Current Issues Affecting the Practice of Pediatric Orthopaedic Surgeons: Results of the 2014 Workforce Survey of American Academy of Pediatrics Section on Orthopaedics

Impact of Pediatric Orthopaedic Fellowship Training on Pediatric Supracondylar Humerus Fracture Treatment and Outcomes: A Meta-analysis

BACKGROUND

Supracondylar humerus (SCH) fractures are common pediatric injuries, typically requiring closed reduction and percutaneous pinning or open reduction. These injuries are managed frequently by both pediatric-trained (PTOS) and nonpediatric-trained (NTOS) orthopaedic surgeons. However, some literature suggests that complications for pediatric injuries are lower when managed by PTOS. Therefore, this meta-analysis sought to compile existing literature comparing patients treated by PTOS and NTOS to better understand differences in management and clinical outcomes.

METHODS

Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) methodology, a systematic review was conducted for all articles comparing SCH fractures managed by PTOS and NTOS in 4 online databases (PubMed, Embase, CINAHL, Cochrane). Study quality was assessed through the use of the Newcastle-Ottawa Scale. Meta-analyses were then performed for postoperative outcomes using pooled data from the included studies. Statistics were reported as odds ratios and 95% CI.

RESULTS

This search strategy yielded 242 unique titles, of which 12 underwent full-text review and 7 met final inclusion. All studies were retrospective and evaluated patients treated in the United States. There were a total of 692 and 769 patients treated by PTOS and NTOS, respectively. PTOS had shorter operative times [mean difference, 13.6 min (CI, -23.9 to -3.4), P=0.01] and less frequently utilized a medial-entry pin [odds ratios, 0.36 (CI, 0.2 to 0.9), P=0.03]. There were no differences in time to treatment, the necessity of open reduction, postoperative Baumann angle, or complications including surgical site infection or iatrogenic nerve injury.

CONCLUSIONS

Despite shorter operative times and lower frequency of cross-pinning when treated by PTOS, pediatric SCH fracture outcomes are similar when treated by PTOS and NTOS. These findings demonstrate that these fractures may possibly be treated safely by both PTOS and experienced fellowship-trained academic NTOS who are comfortable managing these injuries in pediatric patients.

LEVEL OF EVIDENCE

Level III; Meta-analysis.

Trends in Leadership at Pediatric Orthopaedic Fellowships

BACKGROUND

Pediatric orthopaedic fellowship directors (FDs) have a valuable impact on the education of trainees and future leaders in the field. There is currently no research on the characteristics of pediatric orthopaedic FDs.

METHODS

Programs were identified using the Pediatric Orthopaedic Society of North America fellowship directory. Operative, nonoperative, and specialty programs were included. Data was collected through Qualtrics survey, e-mail, telephone, and online searches. Variables included demographics (age, sex, race/ethnicity), Hirsch index (h-index) as a measure of research productivity, graduate education, residency and fellowship training, years of hire at current institution and as FD, and leadership roles.

RESULTS

Fifty-five FDs were identified. The majority (49/55, 89%) were male and 77% (27/35) were Caucasian. The mean age at survey was 51.1±8.2 years. The mean h-index was 17.2. Older age correlated with higher h-index (r=0.48, P=0.0002). The average duration from fellowship graduation to FD appointment was 9.6±6.7 and 6.9±6.1 years from institutional hire. Sixteen FDs (29%) had additional graduate level degrees. Almost all (52/55, 95%) FDs completed orthopaedic surgery residencies and all graduated fellowship training. Twenty-nine percent (16/55) completed more than 1 fellowship. Most FDs (51/55, 93%) completed a fellowship in pediatric orthopaedic surgery. Ten FDs (18%) completed pediatric orthopaedic surgery fellowships that included spine-specific training. One-third of all current FDs were fellowship-trained at either Boston Children's Hospital (9/55, 16%) or Texas Scottish Rite Hospital for Children (9/55, 16%).

CONCLUSIONS

Pediatric orthopaedic FDs are typically early-career to mid-career when appointed, with a strong research background. Nearly a third completed additional graduate degrees or multiple fellowships. Although male dominated, there are more female FDs leading pediatric orthopaedic programs compared with adult reconstruction, trauma, and spine fellowships. As fellowships continue to grow and diversify, this research will provide a baseline to determine changes in FD leadership.

Pediatric Orthopaedic Surgeon Time Utilization in Clinic: A Pilot Study

BACKGROUND

The purpose of this study is to quantify how pediatric orthopaedic surgeons spend time in clinic.

METHODS

Two pediatric orthopaedic surgeons were individually observed and activities were timed during 3 clinic sessions. One medical student observed and recorded the time using a data collection sheet and a watch. The duration of each clinic session was 4 hours and a new patient was seen every 20 minutes. Data was collected in 7 categories including: time with the patient; time with staff; time listening to the resident presentations, time teaching, time multitasking, time dictating, and time on the electronic medical record (EMR). The number of computer mouse clicks needed to complete each patient encounter was also recorded. The Cerner EMR system was used (Cerner Inc. North Kansas City, MO).

RESULTS

Thirty-six percent of the physician's time was spent on the EMR. Thirty-five percent of time was spent with the patient, 7% was spent dictating, 7% teaching, 5% multitasking, 6% with staff, and 4% listening to resident presentations. Overall, during a 20-minute patient visit, 7.2 minutes was spent on the EMR. During a 4-hour clinic, 87 minutes was spent on the EMR. During a full day of clinic-two 4-hour sessions-173 minutes were spent on the EMR. The average number of computer mouse clicks to complete a patient encounter was 70 (range: 42 to 110). A total of 1680 clicks were needed to see 24 patients in a typical 2 session clinic.

CONCLUSION

Pediatric orthopaedic surgeons spend more time on the EMR than with patients. About 70 computer mouse clicks are needed per patient encounter. The excessive computer time can diminish the patient-physician relationship. Click fatigue in physicians is real and needs to be resolved by improved EMR technology, utilization of medical scribes, or a return to partial use of paper.

LEVEL OF EVIDENCE

Level IV-an observational study.

High rate of inappropriate referrals to pediatric orthopedics in an egalitarian healthcare system

Previous studies have shown relatively high rates of inappropriate referrals to pediatric orthopedic surgery. The purpose of this study was to determine the rate of inappropriate referrals in an egalitarian healthcare system. We reviewed all 400 referrals to our pediatric orthopedic surgery practice over a 2-year period and assessed the appropriateness of each based on the American Academy of Pediatrics guidelines. A total 206 (52%) referrals were deemed appropriate. There is a high rate of inappropriate referral to pediatric orthopedic surgery even within a closed, egalitarian healthcare system. Targeted education of primary care providers may help reduce this rate.

Changes in Pediatric Spine Surgery Patterns Over the Last 10 Years Among ABOS Part II Candidates

STUDY DESIGN

A retrospective review of prospectively collected data.

OBJECTIVE

Our purpose was to evaluate the volume of pediatric spine cases being done by surgeons applying for American Board of Orthopaedic Surgeons (ABOS) certification.

SUMMARY OF BACKGROUND DATA

Pediatric orthopedic surgery has become increasingly subspecialized over the past decade.

METHODS

Data were reviewed from the ABOS for surgeons undergoing part II of ABOS certification between 2004 and 2014. Applicants were divided into pediatric orthopedic surgeons and spine surgeons based on their self-declared subspecialty for the ABOS Part II examination. A total of 102,424 cases were reviewed to identify spine cases performed on patients <18 years old.

RESULTS

Between 2004 and 2014, the total number of ABOS part II pediatric candidates increased significantly, from a low of 15 to a high of 44 (r = 0.68, P = 0.001). During this time frame, there has been no significant increase in the total number of pediatric spine cases reported (r = 0.09, P = 0.19). In 2004, 46.5% (33/71) of the pediatric spine cases were done by spine surgeons, which decreased to 17.3% (28/162) in 2014. Conversely in 2004, 53.5% (38/71) of pediatric spine cases were done by pediatric orthopedists, which increased to 82.7% (134/162) in 2014. The number of pediatric candidates performing pediatric spine cases decreased 35% from 2004 to 2014, but the percentage performing >20 spine cases during their candidate year has increased from 0% to 7% (r = 0.31, P = 0.04).

CONCLUSION

The share of pediatric spine surgeries performed by pediatric candidates has increased from 54% in 2004 to 83%, with a corresponding fall in the share surgeries performed by spine candidates (47% to >17%). The percentage of pediatric candidates performing more than 20 spine cases/year increased from 0% to 7%, reflecting a trend of spine subspecialization within pediatric surgery.

LEVEL OF EVIDENCE

3.

Pediatric Orthopedic Workforce: A Review of Recent Trends

Pediatric orthopedic surgery has changed in many ways over the past 2 decades. Member surveys and recent literature confirm that there has been a sustained balance of interest and opportunity in growth of applicant numbers and fellowship spots. Pediatric orthopedics is leading the way in gender diversity in orthopedics. Concerns of competition are valid and appear to be rising; however, case load data suggest that with increased training of pediatric orthopedists, there seems to be an adequate increase in cases. Periodic workforce analysis should continue to gauge any changes in attitudes or monitor concerns of competition.

Pediatric Infectious Diseases Meets the Future

Pediatric infectious diseases physicians are dedicated to the diagnosis, prevention, and management of infections in children. As such, we play large, and important, roles in the clinical care of children from birth to late adolescence and in infection prevention, antimicrobial stewardship, research pertaining to infections, public health, international and global health, and advocacy for children's health. Furthermore, we are critical to the education of future physicians (in general), pediatricians, and infectious diseases doctors. In addition to diagnosing and treating bacterial, fungal, viral, and parasitic infections known through the ages, we have been at the forefront of meeting today's new infectious threats to children's health, which include the following: antibiotic-resistant organisms; hospital-acquired infections; global outbreaks such as Ebola, Zika, human immunodeficiency virus-acquired immune deficiency syndrome, and new strains of influenza; infections in immunocompromised children; vaccine-preventable infections; the inefficient use of medical resources; and the high cost of medical care.

Orthopaedic Care for Children: Who Provides It? How Has It Changed Over the Past Decade? Analysis of the Database of the American Board of Orthopaedic Surgery

BACKGROUND

The field of orthopaedic surgery has subspecialized over the past decade with an increasing number of graduates of orthopaedic residency programs entering fellowship training. The number of graduates from pediatric orthopaedic fellowships has also increased over the past decade. We hypothesize as the number of pediatric orthopaedic fellowship graduates has increased, the proportion of orthopaedic cases completed by pediatric surgeons in comparison with adult surgeons has also increased. We have used the database of the American Board of Orthopaedic Surgery (ABOS) to analyze the trends in who is providing the orthopaedic care for children.

METHODS

Procedure logs of applicants for ABOS part II certification from 2004 to 2014 were collected and pediatric cases were used for this study. Applicants were divided into pediatric orthopaedic surgeons and adult orthopaedic surgeons based on the self-declared subspecialty for part II examination. CPT codes were used to place the cases into different categories. Descriptive and statistical analysis were performed to evaluate the change in the practice of pediatric orthopaedics over the past decade.

RESULTS

ABOS part II applicants performed 102,424 pediatric cases during this period. In total, 66,745 (65%) cases were performed by nonpediatric surgeons and 35,679 cases (35%) by pediatric surgeons. In total, 82% of the pediatric cases were done by adult surgeons in 2004 which decreased to 69% in 2009 and to 53% in 2014 (r=0.8232, P=0.0019). In pediatric sports medicine, pediatric orthopaedic surgeons performed 7% of the cases in 2004 which increased to 14% in 2009 and to 28% in 2014 (300% increase from 2004). Pediatric surgeons also increased their share of pediatric trauma cases. In total, 12% of lower extremity trauma cases were attended by pediatric surgeons in 2004 compared with 47% in 2014 (235% increase from 2004). In upper extremity trauma, pediatric surgeons increased their share of the cases from 12% in 2004 to 43% in 2014 (175% increase from 2004).

CONCLUSIONS

Over the past decade, pediatric orthopaedic specialists are caring for an increasing share of pediatric cases. Pediatric trauma, pediatric spine, and pediatric sports medicine have seen the greatest increase in the percentage of cases performed by pediatric orthopaedic surgeons.

LEVEL OF EVIDENCE

Level III.

An evaluation of diagnostic agreement rates between advanced practice physiotherapists and paediatric orthopaedic consultants for children with musculoskeletal complaints

PURPOSE

The purpose of the present study was to establish diagnostic agreement rates between orthopaedic consultants and advanced practice physiotherapists (APPs) for paediatric orthopaedic patients, examine the appropriateness of referrals by APPs to consultants and report on the surgical conversion rate (SCR).

METHODS

A retrospective review of all patients referred from an APP clinic to orthopaedic consultants was conducted for 2013, with a 3-year longitudinal follow-up through to the end of 2016. Study participants were two APPs and four orthopaedic consultants at a single site. Descriptive statistics report the proportion of appropriate onward referrals and SCRs. Raw proportion agreement and kappa coefficients were used to evaluate diagnostic agreement rates.

RESULTS

The mean raw agreement was 82% (95% confidence interval = 73 to 87), with 12 of the 15 individual codes demonstrating agreement rates ≥90% (range 57-100). Good to excellent agreement was demonstrated in almost all categories based on the kappa coefficient. Eighty-seven per cent of referrals from APPs were deemed to be appropriate by the orthopaedic consultants. The SCR was 23%.

CONCLUSIONS

This was the first study to evaluate diagnostic agreement rates between APPs and orthopaedic consultants, the appropriateness of onward referral by APPs and the SCR for paediatric musculoskeletal patients referred from an APP clinic. Good to excellent diagnostic agreement was observed for routine elective paediatric orthopaedic patients, in tandem with agreement levels reported in the adult literature. The study demonstrates that APPs are clinically effective in the diagnosis and onward referral of paediatric orthopaedic patients in a triage setting.

Changes in the Practice of Pediatric Orthopaedic Surgeons Over the Past Decade: Analysis of the Database of the American Board of Orthopaedic Surgery

BACKGROUND

There has been an increase in the number of the graduates of pediatric orthopaedic fellowship programs over the past decade creating the potential for increased competition in the field. The purpose of this study was to analyze the effect of increased number of pediatric orthopaedic fellowship graduates on case volume as well as the type of procedures performed by recent graduates of pediatric orthopaedic fellowship programs from 2004 to 2014.

METHODS

Case logs submitted for the American Board of Orthopaedic Surgery Part II examination by applicants with the self-declared subspecialty of pediatric orthopaedics from 2004 to 2014 were analyzed. Cases were categorized as trauma (upper and lower extremity), spine, sports medicine, hip, deformity correction, foot and ankle, hardware removal, soft tissue procedures, and other. The period was divided into 3 sections: 2004-2007, 2008-2011, 2012-2014. Descriptive analysis was used to report the change in the volume and pattern of practices over the study period.

RESULTS

Although the number of pediatric orthopaedic subspecialty applicants increased from 15 to 44 from 2004 to 2014, the average cases per year increased from 2142 in 2004-2007 to 2960 in 2007-2011, and to 4160 in 2012-2014. The number of cases performed per applicant remained stable over the study period. Upper extremity trauma cases were the largest category of cases reported and increased in case volume by 141% from 2004 to 2014. Sports medicine cases increased in volume by 175%.

CONCLUSIONS

Despite a large increase in the number of pediatric orthopaedic surgeons over the past decade, there is a concomitant increased in case volume across almost all subspecialties within pediatric orthopaedics. As such, pediatric orthopaedic surgeons who start a new practice can expect to develop a robust practice with a diverse group of pathologies.

LEVEL OF EVIDENCE

Level III.