Pediatrician workforce policy statement

An Ethical Analysis of Therapy for Severe Congenital Kidney and Urinary Tract Anomalies

Technological advancements before and after delivery have greatly altered the counseling of pregnant patients facing a fetal diagnosis of severe oligohydramnios or anhydramnios secondary to congenital anomalies of the kidneys and urinary tract. Once considered a nearly uniformly lethal abnormality, long-term survival may now be possible secondary to prenatal innovations aimed at restoring the amniotic fluid volume and the availability of more advanced neonatal dialysis techniques. However, these available therapies are far from perfect. The procedures are onerous for pregnant patients without a guarantee of success, and families must prepare themselves for the complex life-long medical care that will be necessary for surviving individuals. Multidisciplinary counseling is imperative to help pregnant individuals understand the complexity of these conditions and assist them in exercising their right to informed decision-making. Moreover, as with any developing field of medicine, providers must contend with ethical questions related to the treatment options, including questions regarding patient-hood, distributive justice, and the blurred lines between research, innovation, and standard care. These ethical questions are best addressed in a multidisciplinary fashion with consideration of multiple points of view from various subspecialties. Only by seeing the entirety of the picture can we hope to best counsel patients about these highly complex situations and help navigate the most appropriate care path.

The Utilization of Early Outpatient Care for Infants Following NICU Discharge among a National Sample

Outpatient care following discharge from a neonatal intensive care unit (NICU) is critical for streamlined transfer of care. Yet, information is lacking about the characteristics of early outpatient care. The objective of this secondary data analysis is to describe outpatient encounters (OPEs) within the first three months following the discharge of commercially insured infants admitted to NICUs in the MarketScan Research Database nationally from 2015 to 2017. Data were analyzed using descriptive statistics and logistic regression. A total of 22,214 NICU survivors were included, of whom half had an OPE within two days following discharge (quartiles 1, 3) and 90% within five days. The median number of OPEs in the first three months was five (quartiles 4, 7). A majority of first physician visits were with pediatricians (81.5%). A minority of infants with chronic conditions saw subspecialists. Term infants with delayed care had a lower risk of readmission. Spending was higher for preterm infants and those with chronic conditions. We conclude that most patients are seen shortly after discharge and by pediatricians; however, there is room for improvement. Frequent encounters and spending afflict high-risk groups with chronic conditions. Future work should examine the associations of early outpatient care with social determinants of health and other outcomes such as immunizations.

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.

Inequitable access: factors associated with incomplete referrals to paediatric cardiology

OBJECTIVE

To assess the variables associated with incomplete and unscheduled cardiology clinic visits among referred children with a focus on equity gaps.

STUDY DESIGN

We conducted a retrospective chart review for patients less than 18 years of age who were referred to cardiology clinics at a single quaternary referral centre from 2017 to 2019. We collected patient demographic data including race, an index of neighbourhood socio-economic deprivation linked to a patient's geocoded address, referral information, and cardiology clinic information. The primary outcome was an incomplete clinic visit. The secondary outcome was an unscheduled appointment. Independent associations were identified using multivariable logistic regression.

RESULTS

There were 10,610 new referrals; 6954 (66%) completed new cardiology clinic visits. Black race (OR 1.41; 95% CI 1.22-1.63), public insurance (OR 1.29; 95% CI 1.14-1.46), and a higher deprivation index (OR 1.32; 95% CI 1.08-1.61) were associated with higher odds of incomplete visit compared to the respective reference groups of White race, private insurance, and a lower deprivation index. The findings for unscheduled visit were similar. A shorter time elapsed from the initial referral to when the appointment was made was associated with lower odds of incomplete visit (OR 0.62; 95% CI 0.52-0.74).

CONCLUSION

Race, insurance type, neighbourhood deprivation, and time from referral date to appointment made were each associated with incomplete referrals to paediatric cardiology. Interventions directed to understand such associations and respond accordingly could help to equitably improve referral completion.

Interdisciplinary fetal neurology care: Current practice, challenges, and future directions

As the field of fetal-neonatal neurology has expanded over the past 2 decades with increasingly complex diagnoses, multidisciplinary collaboration with many subspecialties including genetics, neonatology, obstetrics, maternal fetal medicine, surgical sub-specialties, cardiology, radiology, palliative care, and ethics has needed to evolve to strive to offer optimal patient care. While comprehensive care delivery with an inter-disciplinary approach is preferred, there are often barriers based on numerous health disparities especially in resource limited settings. Even in the context of comprehensive care, diagnostic and prognostic uncertainty lead to challenges for providers during fetal neurology consultations. We present a case that highlights advantages of a comprehensive multi-disciplinary team in caring for the medical and social challenges of patients faced with a fetal neurologic diagnosis. Inter-disciplinary training focusing on maternal, fetal, neonatal, and childhood neurodevelopmental course and collaboration among the numerous stakeholders that contribute to fetal neurology practice is needed to provide optimal counseling and care for families faced with a fetal neurological diagnosis.

Diagnostic Evaluation of Autism Spectrum Disorder in Pediatric Primary Care

BACKGROUND AND OBJECTIVES

Children with autism spectrum disorder (ASD) continue to experience significant delays in diagnosis and interventions. One of the main factors contributing to this delay is a shortage of developmental-behavioral specialists. Diagnostic evaluation of ASD by primary care pediatricians (PCPs) has been shown to be reliable and to decrease the interval from first concern to diagnosis. In this paper, we present the results of a primary care ASD diagnosis program in which the PCP serves as the primary diagnostician and leverages the infrastructure of the primary care medical home to support the child and family during the pre- and post-diagnostic periods, along with data on parental satisfaction with this model.

METHODS

Retrospective data from a cohort of patients evaluated through this program were analyzed to determine the mean age at diagnosis and interval from referral for evaluation to diagnosis. We used survey methodology to obtain data from parents regarding their satisfaction with the process.

RESULTS

Data from 8 of 20 children evaluated from April 2021 through May 2022 showed a median age of diagnosis of 34.5 months compared to the national average of 49 months. Mean interval from referral for evaluation to diagnosis was 3.5 months. Parental survey responses indicated high satisfaction.

CONCLUSIONS

This model was successful in shortening the interval from referral to diagnosis resulting in significant decrease of age at diagnosis compared with the national average. Widespread implementation could improve access to timely diagnostic services and improve outcomes for children with ASD.

The Relationship Between Regional Growth in Neonatal Intensive Care Capacity and Perinatal Risk

BACKGROUND

The supply of US neonatal intensive care unit (NICU) beds and neonatologists is known to vary markedly across regions, but there have been no investigation of patterns of recent growth (1991-2017) in NICUs in relation to newborn need.

OBJECTIVE

The objective of this study was to test the hypothesis that greater growth in NICU capacity occurred in neonatal intensive care regions with higher perinatal risk.

RESEARCH DESIGN

A longitudinal ecological analysis with neonatal intensive care regions (n=246) as the units of analysis. Associations were tested using linear regression.

SUBJECTS

All US live births ≥400 g in 1991 (n=4,103,528) and 2017 (n=3,849,644).

MEASURES

Primary measures of risk were the proportions of low-birth weight and very low-birth weight newborns and mothers who were Black or had low educational attainment.

RESULTS

Over 26 years, the numbers of NICU beds and neonatologists per live birth increased 42% and 200%, respectively, with marked variation in growth across regions (interquartile range: 0.3-4.1, beds; neonatologists, 0.4-1.0 per 1000 live births). A weak association of capacity with perinatal risk in 1991 was absent in 2017. There was no meaningful (ie, clinical or policy relevant) association between regional changes in capacity and regions with higher perinatal risk or lower capacity in 1991; higher increases in perinatal risk were not associated with higher capacity growth.

CONCLUSION

The lack of association between newborn medical needs and the supply of NICU resources raises questions about the current effectiveness of newborn care at a population level.

State-Level Variation in Medicaid Managed Care Enrollment and Specialty Care for Publicly Insured Children

Importance

Medicaid and Children's Health Insurance Program cover almost 50% of children with special health care needs (CSHCN). CSHCN often require specialty services and have been increasingly enrolled in Medicaid managed care (MMC) plans, but there is a dearth of recent national studies on specialty care access among publicly insured children and particularly CSHCN.

Objective

To provide recent, nationwide evidence on the association of MMC penetration with specialty care access among publicly insured children, with a special focus on CSHCN.

Design, Setting, and Participants

This cross-sectional study used nationally representative data from the 2016 to 2019 National Survey of Children's Health to identify publicly insured children in 41 states that administered comprehensive managed care organizations for Medicaid. Data analysis was performed from May 2022 to March 2023.

Exposure

Form CMS-416 data were used to measure state-year level share of Medicaid-enrolled children who were covered by MMC (ie, MMC penetration).

Main Outcomes and Measures

Measures of specialty care access included whether, in the past year, the child had (1) any visit to non-mental health (MH) specialists, (2) any visit to MH professionals, and (3) any unmet health care needs and (4) whether the caregiver ever felt frustrated getting services for their child. Logistic regression models were used to examine the association of MMC penetration with specialty care access among all publicly insured children, and separately for CSHCN and non-CSHCN.

Results

Among 20 029 publicly insured children, 7164 (35.8%) were CSHCN, 9537 (48.2%) were female, 4110 (37.2%) were caregiver-reported Hispanic, and 2812 (21.4%) were caregiver-reported non-Hispanic Black (all percentages are weighted). MMC was not associated with significant changes in any visit to non-MH specialists and unmet health care needs. In addition, MMC penetration was positively associated with caregiver frustration among all children (adjusted odds ratio, 1.23; 95% CI, 1.03-1.48; P = .02) and was negatively associated with any visit to MH professionals among CSHCN (adjusted odds ratio, 0.75; 95% CI, 0.58-0.98; P = .04).

Conclusions and Relevance

In this cross-sectional study evaluating MMC and specialty care access for publicly insured children, increased MMC enrollment was not associated with improved specialty care access for publicly insured children, including CSHCN. MMC was associated with less access to specialties like MH and increased frustrations among caregivers seeking services for their children.

The patient/physician relationship in a post-Roe world: a neonatologist viewpoint

The Supreme Court ruling in Dobbs v. Jackson Women's Health Organization has far-reaching implications that go beyond the practice of obstetrics and gynecology. The ruling and subsequent laws and bills impact many specialties and have implications for healthcare as a whole. The rapidly changing medicolegal landscape has significant bearings on and implications for the fields of neonatology and pediatrics. These rulings have an impact on the patient-physician relationship and a shared decision-making approach to care. Furthermore, there are significant sequelae of forced birth and resuscitation. This review provides a clinically relevant update of the current medicolegal landscape and applications to the practice of neonatology.

The role of telehealth in pediatric emergency care

In 2006, the Institute of Medicine published a report titled "Emergency Care for Children: Growing Pains," in which it described pediatric emergency care as uneven at best. Since then, telehealth has emerged as one of the great equalizers in care of children, particularly for those in rural and underresourced communities. Clinicians in these settings may lack pediatric-specific specialization or experience in caring for critically ill or injured children. Telehealth consultation can provide timely and safe management for many medical problems in children and can prevent many unnecessary and often long transport to a pediatric center while avoiding delays in care, especially for time-sensitive and acute interventions. Telehealth is an important component of pediatric readiness of hospitals and is a valuable tool in facilitating health care access in low resourced and critical access areas. This paper provides an overview of meaningful applications of telehealth programs in pediatric emergency medicine, discusses the impact of the COVID-19 pandemic on these services, and highlights challenges in setting up, adopting, and maintaining telehealth services.

Developmentally-Trained Primary Care Clinicians: A Pipeline to Improved Access?

OBJECTIVE

The purpose of this study is to decrease wait time and improve access to developmental-behavioral pediatric (DBP) evaluation in children 4 years of age and younger as part of a quality improvement (QI) initiative in an urban safety-net hospital.

METHODS

A primary care pediatrician received DBP minifellowship training 6 hours per week for 1 year to become a developmentally-trained primary care clinician (DT-PCC). DT-PCCs then conducted developmental evaluations that consisted of using a Childhood Autism Rating Scale and Brief Observation of Symptoms of Autism to evaluate children 4 years and younger referred within the practice. Baseline standard practice involved a 3-visit model: DBP advanced practice clinician (DBP-APC) intake visit, neurodevelopmental evaluation by a developmental-behavioral pediatrician (DBP), and feedback by a developmental-behavioral pediatrician. Two QI cycles were completed to streamline the referral and evaluation process.

RESULTS

Seventy patients with a mean age of 29.5 months were seen. The average days to initial developmental assessment decreased from 135.3 days to 67.9 days with a streamlined referral to the DT-PCC. Of the 43 patients who required further evaluation by a DBP, the average days to developmental assessment reduced from 290.1 to 120.4 days.

CONCLUSION

Developmentally-trained primary care clinicians allowed for earlier access to developmental evaluations. Further research should explore how DT-PCCs can improve access to care and treatment for children with developmental delays.

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.

The Importance of Subspecialty Pediatricians to the Health and Wellbeing of the Nation's Children

Through this review of published literature, it is clear that children benefit in measurable ways when they receive care from trained pediatric subspecialists. The improved outcomes provided by pediatric subspecialists supports the care provided in the patient's pediatric medical home and emphasizes the importance of care coordination between all components of the pediatric workforce. The AAP highlights this in a recent policy statement by stating the care provided by pediatric clinicians "encompasses diagnosis and treatment of acute and chronic health disorders; management of serious and life-threatening illnesses; and when appropriate, referral of patients with more complex conditions for medical subspecialty or surgical specialty care" Explicit in this statement is the emphasis on the role of complex care coordination between pediatric specialist and primary care pediatricians and that collaboration and guidance by the pediatrician is central to providing optimal care of patients. ⁶⁵ Improving health outcomes early in life is an important public health strategy for modifying the complications from childhood chronic disease and highlights the role of pediatricians in mitigating the long-term consequences of antecedents of adult disease. ⁶⁶ The recent announcement of the National Academies of Science, Engineering, and Medicine (NASEM)'s plan for a Consensus Study on The Pediatric Subspecialty Workforce and Its Impact on Child Health and Well-being is a related and exciting development, on a national scale. ⁶⁷ In response to shortages and geographic maldistributions of pediatric subspecialists, the NASEM committee intends to assess the impact of current pediatric clinical workforce trends on child health and well-being, in order to develop informed strategies to ensure an adequate, high-quality pediatric workforce, with a robust research portfolio that informs those recommendations. While this large, national initiative will surely lead to a better understanding of and strategies to implement across the pediatric subspecialty workforce, more well-designed studies that specifically measure child outcomes related to access to pediatric subspecialty care, would add meaningfully to the body of pediatric literature and to our national pediatric advocacy initiatives.

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.

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.

Adjusted Cutoff Scores Increase Sensitivity of Depression Screening Measures in Adolescents With Type 1 Diabetes

OBJECTIVE

To measure the acceptability and diagnostic accuracy of commonly used depression screening measures to determine ideal cutoff scores that sensitively identify depressive disorders in adolescents with type 1 diabetes (T1D).

RESEARCH DESIGN AND METHODS

One hundred adolescents (12-17 years old) completed a reference standard, semistructured diagnostic interview and both long and short versions of five commonly used depression screening measures in the United States. To assess feasibility and acceptability, we used screener completion time and participant ratings, respectively. We used descriptive statistics, area under the receiver operating characteristic (ROC) curve analyses, and paired-sample area differences under the ROC curve to assess each measure's diagnostic validity against our reference standard and to determine ideal cutoff scores for this sample.

RESULTS

Adolescents had a mean age of 15.0 ± 1.7 years, time since T1D diagnosis of 6.0 ± 4.1 years, and glycated hemoglobin (HbA1c) of 8.9 ± 1.8%. Sixty percent of adolescents were male, 15% endorsed a current depressive disorder, and 15% endorsed lifetime suicidality. Measures demonstrated low sensitivity (0.33-0.67) to detect current depressive disorders using preexisting cutoff scores. However, adjusted cutoff scores increased sensitivity and reduced false negatives. All depression screening measures demonstrated "good" to "excellent" predictive validity, and the Children's Depression Inventory-2 Short version demonstrated significantly greater diagnostic accuracy than the Patient Health Questionnare-2 item version for adolescents.

CONCLUSIONS

Clinics should consider using screening measures with the greatest diagnostic accuracy as identified in this study and adjusting measure cutoff scores to increase sensitivity and reduce false negatives.

Pediatric Resident Perspectives on the Impact of COVID-19 on Training

OBJECTIVES

At the onset of the coronavirus disease 2019 pandemic, disruptions to pediatric care and training were immediate and significant. We sought to understand the impact of the pandemic on residency training from the perspective of pediatric residents.

METHODS

We conducted a cross-sectional survey of categorical pediatric residents at US training programs at the end of the 2019-2020 academic year. This voluntary survey included questions that explored the impact of the coronavirus disease 2019 pandemic on resident training experiences, postresidency employment plans, and attitudes and perceptions. Data were analyzed by using descriptive statistics and mixed-effects regression models. We performed a sensitivity analysis using respondents from programs with a >40% response rate for questions regarding resident attitudes and perceptions.

RESULTS

Residents from 127 of 201 training programs (63.2%) completed the survey, with a response rate of 18.9% (1141 of 6032). Respondents reported multiple changes to their training experience including rotation schedule adjustments, clinic cancellations, and an increase in the use of telemedicine. Respondents also reported inconsistent access to personal protective equipment and increased involvement in the care of adult patients. Graduating resident respondents reported concerns related to employment. Respondents also noted a negative impact on their personal wellness.

CONCLUSIONS

Responding residents reported that nearly every aspect of their training was impacted by the pandemic. Describing their experiences may help residency program and hospital leaders supplement missed educational experiences, better support residents through the remaining months of the pandemic, and better prepare for extraordinary circumstances in the future.

A Community Capitals Framework for Identifying Rural Adaptation in Maternal-Child Home Visiting

OBJECTIVE

To understand how maternal and child home-visiting programs are adapted, enhanced, and expanded to meet the unique needs of rural communities.

DESIGN

We explored factors shaping the role of home visiting with data from a 2013-2015 statewide evaluation of Maternal, Infant, and Early Childhood Home Visiting-funded programs. Features unique to a rural experiences were mapped onto the Community Capitals Framework.

SETTING

Individual, semistructured interviews were conducted at 11 of 38 home-visiting sites across Pennsylvania.

PARTICIPANTS

Program administrators, home visitors, and clients.

MAIN OUTCOME MEASURE

Program adaptation.

RESULTS

Our analysis represents 150 interviews with 11 program sites serving 14 counties. We document how rural home-visiting programs address community-wide limitations to maternal and child health by adapting program content to better meet the needs of families in rural areas. Data demonstrate how rural home-visiting program's provision of economic and social services reach beyond maternal child health care, building the capacity of individual families and the broader community.

CONCLUSIONS

Home-visiting programs should be viewed as a vehicle for improving community well-being beyond health outcomes. These programs have become an integral part of our public health framework and should be leveraged as such.

Can a Multi-Component Intervention Improve Pediatric Service Delivery in Guangzhou?

Background: Accessible, equitable, and efficient pediatric service is critical to achieve optimal child health. This study aimed to evaluate the effectiveness of a multi-component intervention on the pediatric health system over two different periods in Guangzhou. Methods: Based on the World Health Organization (WHO) "six building blocks" model and Donabedian's "Structure-Process-Outcomes" framework, an intervention package was developed to increase financial and human resouce investment to strengthen basic health care and strive for a better quality of pediatric care. This multi-component intervention package was conducted in Guangzhou to improve the pediatric service delivery during two stages (2011-2014 and 2016-2019). The main outcome indicators were the changes in the allocation of pediatricians and pediatric beds, pediatric service efficiency, and the impact of pediatricians on child mortality. Results: We found that pediatricians per 1,000 children (PPTC) and pediatric beds per 1,000 children (PBPTC) increased from 1.07 and 2.37 in 2010 to 1.37 and 2.39 in 2014, then to 1.47 and 2.93 in 2019, respectively. Infant mortality rate (IMR) and under-5 mortality rate (U5MR) dropped from 5.46‰ and 4.04‰ in 2010 to 4.35‰ and 3.30‰ in 2014 then to 3.26‰ and 2.37‰ in 2019. The Gini coefficients of PPTC and PBPTC decreased from 0.48 and 0.38 in 2010, to 0.35 and 0.28 in 2014, then to 0.35 and 0.22 in 2019, respectively, representing the improvement of pediatric resources distribution according to service population. However, equalities in the spatial distribution were not improved much. The average efficiency of pediatric service fluctuated from 2010 to 2019. A unit increase in PPTC was associated with an 11% reduction in IMR and a 16% reduction in U5MR. Conclusions: Findings suggest this multi-component intervention strategy is effective, particularly on the reduction of child mortality. In future, more rigorous and multi-faceted indicators should be integrated in a comprehensive evaluation of the intervention.

Association of Lifetime Earning Potential and Workforce Distribution Among Pediatric Subspecialists

IMPORTANCE

Differences in lifetime earning potential between pediatric subspecialties may contribute to shortages in the subspecialty workforce.

OBJECTIVES

To evaluate the association between lifetime earning potential and workforce distribution and to investigate the potential role of a pediatric subspecialist-specific loan repayment program (LRP) in workforce expansion.

DESIGN, SETTING, AND PARTICIPANTS

This study was performed on publicly available mean debt and compensation data from national physician surveys from 2018 to 2019 of pediatric subspecialists in academic practice. Linear regression analysis was used to evaluate the association between lifetime earning potential and measures of workforce distribution in 2019, including distance to subspecialists, percentage of hospital referral regions with a subspecialist, and ratio of subspecialists to the regional child population as well as between lifetime earning potential in 2018 to 2019 and mean subspecialty fellowship fill rates between 2014 and 2018. The association between the change in lifetime earning potential from 2007 to 2018 and the change in workforce distribution metrics from 2003 to 2019 was also examined. The potential role of a pediatric subspecialist-specific LRP was modeled.

EXPOSURES

Lifetime earning potential by subspecialty.

MAIN OUTCOMES AND MEASURES

Measures of workforce distribution and fellowship fill rates.

RESULTS

This study included mean compensation data representing 7539 pediatric subspecialists, workforce distribution data representing 24 375 pediatric subspecialists, and fellowship fill rates representing a mean of 1344 pediatric subspecialty fellows per year. Higher lifetime earning potential was associated with shorter distance to subspecialists (-0.59 miles/$100 000 increase in lifetime earning potential; 95% CI, -1.10 to -0.09), higher percentage of hospital referral regions with a subspecialist (+1.17%/$100 000 increase in lifetime earning potential; 95% CI, 0.34-2.00), and higher ratio of subspecialists to regional child population (+0.11 subspecialists/100 000 children/$100 000 increase in lifetime earning potential; 95% CI, 0.04-0.19). The subspecialties for which lifetime earning potential increased the least between 2007 and 2018 experienced the least growth in the ratio of subspecialists to regional child population from 2003 to 2019 (+0.11 subspecialists/100 000 children/$100 000 increase in lifetime earning potential; 95% CI, 0.07-0.16). Higher lifetime earning potential was associated with higher mean fellowship fill rates (+0.96% spots filled/$100 000 increase in lifetime earning potential; 95% CI, 0.15-1.77). Implementing a pediatric subspecialist-specific LRP could increase fellowship fill rates and improve workforce distribution.

CONCLUSIONS AND RELEVANCE

Lifetime earning potential based on subspecialty may contribute to imbalances in both the current and future pediatric subspecialty workforce. Pediatric subspecialist-specific LRPs, especially for underfilled subspecialties, are potential tools for policy makers to target workforce shortages.

Optimizing e-Consultations to Adolescent Medicine Specialists: Qualitative Synthesis of Feedback From User-Centered Design

BACKGROUND

e-Consultations between primary care physicians and specialists are a valuable means of improving access to specialty care. Adolescents and young adults (AYAs) face unique challenges in accessing limited adolescent medicine specialty care resources, which contributes to delayed or forgone care. e-Consultations between general pediatricians and adolescent medicine specialists may alleviate these barriers to care. However, the optimal application of this model in adolescent medicine requires careful attention to the nuances of AYA care.

OBJECTIVE

This study aims to qualitatively analyze feedback obtained during the iterative development of an e-consultation system for communication between general pediatricians and adolescent medicine specialists tailored to the specific health care needs of AYAs.

METHODS

We conducted an iterative user-centered design and evaluation process in two phases. In the first phase, we created a static e-consultation prototype and storyboards and evaluated them with target users (general pediatricians and adolescent medicine specialists). In the second phase, we incorporated feedback to develop a functional prototype within the electronic health record and again evaluated this with general pediatricians and adolescent medicine specialists. In each phase, general pediatricians and adolescent medicine specialists provided think-aloud feedback during the use of the prototypes and semistructured exit interviews, which was qualitatively analyzed to identify perspectives related to the usefulness and usability of the e-consultation system.

RESULTS

Both general pediatricians (n=12) and adolescent medicine specialists (n=12) perceived the usefulness of e-consultations for AYA patients, with more varied perceptions of potential usefulness for generalist and adolescent medicine clinicians. General pediatricians and adolescent medicine specialists discussed ways to maximize the usability of e-consultations for AYAs, primarily by improving efficiency (eg, reducing documentation, emphasizing critical information, using autopopulated data fields, and balancing specificity and efficiency through text prompts) and reducing the potential for errors (eg, prompting a review of autopopulated data fields, requiring physician contact information, and prompting explicit discussion of patient communication and confidentiality expectations). Through iterative design, patient history documentation was streamlined, whereas documentation of communication and confidentiality expectations were enhanced.

CONCLUSIONS

Through an iterative user-centered design process, we identified user perspectives to guide the refinement of an e-consultation system based on general pediatrician and adolescent medicine specialist feedback on usefulness and usability related to the care of AYAs. Qualitative analysis of this feedback revealed both opportunities and risks related to confidentiality, communication, and the use of tailored documentation prompts that should be considered in the development and use of e-consultations with AYAs.

Lymphatic malformations: a 20-year single institution experience

PURPOSE

Lymphatic malformations (LMs) are congenital abnormalities which result from disturbances in the embryologic development of the lymphatic system. We sought to determine the characteristics and treatment patterns for LMs in a rural setting, and the effect of a specialized vascular malformations clinic on triage and follow-up.

METHODS

This is a retrospective cohort study at a single tertiary care institution. Sixty-two patients were identified; chart review was completed to obtain demographic, surgery/sclerotherapy session and follow-up information.

RESULTS

The head/neck region was the most predominant LM location (N = 26, 41.9%), followed by trunk (N = 16, 25.8%), extremity (N = 11, 17.7%), and intraabdominal/retroperitoneal (N = 7, 11.3%). Twenty-eight patients were managed non-surgically, while 21, 7 and 6 patients required surgery, sclerotherapy, or both. Head/neck LMs were the most likely to recur (73%, p = 0.028). Patients seen in specialty clinic had similar duration of follow-up and time to intervention, but were more often below 1 year of age (p = 0.030). Average LM volume among patients with available imaging was much larger in those referred to specialty clinic (73.2 cm³ versus 14.8 cm³, p = 0.022).

CONCLUSION

Our experience reiterates not only the wide variety of clinical presentations of lymphatic malformations, but also demonstrates the necessity of multiple subspecialties and their collaboration to achieve prompt and efficacious treatment.

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.

Generosity of state insurance mandates and growth in the workforce for autism spectrum disorder

LAY ABSTRACT

To improve access to health services for children with autism spectrum disorder, US states have passed laws requiring health insurers to cover autism-related care, commonly known as state insurance mandates. However, the features of mandates differ across states, with some state laws containing very generous provisions and others containing very restrictive provisions such as whether the mandates include children aged above 12 years, whether there is a limit on spending, and whether there are restrictions on the types of services covered. This study examined the relationship between generosity of mandates and growth in the health workforce between 2003 and 2017, a period during which 44 states passed mandates. We found that states that enacted more generous mandates experienced significantly more growth in board-certified behavioral analysts who provide behavioral therapy as well as more growth in child psychiatrists. We did not find differences in the growth of pediatricians, which is a less specialized segment of the workforce. Our findings were consistent across eight different mandate features and suggest that the content of legislation may be as important as whether or not legislation has been passed in terms of encouraging growth in the supply of services for children with autism spectrum disorder.

Understanding How Parents Make Meaning of Their Child's Behaviors During Screening for Autism Spectrum Disorders: A Longitudinal Qualitative Investigation

A family's journey in understanding their child's behaviors in relation to Autism Spectrum Disorders (ASD) frequently begins with screening. This study aimed to characterize the interpretive processes that unfold for parents. We employed longitudinal interviews with 19 families engaged in a community-based multi-stage screening protocol. Parents participated in 1-6 interviews dependent upon children's length of engagement in the screening protocol; data were analyzed through modified grounded theory. Parents who moved towards understanding their child's behaviors as ASD expressed (1) sensitization to ASD symptoms, (2) differentiation from other developmental conditions, and (3) use of the ASD diagnosis to explain the etiology of concerning behaviors. Identifying interpretive processes involved during ASD screening provides new opportunities for shared decision-making.

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.

International Medical Graduates in the Pediatric Workforce in the United States

BACKGROUND AND OBJECTIVES

To describe the supply, distribution, and characteristics of international medical graduates (IMGs) in pediatrics who provide patient care in the United States.

METHODS

Cross-sectional study, combining data from the 2019 Physician Masterfile of the American Medical Association and the Educational Commission for Foreign Medical Graduates database.

RESULTS

In total, 92 806 pediatric physicians were identified, comprising 9.4% of the entire US physician workforce. Over half are general pediatricians. IMGs account for 23.2% of all general pediatricians and pediatric subspecialists. Of all IMGs in pediatrics, 22.1% or 4775 are US citizens who obtained their medical degree outside the United States or Canada, and 15.4% (3246) attended medical school in the Caribbean. Fifteen non-US medical schools account for 29.9% of IMGs currently in active practice in pediatrics in the United States. IMGs are less likely to work in group practice or hospital-based practice and are more likely to be employed in solo practice (compared with US medical school graduates).

CONCLUSIONS

With this study, we provide an overview of the pediatric workforce, quantifying the contribution of IMGs. Many IMGs are US citizens who attend medical school abroad and return to the United States for postgraduate training. Several factors, including the number of residency training positions, could affect future numbers of IMGs entering the United States. Longitudinal studies are needed to better understand the implications that workforce composition and distribution may have for the care of pediatric patients.

When a Specialty Becomes "Women's Work": Trends in and Implications of Specialty Gender Segregation in Medicine

The gender composition of physician specialties varies dramatically with some becoming increasingly female predominant while others remain overwhelmingly male. In their analysis of physician workforce data, the authors demonstrate that despite large increases in the number of female physicians over 4 decades, the degree of gender segregation between specialties has not declined. The authors describe lessons from the highly gender-segregated U.S. workforce as a whole to understand these demographic patterns in the physician workforce. Echoing U.S. workforce findings, women physicians are becoming overrepresented in certain specialties, and this appears to be associated with a relative decline in earnings for physicians in these specialties over time. The authors found a strong negative relationship between the proportion of female physicians in a specialty and its mean salary, with gender composition explaining 64% of the variation in salaries among the medical specialties.Female physicians face biases in the workplace and fall behind male peers in leadership attainment, academic advancement, and earnings. Tenacious gender stereotypes and the conflation of gender and status contribute to these biases and reinforce occupational gender segregation. The clustering of women in certain specialties means these specialties will be disproportionately affected by gender bias. Recognizing the consequences of gender demographics within physician specialties is important to maintain the strong and diverse physician workforce needed to support the health care needs of the populations who depend on these specialties for care.

State Insurance Mandates and the Workforce for Children With Autism

BACKGROUND

State mandates have required insurance companies to provide coverage for autism-related child health care services; however, it has not been determined if insurance mandates have improved the supply of child health care providers. We investigate the effect of state insurance mandates on the supply of child psychiatrists, pediatricians, and board-certified behavioral analysts (BCBAs).

METHODS

We used data from the National Conference of State Legislatures and Health Resources and Services Administration's Area Health Resource Files to examine child psychiatrists, pediatricians, and BCBAs in all 50 states from 2003 to 2017. Fixed-effects regression models compared change in workforce density before versus one year after mandate implementation and the effect of mandate generosity across 44 US states implementing mandates between 2003 and 2017.

RESULTS

From 2003 to 2017, child psychiatrists increased from 7.40 to 10.03 per 100 000 children, pediatricians from 62.35 to 68.86, and BCBAs from 1.34 to 29.88. Mandate introduction was associated with an additional increase of 0.77 BCBAs per 100 000 children (95% confidence interval [CI]: 0.18 to 1.42) one year after mandate enactment. Mandate introduction was also associated with a more modest increase among child psychiatrists (95% CI: 0.10 to 0.91) and was not associated with the prevalence of pediatricians (95% CI: -0.76 to 1.13). We also found evidence that more generous mandate benefits were associated with larger effects on workforce supply.

CONCLUSIONS

State insurance mandates were associated with an ∼16% increase in BCBAs from 2003 to 2017, but the association with child psychiatrists was smaller and nonsignificant among pediatricians. In these findings, it is suggested that policies are needed that specifically address workforce constraints in the provision of services for children with autism spectrum disorder.

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.

Implementation of Telemedicine in Pediatric and Neonatal Transport

OBJECTIVE

Telemedicine uses video technology to communicate visual clinical information. This study aimed to implement telemedicine in pediatric and neonatal transport, assess its value, and identify barriers.

METHODS

This prospective study implemented telemedicine before transport to a tertiary care children's hospital. A preimplementation survey assessed attitudes toward telemedicine and perceived barriers. During the 12-week pilot, a video connection was initiated between transport and medical control. We collected survey results measuring telemedicine usefulness and hindrance after each use. A postimplementation survey assessed opinions about when telemedicine was useful.

RESULTS

Initially, 82% of users had no direct experience with telemedicine. Perceived utility and burden of telemedicine varied significantly by department. During the study, telemedicine was offered 65% of the time, initiated in 47% of cases, and successful in 30% of cases. The greatest barrier was connectivity. Over time, transport members and physicians found telemedicine to be significantly more useful. In 14 cases, telemedicine changed patient outcome or management. Providers who reported a change in management rated telemedicine as significantly more useful.

CONCLUSION

This prospective pilot successfully implemented telemedicine before pediatric transport. Telemedicine was more useful in patients with visual findings on examination and, in some cases, changed the clinical outcome.

Telemedicine and Outpatient Subspecialty Visits Among Pediatric Medicaid Beneficiaries

OBJECTIVE

Live interactive telemedicine is increasingly covered by state Medicaid programs, but whether telemedicine is improving equity in utilization of subspecialty care is not known. We examined patterns of telemedicine use for outpatient pediatric subspecialty care within the state Medicaid programs.

METHODS

We identified children ≤17 years old in 2014 Medicaid Analysis eXtract data for 12 states. We identified telemedicine-using and telemedicine-nonusing medical and surgical subspecialists. Among children cared for by telemedicine-using subspecialists, we assessed child and subspecialist characteristics associated with any telemedicine visit using logistic regression with subspecialist-level random effects. Among children cared for by telemedicine-using and nonusing subspecialists, we compared visit rates across child characteristics by assessing negative binomial regression interaction terms.

RESULTS

Of 12,237,770 pediatric Medicaid beneficiaries, 2,051,690 (16.8%) had ≥1 subspecialist visit. Of 42,695 subspecialists identified, 146 (0.3%) had ≥1 telemedicine claim. Among children receiving care from telemedicine-using subspecialists, likelihood of any telemedicine use was increased for rural children (odds ratio [OR] 10.4, 95% confidence interval [CI] 6.3-17.1 compared to large metropolitan referent group) and those >90 miles from the subspecialist (OR 13.4, 95% CI 10.2-17.7 compared to 0-30 mile referent group). Compared to children receiving care from telemedicine-nonusing subspecialists, matched children receiving care from telemedicine-using subspecialists had larger differences in visit rates by distance to care, county rurality, ZIP code median income, and child race/ethnicity (P < .001 for interaction terms).

CONCLUSIONS

Children in rural communities and at distance to subspecialists had increased likelihood of telemedicine use. Use overall was low, and results indicated that early telemedicine policies and implementation did not close disparities in subspecialty visit rates by child geographic and sociodemographic characteristics.

Systematic Review: United States Workforce for Autism-Related Child Healthcare Services

OBJECTIVE

A diversity of health professional disciplines provide services for children with autism spectrum disorder (ASD) in the United States. We conducted a systematic review examining the availability, distribution, and competencies of the US workforce for autism-related child health care services, and assess studies' strength of evidence.

METHOD

We searched PubMed, PsychINFO, Embase, and Google Scholar from 2008 to 2018 for relevant US-based studies. Two investigators independently screened and evaluated studies against a set of prespecified inclusion criteria and evaluated strength of evidence (SOE) using a framework designed to integrate a mixed-methods research.

RESULTS

Of 754 records identified, 33 studies (24 quantitative, 6 qualitative, and 3 mixed-methods) were included. Strength of evidence associated was low-to-moderate, with only 8 studies (24%) satisfying criteria for strong SOE. Geographies and provider cadres varied considerably. The most common specialties studied were pediatricians (n = 13), occupational therapists (n = 12), speech therapists (n = 11), physical therapists (n = 10), and child psychiatrists (n = 8). Topical areas included the following: provider availability by service area and care delivery model; qualitative assessments of provider availability and competency; role of insurance mandates in increasing access to providers: and disparities in access. Across provider categories, we found that workforce availability for autism-related services was limited in terms of overall numbers, time available, and knowledgeability. The greatest unmet need was observed among minorities and in rural settings. Most studies were short term, were limited in scope, and used convenience samples.

CONCLUSION

There is limited evidence to characterize the availability and distribution of the US workforce for autism-related child health care services. Existing evidence to date indicates significantly restricted availability.

Connected Subspecialty Care: Applying Telehealth Strategies to Specific Referral Barriers

Nearly a quarter of families of children with need of subspecialty care report difficulty accessing that care. Telehealth is a method to overcome barriers to subspecialty care. However, improving access to subspecialty care through telehealth requires granular identification of specific subspecialty barriers and recognition of the strengths and limitations of each telehealth strategy for addressing identified barriers. Focusing on each sequential step in subspecialty referrals and potential associated barriers, we summarize specific telehealth and technology-enabled strategies to improve access to subspecialty care, including electronic consultations, live interactive telemedicine, store-and-forward telemedicine, tele-mentoring, patient portals, and remote patient monitoring. Intentionally selecting telehealth strategies to target specific subspecialty referral barriers may avoid risks from misapplication of telehealth, may more clearly elevate equitable access as an essential goal within telehealth initiatives, and may also lead to synergistic use of strategies that overcome sequential barriers.

Policies and Challenges on the Distribution of Specialists and Subspecialists in Rural Areas of Iran

Background and objectives: Having fair access to medical services may probably be a standard feature and indisputable right of all health policies. The health policy of Iran enunciates this right. Unfortunately, as may happen in many countries, the execution of this policy depends on different factors. Among these parameters, the suitable distribution of professionals, hospitals, and medical facilities should be quoted. On the other hand, in Iran, there are many other problems linked to accessing areas with natural hindrances. Materials and methods: A literature search was conducted in PubMed and CINAHL libraries, specifically studies from 2010 to 2019. A Boolean operated medical subject headings (MeSH) term was used for the search. Newcastle–Ottawa Scale (NOS) scoring was adopted to assess the quality of each study. Results: A total of 118 studies were displayed, and among them, 102 were excluded due to duplication and study relevance. Study selection was made based on content classified into two groups: (1) shortage and unsuitable distribution of specialist and subspecialist physicians in Iran and (2) studies that explained the status of degradation in different areas of Iran. Outcomes demonstrated that Iran is generally suffering a shortage and unsuitable distribution of specialists and subspecialists. This lack is particularly crucial in deprived and areas far away from the cities. Conclusions: The present study analyzed in detail research studies regarding policies and challenges that reflect on the provision of specialists and subspecialists in Iranian rural areas.

PedMap: a pediatric diseases map generated from clinical big data from Hangzhou, China

Epidemiological knowledge of pediatric diseases may improve professionals’ understanding of the pathophysiology of and risk factors for diseases and is also crucial for decision making related to workforce and resource planning in pediatric departments. In this study, a pediatric disease epidemiology knowledgebase called PedMap (http://pedmap.nbscn.org) was constructed from the clinical data from 5 447 202 outpatient visits of 2 189 868 unique patients at a children’s hospital (Hangzhou, China) from 2013 to 2016. The top 100 most-reported pediatric diseases were identified and visualized. These common pediatric diseases were clustered into 4 age groups and 4 seasons. The prevalence, age distribution and co-occurrence diseases for each disease were also visualized. Furthermore, an online prediction tool based on Gaussian regression models was developed to predict pediatric disease incidence based on weather information. PedMap is the first comprehensive epidemiological resource to show the full view of age-related, seasonal, climate-related variations in and co-occurrence patterns of pediatric diseases.

The Effect of a Student Pharmacist Directed Health-Education Program for Elementary-School Children

Objective:

The primary objective of this study was to measure the effect of an annual student pharmacist led elementary-school health education program by assessing children’s comprehension of educational sessions. Secondary objectives were to evaluate student pharmacists’ knowledge of health-related topics and practice skills.

Methods:

Student pharmacists led interactive learning sessions for elementary school students on nutrition, physical activity, summer safety, hygiene, medication safety, and tobacco prevention. Pre- and post-intervention surveys were administered to measure change in knowledge of health promotion and healthy lifestyles. Student pharmacists also completed pre- and post-health education intervention surveys to measure change in self-perception of knowledge, confidence, and practice application of health-related topics and practice skills.

Results:

Three-hundred and four elementary school children participated in the study with significant knowledge improvements observed in medication safety and tobacco prevention. Twenty-five student pharmacists completed surveys, resulting in a collective self-improvement in each area measured.

Conclusion:

Interactive educational sessions led by student pharmacists have a positive impact on elementary school children’s knowledge. Student pharmacists also demonstrated professional growth through increased knowledge, confidence, and communication skills in interacting with pediatric populations.

Practice Implication:

A co-curricular educational activity allowed student pharmacists to promote health and wellness to elementary students, a Healthy People 2020 goal, while also providing an opportunity to develop professional skills for future practice with pediatric patients.

Funding Sources and Perceived Financial Insecurity in Pediatric Subspecialty Fellowship Programs

OBJECTIVE

Shortages of pediatric subspecialists exist in many fields with insufficient recruitment of new fellows. The current system of funding graduate medical education is inadequate. We examined funding sources for trainee salary and educational expenses in pediatric fellowship programs, effects of funding constraints, and program characteristics associated with financial insecurity as reported by fellowship program directors (FPD).

METHODS

We conducted a national survey of FPD between November 1, 2016 and February 9, 2017. We used multivariable logistic regression to examine the association between perceived financial insecurity, program characteristics, and funding sources for fellow salary.

RESULTS

We obtained data from 519 FPD, representing 14 different pediatric subspecialties. FPD reported that funding limitations restricted program size and educational resources in 22% and 36% of programs, respectively. Nineteen percent of FPD perceived funding of their program to be insecure. Programs with 7 or more fellows (OR .50 [95% CI .27-.90], P = .03) or hospital or graduate medical education/Children's Hospital graduate medical education funding (OR .58 [95% CI .35-.96], P = .04) were less likely to be perceived as insecure. Conversely, programs with extramural (OR 1.74 [95% CI 1.07-2.81], P = .03) or division funding (OR 1.70 [95% CI 1.02-2.82], P = .04) or in subspecialties with more than 25% unfilled positions or programs (OR 1.86 [95% CI 1.11-3.09], P = .02) were more likely to be perceived as insecure.

CONCLUSIONS

Perceived financial insecurity of fellowship programs was strongly associated with program size, funding source, and unfilled positions, limiting recruitment and resources. Stable funding of fellowship programs is critical to maintain an adequate pediatric subspecialty workforce.