfrom PHIS included all patients dischargedfrom the HM service, regardless of theamount of time the HM service cared forthat patient. Therefore, the charges orLOS for some patients may be moreattributable to different servicesdepending on time spent in the ICU orother factors. Total billed charges likely didnot change given the fixed costs associatedwith hospital stays32 and the relativelysmall contribution of these panels to thetotal billed charge.

Almost all of the sustainability plans forthis project were done manually, but thelevel of reliability could be greatly increasedwith information technology interventions.Alterations to the progress note toautomatically include a section forlaboratory plans, inclusion of laboratorycharges in the computerized physicianorder entry system instead of note cards,and automated methods for feedback maymake this less labor-intensive, and thetechnology could potentially be sharedamong institutions.

Finally, our definition of “unnecessary” isnot a validated metric. Although somestudies have set forth to determine theclinical necessity of laboratory testing,33

clinical nuance likely prohibits anoverarching definition such as the onewe developed. The metric also would notbe appropriate for different patientpopulations. This represents an area forfuture study.

CONCLUSIONS

Through a quality improvement initiativewith multiple interventions, we were ableto successfully reduce and sustain thepercentage of unnecessary BMPs and CBCson our HM service and decrease totallaboratory charges per patient while seeingno change in our balancing measures. Wepropose that we have improved the valueof care provided for these patients bydemonstrably reducing laboratory chargesand, although not directly measured,potentially improving the patientexperience. Further research is needed todetermine if this approach is generalizable

to other settings, patient populations, andlaboratory or radiographic testing,especially in resource-intensive settingssuch as the ICU. Such efforts broadened toother areas of resource utilization maybegin to bend the value curve by providinghigher quality care at lower cost.

Acknowledgments

Surveys within this study were developedand administered by using REDCapdatabase, which is supported byUL1 TR000445 from National Center forAdvancing Translational Sciences/NationalInstitutes of Health. David Johnson receivedmultiple thoughts and suggestionsregarding this project from his classmatesand faculty in the IntermediateImplementation Science Series (I2S2) giventhrough Cincinnati Children’s Hospital.Thanks to Dr Derek Williams for assistingwith the data analysis for LOS and charges,Dr Jim Gay for helping extract the PHIS data,and Travis Harper for creating the datadashboard.

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DOI: 10.1542/hpeds.2015-0099 originally published online January 1, 2015; 2016;6;1Hospital Pediatrics 

VanVliet, James Nichols, Carol A. Rauch, Brenda Lee and Stephen E. MuethingDavid P. Johnson, Carrie Lind, Sarah E.S. Parker, Christian Beuschel, Stacey

Pediatric Hospitalist ServiceUnnecessary Repeat Complete Blood Counts and Basic Metabolic Panels on a

Toward High-Value Care: A Quality Improvement Initiative to Reduce

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DOI: 10.1542/hpeds.2015-0099 originally published online January 1, 2015; 2016;6;1Hospital Pediatrics 

VanVliet, James Nichols, Carol A. Rauch, Brenda Lee and Stephen E. MuethingDavid P. Johnson, Carrie Lind, Sarah E.S. Parker, Christian Beuschel, Stacey

Pediatric Hospitalist ServiceUnnecessary Repeat Complete Blood Counts and Basic Metabolic Panels on a

Toward High-Value Care: A Quality Improvement Initiative to Reduce

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Print ISSN: 2154-1663. Illinois, 60143. Copyright © 2016 by the American Academy of Pediatrics. All rights reserved. published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca,publication, it has been published continuously since 2012. Hospital Pediatrics is owned, Hospital Pediatrics is the official journal of the American Academy of Pediatrics. A monthly

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