General pediatricians, pediatric subspecialists, and pediatric primary care

Pediatric Primary Care Involvement in End-of-Life Care for Children

OBJECTIVES

To examine the relationship between pediatric primary care involvement and hospice and home health care use at end of life.

METHODS

California Medicaid data were used to estimate the relationship between pediatric primary care involvement and use of hospice and home health care using generalized estimating equations.

RESULTS

Of the 2037 children who died between 2007 and 2010, 11% used hospice and 23% used home health. Among all children, primary care was not related to hospice use and was associated with home health use, usual source of care (OR = 1.83, P < .05), comprehensive care (OR = 1.60, P < .05), and continuous care (low: OR = 1.49, P < .05; moderate: OR = 2.57, P < .05; high: OR = 2.12, P < .05). Primary care for children aged 15 to 20 years was related to hospice use, usual source of care (OR = 4.06, P < .05) and continuous care (low: OR = 4.92, P < .05; moderate OR = 4.09, P < .05; high OR = 3.92, P < .05). Primary care for children under 5 years was associated with home health use, usual source of care (OR = 2.59, P < .05), comprehensive care (OR = 2.49, P < .05), and continuous care (low: OR = 2.22, P < .05; moderate: OR = 3.64, P < .05; high: OR = 3.62, P < .05). For children aged 6 to 14 years, this association was seen with continuous care (moderate: OR = 2.38, P < .05; high: OR = 2.13, P < .05). Home health for children aged 15 to 20 years was related to continuous care (moderate: OR = 2.32, P < .05).

CONCLUSION

Primary care involvement affected hospice use among older age-groups and home health use among younger age-groups. These findings underscore the need for clinical knowledge about end-of-life care for children of all ages among primary care providers.

Medical Homes for Children With Special Health Care Needs: Primary Care or Subspecialty Service?

OBJECTIVE

To examine primary care pediatricians' (PCPs) beliefs about whether the family-centered medical home (FCMH) should be in primary or subspecialty care for children with different degrees of complexity; and to examine practice characteristics associated with these beliefs.

METHODS

Data from the American Academy of Pediatrics Periodic Survey (PS 79) conducted in 2012 were analyzed. Outcomes were agreement/strong agreement that 1) primary care should be the FCMH locus for most children with special health care needs (CSHCN) and 2) subspecialty care is the best FCMH locus for children with rare or complex conditions. In multivariate models, we tested associations between outcomes and practice barriers (eg, work culture, time, cost) and facilitators (eg, having a care coordinator) to FCMH implementation.

RESULTS

Among 572 PCPs, 65% agreed/strongly agreed primary care is the best FCMH setting for most CSHCN, and 43% agreed/strongly agreed subspecialty care is the best setting for children with complexity. Cost and time as barriers to FCMH implementation were oppositely associated with the belief that primary care was best for most CSHCN (cost: adjusted odds ratio [AOR] 2.31, 1.36-3.90; time: AOR 0.48, 0.29-0.81). Lack of skills to communicate and coordinate care was associated with the belief that specialty care was the best FCMH for children with complexity (AOR 1.99, 1.05-3.79).

CONCLUSIONS

A substantial minority endorsed specialty care as the best FCMH locus for children with medical complexity. Several barriers were associated with believing primary care to be the best FCMH for most CSHCN. Addressing medical complexity in FCMH implementation may enhance perceived value by pediatricians.

Differences in pediatric drug information sources used by general versus subspecialist pediatricians

OBJECTIVE

To describe pediatric labeling information needs and sources of general and subspecialist pediatricians. Study design. Self-administered questionnaire of Fellows of the American Academy of Pediatrics (AAP).

RESULTS

The response rate was 48%. Top sources used by pediatricians to obtain pediatric labeling information were journals (86%), pediatric dosage books (84%), AAP News (77%), drug representatives (65%), and PDA-based databases (35%). Generalists were more likely than subspecialists to use AAP News (82% vs 60%; P < .001) and drug representatives (72% vs 41%; P < .001) to obtain prescribing information. Both groups reported that it was most important to have additional prescribing information for mental health and cardiovascular medications.

CONCLUSIONS

Despite differences in the methods used to obtain pediatric labeling information, generalist and subspecialist pediatricians both prioritized mental health and cardiovascular medications as needing additional prescribing information. Interventions to effectively disseminate new or revised pediatric labeling information to pediatricians should consider using methods identified in this study.

Underdiagnosis of pediatric obesity during outpatient preventive care visits

OBJECTIVE

To examine obesity diagnosis, obesity-related counseling, and laboratory testing rates among obese pediatric patients seen in US preventive outpatient visits and to determine patient, provider, and practice-level factors that are associated with obesity diagnosis.

METHODS

By using 2005-2007 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data, outpatient preventive visits made by obese (body mass index ≥95%) 2- to 18-year-old patients were examined for frequencies of obesity diagnosis, diet, exercise, or weight reduction counseling, and glucose or cholesterol testing. Multivariable logistic regression was used to examine whether patient-level (gender, age, race/ethnicity, insurance type) and provider/practice-level (geographic region, provider specialty, and practice setting) factors were associated with physician obesity diagnosis.

RESULTS

Physicians documented an obesity diagnosis in 18% (95% confidence interval, 13-23) of visits made by 2- to 18-year-old patients with a body mass index ≥95%. Documentation of an obesity diagnosis was more likely for non-white patients (odds ratio 2.87; 95% confidence interval, 1.3-6.3). Physicians were more likely to provide obesity-related counseling (51% of visits) than to conduct laboratory testing (10% of visits) for obese pediatric patients.

CONCLUSION

Rates of documented obesity diagnosis, obesity-related counseling, and laboratory testing for comorbid conditions among obese pediatric patients seen in US outpatient preventive visits are suboptimal. Efforts should target enhanced obesity diagnosis as a first step toward improving pediatric obesity management.

Recently trained pediatric subspecialists: perspectives on training and scope of practice

OBJECTIVES

Little is known regarding the factors influencing the decision to pursue pediatric subspecialty fellowship training and the timing of when such a decision is made. In addition, there is no information regarding whether the general pediatrics training received in residency is perceived as valuable by subspecialists. This study was conducted to characterize the strengths and weaknesses of residency and fellowship training from the perspective of recently trained pediatric subspecialists and to assess their current and future career goals and intended scope of practice.

METHODS

A random sample of 550 subspecialists whose initial application for pediatric subspecialty certification occurred between 2002 and 2003 (4-5 years out of training) and 550 subspecialists who applied for board certification between 2005 and 2006 (1-2 years out of training) received a structured questionnaire by mail. The survey focused on decision-making in selection of residency and fellowship programs, strength of residency training in preparation for clinical care provision, and scope of current practice.

RESULTS

The overall response rate was 77%. More than half (54%) of the recently trained subspecialists would have shortened either their pediatric residency or fellowship training if given the opportunity, and 7% were unsure. More than one third of the respondents made the decision to pursue subspecialty training before the start of residency (36% [n = 198]), whereas approximately half of them made this decision during the first (19% [n = 106]) or second (27% [n = 150]) year of residency.

CONCLUSIONS

Many subspecialists would have been interested in modifications to their pediatric residency and fellowship training programs, which may reflect changing patterns of professional activities or the preferences of a younger generation of subspecialists. Given that a substantial proportion of subspecialists decide to pursue subspecialty training before or early in residency, greater flexibility in configuring some residency experiences to meet their career goals would be feasible.

The pediatric subspecialty workforce: public policy and forces for change

Policy has not adequately addressed the unique circumstances of pediatric subspecialties, many of which are facing workforce shortages. Pediatric subspecialties, which we define to include all medical and surgical subspecialties, are discrete disciplines that differ significantly from each other and from adult medicine subspecialties. Concerns about a current shortage of pediatric subspecialists overall are driven by indicators ranging from recruitment difficulties to long wait times for appointments. The future supply of pediatric subspecialists and patient access to pediatric subspecialty care will be affected by a number of key factors or forces for change. We discuss 5 of these factors: changing physician and patient demographics; debt load and lifestyle considerations; competition among providers of subspecialty care; equitable reimbursement for subspecialty services; and policy to regulate physician supply. We also identify issues and strategies that medical and specialty societies, pediatric subspecialists, researchers, child advocates, policy makers, and others should consider in the development of subspecialty-specific workforce-policy agendas.

Who cares for medicaid-enrolled children with chronic conditions?

OBJECTIVE

To estimate generalist, pediatric subspecialist, and any subspecialist use by Medicaid-enrolled children with chronic conditions and to determine the correlates of use.

METHODS

We analyzed Medicaid claims data collected from 1989 to 1992 from 4 states for 57 328 children and adolescents with 11 chronic conditions. We calculated annual rates of generalist, subspecialist, and pediatric subspecialist use. We used logistic regression to determine the association of demographics, urban residence, and case-mix (Adjusted Clinical Groups) with the use of relevant pediatric and any subspecialist care.

RESULTS

Most children with chronic conditions had visits to generalists (range per condition: 78%-90% for children with Supplemental Security Income [SSI] and 85%-94% for children without SSI) during the year studied. Fewer children visited any relevant subspecialists (24%-59% for children with SSI and 13%-56% for children without SSI) or relevant pediatric subspecialists (10%-53% for children with SSI and 3%-37% for children without SSI). In general, children who were more likely to use pediatric subspecialists were younger, lived in urban areas, were white (only significant for non-SSI children), and had higher Adjusted Clinical Groups scores. Use of any subspecialists followed a similar pattern except that urban residence is statistically significant only for children with SSI and the youngest age group does not differ from the oldest age group for children without SSI.

CONCLUSIONS

Children who had chronic conditions and were enrolled in Medicaid received a majority of their care from generalist physicians. For most conditions, a majority of children did not receive any relevant subspecialty care during the year and many of these children did not receive care form providers with pediatric-specific training.

Characteristics of women pediatricians

To contrast women pediatricians (n = 807) with other U.S. women physicians, we used data from the Women Physicians' Health Study, a national, randomly sampled questionnaire survey (total n = 4,501). Compared with other women physicians, women pediatricians worked less and reported lower incomes but also reported less work stress and less career dissatisfaction. Pediatricians were less likely to counsel/perform screening regarding cholesterol, HIV, smoking, and alcohol but more likely regarding skin cancer or sunscreen use, nutrition, and weight. Given current emphases on trying to improve U.S. children's health practices, these findings are of concern.

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

OBJECTIVE

To provide a snapshot of pediatric subspecialty practice, examine issues pertaining to the subspecialty workforce, and analyze subspecialists' perspective on the health care market.

BACKGROUND

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.

METHODS

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.

RESULTS

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%).

CONCLUSION

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.

Parental preferences for primary and specialty care collaboration in the management of teenagers with congenital heart disease

OBJECTIVES

We examined parental preferences for locus of service delivery for their teenager's congenital heart disease (CHD) and the influence of disease severity, sociodemographic factors, and insurance on these preferences.

METHODS

A consecutive sample of parents of teenagers followed in a pediatric cardiology clinic completed a mailed questionnaire. Disease severity was classified as low (</=1 cardiovascular procedure), moderate (>1 cardiovascular procedure), and high (cyanosis or single ventricle physiology).

RESULTS

Eighty-six of 148 parents responded (58%): 40, low severity; 36, moderate severity; and 10, high severity of illness. Parents preferred using primary care providers (PCPs) as a point of first contact for all 11 of 11 general health concerns and 5 of 7 potential cardiovascular-related concerns: chest pain (52%), syncope (73%), seeming seriously ill (79%), sports physical examination (79%), and endocarditis prophylactic antibiotics (94%). Increasing disease severity was significantly associated with preferring cardiologists for 6 of 7 cardiovascular-related concerns. Overall, 58% of parents viewed their care as a PCP-cardiologist comanagement model versus a cardiologist-dominated model. Lower family income (odds ratio [OR]: 1.5; confidence interval [CI]: 1.0-2.2) and severity of illness (OR: 2.1; CI: 1.0-4.4) were associated with a comanagement model of health care versus a cardiologist-dominated model.

CONCLUSIONS

This study suggests that the majority of parents of teenagers with CHD prefer to use their teenager's PCP for all routine health care needs and many cardiovascular health needs. Severity of illness and family income are positively associated with greater preference for cardiologist care.