International Networks for Pediatric Inpatient Research and Excellence (INSPIRE): A global initiative in pediatric hospital medicine

Pediatric hospital medicine (PHM) has emerged as one of the fastest-growing pediatric subspecialties.1, 2 Internationally, PHM is most established in the United States, with fellowship training and accreditation as a board-certified specialty, while in other countries (e.g., Australia), core pediatric training includes competencies focused on hospital medicine. Training, accreditation, inpatient staffing models, and the use of the terms “hospital medicine” and “hospitalist” differ across countries, but there is universal recognition of the expertise required to provide care in this setting.3 While the clinical expertise is well established, including its growing importance with the rise in complexity of children managed in hospital,4 PHM is underdeveloped as an academic field. Less than one-third (30.9%) of PHM clinicians have protected time for research, compared to 52.6% for other pediatric subspecialties, and less than 4% spend >25% time on research.1 Researchers in other pediatric subspecialties have developed national networks to build academic capacity with the aim of improving quality of care and reducing unwarranted variation. Pediatric networks in emergency medicine,5 oncology,6 and critical care7 have focused on conducting multicenter studies, in particular, high-quality randomized controlled trials (RCTs) on important clinical questions.8-10 Learning from the success and impact of other pediatric research networks, the past decade has seen the emergence of several PHM national and regional research networks focused on generating evidence to improve quality of care and outcomes for hospitalized children and youth. The objective of this perspective article is to describe the development of an international network of networks focused on PHM research called INSPIRE—the International Networks for Pediatric Inpatient Research and Excellence (www.inspire-global.net). Launched in 2001, the US Pediatric Research in Inpatient Settings (PRIS) Network is the earliest PHM research network.11 Following a rapid growth and development of the field of PHM in the United States, PRIS was redesigned in 2009 and led by a group of hospitalist investigators focused on multicentre research. PRIS also envisioned strong international collaborations, leading to United States–Canadian partnership on multicenter prospective observational studies (e.g., the I-PASS handoff program),12 using administrative databases,13 and inclusion of Canadian sites in surveys (e.g., pulse oximetry in bronchiolitis),14 and more recently collaborations with Australian researchers in hybrid-effectiveness trials. This foundational work from PRIS inspired the launch of PHM networks in other regions in the past decade. Networks now include the General and Adolescent Paediatric Research in the United Kingdom and Ireland (GAPRUKI—https://bagp.org.uk/gapruki/) in 2016; the Children's Inpatient Research Collaboration of Australia and New Zealand (CIRCAN—https://circan.org/) in 2018, and the Canadian Paediatric Inpatient Research Network (PIRN—https://www.pirncanada.com/) in 2019. Table 1 outlines the characteristics of the four currently established pediatric research networks focused on inpatient hospital care. The practice context across the four networks vary with respect to medical training, hospital medicine accreditation as a specialty, inpatient staffing models, and healthcare insurance coverage. Beginning in 2019, there were out-reach efforts made across the networks to arrange quarterly calls to share updates, discuss challenges, and identify opportunities for international collaborations. Building on the foundational work in PRIS,15 each of the three newly established networks focused early work on prioritization studies, including those of parents and families,16 clinicians,17 researchers, and health system impact.18, 19 These meetings also created opportunities to collaborate on workshop submissions to Pediatric Academic Society (PAS) meetings, invitations to speak at respective network meetings (e.g., monthly webinars, annual keynote lectures), cross-network PHM prioritization studies,20 methodological articles,21 and specific studies.22, 23 In other fields, such as pediatric emergency medicine and critical care, international networks have been established, including the Pediatric Emergency Research Networks (PERN—https://pern-global.com/) and the World Federation of Pediatric Intensive & Critical Care Societies (https://wfpiccs.org/).24, 25 For example, PERN launched an international study to evaluate predictors of severe H1N1 infection in children and evaluated asthma guidelines recommendations across regions.26, 27 However, no international research network in pediatric or adult hospital medicine currently exists. Building on the early discussions and collaborations across the newly launched regional PHM networks, there was growing consensus of the value of an international network. An international research network in PHM could facilitate sharing expertise and academic infrastructure and building on different individual network strengths; enable the study of diverse populations leading to more generalizable findings;26 facilitate clinical trial efficiency and large-scale trials;28 support greater success in obtaining funding by creating opportunities for collaborative grant applications and increasing awareness of potential funding sources; share best practices in healthcare delivery and research methods;27 and address global health challenges, such as the COVID-19 pandemic.29 Formalizing an international PHM network could further promote collaboration, accelerate progress, and ultimately lead to better health outcomes for children. The PAS 2024 meeting in Toronto, Canada, presented a unique opportunity that brought together leaders in-person from each of the four regional PHM research networks–PRIS, GAPRUKI, CIRCAN, and PIRN. Building on the growing momentum and success of the regional networks, there was a commitment launch the INSPIRE. In late 2023, the four network leads submitted a proposal to host a PHM Research Networks Reception during the PAS 2024 meeting. Bimonthly meetings were scheduled to outline the agenda, select speakers, draft goals and objectives, and secure funding. The reception was scheduled for 90 min, and there was an additional evening dinner reception for attendees. As PAS 2024 was being held in Canada, PIRN hosted the event and secured funding for most of the costs (e.g., room booking, catering, audio-visual), with PIRN and PRIS funding the rest. There was no cost to attend the event, but individuals had to be attending the PAS meeting. The INSPIRE meeting featured presentations from Dr. Francine Buchanan, a leader on patient partnership, on the importance of engaging children and families and resources for researchers; Dr. Terry Klassen, the Co-Founder of the PERN (https://pern-global.com/), on the genesis of PERN, successes and challenges of international collaboration; and leaders of each of the four pediatric research networks who provided an overview of their network missions and opportunities for collaboration. The 90-min reception was attended by over 70 delegates representing the four PHM networks, including trainees, patient partners, and research staff. A panel discussion followed with a focus on outlining next steps for the international research network in PHM. Research conduct: Generating network or seed grant funding to support study development and initiation; securing funding to expand studies across regions; utilizing and linking administrative data internationally; and providing letters of support and/or collaboration for grants Patient partnership: Involving and partnering with children, youth, parents, and caregivers, and sharing expertise on patient partnership across the network (e.g., PIRN Patient and Family Engagement Coordinator) Capacity building: Supporting research capacity building and mentorship, particularly, for academic clinicians, including nursing and other allied health professionals Governance design: Establishing a governance structure and processes to determine study selection and endorsement, and also strategies to secure research funding Knowledge sharing: Organizing educational sessions and webinars across regions; collaborating to co-create workshops and sessions on key topics. Throughout the discussion, there was a clear emphasis on the need for global collaboration to improve inpatient care. Beyond the meeting, further discussion and networking occurred at a dinner attended by over 30 individuals across the networks. The relationships formed at the inaugural meeting will form the foundation to build on large collaborative research studies to address important clinical questions. The inaugural meeting of INSPIRE reinforced and invigorated the common desire to collaborate to improve care and outcomes for hospitalized children. One of our first projects will be to conduct a systematic review of prioritization studies for hospitalized children to identify overlapping priorities of interest.16, 17, 20 Using a pragmatic approach, the networks are working to identify current projects that could be expanded internationally (e.g., current regional multisite studies),30 spreading the expertise of novel effectiveness-implementation hybrid designs across networks,31 conducting low-cost High-Efficiency RandOmIzed Controlled (HEROIC) trials,21 and leveraging funding and infrastructure of on-going trials, such as partnering with adult colleagues.32 Other examples include studying variation in care internationally using administrative data and practice surveys. There are also opportunities for capacity building by supporting PHM fellowship program development, including sharing best practices.33 Since the inaugural meeting, there has already been collaborations on grant submissions as co-applicants for pilot trials, letters of support provided for grant applications for projects in the United States, United Kingdom, and Canada, webinars hosted across networks, and an INSPIRE workshop submission to PAS 2025 focused on multi-center research. Participants also acknowledged the importance of connections with other global regions that are not represented by the current networks, including continental Europe, Asia, Africa, and South America. To make this a truly international collaboration, we plan to establish connections in these regions after establishing our initial infrastructure. We would like to thank Dr. Colin Macarthur and Dr. Eyal Cohen for supporting the meeting, Dr. Carla Southward and Hadley Sauers-Ford for their assistance organizing the event, Dr. Terry Klassen for speaking, and all the participants that attended the inaugural meeting. The meeting was supported by the Ontario Child Health Support Unit, the SickKids Research Institute, the Canadian Paediatric Inpatient Research Network (PIRN), and the Pediatric Research in Inpatient Settings (PRIS) network. P. J. G. and S. M. have received grants from the Canadian Institute of Health Research (CIHR), the PSI Foundation, and The Hospital for Sick Children. S. V. K. has received grants from the National Institutes of Health (NIH) and the Agency for Healthcare Research and Quality (AHRQ). K. C. acts on behalf of University Hospital Southampton NHS Foundation Trust as an investigator and/or providing consultative advice on studies funded or sponsored by vaccine manufacturers including AstraZeneca, GlaxoSmithKline, Janssen, Medimmune, Merck, Pfizer, Sanofi, Iliad, Moderna, and Valneva. She received no personal financial payment for this work. The authors declare no conflict of interest. The article did not require research ethics board approval.

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