Evolving Challenges in Pediatric Pulmonary Medicine. New Opportunities to Reinvigorate the Field

Outpatient clinical care for bronchopulmonary dysplasia: A survey of the BPD collaborative

BACKGROUND

Bronchopulmonary dysplasia, a sequela of preterm birth, is the most common chronic respiratory disorder in infancy, and the second most common in children. Despite this, clinical care remains highly variable with guidelines supported by limited evidence, and do not provide specific guidance for timing of clinical follow-up, echocardiography, modalities of pulmonary function testing, etc. OBJECTIVE/METHODS: To further our understanding of care delivery for BPD, we sought to describe outpatient care patterns at tertiary care centers through survey data from 27 well-established BPD programs.

RESULTS

We observed variability in referral patterns to outpatient BPD clinics, ancillary services provided, indications for follow-up echocardiograms, availability of lung function testing, and criteria for discharge from care.

CONCLUSION

More comprehensive and detailed clinical guidelines similar to other pulmonary diseases such as asthma and cystic fibrosis should be developed to help standardize care and may improve long term outcomes.

A statement on the current status and future needs of the pediatric pulmonology workforce: Pipeline Workgroup

There is growing concern that current trends in pediatric pulmonology will lead to a workforce shortage resulting in patients having difficulty accessing subspecialty care. As part of the Pediatric Pulmonology Division Directors Association and Pediatric Pulmonary Training Directors Association Workforce Summit, we examined factors affecting the recruitment of learners into pediatric pulmonary fellowship training (PPFT) programs. The goal of our workgroup was to describe these issues and develop a plan to increase the pipeline of learners who ultimately pursue PPFT. Specifically, we summarize factors that impact decisions to undertake PPFT, describe existing initiatives to enhance recruitment, and propose future strategies to increase early career learner interest.

Assessing the pediatric subspecialty pipeline: it is all about the data source

BACKGROUND

National Resident Match Program (NRMP) data are often used to identify the pediatric subspecialty pipeline. Other data sources may provide greater accuracy.

METHODS

Analysis of data from the NRMP and the American Board of Pediatrics (ABP) for 14 pediatric subspecialties from 2008 to 2020. We calculated, within each subspecialty, the annual number of first-year fellowship positions offered, the NRMP match rate, the actual number of fellows entering training (ABP data) relative to the number of positions in the match (fill rate), and the actual number of matriculating first-year fellows each year.

RESULTS

For all subspecialties and years, the fill rate was greater than the match rate. All subspecialties had an increase in the relative and absolute number of first-year fellows, with the largest increases seen in emergency medicine (73.3%) and critical care (68.9%). Except for adolescent medicine, all subspecialties had an absolute increase in the number of positions offered, with the largest increase in pulmonology (32.1%).

CONCLUSIONS

NRMP data underestimate the actual number of first-year fellows entering subspecialty training. For all subspecialties, the number of first-year fellows has increased over time, indicating continued expansion in the pipeline for most. However, there remains great variation across subspecialties.

IMPACT

Perceptions of the pipeline for the pediatric subspecialty workforce vary depending on the data source. The use of NMRP match data alone underestimates the number of matriculating trainees. The number of unmatched fellowship positions has created a perception of a diminishing number of pediatric subspecialty fellows. This study uses multiple data sources to better understand the actual number of fellows entering pediatric subspecialty training and demonstrates that the NRMP match rate alone underestimates the pipeline of the pediatric subspecialty workforce.

Structural Inequities in Medicine that Contribute to Racial Inequities in Asthma Care

Structural inequities in medicine have been present for centuries in the United States, but only recently are these being recognized as contributors to racial inequities in asthma care and asthma outcomes. This chapter provides a systematic review of structural factors such as racial bias in spirometry algorithms, the history of systemic racism in medicine, workforce/pipeline limitations to the presence of underrepresented minority health care providers, bias in research funding awards, and strategies to solve these problems.

Scholarly activity training in pediatric pulmonology fellowship programs

BACKGROUND

Scholarly activity training is a required component of pediatric pulmonology fellowship programs. However, there are no data on resources and barriers to training and factors associated with fellow productivity.

METHODS

We surveyed US pediatric pulmonology fellowship program directors (FPDs) between March and October 2019. Our primary outcome was fellow productivity (>75% of fellows in the past 5 years had a manuscript accepted in a peer-reviewed journal). Analyses included descriptive statistics, χ² and Fisher's exact tests for categorical values, and t-test or Wilcoxon rank-sum test for numerical values.

RESULTS

Sixty-one percent (33/54) of FPDs completed the survey. Seventy-nine percent reported that most fellows completed clinical, basic science, or translational research. However, only 21% reported that most fellows pursued research positions after graduation; academic clinical positions were more common. For 21%, lack of funding and competing clinical responsibilities were barriers to completing the scholarly activity. Only 39% had highly productive programs; those FPDs were more likely to be highly satisfied with fellow scholarly activity products (p = 0.049) and have >6 publications in the previous 3 years (p = 0.03). Fifty-two percent of FPDs believed that pediatric pulmonary training should be shortened to 2 years for those pursuing clinical or clinician-educator careers.

CONCLUSIONS

Barriers to scholarly activity training in pediatric pulmonology programs threaten the pipeline of academic pediatric pulmonologists and physician-investigators. Aligning fellow scholarly activity and clinical training with the skills required in their postgraduate positions could optimize the utilization of limited resources and better support career development.

Accuracy of Asthma Computable Phenotypes to Identify Pediatric Asthma at an Academic Institution

OBJECTIVES

Asthma is a heterogenous condition with significant diagnostic complexity, including variations in symptoms and temporal criteria. The disease can be difficult for clinicians to diagnose accurately. Properly identifying asthma patients from the electronic health record is consequently challenging as current algorithms (computable phenotypes) rely on diagnostic codes (e.g., International Classification of Disease, ICD) in addition to other criteria (e.g., inhaler medications)-but presume an accurate diagnosis. As such, there is no universally accepted or rigorously tested computable phenotype for asthma.

METHODS

We compared two established asthma computable phenotypes: the Chicago Area Patient-Outcomes Research Network (CAPriCORN) and Phenotype KnowledgeBase (PheKB). We established a large-scale, consensus gold standard (n = 1,365) from the University of California, Los Angeles Health System's clinical data warehouse for patients 5 to 17 years old. Results were manually reviewed and predictive performance (positive predictive value [PPV], sensitivity/specificity, F1-score) determined. We then examined the classification errors to gain insight for future algorithm optimizations.

RESULTS

As applied to our final cohort of 1,365 expert-defined gold standard patients, the CAPriCORN algorithms performed with a balanced PPV = 95.8% (95% CI: 94.4-97.2%), sensitivity = 85.7% (95% CI: 83.9-87.5%), and harmonized F1 = 90.4% (95% CI: 89.2-91.7%). The PheKB algorithm was performed with a balanced PPV = 83.1% (95% CI: 80.5-85.7%), sensitivity = 69.4% (95% CI: 66.3-72.5%), and F1 = 75.4% (95% CI: 73.1-77.8%). Four categories of errors were identified related to method limitations, disease definition, human error, and design implementation.

CONCLUSION

The performance of the CAPriCORN and PheKB algorithms was lower than previously reported as applied to pediatric data (PPV = 97.7 and 96%, respectively). There is room to improve the performance of current methods, including targeted use of natural language processing and clinical feature engineering.

Quality improvement approach to increasing respiratory therapist driven teach back style asthma education

OBJECTIVE

Asthma is a common chronic medical condition that can require treatment with multiple inhaled medications. Our quality improvement group established a standard asthma teaching protocol with respiratory therapists utilizing the teach back method. We aimed to increase the percentage of pulmonary asthma clinic visits receiving this education from a baseline of 42.7% in 2016 to 80% by December 2019.

METHODS

Multiple interventions were put in place and data was collected monthly from the electronic medical record system. Data was recorded in statistical process control charts using a p chart. Nelson's established rules for determining special versus common cause variation were used.

RESULTS

Over the three-year project the percentage of asthma clinic visits receiving the standardized respiratory therapist driven teach back asthma education increased to 82.3%.

CONCLUSION

Utilizing a standardized approach, it's possible to deliver standardized asthma education in a busy pulmonary clinic.

Growth and changes in the pediatric medical subspecialty workforce pipeline

BACKGROUND

To inform discussions of pediatric subspecialty workforce adequacy and characterize its pipeline, we examined trends in first-year fellows in the 14 American Board of Pediatrics (ABP)-certified pediatric medical subspecialties, 2001-2018.

METHODS

Data were obtained from the ABP Certification Management System. We determined, within each subspecialty, the annual number of first-year fellows. We assessed for changes in the population using variables available throughout the study period (gender, medical school location, program region, and program size). We fit linear trendlines and calculated χ² statistics.

RESULTS

The number of first-year pediatric medical subspecialty fellows increased from 751 in 2001 to 1445 in 2018. Fields with the growth of 3 or more fellows per year were Cardiology, Critical Care, Emergency Medicine, Gastroenterology, Neonatology, and Hematology Oncology (P value <0.05 for all). The number of fellows entering Adolescent Medicine, Child Abuse, Infectious Disease, and Nephrology increased at a rate of 0.5 fellows or fewer per year. Female American Medical Graduates represented the largest and growing proportions of several subspecialties. Distribution of programs by region and size were relatively consistent over time, but varied across subspecialties.

CONCLUSIONS

The number of pediatricians entering medical subspecialty fellowship training is uneven and patterns of growth differ between subspecialties.

IMPACT

The number of individuals entering fellowship training has increased between 2001 and 2018. Growth in the number of first-year fellows is uneven. Fields with the greatest growth: Critical Care, Emergency Medicine, and Neonatology. Fields with limited growth: Adolescent Medicine, Child Abuse, Infectious Disease, and Nephrology. Concerns about the pediatric medical subspecialty workforce are not explained by the number of individuals entering the fellowship.

How and Why Trainees Choose a Career in Pediatric Pulmonology. A Qualitative Study

Background: There is concern that inadequate recruitment of new subspecialty trainees to replace the aging physician population will lead to significant workforce issues in pediatric pulmonology. The factors leading trainees to pursue a fellowship in pediatric pulmonology are unclear.

Objective: To gain a better understanding of the decision-making process surrounding the choice to pursue a pediatric pulmonary fellowship and to provide informed recommendations to increase recruitment of new trainees.

Methods: Informed by the Social Cognitive Career Theory, eight focus groups were held with pediatric residents and fellows attending the 2019 American Thoracic Society International Conference. Questions focused on personal background, learning experiences, self-efficacy and outcome expectations, interests, and goals. Transcripts were analyzed by conventional content analysis.

Results: Fifty-six residents and fellows representing 42 different institutions participated. Responses resulted in seven major themes: 1) attractive aspects of pediatric pulmonology draw trainees to the field, 2) exposure to the breadth and scope of the field is limited, 3) mentorship is key, 4) decisions surrounding fellowship selection occur early in the second year, 5) trainees want flexibility in length and structure of fellowship, 6) financial considerations are not the driving factor in decision-making, and 7) there are inherent aspects of pulmonology that trainees may not enjoy.

Conclusion: A lack of broad exposure to pediatric pulmonology during residency results in false perceptions of the field and is a deterrent to recruitment. Improving faculty engagement, guaranteeing broad and early exposure to the field, and creating learning experiences aimed at raising self-efficacy may improve recruitment and ultimately improve the pediatric pulmonary workforce.

A proposal for the addressing the needs of the pediatric pulmonary work force

Unprecedented opportunities and daunting difficulties are anticipated in the future of pediatric pulmonary medicine. To address these issues and optimize pediatric pulmonary training, a group of faculty from various institutions met in 2019 and proposed specific, long-term solutions to the emerging problems in the field. Input on these ideas was then solicited more broadly from faculty with relevant expertise and from recent trainees. This proposal is a synthesis of these ideas. Pediatric pulmonology was among the first pediatric specialties to be grounded deliberately in science, requiring its fellows to demonstrate expertise in scientific inquiry (1). In the future, we will need more training in science, not less. Specifically, the scope of scientific inquiry will need to be broader. The proposal outlined below is designed to help optimize the practices of current providers and to prepare the next generation to be leaders in pediatric care in the future. We are optimistic that this can be accomplished. Our broad objectives are (a) to meet the pediatric subspecialty workforce demand by increasing interest and participation in pediatric pulmonary training; (b) to modernize training to ensure that future pediatric pulmonologists will be prepared clinically and scientifically for the future of the field; (c) to train pediatric pulmonologists who will add value in the future of pediatric healthcare, complemented by advanced practice providers and artificial intelligence systems that are well-informed to optimize quality healthcare delivery; and (d) to decrease the cost and improve the quality of care provided to children with respiratory diseases.

Funding sources and effects of limited funding in pediatric pulmonology fellowship programs

BACKGROUND

The pediatric pulmonology workforce is at risk. Access to pediatric pulmonologists to meet patient needs is limited and recruitment of new trainees to replace the aging, retiring physician population may be inadequate. Furthermore, sources of funding for graduate medical education are insecure. However, no prior studies have identified the funding sources of pediatric pulmonology fellowships or the effects of funding constraints.

METHODS

We conducted a national survey of pediatric pulmonology training directors (PPTD) in the United States between 1 November, 2016 and 9 February, 2017 to examine the sources of funding for pediatric pulmonary fellows and the effect of funding limitations.

RESULTS

We obtained data from 48 PPTD, representing 89% of pediatric pulmonology programs (N = 54). Limitations in funding restricted program size in 31% of programs. A significant number of programs had no funding to cover educational resources such as advanced degrees (38%), courses (23%), society membership (25%), and journals and books (15%). Twenty seven percent of PPTD perceived their program as financially insecure for academic year 2019 and beyond.

CONCLUSIONS

Insufficient funding has limited the size of pediatric pulmonology programs and access to important educational resources. It is critical to ensure that there is adequate funding for pediatric pulmonology fellowship programs, as insecurity further endangers the pediatric pulmonology workforce and future provision of care for children with respiratory diseases.