Pediatric Medical Subspecialties Research Articles

Call to action: Screening and addressing caregiver mental health needs within all pediatric medical subspecialty settings as standard of care.

Call to action: Screening and addressing caregiver mental health needs within all pediatric medical subspecialty settings as standard of care.

Pediatric Medical Subspecialist Use in Outpatient Settings

A first step toward understanding whether pediatric medical subspecialists are meeting the needs of the nation's children is describing rates of use and trends over time. To quantify rates of outpatient pediatric medical subspecialty use. This repeated cross-sectional study of annual subspecialist use examined 3 complementary data sources: electronic health records from PEDSnet (8 large academic medical centers [January 1, 2010, to December 31, 2021]); administrative data from the Healthcare Integrated Research Database (HIRD) (14 commercial health plans [January 1, 2011, to December 31, 2021]); and administrative data from the Transformed Medicaid Statistical Information System (T-MSIS) (44 state Medicaid programs [January 1, 2016, to December 31, 2019]). Annual denominators included 493 628 to 858 551 patients younger than 21 years with a general pediatric visit in PEDSnet; 5 million beneficiaries younger than 21 years enrolled for at least 6 months in HIRD; and 35 million Medicaid or Children's Health Insurance Program beneficiaries younger than 19 years enrolled for any amount of time in T-MSIS. Calendar year and type of medical subspecialty. Annual number of children with at least 1 completed visit to any pediatric medical subspecialist in an outpatient setting per population. Use rates excluded visits in emergency department or inpatient settings. Among the study population, the proportion of girls was 51.0% for PEDSnet, 51.1% for HIRD, and 49.3% for T-MSIS; the proportion of boys was 49.0% for PEDSnet, 48.9% for HIRD, and 50.7% for T-MSIS. The proportion of visits among children younger than 5 years was 37.4% for PEDSnet, 20.9% for HIRD, and 26.2% for T-MSIS; most patients were non-Hispanic Black (29.7% for PEDSnet and 26.1% for T-MSIS) or non-Hispanic White (44.9% for PEDSnet and 43.2% for T-MSIS). Annual rates for PEDSnet ranged from 18.0% to 21.3%, which were higher than rates for HIRD (range, 7.9%-10.4%) and T-MSIS (range, 7.6%-8.6%). Subspecialist use increased in the HIRD commercial health plans (annual relative increase of 2.4% [95% CI, 1.6%-3.1%]), but rates were essentially flat in the other data sources (PEDSnet, -0.2% [95% CI, -1.1% to 0.7%]; T-MSIS, -0.7% [95% CI, -6.5% to 5.5%]). The flat PEDSnet growth reflects a balance between annual use increases among those with commercial insurance (1.2% [95% CI, 0.3%-2.1%]) and decreases in use among those with Medicaid (-0.9% [95% CI, -1.6% to -0.2%]). The findings of this cross-sectional study suggest that among children, 8.6% of Medicaid beneficiaries, 10.4% of those with commercial insurance, and 21.3% of those whose primary care is received in academic health systems use pediatric medical subspecialty care each year. There was a small increase in rates of subspecialty use among children with commercial but not Medicaid insurance. These data may help launch innovations in the primary-specialty care interface.

Comanagement of Surgical Pediatric Patients in the Acute Care Inpatient Setting.

The care of children with primary surgical diagnoses in acute care units often involves a shared surgical and medical model ("comanagement"). There are no formal guidelines for how such programs should be structured or care provided. We used a modified Delphi process, including national experts in pediatrics and pediatric medical subspecialties, pediatric surgical specialties, and pediatric anesthesiology, to develop recommendations for best practices for comanagement programs in community and tertiary care settings.

A Closer Look: Examination of Suicide Risk Screening Results and Outcomes for Minoritized Youth in Subspecialty Pediatrics.

To describe a sample of minoritized youth who screened positive for suicide risk within medical subspecialty pediatrics, compared to non-minoritized youth and describe the screening outcomes of these youth. This retrospective chart review from October 2018 to April 2021 used electronic medical record data from an academic pediatric medical subspecialty clinic that screens universally for suicide risk for all patients ages 9 and up. Chart reviews were conducted for 237 minoritized youth (operationalized as identifying as non-White or Hispanic/Latinx, identifying as a gender minority, and having a preferred language other than English) who screened positive for suicide risk. Descriptive statistics include need for escalation to an emergency room, connection to mental health care, receival of a mental health referral, and attendance at follow-up visits. Minoritized youth were more likely to screen positive and report a history of suicide attempt when compared to non-minoritized peers. Youth identifying as gender expansive had significant elevation in suicide risk. The majority of youth in this sample were already connected to mental health care, with youth preferring a language other than English being the least likely to be connected. Findings indicate heightened suicide risk for minoritized youth, with gender expansive youth having particularly elevated suicide risk. A need to support youth with a preferred language other than English in getting connected to mental health care was also revealed.

The Clinical Sustainability Assessment Tool: measuring organizational capacity to promote sustainability in healthcare

BackgroundFew validated assessment tools are available to increase understanding and measure factors associated with sustainment of clinical practices, an increasingly recognized need among clinicians. We describe the development of the Clinical Sustainability Assessment Tool (CSAT), designed to assess factors that contribute to sustainable practices in clinical settings.MethodsSixty-four participants from clinical and research fields participated in concept mapping and were recruited to brainstorm factors that lead to sustained clinical practices. Once repeated factors were removed, participants sorted items based on similarity and rated them by importance and feasibility. Using concept mapping analyses, items were grouped into meaningful domains to develop an initial tool. We then recruited pilot sites and early adopters, for a total of 286 practicing clinicians, to pilot and evaluate the tool. Individuals were recruited from clinical settings across pediatric and adult medical and surgical subspecialties. The data were analyzed using confirmatory factor analysis (CFA) to test hypothesized subscale structure in the instrument. We used root mean square error of approximation (RMSEA) and the standardized root mean square residual (SRMR) to assess fit and thus the ability of CSAT to measure the identified domains.ResultsThe concept mapping produced sorted statements that were edited into items that could be responded to, resulting in the creation of a tool with seven determinant domains and 47 items. The pilot and CFA testing resulted in a final CSAT instrument made up 35 items, five per domain. CFA results demonstrated very good fit of the seven domain structure of the CSAT (RMSEA = 0.049; SRMR = 0.049). Usability testing indicated the CSAT is brief, easy to use, easy to learn, and does not require extensive training. Additionally, the measure scored highly (18/20) on the Psychometric and Pragmatic Evidence Rating Scale (PAPERS). The seven final CSAT domains were engaged staff and leadership, engaged stakeholders, organizational readiness, workflow integration, implementation and training, monitoring and evaluation, and outcomes and effectiveness.ConclusionsThe CSAT is a new reliable assessment tool which allows for greater practical and scientific understanding of contextual factors that enable sustainable clinical practices over time.

Growth and changes in the pediatric medical subspecialty workforce pipeline.

BackgroundTo inform discussions of pediatric subspecialty workforce adequacy and characterize its pipeline, we examined trends in first-year fellows in the 14 American Board of Pediatrics (ABP)-certified pediatric medical subspecialties, 2001–2018.MethodsData were obtained from the ABP Certification Management System. We determined, within each subspecialty, the annual number of first-year fellows. We assessed for changes in the population using variables available throughout the study period (gender, medical school location, program region, and program size). We fit linear trendlines and calculated χ2 statistics.ResultsThe number of first-year pediatric medical subspecialty fellows increased from 751 in 2001 to 1445 in 2018. Fields with the growth of 3 or more fellows per year were Cardiology, Critical Care, Emergency Medicine, Gastroenterology, Neonatology, and Hematology Oncology (P value <0.05 for all). The number of fellows entering Adolescent Medicine, Child Abuse, Infectious Disease, and Nephrology increased at a rate of 0.5 fellows or fewer per year. Female American Medical Graduates represented the largest and growing proportions of several subspecialties. Distribution of programs by region and size were relatively consistent over time, but varied across subspecialties.ConclusionsThe number of pediatricians entering medical subspecialty fellowship training is uneven and patterns of growth differ between subspecialties.Impact The number of individuals entering fellowship training has increased between 2001 and 2018.Growth in the number of first-year fellows is uneven.Fields with the greatest growth: Critical Care, Emergency Medicine, and Neonatology.Fields with limited growth: Adolescent Medicine, Child Abuse, Infectious Disease, and Nephrology.Concerns about the pediatric medical subspecialty workforce are not explained by the number of individuals entering the fellowship.

Timing and Stability of Fellowship Choices during Pediatric Residency: A Longitudinal Survey

To determine, among pediatric residents, the timing and stability of decisions to pursue fellowship training and select a specific subspecialty, which can be used to inform strategies to better match the distribution of pediatric subspecialist with the needs of children. A longitudinal survey administered with the General Pediatrics In-training Exam to pediatric residents in the US and Canada, 2010-2014. The study included residents who responded in each of their first 3 years of residency and indicated plans to enter fellowship or matriculated, 2013-2016, into 1 of the 14 medical subspecialty fellowships for which the American Board of Pediatrics grants a certificate. Descriptive and χ2 statistics were calculated. Of the 7580 residents who completed 3 annual surveys (response rate 99%) 4963 (65.5%) indicated plans to pursue fellowship training and 2843 (37.5%) matriculated into fellowship. Residents who did not enter fellowship were in smaller residency programs and programs with less interest in fellowship among interns. Most residents who matriculated into fellowship (68.4%) planned to do so as interns and maintained that plan throughout residency. In contrast, 22.7% had selected a specific subspecialty as interns. Fellowship decisions were made later in residency by female residents, American Medical Graduates, and residents in programs where <50% of interns planned to pursue fellowship training. Timing and stability of decisions varied across subspecialty fields. Understanding the timing of pediatric medical subspecialty fellowship decisions could be used to shape medical education and, ultimately, the pediatric workforce.

Referral to Pediatric Surgical Specialists

The American Academy of Pediatrics, with the collaboration of the Surgical Sections of the American Academy of Pediatrics, has created referral recommendations intended to serve as voluntary practice parameters to assist general pediatricians in determining when and to whom to refer their patients for pediatric surgical specialty care. It is recognized that these recommendations may be difficult to implement, because communities vary in terms of access to major pediatric medical centers. Limited access does not negate the value of the recommendations, however, because the child who needs specialized surgical and anesthetic care is best served by the skills of the appropriate pediatric surgical team. Major congenital anomalies, malignancies, major trauma, and chronic illnesses (including those associated with preterm birth) in infants and children should be managed by pediatric medical subspecialists and pediatric surgical specialists at pediatric referral centers that can provide expertise in many areas, including the pediatric medical subspecialties and surgical specialties of pediatric radiology, pediatric anesthesiology, pediatric pathology, and pediatric intensive care. The optimal management of the child with complex problems, chronic illness, or disabilities requires coordination, communication, and cooperation of the pediatric surgical specialist with the child's primary care pediatrician or physician.

Interdisciplinary Development and Implementation of Communication Checklist for Postoperative Management of Pediatric Airway Patients

The authors describe their multidisciplinary experience in applying the Institute of Health Improvement methodology to develop a protocol and checklist to reduce communication error during transfer of care for postoperative pediatric surgical airway patients. Preliminary outcome data following implementation of the protocol and checklist are also presented. Prospective study from July 1, 2009, to February 1, 2011. Tertiary care center. Subjects. One hundred twenty-six pediatric airway patients who required coordinated care between Massachusetts Eye and Ear Infirmary and Massachusetts General Hospital. Two sentinel events involving airway emergencies demonstrated a critical need for a standardized, comprehensive instrument that would ensure safe transfer of care. After development and implementation of the protocol and checklist, an initial pilot period on the first set of 9 pediatric airway patients was reassessed. Subsequent prospective 11-month follow-up data of 93 pediatric airway patients were collected and analyzed. A multidisciplinary pediatric team developed and implemented a formalized, postoperative checklist and transfer protocol. After implementation of the checklist and transfer protocol, prospective analysis showed no adverse events from miscommunication during transfer of care over the subsequent 11-month period involving 93 pediatric airway patients. There has been very little written in the quality and safety patient literature about coordinating effective transfer of care between the pediatric surgical and medical subspecialty realms. After design and implementation of a simple, electronically based transfer-of-care checklist and protocol, the number of postsurgical pediatric airway information transfer and communication errors decreased significantly.

Primary Care Pediatricians' Satisfaction with Subspecialty Care, Perceived Supply, and Barriers to Care

To compare satisfaction with specialty care by primary care pediatricians (PCPs), perceived barriers to care, and adequacy of specialist supply. A survey of U.S. pediatricians was conducted in 2007. PCPs were asked about satisfaction with specialty care for their patients, as well as supply of specific pediatric subspecialists. Responses of rural and nonrural PCPs were compared regarding 10 potential barriers to care. Most PCPs are satisfied with the quality of subspecialty care. However, they were not satisfied with wait times for appointments, and the availability of many pediatric medical subspecialties and several pediatric surgical specialties. Rural PCPs were significantly more likely to report these shortages compared with nonrural pediatricians; these included 9 of the 18 medical and 5 of the 7 surgical specialties. In addition to wait times for appointments, PCPs reported that subspecialists' nonparticipation in health insurance plans and lack of acceptance of uninsured patients were also barriers to obtaining subspecialty care for their patients. PCPs provide valuable insight into access to the pediatric subspecialty workforce. This survey of PCPs raises significant concerns about the adequacy of children's access to pediatric subspecialists, especially in rural communities.

Financing Graduate Medical Education to Meet the Needs of Children and the Future Pediatrician Workforce

This policy statement articulates the positions of the American Academy of Pediatrics on graduate medical education and the associated costs and funding mechanisms. It reaffirms the policy of the American Academy of Pediatrics that graduate medical education is a public good and is an essential part of maintaining a high-quality physician workforce. The American Academy of Pediatrics advocates for lifelong learning across the continuum of medical education. This policy statement focuses on the financing of one component of this continuum, namely residency education. The statement calls on federal and state governments to continue their support of residency education and advocates for stable means of funding such as the establishment of an all-payer graduate medical education trust fund. It further proposes a portable authorization system that would allocate graduate medical education funds for direct medical education costs to accredited residency programs on the basis of the selection of the program by qualified student or residents. This system allows the funding to follow the residents to their program. Recognizing the critical workforce needs of many pediatric medical subspecialties, pediatric surgical specialties, and other pediatric specialty disciplines, this statement maintains that subspecialty fellowship training and general pediatrics research fellowship training should receive adequate support from the graduate medical education financing system, including funding from the National Institutes of Health and other federal agencies, as appropriate. Furthermore, residency education that is provided in freestanding children's hospitals should receive a level of support equivalent to that of other teaching hospitals. The financing of graduate medical education is an important and effective tool to ensure that the future pediatrician workforce can provide optimal heath care for infants, children, adolescents, and young adults.

The Changing Composition of the Pediatric Medical Subspecialty Work-force

The Changing Composition of the Pediatric Medical Subspecialty Work-force

Pediatric Workforce: A Look at Adolescent Medicine Data from the American Board of Pediatrics

Pediatric Workforce: A Look at Adolescent Medicine Data from the American Board of Pediatrics

Are We There Yet? Distance to Care and Relative Supply Among Pediatric Medical Subspecialties

The objective of this study was to describe geographic proximity, quantify variation in supply, and estimate pediatric population increments that are needed to support providers across pediatric subspecialties. Data from the American Board of Pediatrics and the Claritas Pop-Facts Database were used to calculate subspecialty-specific straight-line distances between each zip code and the nearest board-certified subspecialist. These data sources also were used to estimate the percentage of hospital referral regions with providers and calculate physician-to-population ratios for each of 16 pediatric medical subspecialties. Coefficients of variation for the ratios were used to assess intraspecialty variation in supply across markets. Estimates of the pediatric population that is needed to support an initial or additional physician in a market were generated using subspecialty-specific ordered logit analyses. The population-weighted average distance to a subspecialist ranged from 15 miles for neonatology to 78 miles for pediatric sports medicine. For most pediatric subspecialties, more than two thirds of children live within 40 miles of a certified physician. For 7 of 16 of pediatric subspecialties, fewer than one half of hospital referral regions have a provider. Coefficients of variation vary across subspecialties and are lowest for neonatology at 76% and greatest for pediatric sports medicine at 287%. Pediatric population thresholds likewise vary with a tendency toward lower thresholds for procedural specialties, such as cardiology and critical care medicine. The practice locations of pediatric subspecialists parallel the geographic distribution of children in the United States, yet many hospital referral regions lack pediatric subspecialists and coefficients of variation vary widely across subspecialties. These findings suggest that either the supply of pediatric subspecialists is inadequate, pediatric subspecialists are distributed inequitably, or the market for pediatric subspecialists is larger than the hospital referral regions. Furthermore, population thresholds for many cognitive pediatric subspecialties are high; the extent to which high thresholds reflect low disease prevalence versus other factors, such as inadequate reimbursement, is not established.

Pediatric workforce: A look at pediatric gastroenterology data from the American Board of Pediatrics

his report, which is part of a series discussing workforce trends for general pediatrics and related subspecialty areas, highlights the American Board of Pediatrics’ (ABP) workforce data for pediatric gastroenterology. Readers are encouraged to read the initial report in the series, because it provides information about general pediatrics and summary nformation about other ABP subspecialties. In 1990, pediatric gastroenterology became the eighth ABP subboard to offer a ertification examination, with the first examination yielding 275 board-certified pediatric gastroenterologists. Today, almost 900 ediatricians have been certified by the ABP as pediatric gastroenterologists. The focus of this report is to provide a snapshot f the current ABP workforce data for this subspecialty. The full ABP workforce data are available on the ABP Web site at ww.abp.org.

Pediatric workforce: A look at pediatric critical care medicine data from the American Board of Pediatrics

his report, which is part of a series discussing workforce trends for general pediatrics and related subspecialty areas, highlights the American Board of Pediatrics’ (ABP) workforce data for pediatric critical care medicine. Readers are encouraged to read the initial report in the series, because it provides information about general pediatrics and summary nformation about other ABP subspecialties. In 1987, pediatric critical care medicine became the seventh ABP subboard to offer certification examination, with the first examination yielding 182 board-certified pediatric critical care physicians. Today, lmost 1300 pediatricians have been certified by the ABP as pediatric critical care physicians. This report provides a snapshot f the current ABP workforce data for this subspecialty. The full ABP workforce data are available on the ABP Web site at ww.abp.org.

The Changing Composition of the Pediatric Medical Subspecialty Workforce

To characterize the composition of the pediatric subspecialty workforce in terms of the distribution of women and international medical graduates (IMGs) across pediatric medical subspecialties and to determine whether the proportions of board-certified pediatric subspecialists who are women or IMGs differ between graduation cohorts. We used board certification data from the American Board of Pediatrics. Within each pediatric subspecialty, we classified physicians into 2 groups, ie, recent graduates, defined as those who completed medical school after January 1, 1987, and nonrecent graduates, who completed medical school before that date. We calculated the percentage of female physicians for each subspecialty and computed 95% confidence intervals around those estimates to identify male-dominated subspecialties. Using Pearson chi2 tests, we compared the percentages of women between the 2 graduation cohorts for each subspecialty. Similar calculations were performed for the percentage of IMGs in each subspecialty. Sensitivity analyses were performed with data from the 2002 American Medical Association Physician Masterfile. For 9 of 16 pediatric medical subspecialties studied, the percentages of board-certified women were significantly greater in the recent cohort than in the nonrecent cohort. Subspecialties that remain predominantly male in the recent graduation cohort include cardiology, critical care medicine, gastroenterology, pulmonology, and sports medicine. In contrast, the percentages of board-certified IMGs were significantly lower for 6 of the 16 specialties studied; endocrinology and gastroenterology remain relatively reliant on IMGs. For the majority of pediatric medical subspecialties, concerns that the predominance of women in pediatric training may negatively affect the supply of subspecialists are likely unfounded; however, a small number of procedure-based specialties, as well as sports medicine, continue to rely disproportionately on men. There do not seem to be consistent differences in the role of IMGs across the pediatric medical subspecialties between recent and nonrecent graduates, which may reflect differing tendencies to become certified.

Providing pediatric subspecialty care: A workforce analysis. AAP Committee on Pediatric Workforce Subcommittee on Subspecialty Workforce.

To provide a snapshot of pediatric subspecialty practice, examine issues pertaining to the subspecialty workforce, and analyze subspecialists' perspective on the health care market. Before the effort of the Future of Pediatric Education II (FOPE II) Project, very little information existed regarding the characteristics of the pediatric subspecialty workforce. This need was addressed through a comprehensive initiative involving cooperation between subspecialty sections of the American Academy of Pediatrics and other specialty societies. Questionnaires were sent to all individuals, identified through exhaustive searches, who practiced in 17 pediatric medical and surgical subspecialty areas in 1997 and 1998. The survey elicited information about education and practice issues, including main practice setting, major professional activity, referrals, perceived competition, and local workforce requirements. The number of respondents used in the analyses ranged from 120 (plastic surgery) to 2034 (neonatology). In total, responses from 10 010 pediatric subspecialists were analyzed. For 13 of the subspecialties, a medical school setting was specified by the largest number of respondents within each subspecialty as their main employment site. Direct patient care was the major professional activity of the majority of respondents in all the subspecialties, with the exception of infectious diseases. Large numbers of subspecialists reported increases in the complexity of referral cases, ranging between 20% (cardiology) and 44% (critical care), with an average of 33% across the entire sample. In all subspecialties, a majority of respondents indicated that they faced competition for services in their area (range: 55%-90%; 71% across the entire sample); yet in none of the subspecialties did a majority report that they had modified their practice as a result of competition. In 15 of the 17 subspecialties, a majority stated that there would be no need in their community over the next 3 to 5 years for additional pediatric subspecialists in their discipline. Across the entire sample, 42% of respondents indicated that they or their employer would not be hiring additional, nonreplacement pediatric subspecialists in their field in the next 3 to 5 years (range: 20%-63%). This survey provides the first comprehensive analysis to date on how market forces are perceived to be affecting physicians in the pediatric subspecialty workforce. The data indicate that pediatric subspecialists in most areas are facing strong competitive pressures in the market, and that the market's ability to support additional subspecialists in many areas may be diminishing.

Issues in pediatric critical care medicine

'T IS AN OFTEN-HEARD ADAGE that chil.dren are a unique species and not just small adults. There are few areas of pediatrics where this is more true than in the care of the critically ill child. Even though it has taken many years to organize the specialized skills and care into dedicated units and develop the subspeciality of pediatric critical care medicine, few specialities have experienced the tremendous growth that pediatric critical care has seen. Critically ill children can now receive care that results from a marriage of the most powerful advances in technology with an in-depth understanding of the unique physiology of the developing child under the guidance of physicians schooled within a multidisciplinary framework incorporating anesthesia, pediatrics, and all of the pediatric medical and surgical subspecialties. It has been through this synthesis and the thoughtful application of technology that the role of the pediatric critical care physician has evolved from that of a postoperative adjunct to that of the true intensivist of today. Pediatric intensive care units are multidisciplinary ICUs that care for children with the whole spectrum of critical illness. Clearly, pediatric critical care medicine is a complex area that is constantly evolving. Thus, it would be impossible to discuss the entire spectrum of critical care for children in this article. The authors have selected a few areas of interest where significant developments in understanding or practice have changed in the last few years, and they present these as an update on the practice of pediatric critical care medicine. As the pediatric ICU continues to develop technologically, thus enabling increasingly sophisticated monitoring and intervention, new challenges