White Paper: Critical Shortage of Pediatric Nurse Practitioners Predicted

Outcomes of pediatric-focused advanced practice provider fellowship programs: An integrative review

BACKGROUND

An increased demand for pediatric-focused advanced practice providers (APPs) exists to address the health care needs of children with medical complexity. Postlicensure advanced practice fellowship programs have been developed to help improve novice provider transition to practice, reducing attrition.

OBJECTIVES

The objectives of this integrative review are to (1) identify outcome measurements of pediatric-focused advanced practice fellowship programs and (2) evaluate the outcome measures to guide future implications for practice.

DATA SOURCES

A systematic integrative literature review was conducted in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses. PubMed, CINAHL, Embase, and Google Scholar were searched in August and September 2022. Articles met inclusion criteria if they included new graduate APPs, reported the intervention of a pediatric fellowship program, and shared outcome measurements. Studies were excluded if they did not directly report on fellowship program outcome measures. Thirteen studies met inclusion criteria and were summarized and appraised for quality using the Johns Hopkins Evidence-Based Practice Model.

CONCLUSIONS

Four themes from the literature included the favorable impact of advanced practice fellowship programs on (a) job satisfaction, (b) retention, (c) clinical and professional performance, and (d) financial outcomes. Variable strategies were used to measure outcomes across programs.

IMPLICATIONS FOR PRACTICE

Postlicensure pediatric-focused advanced practice fellowship programs seem to improve retention and job satisfaction, increase provider confidence, and bring a favorable return on investment for the organization. Future work should include investment in developing validated, standardized assessment tools to support future development of these programs in the pediatric population.

Facilitators and Barriers to Pediatric Nurse Practitioner Practice in the United States: A Systematic Review

INTRODUCTION

The pediatric nurse practitioner (PNP) workforce was designed to improve child health equity. We aimed to systematically review the evidence on facilitators and barriers to PNP practice.

METHOD

We included empirical studies on PNP practice in the United States and excluded studies with non-identifiable PNP data. We applied Joanna Briggs Institute tools to appraise studies and applied critical interpretive synthesis principles to synthesize.

RESULTS

The final sample is 26 studies, mostly published before 2013 and observational. Prescriptive privileges, training program availability, organizational climate, and telehealth are facilitators. Mandated physician supervision, reduced pediatric curricula, geographically disparate training programs, and poor data infrastructure are barriers. The sample is limited by a moderate to high risk of bias.

DISCUSSION

Evidence suggests modifiable factors impact PNP practice and could have important implications for child health equity. We offer a theoretical model to guide robust research studying the PNP workforce and health equity.

US nurse practitioner voluntary turnover: Development of a framework for analysis

BACKGROUND

There is growing interest in nurse practitioner (NP) turnover with some reports indicating it is as high as 15% annually. However, there is a lack of generalizability and other conceptual weaknesses in the literature. These weaknesses support the development of a framework to operationalize NP turnover for administrators to develop workplace initiatives to reduce turnover.

PURPOSE

To describe the demographic and job characteristics of four NP voluntary turnover groups (i.e., dynamic leavers, static leavers, dynamic stayers, and static stayers) representing voluntary turnover intention and actual turnover among US NPs.

METHODOLOGY

A cross-sectional, descriptive secondary analysis of NPs ( N = 86,632) from the 2018 National Sample Survey of Registered Nurses (NSSRN) was used to delineate and describe four NP voluntary turnover groups.

RESULTS

Nurse practitioners who left nursing (static leavers) were older and had the most work experience. Nurse practitioners who changed jobs and stayed in nursing (dynamic leavers) were younger, less experienced, and reported the least job satisfaction. Nurse practitioners who remained in their positions (stayers) regardless of whether they reported turnover intentions or not earned the most and reported the most job satisfaction.

CONCLUSIONS

Four NP voluntary turnover groups were defined and described to distinguish voluntary turnover intentions from actual turnover.

IMPLICATIONS

Characterizing NP voluntary turnover can help administrators mitigate losses and project organizational needs associated with NP turnover. A framework developed from the 2018 NSSRN can be used to research and develop key initiatives to strengthen the NP workforce.

Tracheal Intubation by Advanced Practice Registered Nurses in Pediatric Critical Care: Retrospective Study From the National Emergency Airway for Children Registry (2015-2019)

OBJECTIVES

To describe tracheal intubation (TI) practice by Advanced Practice Registered Nurses (APRNs) in North American PICUs, including rates of TI-associated events (TIAEs) from 2015 to 2019.

DESIGN/SETTING

Retrospective study using the National Emergency Airway Registry for Children with all TIs performed in PICU and pediatric cardiac ICU between January 2015 and December 2019. The primary outcome was first attempt TI success rate. Secondary outcomes were TIAEs, severe TIAEs, and hypoxemia.

SUBJECTS

Critically ill children requiring TI in a PICU or pediatric cardiac ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Among 11,012 TIs, APRNs performed 1,626 (14.7%). Overall, TI by APRNs, compared with other clinicians, occurred less frequently in patients with known difficult airway (11.1% vs. 14.3%; p < 0.001), but more frequently in infants younger than 1 year old (55.9% vs. 44.4%; p < 0.0001), and in patients with cardiac disease (26.3% vs. 15.9%; p < 0.0001).There was lower odds of success in first attempt TI for APRNs vs. other clinicians (adjusted odds ratio, 0.70; 95% CI, 0.62-0.79). We failed to identify a difference in rates of TIAE, severe TIAE, and oxygen desaturation events for TIs by APRNs compared with other clinicians. The TI first attempt success rate improved with APRN experience (< 1 yr: 54.2%, 1-5 yr: 59.4%, 6-10 yr: 67.6%, > 10 yr: 63.1%; p = 0.021).

CONCLUSIONS

TI performed by APRNs was associated with lower odds of first attempt success when compared with other ICU clinicians although there was no appreciable difference in procedural adverse events. There appears to be a positive relationship between experience and success rates. These data suggest there is an ongoing need for opportunities to build on TI competency with APRNs.

Child Health and the US Pediatric Subspecialty Workforce: Planning for the Future

This article opens a multi-article Pediatrics supplement that provides a rigorous analysis of the projected pediatric subspecialty workforce in the United States. Congenital variations, epigenetics, exposures, lifestyle, preventive care, and medical interventions from conception through young adulthood set the stage for health and wellbeing in adulthood. Although care provided by pediatric subspecialists is associated with better outcomes and lower costs compared with adult providers, the authors of recent articles in the lay and medical literature have questioned the capacity of pediatric subspecialists to meet children's health care needs. This article highlights that, despite numerous advances in prevention, diagnosis, and treatment, the last decade has witnessed increasing numbers of children with acute or chronic physical and mental health disorders, including medical complexity, obesity, type 2 diabetes, anxiety, depression, and suicidality, all of which are exacerbated by poverty, racism, and other social drivers of health. In this article, we then describe the variability in the demographics, practice characteristics, and geographic distribution of the 15 core pediatric subspecialties certified by the American Board of Pediatrics. We then discuss the rationale and approach to the development of a pediatric subspecialty workforce model that forecasts subspecialist supply from 2020 to 2040 for 14 subspecialties at the national and subnational levels (not including the newest subspecialty, pediatric hospital medicine), accounting for US Census Bureau child population projections. The model does not account for the unique physical and mental needs of individual children, nor does it address the increasingly precarious commitment to, and financing of, pediatric subspecialty care in the US health care system impacting market demand.

Projecting the Future Pediatric Subspecialty Workforce: Summary and Recommendations

This article summarizes the findings of a Pediatrics supplement addressing the United States workforce for 15 pediatric subspecialties. It includes results from a microsimulation model projecting supply through 2040; growth is forecasted to be uneven across the subspecialties with worsening geographic maldistribution. Although each subspecialty has unique characteristics, commonalities include (1) the changing demographics and healthcare needs of children, including mental health; (2) poor outcomes for children experiencing adverse social drivers of health, including racism; and (3) dependence on other subspecialties. Common healthcare delivery challenges include (1) physician shortages for some subspecialties; (2) misalignment between locations of training programs and subspecialists and areas of projected child population growth; (3) tension between increasing subsubspecialization to address rare diseases and general subspecialty care; (4) the need to expand clinical reach through collaboration with other physicians and advanced practice providers; (5) the lack of parity between Medicare, which funds much of adult care, and Medicaid, which funds over half of pediatric subspecialty care; and (6) low compensation of pediatric subspecialists compared with adult subspecialists. Overall, subspecialists identified the lack of a central authority to monitor and inform child healthcare provided by pediatric subspecialists as a challenge. Future research on the pediatric subspecialty workforce and the children it serves will be necessary to ensure these children's needs are met. Together, these articles provide overarching and subspecialty-specific recommendations to improve training, recruitment, and retention of a diverse workforce, implement innovative models of care, drive policy changes, and advise future research.

Extension for Community Healthcare Outcomes fetal alcohol spectrum disorder (ECHO FASD): Tele-mentoring program to increase healthcare capacity for FASD diagnosis

BACKGROUND

Children with fetal alcohol spectrum disorder (FASD) often experience delayed, missed, or incorrect diagnosis due to low FASD awareness and diagnostic capacity. Current strategies to expand awareness and diagnostic capacity are insufficient or impractical.

METHODS

This project examined the feasibility of Extension for Community Healthcare Outcomes (ECHO) tele-mentoring to train community clinicians about FASD. Participants attended ten 1-h weekly ECHO sessions that included presentations, vignettes, and discussions. Measurement utilized Bowen's feasibility domains.

RESULTS

Robust webpage traffic yielded 19 participants (demand). Fidelity scores, hub team field notes, and participant ratings indicated feasibility based on acceptability, implementation, practicality, and adaptation. Clinicians' knowledge and confidence improved and case-based diagnostic accuracy was high (limited efficacy).

CONCLUSIONS

ECHO FASD is a feasible training method that shows promise in increasing diagnostic capacity across many geographic regions.

Infant-rearing experiences of parents during the COVID-19 pandemic in South Korea: a mixed-methods approach

PURPOSE

This study aimed to identify the infant-rearing experiences of parents during the coronavirus disease 2019 (COVID-19) pandemic and provide foundational data for the development of infant-rearing support programs during pandemic situations.

METHODS

Convergent mixed methods were used to better understand the research outcomes by converging both quantitative and qualitative data. A total of 149 parents with infant-rearing experiences during the pandemic responded to a self-report survey, and 10 parents participated in the interviews. Data were analyzed using Colaizzi's method, descriptive statistics, t-test, one-way analysis of variance, the Scheffé test, Pearson correlation coefficients, and hierarchical regression.

RESULTS

Analysis of qualitative data yielded the following three categories: five theme clusters, ten themes, and thirty-nine sub-themes. The factors influencing infant-rearing behavior were nuclear family (β=.34, p<.001) and rearing stress (β=-.39, p<.001). The explanatory power of the regression equation was 26.6%.

CONCLUSION

Infectious disease disasters, such as the COVID-19 pandemic, can quickly alter infant-rearing conditions, causing heightened parental anxiety. This may affect infant-rearing behaviors and hinder healthy infant development. Future research should develop a comprehensive tool to measure holistic health-related parenting behaviors across the different stages of child development. Additionally, pediatric nurse practitioners can play an active role in educating parents, supporting parenting, and promoting healthy infant development in their communities, making pediatric nurse practitioners a highly relevant and necessary healthcare profession during infectious disease disasters. Thus, there is a need to improve institutions and build infrastructure at the national level to support them.

The STAMPPed Initiative for Pediatric Nurse Practitioner Students

ABSTRACT

As the demand for nurse practitioners increases to meet health care needs, pathways to facilitate the transition into specialty advanced practice nursing education must be developed. The STudent Advisor/Mentorship Program for Pediatrics (STAMPPed) program was an innovative strategy established to support graduate nursing students with little to no pediatric clinical experience who demonstrated an interest in becoming pediatric nurse practitioners. The program provided structured guidance and support from experienced pediatric nursing faculty through monthly group meetings and the formulation of one-to-one student-faculty mentoring dyads. Mentees found the program to be helpful and foster supportive relationships.

Pediatric nurse practitioner workforce shortage threatens child health equity: Key contributors and recommendations

ABSTRACT

The pediatric nurse practitioner (PNP) workforce shortage has begun to limit access to providers participating in Medicaid and/or the Children's Health Insurance Program, threatening child health equity in the United States. The following are key contributors: an emphasis on adult-focused NP programs and subsequent reduction in undergraduate pediatric content, common practice of student advisement to choose family NP programs, decreased PNP student enrollment leading to nonurban pediatric program closures, an acute shortage of PNP preceptors, and invisibility of the PNP workforce in national workforce data and strategic planning. We outline feasible action steps that nurses, NPs, educators, physicians, and policymakers can take to support PNP workforce growth to advance child health equity in the United States.

The incidence and prevalence of medical device-related pressure injuries in pediatric patients: Systematic review and meta-analysis

PROBLEM

To determine the pooled incidence and prevalence rate of medical device-related pressure injuries(MDRPIs) using the Braden QD scale, medical devices that frequently cause MDRPIs, and anatomical locations that are vulnerable to them.

ELIGIBILITY CRITERIA

Using the Braden QD scale, being published in English between 01/01/2018-and 01/03/2023.

METHODS

This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations and registered in the International Prospective Register of Systematic Reviews database (No: CRD42021276501).

SAMPLE

A total of 7 studies with 25,742 pediatric patients were included.

RESULTS

The pooled prevalence and cumulative incidence of hospital-acquired pressure injuries(HAPIs) were 7.8% (95% CI: 5.2-11.4%) and 3.9% (95% CI: 0.5-24.6%) respectively, and the incidence rate was 8.2/1000 person-days (95% CI: 2.4-14.2/1000 person-days). The pooled prevalence and cumulative incidence of MDRPIs were 7% (95% CI: 5.5-8.8%) and 5% (95% CI: 3.2-7.8%) respectively, and the incidence rate was 6.7/1000 person-days (95% CI, 0.11-13.4/1000 person-days). The most affected anatomical locations were the face (29.1%), ankle/foot (20.1%), and head (15.7%). Medical devices that frequently caused MDRPIs were external monitoring devices (24.5%), respiratory devices (22.8%), and supportive/securing devices (14.9%).

CONCLUSIONS

According to the current systematic review and meta-analyses, the incidence and prevalence of HAPIs and MDRPIs are moderate to high.

IMPLICATIONS

The findings suggested that healthcare providers should pay more attention to reducing HAPIs and MDRPIs and future studies should be conducted to understand their characteristics and risk factors.

The Pediatrician Workforce in the United States and China

From 2019 to 2022, the For Our Children project gathered a team of Chinese and American pediatricians to explore the readiness of the pediatric workforce in each country to address pressing child health concerns. The teams compared existing data on child health outcomes, the pediatric workforce, and education and combined qualitative and quantitative comparisons centered on themes of effective health care delivery outlined in the World Health Organization Workforce 2030 Report. This article describes key findings about pediatric workload, career satisfaction, and systems to assure competency. We discuss pediatrician accessibility, including geographic distribution, practice locations, trends in pediatric hospitalizations, and payment mechanisms. Pediatric roles differed in the context of each country's child health systems and varied teams. We identified strengths we could learn from one another, such as the US Medical Home Model with continuity of care and robust numbers of skilled clinicians working alongside pediatricians, as well as China's Maternal Child Health system with broad community accessibility and health workers who provide preventive care.In both countries, notable inequities in child health outcomes, evolving epidemiology, and increasing complexity of care require new approaches to the pediatric workforce and education. Although child health systems in the United States and China have significant differences, in both countries, a way forward is to develop a more inclusive and broad view of the child health team to provide truly integrated care that reaches every child. Training competencies must evolve with changing epidemiology as well as changing health system structures and pediatrician roles.

Career Choices and Experiences in Role Transition: A Multistate Survey of Pediatric-Focused Hospital-Based Nurse Practitioners

INTRODUCTION

We examined factors influencing pediatric hospital-based APPs' career decisions and described the transition to practice experiences.

METHOD

We conducted a cross-sectional, descriptive electronic survey using a novel instrument to examine APP career decisions and transition to practice experiences among APPs in four Southeastern children's hospitals.

RESULTS

There were 158 respondents composed of family nurse practitioners (NPs) (30%), primary care pediatric NPs (24%), and acute care pediatric NPs (18%). APPs chose their career to further their education (46%) and because of interest in pediatrics (18%). Most APPs had experience in pediatrics on APP graduation and were well prepared for the role (47%) and to care for pediatric patients (56%). Nearly two-thirds of APPs had an orientation.

DISCUSSION

Early exposure to pediatrics influenced APP career choices and increased career preparedness. Although most APPs had an orientation, future studies should assess the impact of orientation on patient, professional, and organizational outcomes.

Evaluating the Practice of Pediatric Nurse Practitioners: Is It Time for Dual Primary and Acute Care Preparation?

This survey aimed to evaluate contemporary pediatric nurse practitioner (PNP) practice as it relates to the competencies of both the primary and acute care population focus and settings of practice to guide curriculum revisions. The design of the study was a cross-sectional survey of PNPs certified by the Pediatric Nursing Certification Board. There were 2,265 surveys completed. Regardless of the certification type, PNPs report providing care across settings and integrating the competencies of both the primary and acute care PNP into practice. This warrants further consideration by programs to prepare future PNPs for dual primary and acute care certification.

The Development and Implementation of a Postgraduate Pediatric Primary Care Advanced Practice Nursing Fellowship

Recent calls for the expansion of postgraduate residencies in nursing have led to an increase in advanced practice nursing residencies and fellowships concentrating on the adult population, whereas pediatric advanced practice nursing fellowships remain limited. The development and implementation of a postgraduate pediatric primary care advanced practice nursing fellowship and the positive impact on a children's health system are described.

Meeting the need for nurse practitioner clinicals: A survey of practitioners

BACKGROUND

The increase in the number of nurse practitioner (NP) students requires increased clinical practice sites and prepared preceptors.

PURPOSE

This study describes NPs' clinical experiences as a student and their current practices as an NP preceptor.

METHODOLOGY

A descriptive study design used a 38-item web-based survey conducted in June and July 2021.

RESULTS

A total of 334 NPs practicing in Texas responded; most had been NPs for 10 or fewer years (58.2%) and in their positions less than 5 years (50.3%). A plurality of respondents was required to find their own clinical placements (46%). The most common challenge in obtaining clinical placements was finding preceptors (33%). Nurse practitioners reported excellent clinical experiences (39.3%) as a student and believed that they were generally well prepared for the NP role (38.9%) and to care for their specialty patient population (46.1%) upon graduation. Sixty percent of respondents reported not currently precepting, 37.6% had never been asked to precept, whereas 32.8% reported that employers restricted precepting. Family NPs were the least likely to precept.

CONCLUSIONS

Nurse practitioners report positive clinical experiences that prepare them for NP careers. Multiple opportunities exist to enlist additional NPs as preceptors for NP students.

IMPLICATIONS

There is capacity within the current NP workforce to meet the clinical educational needs of NP students. Future work should examine best practices to engage NPs who are not currently preceptors. As policies change NP education, research should examine the implications of the preparation for NP roles at the time of graduation, organizational outcomes, and quality of care.

Acute Care Pediatric Nurse Practitioner: The 2018 Practice Analysis

INTRODUCTION

Practice research serves as the certification framework for validating advanced practice roles and updating national qualifying examinations. This national study informed an update of the Certified Pediatric Nurse Practitioner - Acute Care (CPNP-AC) examination content outline.

METHOD

A descriptive analysis of a survey completed in 2018 by 373 pediatric nurse practitioners (PNP) practicing as an acute care role (AC).

RESULTS

Respondents were primarily females aged 25 to 34 years (35.4%) and formally educated as AC PNPs (84.2%) and held the CPNP-AC credential (98.9%). Most respondents (83.6%) practiced in urban areas and spent 84% of their time in direct patient care with 74% working in inpatient settings. The majority (87%) worked in subspecialty practice such as critical care (18.5%) and cardiac intensive care (12.3%).

DISCUSSION

This is the fourth practice analysis of the AC PNP role that demonstrates continuous evolution in clinical practice, educational preparation, and subspecialty practice distribution.

Exhausted and Burned Out: COVID-19 Emerging Impacts Threaten the Health of the Pediatric Advanced Practice Registered Nursing Workforce

INTRODUCTION

The purpose of this study was to describe the holistic impacts of COVID-19 on pediatric advanced practice registered nurses (APRNs).

METHOD

AA convenience sample of APRNs affiliated with the National Association of Pediatric Nurse Practitioners participated in this cross-sectional descriptive study. An investigator-developed survey explored multifocal, holistic impacts of COVID-19.

RESULTS

A total of 886 participants were provided the survey, with 796 (90%) completing the entire survey. Respondents indicated adverse impacts across personal, clinical, educational, and research foci. Among the most alarming findings, 34% indicated moderate or extreme concern for feeling professionally burned out, 25% feeling nervous or anxious, and 15% feeling depressed or hopeless.

DISCUSSION

The pediatricAPRN workforce pipeline is at significant risk for provider burnout and compromised mental health. Acknowledgment of pandemic-related trauma on families, children and APRNs is essential. Sustained intentional efforts to cultivate holistic wellness are critically emergent.

The Pediatric Workforce: Recent Data Trends, Questions, and Challenges for the Future

The future of the pediatric workforce has been the subject of significant dialogue in the pediatric community and generated much discussion in the academic literature. There are significant concerns regarding the ability of pediatricians to meet the growing demands of our pediatric population. Over the past 5 years, there has been a decline in the percentage of doctor of osteopathic medicine students who pursue a career in pediatrics but an equally important increase in the number of pediatric positions that are filled by doctor of osteopathic medicine students and international medical graduates. Although there has been an increase in the number of pediatric positions offered in the National Resident Matching Program, the last 4 years have seen a significant increase in the number of unfilled pediatric positions. A number of pediatric subspecialties struggle to fill their training positions, and those with low match rates may have 20% to 40% fewer applicants than positions. The pediatric vision for the future must include a commitment to a comprehensive strategic planning process with the many organizations involved across the multiple stages of the educational continuum. It is time to elucidate and address the questions raised by the workforce data. Developing solutions to these questions will require a careful planning process and a thoughtful analysis of the pediatric workforce data. Establishing this as an important priority will require a major collaborative effort between pediatric academic and professional organizations, but the future benefit to the nation's children will be significant.

Enablers, Barriers, and Contributions of Pediatric Nurse Practitioners to Ambulatory Specialty Care

INTRODUCTION

The objective of this study was to explore the enablers of and barriers to the contribution of nurse practitioners (NPs) in pediatric specialty care.

METHOD

A total of 11 NPs in pediatric medical specialties were interviewed regarding teamwork, communication, documentation, satisfaction, overall role, and perception of the value they contribute to care.

RESULTS

Themes were identified related to structural and organizational enablers and barriers that facilitate or hinder the NPs' contribution to pediatric specialty care.

DISCUSSION

The findings of this study can provide a better understanding of the role of NPs caring for pediatric patients in the specialty setting and can also help guide organizational environments to maximize the potential of pediatric NPs to positively affect patient care.

Comparison of Number and Geographic Distribution of Pediatric Subspecialists and Patient Proximity to Specialized Care in the US Between 2003 and 2019

IMPORTANCE

Geographic proximity to a pediatric subspecialist is a key factor in obtaining specialized care. However, comparative data regarding the number of pediatric subspecialists, distribution of subspecialists, and patient proximity to subspecialists in the United States between 2003 and 2019 have not been explored; the last known national analysis was published in 2006 and used data from 2003.

OBJECTIVE

To compare the number and distribution of pediatric subspecialists and patient proximity to pediatric subspecialists in the United States between 2003 and 2019 and to assess whether the increase in the number of pediatric subspecialists is associated with improvements in patient proximity to specialized care and the geographic distribution of pediatric subspecialists.

DESIGN, SETTING, AND PARTICIPANTS

This national repeated cross-sectional study used data from the American Board of Pediatrics to examine the overall change in the number of subspecialists for 20 pediatric subspecialties between 2003 and 2019. The study included 24 375 pediatric subspecialists who were 70 years or younger, had active certification from the American Board of Pediatrics as of June 2019, and had addresses in the United States. Subspecialists' addresses were linked by zip code to child population data to evaluate the geographic distribution of subspecialists, the population-weighted averages for service areas, and the straight-line distances to subspecialists. Descriptive statistics and maps were used to examine patient proximity to subspecialists and regional subspecialist distribution and dispersion by hospital referral region. Subspecialist-to-child population ratios per 100 000 children, changes over time, and coefficients of variation were calculated to further elucidate subspecialist distribution. Data were collected in June 2019 and analyzed from July 8, 2019, to December 17, 2019.

MAIN OUTCOMES AND MEASURES

Values from 2019 were compared with data from 2003 for mean straight-line distance in miles from patients to subspecialists, by subspecialty; percentage of children younger than 18 years living at specific distance ranges; subspecialist-to-child population ratios across hospital referral regions; and coefficients of variation for population ratios.

RESULTS

Among 24 375 pediatric subspecialists 70 years and younger, 23 436 subspecialists were certified in 1 subspecialty, and 939 subspecialists were certified in more than 1 subspecialty. The number of certified pediatric subspecialists in the United States increased by 76.8% between 2003 and 2019, with increases varying across subspecialties. The estimated means for travel distances decreased among all subspecialties; however, depending on the subspecialty, an estimated 1 million to 39 million children (2%-53%) resided 80 miles or more from a subspecialist. An analysis across hospital referral regions indicated increased subspecialist-to-child ratios and an increased number of regions with a subspecialist but continued wide variation across regions for most subspecialties. Eleven subspecialties had 1 or fewer subspecialists per 100 000 children across hospital referral regions.

CONCLUSIONS AND RELEVANCE

Although patient proximity to pediatric subspecialty care has improved nationally, substantial distribution gaps among specific subspecialties remain. Long-term solutions that encourage movement of subspecialists to underserved locations or that extend the practice of current subspecialties may warrant consideration, particularly among subspecialties with a limited number of practitioners.