Clinical Full-time Equivalents Research Articles

Clinical Full-Time Equivalent in PICUs: Survey of the U.S. Pediatric Critical Care Chiefs Network, 2020-2022.

To inform workforce planning for pediatric critical care (PCC) physicians, it is important to understand current staffing models and the spectrum of clinical responsibilities of physicians. Our objective was to describe the expected workload associated with a clinical full-time equivalent (cFTE) in PICUs across the U.S. Pediatric Critical Care Chiefs Network (PC3N). Cross-sectional survey. PICUs participating in the PC3N. PICU division chiefs or designees participating in the PC3N from 2020 to 2022. None. A series of three surveys were used to capture unit characteristics and clinical responsibilities for an estimated 1.0 cFTE intensivist. Out of a total of 156 PICUs in the PC3N, the response rate was 46 (30%) to all three distributed surveys. Respondents used one of four models to describe the construction of a cFTE-total clinical hours, total clinical shifts, total weeks of service, or % full-time equivalent. Results were stratified by unit size. The model used for construction of a cFTE did not vary significantly by the total number of faculty nor the total number of beds. The median (interquartile range) of clinical responsibilities annually for a 1.0 cFTE were: total clinical hours 1750 (1483-1858), total clinical shifts 142 (129-177); total weeks of service 13.0 (11.3-16.0); and total night shifts 52 (36-60). When stratified by unit size, larger units had fewer nights or overnight hours, but covered more beds per shift. This survey of the PC3N (2020-2022) provides the most contemporary description of clinical responsibilities associated with a cFTE physician in PCC. A 1.0 cFTE varies depending on unit size. There is no correlation between the model used to construct a cFTE and the associated clinical responsibilities.

2363. Clinician Educators within Infectious Diseases Society of America (IDSA): Who We Are, What We Do, and What We Need to Succeed

Abstract Background To best support, its membership, the IDSA Medical Education Community of Practice (Med Ed CoP) must know the spectrum of educational duties, common challenges, and needs among its clinician educators (CE). Further, benchmark data for medical education is lacking, including average time to perform duties, salary support, and other resources. Therefore, we conducted a survey to help identify opportunities for institutions and IDSA to support Infectious Disease (ID) CE. Methods We conducted an anonymous electronic mixed-methods survey of ID CE faculty in the United States. The survey link was distributed through the IDSA Med Ed CoP and Program Director discussion forums and receptions at IDWeek 2021. Results Approximately 90/552 (16%) participants completed a majority of the survey. Respondents were evenly distributed by gender and geographic region. A majority of respondents were Caucasian, aged 30 – 49 years, and at the Assistant or Associate Professor level (Table 1). Overall breakdown of allocated duties is as follows; median education full-time equivalent (FTE) was 0.25, clinical FTE=0.50, administrative FTE=0.16, and research FTE=0 (Table 1). Faculty most commonly taught medical students (95%), physician residents (92%), and fellows (88%) and held positions within ID fellowship programs (69%) and medical schools (50%, Table 2). CE's common challenges included competing responsibilities (69%), lack of medical education mentorship (51%), and inexperience in medical education publication (67%). In addition, 77% reported burnout in the past year, frequently due to an increased pandemic-related workload. CEs would like to see opportunities for IDSA grants, advocacy for salary support, and increased opportunities to publish within IDSA journals. CEs report finding reward in their educational work related to: teaching the next generation, developing relationships with learners and colleagues, and promoting others’ success. Conclusion In our study, ID CEs identified common challenges including educational work often requiring more time than allocated FTE, lack of mentors, publishing educational activities, recognition of CE work for promotion, and burnout. Additionally, ID CEs identified practical strategies in which their institutions and IDSA can offer support. Disclosures All Authors: No reported disclosures.

8551 Investigating the Impact of the Addition of a MIGS Surgeon on Surgical Volume of General Obstetrics and Gynecologys

Study Objective The primary objective was to determine whether adding a fellowship-trained minimally invasive gynecologic surgeon (FMIGS) would decrease the surgical volumes of physicians in other subspecialties within an academic obstetrics and gynecology (Obstetrics and Gynecology) department. Design The study compared case type and quantity, and case minutes of general Obstetrics and Gynecology, Female Pelvic Medicine & Reconstructive Surgery (FPMRS), and Reproductive Endocrinology & Infertility (REI) physicians before and after the addition of a FMIGS-trained surgeon. “Before” was academic years 2015-16 and 2016-17. “After” was academic years 2017-18, 2018-19, 2019-20, and 2020-21. Setting An academic Obstetrics and Gynecology department that grew from twelve to twenty surgeons from AY 2015-21. Patients or Participants All general Obstetrics and Gynecology, REI, and FPMRS physicians within an academic Obstetrics and Gynecology department. Interventions Surgical data including numbers of surgeries, categorized by major and minor, with and without endometriosis, and total case minutes from all general Obstetrics and Gynecology, REI, and FPMRS physicians from AY 2015-21 were collected for each academic year. Clinical full-time equivalents (FTE) per academic year, adjusted for hire date and medical leaves, were also collected. Major cases included hysterectomy, laparoscopic or abdominal myomectomy, and sacrocolpopexy. Minor cases included other laparoscopies, hysteroscopy, dilation and curettage, and suburethral slings. Endometriosis had its own sub-category due to the wide range of associated surgical interventions. Measurements and Main Results The FMIGS surgical volume grew from 95 cases to 213 cases in four years. Case volumes did not change for any subspecialty after the hire of the FMIGS surgeon, with and without adjustment for FTE, or when sub-categorized into major, minor, and endometriosis cases. Case duration did not show any change before and after the addition of the FMIGS surgeon. Conclusion The addition of a FMIGS-trained surgeon to this department's surgical practice did not decrease surgical volumes for the other sub-specialties. This information can help overcome concerns of other members of the faculty when considering whether to hire a FMIGS-trained surgeon. The primary objective was to determine whether adding a fellowship-trained minimally invasive gynecologic surgeon (FMIGS) would decrease the surgical volumes of physicians in other subspecialties within an academic obstetrics and gynecology (Obstetrics and Gynecology) department. The study compared case type and quantity, and case minutes of general Obstetrics and Gynecology, Female Pelvic Medicine & Reconstructive Surgery (FPMRS), and Reproductive Endocrinology & Infertility (REI) physicians before and after the addition of a FMIGS-trained surgeon. “Before” was academic years 2015-16 and 2016-17. “After” was academic years 2017-18, 2018-19, 2019-20, and 2020-21. An academic Obstetrics and Gynecology department that grew from twelve to twenty surgeons from AY 2015-21. All general Obstetrics and Gynecology, REI, and FPMRS physicians within an academic Obstetrics and Gynecology department. Surgical data including numbers of surgeries, categorized by major and minor, with and without endometriosis, and total case minutes from all general Obstetrics and Gynecology, REI, and FPMRS physicians from AY 2015-21 were collected for each academic year. Clinical full-time equivalents (FTE) per academic year, adjusted for hire date and medical leaves, were also collected. Major cases included hysterectomy, laparoscopic or abdominal myomectomy, and sacrocolpopexy. Minor cases included other laparoscopies, hysteroscopy, dilation and curettage, and suburethral slings. Endometriosis had its own sub-category due to the wide range of associated surgical interventions. The FMIGS surgical volume grew from 95 cases to 213 cases in four years. Case volumes did not change for any subspecialty after the hire of the FMIGS surgeon, with and without adjustment for FTE, or when sub-categorized into major, minor, and endometriosis cases. Case duration did not show any change before and after the addition of the FMIGS surgeon. The addition of a FMIGS-trained surgeon to this department's surgical practice did not decrease surgical volumes for the other sub-specialties. This information can help overcome concerns of other members of the faculty when considering whether to hire a FMIGS-trained surgeon.

Association Between Electronic Health Record Time and Quality of Care Metrics in Primary Care

Physicians across the US spend substantial time working in the electronic health record (EHR), with primary care physicians (PCPs) spending the most time. The association between EHR time and ambulatory care quality outcomes is unclear. To characterize measures of EHR use and ambulatory care quality performance among PCPs. A cross-sectional study of PCPs with longitudinal patient panels using a single EHR vendor was conducted at Brigham and Women's Hospital and Massachusetts General Hospital during calendar year 2021. Independent variables included PCPs demographic and practice characteristics and EHR time measures (PCP-level mean of daily total EHR time, after-hours time, time from 5:30 pm to 7:00 am and time on weekends, and daily EHR time on notes, sending and receiving patient, staff, results, prescription, or system messages [in-basket], and clinical review). Outcome variables were ambulatory quality measures (year-end, PCP panel-level achievement of targets for hemoglobin A1c level control, lipid management, hypertension control, diabetes screening, and breast cancer screening). The sample included 291 physicians (174 [59.8%] women). Median panel size was 829 (IQR, 476-1157) patients and mean (SD) clinical full-time equivalent was 0.54 (0.27). The PCPs spent a mean (SD) of 145.9 (64.6) daily minutes on the EHR. There were significant associations between EHR time and panel-level achievement of hemoglobin A1c control, hypertension control, and breast cancer screening targets. In adjusted analyses, each additional 15 minutes of total daily EHR time was associated with 0.58 (95% CI, 0.32-0.84) percentage point greater panel-level hemoglobin A1c control, 0.52 (95% CI, 0.33-0.71) percentage point greater hypertension control, and 0.28 (95% CI, 0.05-0.52) higher breast cancer screening rates. Each daily additional 15 minutes of in-basket time was associated with 2.26 (95% CI, 1.05-3.48) greater panel-wide hemoglobin A1c control, 1.65 (95% CI, 0.83-2.47) percentage point greater hypertension control, and 1.26 (95% CI, 0.51-2.02) percentage point higher breast cancer screening rates. Associations were largely concentrated among PCPs with 0.5 clinical full-time equivalent or less. There were no associations between EHR use metrics and diabetes screening or lipid management in patients with cardiovascular disease. This cross-sectional study found an association between EHR time and some measures of ambulatory care quality. Although increased EHR time is associated with burnout, it may represent a level of thoroughness or communication that enhances certain outcomes. It may be useful for future studies to characterize payment models, workflows, and technologies that enable high-quality ambulatory care delivery while minimizing EHR burden.

Abstract 202: Impact Of Productivity Targets And Performance Reviews For Specialty Practices In The Veterans Health Administration

Introduction: In 2013, the Veterans Health Administration (VHA) introduced a program setting minimum physician productivity targets for specialty practices based on the ratio of total work Relative Value Units to clinical full-time equivalents. Practices with productivity below their targets were required to undergo annual reviews and submit remediation plans. We have previously demonstrated that reviewed cardiology practices experienced large increases in productivity though the contribution from regression toward the mean is unknown. Hypothesis: We hypothesized that the introduction of the VHA’s program was associated with larger increases in productivity at low-productivity practices. Methods: We extracted productivity metrics from fiscal year 2009-2019 reports for VHA practices in 4 specialties: cardiology, gastroenterology, neurology, and surgery. We identified low-productivity practices using VHA minimum productivity targets. We used linear regression to compare changes in productivity at these practices before and after implementation of the VHA’s program, controlling for specialty and facility level effects. Results: Of 4,249 specialty practice-years, we identified 383 as low productivity. Prior to implementation of the VHA’s program, there was evidence of regression toward the mean with relative increases in productivity ranging from 21% for surgery to 27% for cardiology the year after a practice was designated as low productivity. After implementation of the VHA’s program, there was evidence of an independent program effect with an additional relative annual productivity increase of 3.0% (95% CI 1.1 to 4.9%) at these practices. There was no evidence of effect modification for cardiology practices. Conclusions: A majority of the increase in productivity observed at low-productivity VHA specialty practices appears to be due to regression toward the mean, with a smaller but significant contribution from the VHA’s productivity program. Policies incentivizing productivity of specialist physicians at the group level may be an effective way to increase care efficiency in integrated healthcare systems. Evaluations of programs targeting low-performing practices should be designed to account for regression toward the mean.

The 2021 Pediatric Hospital Medicine Workforce: Results of a National Survey of Program Leaders.

Pediatric Hospital Medicine (PHM) is a young subspecialty with practice models that continue to evolve. To inform program and workforce planning, it is essential to understand the current state. This study sought to delineate current work models for PHM. In the spring of 2021, we conducted a survey-based cohort study of individuals identifying as PHM program leaders. Individuals were invited based on membership in the 3 PHM sponsoring societies. Additional respondents were recruited through society listservs. One hundred ninety-eight program leaders responded to the program model survey. One-half covered only community sites, 21.2% covered only university sites, and 21.2% covered both university and community sites. Programs provided a diverse set of services, with community sites covering more services, including newborn nurseries, emergency department consultation, and delivery room care. Median total hours for 1.0 clinical full time equivalent were 1849 across all sites, 1800 at university-only sites, and 1900 at community-only sites. Inpatient floor patient caps, when present, were higher for resident covered versus noncovered teams (16 vs 13). Similarly, back-up activation was higher for resident-covered teams (15-16) than noncovered teams (12-13.5). Current data on clinical work hours for pediatric hospitalists are consistent with recent, smaller studies, suggesting that the current national median for a 1.0 FTE clinical position at university-based sites is 1800 annual hours. Community hospitalists often work more clinical hours than university sites and more commonly provide a broader range of service lines. More studies are needed to explore the differences between community and university site work models.

Workforce demographics and unit structure in paediatric cardiac critical care in the United States.

To assess current demographics and duties of physicians as well as the structure of paediatric cardiac critical care in the United States. REDCap surveys were sent by email from May till August 2019 to medical directors ("directors") of critical care units at the 120 United States centres submitting data to the Society of Thoracic Surgeons Congenital Heart Surgery Database and to associated faculty from centres that provided email lists. Faculty and directors were asked about personal attributes and clinical duties. Directors were additionally asked about unit structure. Responses were received from 66% (79/120) of directors and 62% (294/477) of contacted faculty. Seventy-six percent of directors and 54% of faculty were male, however, faculty <40 years old were predominantly women. The majority of both groups were white. Median bed count (n = 20) was similar in ICUs and multi-disciplinary paediatric ICUs. The median service expectation for one clinical full-time equivalent was 14 weeks of clinical service (interquartile range 12, 16), with the majority of programmes (86%) providing in-house attending night coverage. Work hours were high during service and non-service weeks with both directors (37%) and faculty (45%). Racial and ethnic diversity is markedly deficient in the paediatric cardiac critical care workforce. Although the majority of faculty are male, females make up the majority of the workforce younger than 40 years old. Work hours across all age groups and unit types are high both on- and off-service, with most units providing attending in-house night coverage.

Abstract 11828: Productivity Targets and Performance Reviews for Cardiology Practices in the Veterans Health Administration: Do They Work?

Introduction: The optimal mode of promoting physician productivity in integrated healthcare systems is unknown. In 2013, the Veterans Health Administration (VHA) introduced a program setting productivity targets for specialty practices based on the ratio of total work Relative Value Units (wRVUs) to clinical full-time equivalents (FTEs). Practices with productivity less than 1.25 SDs below the mean for their complexity group were required to undergo annual performance reviews and develop remediation plans. Hypothesis: We hypothesized that performance reviews were associated with increased cardiology practice productivity and clinical volume. Methods: We extracted productivity metrics for 125 cardiology practices from fiscal year 2012-2019 reports. We used linear regression to assess the association of reviews with changes in productivity, clinical volume, and access measures, controlling for practice-level trends. Results: Performance reviews were associated with a 38% (95% CI 29 to 47%) relative increase in cardiology practice productivity in the year following review. In the year before review, these practices experienced a relative productivity decrease of 24% (95% CI -35 to -14%), suggesting the observed effect was not due to regression to the mean alone. Reviews were associated with a relative annual increase in practice wRVUs of 29% (95% CI 15 to 44%), a decrease in reported clinical FTEs of 12% (95% CI -24 to -1%), an increase in clinical encounters of 32% (95% CI 16 to 49%), and an increase in the total number of patients receiving care of 23% (95% CI 9 to 36%). There was no significant association between reviews and the annual change in the percentage of new or established patients waiting more than 30 days for an appointment. Conclusions: A program of productivity targets and reviews of low-performing practices was associated with increased cardiologist productivity and total wRVUs, clinical encounters, and number of patients receiving care at reviewed practices. Programs setting productivity targets for groups of specialist physicians may be an effective way to increase care efficiency in integrated healthcare systems. Future research should investigate the impact of these programs on care utilization, appropriateness, and quality.

Variations in Pediatric Rheumatology Workforce and Care Processes Across Canada

To examine the Canadian pediatric rheumatology workforce and care processes. Pediatric rheumatologists and allied health professionals (AHPs) participated. A designee from each academic center provided workforce information including the number of providers, total and breakdown of full-time equivalents (FTEs), and triage processes. We calculated the clinical FTE (cFTE) available per 75,000 (recommended benchmark) and 300,000 (adjusted) children using 2019 census data. The national workforce deficit was calculated as the difference between current and expected cFTEs. Remaining respondents were asked about ambulatory practices. The response rate of survey A (workforce information) and survey B (ambulatory practice information) was 100% and 54%, respectively. The majority of rheumatologists (91%) practiced in academic centers. The median number of rheumatologists per center was 3 (IQR 3) and median cFTE was 1.9 (IQR 1.5). The median cFTE per 75,000 was 0.2 (IQR 0.3), with a national deficit of 80 cFTEs. With the adjusted benchmark, there was no national deficit, but there was a regional maldistribution of rheumatologists. All centers engaged in multidisciplinary practices with a median of 4 different AHPs, although the median FTE for AHPs was ≤ 1. Most centers (87%) utilized a centralized triage process. Of 9 (60%) centers that used an electronic triage process, 6 were able to calculate wait times. Most clinicians integrated quality improvement practices, such as previsit planning (67%), postvisit planning (68%), and periodic health outcome monitoring (36-59%). This study confirms a national deficit at the current recommended benchmark. Most rheumatologists work in multidisciplinary teams, but AHP support may be inadequate.

The influence of a Sprint optimization and training intervention on time spent in the electronic health record (EHR).

ObjectiveWe report the influence of Sprint electronic health record (EHR) training and optimization on clinician time spent in the EHR.Materials and MethodsWe studied the Sprint process in one academic internal medicine practice with 26 providers. Program offerings included individualized training sessions, and the ability to clean up, fix, or build new EHR tools during the 2-week intervention. EHR usage log data were available for 24 clinicians, and the average clinical full-time equivalent was 0.44. We used a quasi-experimental study design with an interrupted time series specification, with 8 months of pre- and 12 months of post-intervention data to evaluate clinician time spent in the EHR.ResultsWe discovered a greater than 6 h per day reduction in clinician time spent in the EHR at the clinic level. At the individual clinician level, we demonstrated a time savings of 20 min per clinician per day among those who attended at least 2 training sessions.DiscussionWe can promote EHR time savings for clinicians who engage in robust EHR training and optimization programs. To date, programs have shown a positive correlation between participation and subjective EHR satisfaction, efficiency, or time saved. The impact of EHR training and optimization on objective time savings remains elusive. By measuring time in the EHR, this study contributes to an ongoing conversation about the resources and programs needed to decrease clinician EHR time.ConclusionsWe have demonstrated that Sprint is associated with time savings for clinicians for up to 6 months. We suggest that an investment in EHR optimization and training can pay dividends in clinician time saved.

Monitoring Perioperative Services Using 3D Multi-Objective Performance Frontiers

The Acute Care Surgery model has been widely adopted by hospitals across the United States, with Acute Care Surgery services managing Emergency General Surgery patients that were previously being treated by General Surgery. In this analysis, we evaluate the impact of an Acute Care Surgery service model on General Surgery at the University of Vermont Medical Center using three metrics: under-utilized time, spillover time, and a financial ratio of work Relative Value Units over clinical Full Time Equivalents. These metrics are evaluated and used to identify three-dimensional Pareto optimality of General Surgery prior to and after the October 2015 tactical allocation to the Acute Care Surgery model. Our analysis was further substantiated using a Markov Chain Monte Carlo model for Bayesian Inference. We applied multi-objective Pareto and Bayesian breakpoint analysis to three operating room metrics to assess the impact of new operating room management decisions. In the two-dimensional space of Fig.2, panel a), the post-tactical allocation front lies closer to the origin representing more optimal solutions for productivity and under-utilized time. The post-tactical allocation front is also closer to the origin for productivity and spillover time as shown in the two-dimensional space of Fig.2, panel b). The results of the three-dimensional multi-objective analysis of Fig.3 illustrate that the GS post-tactical allocation Pareto-surface is contained within a much smaller volume of space than the GS pre-tactical allocation Pareto-surface. The post-tactical allocation Pareto-surface is slightly lower along the z-axis, representing lower productivity than the pre-tactical allocation surface. This methodology might contribute to the external benchmarking and monitoring of perioperative services by visualizing the operational implications following tactical decisions in operating room management.

Abstract 321: Association of Specialist Physician Productivity With Trainee and Staffing Levels in the Veterans Health Administration

Background: The effect of trainee, associate provider, and support staff levels on physician productivity by specialty is unknown. In 2013, the Veterans Health Administration (VHA) introduced a program to measure specialist physician productivity at the practice level, defined as the total work Relative Value Units (RVUs) generated by the physicians in a practice divided by the number of clinical full-time equivalents (FTEs) attributed to that practice. Data from this program can be utilized to understand the effect of specialty practice features on physician productivity. Methods: We extracted physician productivity levels and the numbers of trainees, associate providers, administrative support staff, and clinical support staff from fiscal year 2019 workforce reports produced by the VHA Office of Productivity, Efficiency, and Staffing for practices in four representative specialties: cardiology, gastroenterology, neurology, and surgery. We used linear regression to identify associations between physician productivity and trainee and staffing levels, adjusting for the complexity group of included practices as some practices do not perform procedures. Results: A total of 122 cardiology, 112 gastroenterology, 118 neurology, and 123 surgery practices with at least 0.5 clinical FTE were included. Physician (practice) productivity ranged from 2153 to 12,497 (mean 6899) RVUs/FTE for cardiology, 1189 to 13,435 (mean 7080) RVUs/FTE for gastroenterology, 1753 to 11,322 (mean 4154) RVUs/FTE for neurology, and 1761 to 8792 (mean 4251) RVUs/FTE for surgery. Physician productivity was positively associated with the number of trainees per clinical FTE for cardiology [coefficient 818 (95% CI 260, 1376) additional RVUs/FTE] and surgery [coefficient 253 (95% CI 56, 451) additional RVUs/FTE] but not for other specialties. Only neurologist productivity was positively associated with the number of associate providers per clinical FTE [coefficient 1095 (95% CI 128, 2061) additional RVUs/FTE]. There were no significant associations between physician productivity and the numbers of administrative and clinical support staff per clinical FTE. Conclusion: There is significant variation in VHA physician productivity across practices within each specialty. Physician productivity is positively associated with the number of trainees in a practice for some specialties, including cardiology, suggesting that trainees in those specialties may enhance physician productivity. The relationship between physician productivity and trainee and associate provider ratios varies by specialty. These specialty-specific associations can inform efforts to improve VHA physician productivity.

Does implementation of a surgical fellowship program increase productivity? A retrospective analysis using operating room management metrics and statistical process control

BackgroundIn 2016, our institution implemented a 5 + 2 year vascular surgery fellowship program, providing graduates of general surgery residencies two years of advanced training in open vascular and endovascular surgery. In this study, we use statistical process control to evaluate the clinical performance of the vascular surgery service, before and after implementation of the fellowship program, within an operating room (OR) block utilization framework. Study DesignUsing WiseOR, we extracted monthly vascular surgery operating room utilization data for the fifteen months before and after the implementation of the fellowship. Monthly block productivity was calculated: Productivity = (workload)/(allocated hours + 1.75 * over-utilized time). From financial reports, we obtained monthly work Relative Value Units (wRVUs) and clinical Full Time Equivalents (FTEs) for faculty of the vascular surgery service for the same 30-month study period. I-control charts were used to analyze changes in productivity and wRVU/FTE ratio across implementation of the fellowship. We visualized changes in block utilization and productivity by constructing a novel three-dimensional chart plotting under-utilized time vs. over-utilized time for each month of the study, while representing productivity via a color gradient based on Delaunay triangulation. ResultsThe vascular surgery service saw a significant increase in both normal-hours and after-hours case time after implementation of the fellowship. Under-utilized OR block time decreased (p = 0.002) and over-utilized time increased (p < 0.001) after implementation of the fellowship. The fellowship implementation coincided with an upwards special cause variation in both clinical productivity and faculty wRVU/FTE ratio for the vascular surgery service during the study period. ConclusionImplementation of the fellowship training program marked an upward shift in block productivity and revenue generation of the vascular surgery service, with the additional workload compensating for an increase in over-utilized block time.

Implementation of electronic charting is not associated with significant change in physician productivity in an academic emergency department.

ObjectivesTo compare physician productivity and billing before and after implementation of electronic charting in an academic emergency department (ED).Materials and methodsThis retrospective, blinded, observational study compared the 6 months pre-implementation (January to June 2012) with the 6 months post-implementation 1 year later (January to June 2013). Thirty-one ED physicians were recruited, with each physician acting as his/her own control in a before-after design. Productivity was measured via total number of encounters and “productivity index” defined as worked relative value units divided by the clinical full-time equivalent. Values for charges, encounters, and productivity index were determined during each study period and separately for procedures, observational stays, and critical care.ResultsNo differences were found for total productivity index per month (758 [623-876] pre-group vs. 756 [673-886] post-group; P = 0.30). There was, however, a 9% decrease in total encounters per month (138 [101-163] pre-group vs. 125 [99-159] post-group; P = 0.01). Significant decreases were seen across all observation stay categories. Conversely, significant increases were seen across all critical care categories. There was no difference in total charges per month.DiscussionThis is one of few studies to demonstrate minimal disruption in physician productivity after transitioning to electronic documentation. The reasons for these findings are likely multi-factorial.ConclusionIn this study, implementation of electronic charting was not associated with decreases in productivity or billing for total ED care, but may be associated with increases for critical care and decreases for observational stays.

A needs-based workforce model to deliver tertiary-level community mental health care for distressed infants, children, and adolescents in South Australia: a mixed-methods study

High-quality mental health services for infants, children, adolescents, and their families can improve outcomes for children exposed to early trauma. We sought to estimate the workforce needed to deliver tertiary-level community mental health care to all infants, children, adolescents, and their families in need using a generalisable model, applied to South Australia (SA). Workforce estimates were determined using a workforce planning model. Clinical need was established using data from the Longitudinal Study of Australian Children and the Young Minds Matter survey. Care requirements were derived by workshopping clinical pathways with multiprofessional panels, testing derived estimates through an online survey of clinicians. Prevalence of tertiary-level need, defined by severity and exposure to childhood adversities, was estimated at 5-8% across infancy and childhood, and 16% in mid-adolescence. The derived care pathway entailed reception, triage, and follow-up (mean 3 h per patient), core clinical management (mean 27 h per patient per year), psychiatric oversight (mean 4 h per patient per year), specialised clinical role (mean 12 h per patient per year), and socioeconomic support (mean 12 h per patient per year). The modelled clinical full-time equivalent was 947 people and budget was AU$126 million, more than five times the current service level. Our novel needs-based workforce model produced actionable estimates of the community workforce needed to address tertiary-level mental health needs in infants, children, adolescents, and their families in SA. A considerable expansion in the skilled workforce is needed to support young people facing current distress and associated family-based adversities. Because mental illness is implicated in so many burgeoning social ills, addressing this shortfall could have wide-ranging benefits. National Health and Medical Research Council (Australia), Department of Health SA.

2015 American College of Rheumatology Workforce Study: Supply and Demand Projections of Adult Rheumatology Workforce, 2015-2030.

To describe the character and composition of the 2015 US adult rheumatology workforce, evaluate workforce trends, and project supply and demand for clinical rheumatology care for 2015-2030. The 2015 Workforce Study of Rheumatology Specialists in the US used primary and secondary data sources to estimate the baseline adult rheumatology workforce and determine demographic and geographic factors relevant to workforce modeling. Supply and demand was projected through 2030, utilizing data-driven estimations regarding the proportion and clinical full-time equivalent (FTE) of academic versus nonacademic practitioners. The 2015 adult workforce (physicians, nurse practitioners, and physician assistants) was estimated to be 6,013 providers (5,415 clinical FTE). At baseline, the estimated demand exceeded the supply of clinical FTE by 700 (12.9%). By 2030, the supply of rheumatology clinical providers is projected to fall to 4,882 providers, or 4,051 clinical FTE (a 25.2% decrease in supply from 2015 baseline levels). Demand in 2030 is projected to exceed supply by 4,133 clinical FTE (102%). The adult rheumatology workforce projections reflect a major demographic and geographic shift that will significantly impact the supply of the future workforce by 2030. These shifts include baby-boomer retirements, a millennial predominance, and an increase of female and part-time providers, in parallel with an increased demand for adult rheumatology care due to the growing and aging US population. Regional and innovative strategies will be necessary to manage access to care and reduce barriers to care for rheumatology patients.

The Relative Financial Cost and Benefit of an Ophthalmology Resident Compared to an Advanced Practice Provider, Optometrist, or Faculty Ophthalmologist

Objective The main objective of the article is to determine the relative direct financial cost and benefit of an advanced practice provider (APP), optometrist, and faculty ophthalmologist compared with an ophthalmology resident. Design Single center cost–benefit financial analysis. Methods The direct total expenses, including mean salary and benefits; the cost/week, based upon calculated hours worked; and net revenue, based upon technical collections subtracted from total expenses were collected for all APPs, optometrists, faculty ophthalmologists, and ophthalmology residents at the University of Kentucky for the 2016 to 2017 academic year. Optometry and ophthalmology faculty collections were adjusted for clinical full-time equivalents. Results Total annual mean salary and benefits for 242 APPs, 4 optometrists, 17 faculty ophthalmologists, and 9 ophthalmology residents were $126,797, $117,021, $338,233, and $71,210, respectively. Assuming a 50-hour-work week, the calculated hourly costs were $48.77, $45.01, $130.09, and $27.39, respectively. Ophthalmology residents do not directly generate work relative value units or collections. On this basis, the net annual revenues were −$62,729, $122,757, $566,119, and −$71,210, respectively. Conclusions Ophthalmology residents are relatively inexpensive compared with potential substitute health care providers, although they are unable to generate direct revenue. Indirect costs and benefits are likely substantial, but currently incalculable. More candid analyses of the role and financial impact of trainees in health care are needed.

Measuring the Rheumatology Workforce in Canada: A Literature Review.

The number of rheumatologists per capita has been proposed as a performance measure for arthritis care. This study reviews what is known about the rheumatologist workforce in Canada. A systematic search was conducted in EMBASE and MEDLINE using the search themes "rheumatology" AND "workforce" AND "Canada" from 2000 until December 2014. Additionally, workforce databases and rheumatology websites were searched. Data were abstracted on the numbers of rheumatologists, demographics, retirement projections, and barriers to healthcare. Twenty-five sources for rheumatology workforce information were found: 6 surveys, 14 databases, 2 patient/provider resources, and 3 epidemiologic studies. Recent estimates say there are 398 to 428 rheumatologists in Canada, but there were limited data on allocation of time to clinical practice. Although the net number of rheumatologists has increased, the mean age was ≥ 47.7 years, and up to one-third are planning to retire in the next decade. There is a clustering of rheumatologists around academic centers, while some provinces/territories have suboptimal ratios of rheumatologists per capita (range 0-1.1). Limited information was found on whether rural areas are receiving adequate services. The most consistent barrier reported by rheumatologists was lack of allied health professionals. In Canada there are regional disparities in access to rheumatologist care and an aging rheumatologist workforce. To address these workforce capacity issues, better data are needed including information on clinical full-time equivalents, delivery of care to remote communities, and use of alternative models of care to increase clinical capacity.

Integration of academic and clinical performance-based faculty compensation plans: a system and its impact on an anaesthesiology department

BackgroundThe current economic environment makes it difficult for academic institutions to maintain academic activities with necessary clinical coverage. Productivity-based faculty compensation is reported to improve clinical work output; however, the impact on academic productivity has not been fully described. MethodsAn academic anaesthesiology department has used a comprehensive clinical and academic performance-based faculty compensation programme as fiscal year (FY) 2004. Faculty choosing to pursue an academic track can devote up to 80% of their time to non-clinical activities. Payment for this time is ‘salary at risk’, which is earned through a merit matrix system, which was newly developed to award points for various academic activities. Unclaimed portions of the salary at risk are absorbed into the department budget at the conclusion of the FY. Clinical activities are measured chiefly based on total hours of anaesthetic care. ResultsAcademic full-time equivalents (FTEs) decreased by 12.0% in FY2005 (FTE of 16.0–14.1) but recovered to the baseline level in FY2006 and remained stable. Clinical FTE also decreased by 6.6% in FY2005 (FTE of 109.1–101.9), then increased in FY2006–FY2010. Increased clinical work output was observed among the clinical and academic faculty members. Each academic faculty member successfully earned their salary at risk in each FY. The annual number of peer-reviewed publications per academic FTE in original research increased from 0.31 (0.18) (FY2001–FY2003) to 0.73 (0.14) (FY2006–FY2011), P=0.024. ConclusionsIntegration of clinical and academic performance-based faculty compensation systems is feasible and can be efficacious in a large academic anaesthesiology department.

Evolution, Current Structure, and Role of a Primary Care Clinical Pharmacy Service in an Integrated Managed Care Organization

The impact of the declining number of primary care physicians is exacerbated by a growing elderly population in need of chronic disease management. Primary care clinical pharmacy specialists, with their unique knowledge and skill set, are well suited to address this gap. At Kaiser Permanente of Colorado (KPCO), primary care clinical pharmacy specialists have a long history of integration with medical practices and are located in close proximity to physicians, nurses, and other members of the health care team. Since 1992, Primary Care Clinical Pharmacy Services (PCCPS) has expanded from 4 to 30 full-time equivalents (FTEs) to provide services in all KPCO medical office buildings. With this growth in size, PCCPS has evolved to play a vital role in working with primary care medical teams to ensure that drug therapy is effective, safe, and affordable. In addition, PCCPS specialists provide ambulatory teaching sites for pharmacy students and pharmacy residents. There is approximately 1 specialist FTE for every 13,000 adult KPCO members and every 9 clinical FTEs of internal medicine and family medicine physicians. All clinical pharmacy specialists in the pharmacy department are required to have a PharmD degree, to complete postgraduate year 2 residencies, and, as a condition of employment, to become board certified in an applicable specialty. The evolution, current structure, and role of PCCPS at KPCO, including factors facilitating successful integration within the medical team, are highlighted. Patient and nonpatient care responsibilities are described.