US Pediatricians Research Articles

Factors Influencing Pediatrician Retirement: A Survey of American Academy of Pediatrics Chapter Members

To assess the factors that may influence physicians' desire to retire through an analysis of data collected through the American Academy of Pediatrics (AAP) State Pediatrician Workforce Survey. An electronic survey was sent to retired and nonretired US pediatricians who held AAP membership. The respondents were asked about the importance of 12 factors that would influence or had influenced their decision to retire. The physicians who were not yet retired also were asked: "If you could afford to today, would you retire from medicine?" The survey was completed by 8867 pediatricians. Among the nonretired respondents, 27% reported that they would retire today if it were affordable. Increasing regulation of medicine, decreasing clinical autonomy, and insufficient reimbursement were rated as very important factors by >50% of these pediatricians. Among retired pediatricians, 26.9% identified the effort to keep up with clinical advances and changes in practice as a very important factor in their decision to retire. Younger physicians were significantly more likely to rate maintenance of certification requirements, insufficient reimbursement, lack of professional satisfaction, and family responsibilities as very important factors. Rural pediatricians were more interested in retiring than those working in academic settings. There were no sex differences. Twenty-seven percent of pediatricians in practice today would retire today if it were affordable. Identifying and addressing the important factors that influence a pediatrician's desire to retire can potentially reduce the retirement rate of pediatricians and thus increase access to care for children.

Cholesterol Screening and Treatment Practices and Preferences: A Survey of United States Pediatricians

To determine pediatricians' practices, attitudes, and barriers regarding screening for and treatment of pediatric dyslipidemias in 9- to 11-year-olds and 17- to 21-year-olds. American Academy of Pediatrics (AAP) 2013-2014 Periodic Survey of a national, randomly selected sample of 1627 practicing AAP physicians. Pediatricians' responses were described and modeled. Of 614 (38%) respondents who met eligibility criteria, less than half (46%) were moderately/very knowledgeable about the 2008 AAP cholesterol statement; fewer were well-informed about 2011 National Heart, Lung, and Blood Institute Guidelines or 2007 US Preventive Service Task Force review (both 26%). Despite published recommendations, universal screening was not routine: 68% reported they never/rarely/sometimes screened healthy 9- to 11-year-olds. In contrast, more providers usually/most/all of the time screened based on family cardiovascular history (61%) and obesity (82%). Screening 17- to 21-year-olds was more common in all categories (P?<?.001). Only 58% agreed with universal screening, and 23% felt screening was low priority. Pediatricians uniformly provided lifestyle counseling but access to healthy food (81%), exercise (83%), and adherence to lifestyle recommendations (96%) were reported barriers. One-half of pediatricians (55%) reported a lack of local subspecialists. Although 62% and 89% believed statins were appropriate for children and adolescents with high low-density lipoprotein cholesterol (200?mg/dL) unresponsive to lifestyle, a minority initiated statins (8%, 21%). US pediatricians report lipid screening and treatment practices that are largely at odds with existing recommendations, likely because of lack of knowledge and conflicts among national guidelines, and concern about treatment efficacy and harms. Education regarding pediatric lipid disorders could promote guideline implementation.

Perspectives and Uses of the Electronic Health Record Among US Pediatricians: A National Survey.

Little is known about how existing electronic health records (EHRs) influence the practice of pediatric medicine. A total of 808 pediatricians participated in a survey about workflows using the EHR. The EHR was the most commonly used source of initial patient information. Seventy-two percent reported requiring between 2 and 10 minutes to complete an initial review of the EHR. Several moderately severe information barriers were reported regarding the display of information in the EHR. Pediatricians acquire information about new patients from EHRs more often than any other source. EHRs play a critical role in pediatric care but require improved design and efficiency.

Payments to Pediatricians in the Sunshine Act.

Under the Sunshine Act, pharmaceutical and product industry payments to physicians are reported in a public database. We sought to characterize payments received by pediatricians in the first full year of disclosures in 2014. We used the National Centers for Medicare and Medicaid Services Open Payment files to identify pediatricians who received payments. Payment characteristics were stratified, and descriptive statistical analysis was performed, including mean, median, and ranges of payments. Between January 1, 2014, and December 31, 2014, 35 697 pediatricians received payments amounting to $30 031 960. General pediatricians received the majority of payments (71%). Median payment was $15 (interquartile range = $12-$24), mostly in the form of noncash items and services (84%). Significant diversity was observed in median payments among specialty providers. In conclusion, 42% of US pediatricians received industry payments in 2014. These data provide a foundation for future research regarding the influence of the Sunshine Act on pediatric clinical practices.

Vaccine Delays, Refusals, and Patient Dismissals: A Survey of Pediatricians.

Parental noncompliance with the American Academy of Pediatrics and Centers for Disease Control and Prevention immunization schedule is an increasing public health concern. We examined the frequency of requests for vaccine delays and refusals and the impact on US pediatricians' behavior. Using national American Academy of Pediatrics Periodic Surveys from 2006 and 2013, we describe pediatrician perceptions of prevalence of (1) vaccine refusals and delays, (2) parental reasons for refusals and/or delays, and (3) physician dismissals. Questions about vaccine delays were asked only in 2013. We examined the frequency, reasons for, and management of both vaccine refusals and delays by using bivariate and multivariable analyses, which were controlled for practice characteristics, demographics, and survey year. The proportion of pediatricians reporting parental vaccine refusals increased from 74.5% in 2006 to 87.0% in 2013 (P < .001). Pediatricians perceive that parents are increasingly refusing vaccinations because parents believe they are unnecessary (63.4% in 2006 vs 73.1% in 2013; P = .002). A total of 75.0% of pediatricians reported that parents delay vaccines because of concern about discomfort, and 72.5% indicated that they delay because of concern for immune system burden. In 2006, 6.1% of pediatricians reported "always" dismissing patients for continued vaccine refusal, and by 2013 that percentage increased to 11.7% (P = .004). Pediatricians reported increased vaccine refusal between 2006 and 2013. They perceive that vaccine-refusing parents increasingly believe that immunizations are unnecessary. Pediatricians continue to provide vaccine education but are also dismissing patients at higher rates.

Using the shortwave infrared to image middle ear pathologies

Visualizing structures deep inside opaque biological tissues is one of the central challenges in biomedical imaging. Optical imaging with visible light provides high resolution and sensitivity; however, scattering and absorption of light by tissue limits the imaging depth to superficial features. Imaging with shortwave infrared light (SWIR, 1-2 μm) shares many advantages of visible imaging, but light scattering in tissue is reduced, providing sufficient optical penetration depth to noninvasively interrogate subsurface tissue features. However, the clinical potential of this approach has been largely unexplored because suitable detectors, until recently, have been either unavailable or cost prohibitive. Here, taking advantage of newly available detector technology, we demonstrate the potential of SWIR light to improve diagnostics through the development of a medical otoscope for determining middle ear pathologies. We show that SWIR otoscopy has the potential to provide valuable diagnostic information complementary to that provided by visible pneumotoscopy. We show that in healthy adult human ears, deeper tissue penetration of SWIR light allows better visualization of middle ear structures through the tympanic membrane, including the ossicular chain, promontory, round window niche, and chorda tympani. In addition, we investigate the potential for detection of middle ear fluid, which has significant implications for diagnosing otitis media, the overdiagnosis of which is a primary factor in increased antibiotic resistance. Middle ear fluid shows strong light absorption between 1,400 and 1,550 nm, enabling straightforward fluid detection in a model using the SWIR otoscope. Moreover, our device is easily translatable to the clinic, as the ergonomics, visual output, and operation are similar to a conventional otoscope.

Provider Attitudes Regarding Vaccine Tracking Systems in Pediatric Practices

ObjectiveTo assess among US pediatricians' systems for tracking vaccine administration and inventory and attitudes about these systems; and attitudes regarding and perceived barriers to adoption of a 2-dimensional bar code systems. MethodsInternet and mail survey of a nationally representative network of pediatricians between September 2011 and January 2012. ResultsThe response rate was 71% (288 of 408). The most common methods for recording vaccine information were manual entry into an electronic (52%) or paper (27%) record; 76% recorded information in ≥2 places. Physicians reported ordering vaccine on the basis of seasonal increases in demand (55%), paper-based inventory (52%), or when stock looks low (47%); 79% reported it was time consuming to track inventory and 24% reported their practices frequently run out of vaccines. Among those participating in an immunization information system, 29% transmitted data by automatic uploads and 58% entered data manually. Physicians agreed that bar codes could facilitate tracking of vaccine inventory (96%), would improve patient safety (96%), would be more reliable and accurate than current systems (93%), and could improve the efficiency of vaccine administration (90%). Barriers to adoption of a bar code system included need for software (52%), information technology support (42%), and computer equipment (33%). The total cost at which >50% reported they would definitely or probably adopt a bar code system was between $1000 and $4999. ConclusionsMost pediatricians report using inefficient systems for tracking vaccine administration and inventory and recognize multiple potential benefits of incorporating vaccine bar coding into their practice. To facilitate adoption, costs will need to be contained and technological barriers addressed.

A Longitudinal Study of Pediatricians Early in Their Careers: PLACES.

The American Academy of Pediatrics (AAP) launched the Pediatrician Life and Career Experience Study (PLACES), a longitudinal study that tracks the personal and professional experiences of early career pediatricians, in 2012. We used a multipronged approach to develop the study methodology and survey domains and items, including review of existing literature and qualitative research with the target population. We chose to include 2 cohorts of US pediatricians on the basis of residency graduation dates, including 1 group who were several years out of residency (2002-2004 Residency Graduates Cohort) and a second group who recently graduated from residency at study launch (2009-2011 Residency Graduates Cohort). Recruitment into PLACES was a 2-stage process: (1) random sample recruitment from the target population and completion of an initial intake survey and (2) completion of the first Annual Survey by pediatricians who responded positively to stage 1. Overall, 41.2% of pediatricians randomly selected to participate in PLACES indicated positive interest in the study by completing intake surveys; of this group, 1804 (93.7%) completed the first Annual Survey and were considered enrolled in PLACES. Participants were more likely to be female, AAP members, and graduates of US medical schools compared with the target sample; weights were calculated to adjust for these differences. We will survey PLACES pediatricians 2 times per year. PLACES data will allow the AAP to examine career and life choices and transitions experienced by early-career pediatricians.

Economic Burden of Atopic Dermatitis in High-Risk Infants Receiving Cow's Milk or Partially Hydrolyzed 100% Whey-Based Formula

To estimate the health and economic impact of feeding partially hydrolyzed formula-whey (PHF-W) instead of standard cow's milk formula (CMF) for the first 4months of life among US infants at high risk for developing atopic dermatitis (AD). A Markov model was developed integrating published data, a survey of US pediatricians, costing sources and market data, and expert opinion. Key modeled outcomes included reduction in AD risk, time spent post AD diagnosis, days without AD flare, and AD-related costs. Costs and clinical consequences were discounted at 3% annually. An estimated absolute 14-percentage point reduction in AD risk was calculated with the use of PHF-W compared with CMF (95% CI for difference, 3%-22%). Relative to CMF, PHF-W decreased the time spent post-AD diagnosis by 8.3months (95% CI, 2.78-13.31) per child and increased days without AD flare by 39days (95% CI, 13-63) per child. The AD-related, 6-year total cost estimate was $495 less (95% CI, -$813 to -$157) per child with PHF-W ($724 per child; 95% CI, $385-$1269) compared with CMF ($1219 per child; 95% CI, $741-$1824). Utilization of PHF-W in place of CMF as the initial infant formula administered to high-risk US infants not exclusively breastfed during the first 4months of life may reduce the incidence and economic burden of AD. Broad implementation of this strategy could result in a minimum savings of $355 million per year to society.

Measles imported to the United States by children adopted from China.

In July 2013, the National Immunization Program of China was notified by the US Centers for Disease Control and Prevention that measles was detected in 3 newly adopted, special needs children with cerebral palsy (CP) from China. We report an investigation of measles transmission in China that led to infection of these children. Interviews were conducted with welfare institute staff and panel physicians; health records of the potentially exposed population were reviewed; and immunization coverage was assessed among institute residents. Five residents with CP, all unvaccinated against measles, among who were the 3 adoptees, were linked epidemiologically into 3 generations of measles transmission antecedent to the US outbreak. In a random sample of residents, first dose of measles containing vaccine (MCV1) and MCV2 coverage was 16 of 17 (94%) and 7 of 11 (64%) among children with CP, and 100% (32 of 32) and 96% (21 of 22) among children without CP. Vaccinators reported reluctance to vaccinate children with CP because the China pharmacopeia lists encephalopathy as a contraindication to vaccination. Panel physicians reported to investigators no necessity of vaccination for adoptees to the United States if US parents sign an affidavit exempting the child from vaccination. We recommend that the China pharmacopeia vaccine contraindications be reviewed and updated, the United States should reconsider allowing vaccination exemptions for internationally adopted children unless there are true medical contraindications to vaccination, and US pediatricians should counsel adopting parents to ensure that their child is up-to-date on recommended vaccinations before coming to the United States.

"Frustrated," "depressed," and "devastated" pediatric trainees: US academic medical centers fail to provide adequate workplace breastfeeding support.

Exclusive breastfeeding (EBF) is recommended until about 6 months of age. Pediatricians are at the forefront of encouraging mothers to achieve this goal, yet pediatricians who parent during their training may face substantial barriers in achieving their own breastfeeding goals. This study aimed to assess breastfeeding support available to US pediatricians in training and the effect of trainees' personal experiences on their attitude toward breastfeeding. An online survey was emailed to American Academy of Pediatrics Section on Medical Students, Residents, and Fellowship Trainees members. There were 927 respondents, of which 421 had children and 346 breastfed their children. Almost 80% agreed that 6 months is the ideal duration for EBF. One in 4 did not have access to or were not aware of a private room to express milk or breastfeed. Forty percent needed to extend the duration of their training for a longer maternity leave, with breastfeeding a factor for longer leave among 44%. One in 4 did not meet their breastfeeding duration goal, and 1 in 3 did not meet their goal for EBF. Negative emotions were common among those not meeting goals. Ninety-two percent felt that their or their partner's experience with breastfeeding affected their clinical interaction with patients' mothers. A majority of respondents cited problems with breastfeeding support during training, and many failed to meet their intended goals. Not meeting personal breastfeeding goals was associated with negative emotions and influenced how they counsel about breastfeeding as a result of personal and often negative attitudes.

A Brief Intervention to Improve Food Allergy Knowledge Among US Pediatricians: Lessons Learned

EE Springston, CH Lau, P Patel. Pediatr Allergy Immunol . 2012;23(7):642–647 To determine if a brief educational tool developed for pediatricians would be effective in addressing gaps in food allergy knowledge. US pediatricians ( N = 61), including practicing pediatricians recruited from 4 Chicago-area practices, graduates from the Children’s Memorial Hospital residency program, and current members of the Illinois chapter of the American Academy of Pediatrics. A Food Allergy Comprehension Tool (FACT) was developed …

Changes in language services use by US pediatricians.

Access to appropriate language services is critical for ensuring patient safety and reducing the impact of language barriers. This study compared language services use by US pediatricians in 2004 and 2010 and examined variation in use in 2010 by pediatrician, practice, and state characteristics. We used data from 2 national surveys of pediatricians (2004: n = 698; 2010: n = 683). Analysis was limited to postresidency pediatricians with patients with limited English proficiency (LEP). Pediatricians reported use of ≥ 1 communication methods with LEP patients: bilingual family member, staff, physician, formal interpreter (professional, telephone), and primary-language written materials. Bivariate analyses examined 2004 to 2010 changes in methods used, and 2010 use by characteristics of pediatricians (age, sex, ethnicity), practices (type, location, patient demographics), and states (LEP population, Latino population growth, Medicaid/Children's Health Insurance Program language services reimbursement). Multivariate logistic regression was performed to determine adjusted odds of use of each method. Most pediatricians reported using family members to communicate with LEP patients and families, but there was a decrease from 2004 to 2010 (69.6%, 57.1%, P < .01). A higher percentage of pediatricians reported formal interpreter use (professional and/or telephone) in 2010 (55.8%) than in 2004 (49.7%, P < .05); the increase was primarily attributable to increased telephone interpreter use (28.2%, 37.8%, P < .01). Pediatricians in states with reimbursement had twice the odds of formal interpreter use versus those in nonreimbursing states (odds ratio 2.34; 95% confidence interval 1.24-4.40). US pediatricians' use of appropriate language services has only modestly improved since 2004. Expanding language services reimbursement may increase formal interpreter use.

Changes in Language Services Use by US Pediatricians

Changes in Language Services Use by US Pediatricians

Malpractice Risk Among US Pediatricians

To characterize malpractice risk among US pediatricians. We analyzed malpractice claims of all pediatricians and other physicians covered by a nationwide liability insurer from 1991 to 2005 (n = 1630 pediatricians; 40 916 total physicians). We characterized annual malpractice risk among pediatricians compared with other physicians. We characterized claims according to patient age, injury type, months required to resolve the claim, and whether an indemnity payment was made. We estimated how patient age and injury type were associated with whether a claim resulted in payment to a patient (and if so, payment size) and the time required to resolve the claim. The annual percentage of pediatricians facing a malpractice claim was 3.1% (7.4% among other physicians, P < .001). Among 404 claims, 83 (20.5%) resulted in an indemnity payment and 15 (3.7%) resulted in a payment exceeding $1 million. Annual rates of indemnity were lower among pediatricians (0.5%) than other physicians (1.6%, P < .001), whereas rates of payments exceeding $1 million were similar (0.13% among pediatricians and 0.11% among other physicians, P = .57). The mean indemnity payment was $562 180 (SD $667 962). Cases with permanent injury (n = 172) had larger mean payments ($703 373) compared with fatalities ($559 102; n = 131) or temporary or psychological injuries ($127 663; n = 101), P < .05. The mean time to resolution was 23.4 months (SD 21.8 months). Indemnity payments among pediatricians are infrequent but large, particularly in cases with permanent patient injury rather than death or temporary injury. The time required to resolve claims may be considered to be long.

Malpractice Risk Among US Pediatricians

Malpractice Risk Among US Pediatricians

Improved Timing of Availability and Administration of Influenza Vaccine Through the US Vaccines for Children Program From 2007 to 2011

The Vaccines for Children (VFC) program distributes one half of all vaccines administered to US children. Compared with commercial vaccine distribution, VFC distribution is more complex. This prospective observational study compares the delivery and administration of VFC versus non-VFC influenza vaccine in US pediatricians' offices across 3 influenza seasons and its apparent impact on 2-dose compliance rates. Because of earlier shipping (mean = 29-42 days) of non-VFC vaccines, administration of VFC vaccines was delayed relative to non-VFC vaccines by approximately 1 month in 2007-2008 and 2008-2009 and 2 weeks in 2010-2011. Two-dose compliance rates for the VFC and non-VFC populations were 38.5% and 47.5% (P < .001) in 2007-2008, 45.9% and 55.1% (P < .001) in 2008-2009, and 50.0% and 52.9% (P < .001) in 2010-2011, respectively. Despite delays, earlier VFC shipment in 2010-2011 enabled greater equity in 2-dose compliance.

Chapter Oral Health Advocates: A Nationwide Model for Pediatrician Peer Education and Advocacy about Oral Health

Objective. (1) To describe an innovative program training US pediatricians to be Chapter Oral Health Advocates (COHAs). (2) To provide insight into COHAs' experiences disseminating oral health knowledge to fellow pediatricians. Patients and Methods. Interviews with 40 COHAs who responded to an email request, from a total of 64 (62% response). Transcripts were analyzed for common themes about COHA activities, facilitators, and barriers. Results. COHAs reported positive experiences at the AAP oral health training program. A subset of academic COHAs focused on legislative activity and another on resident education about oral health. Residents had an easier time adopting oral health activities while practicing pediatricians cited time constraints. COHAs provided insights into policy, barriers, and facilitators for incorporating oral health into practice. Conclusions. This report identifies factors influencing pediatricians' adoption of oral health care into practice. COHAs reported successes in training peers on integrating oral health into pediatric practice, identified opportunities and challenges to oral health implementation in primary care, and reported issues about the state of children's oral health in their communities. With ongoing support, the COHA program has a potential to improve access to preventive oral health services in the Medical Home and to increase referrals to a Dental Home.

Physicians who use social media and other internet-based communication technologies.

The demographic and practice-related characteristics of physicians who use social networking websites, portable devices to access the internet, email to communicate with patients, podcasts, widgets, RSS feeds, and blogging were investigated. Logistic regression was used to analyze a survey of US primary care physicians, pediatricians, obstetrician/gynecologists, and dermatologists (N=1750). Reported technology use during the last 6 months ranged from 80.6% using a portable device to access the internet to 12.9% writing a blog. The most consistent predictors of use were being male, being younger, and having teaching hospital privileges. Physician specialty, practice setting, years in practice, average number of patients treated per week, and number of physicians in practice were found to be inconsistently associated or unassociated with use of the technologies examined. Demographic characteristics, rather than practice-related characteristics, were more consistent predictors of physician use of seven internet-based communication technologies with varying levels of uptake.

Febrile seizures and measles–mumps–rubella–varicella (MMRV) vaccine: What do primary care physicians think?

PurposeMeasles–mumps–rubella–varicella (MMRV) vaccine is associated with increased febrile seizure risk compared with measles–mumps–rubella and varicella vaccine given separately (MMR+V) in children 12–15-month old. We assessed knowledge regarding MMRV and febrile seizures, intended practices, and factors influencing the decision to recommend MMRV. MethodsNational survey administered 10/2008–1/2009 of US pediatricians (Peds) and family physicians (FP). ResultsResponse rate was 73% (620/849). Twenty-nine percent of Peds and 74% of FP (p<0.001) were unaware of increased febrile seizure risk after MMRV. After reading an informational statement, 20% of Peds and 7% of FP (p<0.001) would recommend MMRV to a healthy 12–15-month-old child. The factor most frequently reported as “very important” in the decision to recommend MMRV or MMR+V was ACIP/AAFP/AAP recommendations (pediatricians, 77%, family physicians, 73%, p=0.08). ConclusionsAfter receiving data regarding febrile seizure risk after MMRV, few physicians report they would recommend MMRV to a healthy 12–15-month-old child.