Racial and Ethnic Differences in Insurer Classification of Nonemergent Pediatric Emergency Department Visits.

Importance: Government and commercial health insurers have recently enacted policies to discourage nonemergent emergency department (ED) visits by reducing or denying claims for such visits using retrospective claims algorithms. Low-income Black and Hispanic pediatric patients often experience worse access to primary care services necessary for preventing some ED visits, raising concerns about the uneven impact of these policies. Objective: To estimate potential racial and ethnic disparities in outcomes of Medicaid policies for reducing ED professional reimbursement based on a retrospective diagnosis-based claims algorithm. Design, Setting, and Participants: This simulation study used a retrospective cohort of pediatric ED visits (aged 0-18 years) for Medicaid-insured children and adolescents appearing in the Market Scan Medicaid database between January 1, 2016, and December 31, 2019. Visits missing date of birth, race and ethnicity, professional claims data, and Current Procedural Terminology codes of billing level of complexity were excluded, as were visits that result in admission. Data were analyzed from October 2021 to June 2022. Main Outcomes and Measures: Proportion of ED visits algorithmically classified as nonemergent and simulated per-visit professional reimbursement after applying a current reimbursement reduction policy for potentially nonemergent ED visits. Rates were calculated overall and compared by race and ethnicity. Results: The sample included 8 471 386 unique ED visits (43.0% by patients aged 4-12 years; 39.6% Black, 7.7% Hispanic, and 48.7% White), of which 47.7% were algorithmically identified as potentially nonemergent and subject to reimbursement reduction, resulting in a 37% reduction in ED professional reimbursement across the study cohort. More visits by Black (50.3%) and Hispanic (49.0%) children were algorithmically identified as nonemergent when compared with visits by White children (45.3%; P < .001). Modeling the impact of the reimbursement reductions across the cohort resulted in expected per-visit reimbursement that was 6% lower for visits by Black children and 3% lower for visits by Hispanic children relative to visits by White children. Conclusions and Relevance: In this simulation study of over 8 million unique ED visits, algorithmic approaches for classifying pediatric ED visits that used diagnosis codes identified proportionately more visits by Black and Hispanic children as nonemergent. Insurers applying financial adjustments based on these algorithmic outputs risk creating uneven reimbursement policies across racial and ethnic groups.

Lifetime Earning Potential and Workforce Distribution in Developmental and Behavioral Pediatrics.

OBJECTIVES: Compare lifetime earning potential (LEP) for developmental and behavioral pediatrics (DBP) to general pediatrics and other pediatric subspecialties. Evaluate association between LEP for DBP and measures of workforce distribution. METHODS: Using compensation and debt data from 2018 to 2019 and a net present value analysis, we estimated LEP for DBP compared to general pediatrics and other pediatric subspecialties. We evaluated potential effects of eliminating educational debt, shortening length of fellowship training, and implementing loan repayment or forgiveness programs for pediatric subspecialists. We evaluated the association between LEP for DBP and measures of workforce distribution, including distance to subspecialists, percentage of hospital referral regions (HRRs) with a subspecialist, ratio of subspecialists to regional child population, and fellowship fill rates. RESULTS: LEP was lower for DBP than for general private practice pediatrics ($1.9 million less), general academic pediatrics ($1.1 million less), and all other pediatric subspecialties. LEP of DBP could be improved by shortening fellowship training or implementing loan repayment or forgiveness programs. LEP for subspecialists, including DBP, was associated with distance to subspecialists (-0.5 miles/$100,000 increase in LEP, 95% confidence interval [CI] -0.98 to -0.08), percentage of HRRs with a subspecialist (+1.1%/$100,000 increase in LEP, 95% CI 0.37-1.83), ratio of subspecialists to regional child population (+0.1 subspecialists/100,000 children/$100,000 increase in LEP, 95% CI 0.04-0.17), and average 2014 to 2018 fellowship fill rates (+1% spots filled/$100,000 increase in LEP, 95% CI 0.25-1.65). CONCLUSIONS: DBP has the lowest LEP of all pediatric fields and this is associated with DBP workforce shortages. Interventions to improve LEP may promote workforce growth.

Addressing Gender-Based Disparities in Earning Potential in Academic Medicine.

Importance: Gender-based disparities in compensation in academic medicine are recognized, but their estimated impacts on early career earning potential and strategies to mitigate them have not been well studied. Objectives: To compare earning potential between female and male academic physicians in the first 10 years of posttraining employment and to evaluate the estimated impact of promotion timing, starting salary, and salary growth rate on earning potential. Design, Setting, and Participants: Using publicly available mean debt and compensation data for full-time employed academic physicians in the US from 2019 to 2020, starting salary, salary in year 10 of employment, annual salary growth rate, and overall earning potential in the first 10 years of employment were estimated for each gender by subspecialty. The estimated impacts of promotion timing and potential interventions, including equalizing starting salaries and annual salary growth rates, were modeled. Data analysis was performed from March to May 2021. Exposures: Gender and subspecialty. Main Outcomes and Measures: Starting salary, annual salary growth rate, year-10 salary, and earning potential in first 10 years of employment. Results: This cross-sectional study included compensation data from 24 593 female and 29 886 male academic physicians across 45 subspecialties. Women had lower starting salaries in 42 of 45 subspecialties (93%), year-10 salaries in 43 of 45 subspecialties (96%), mean annual salary growth rates in 22 of 45 subspecialties (49%), and earning potential in 43 of 45 subspecialties (96%) (median [IQR], $214 440 [$130 423-$384 954], or 10%, less). A 1-year delay in promotion from assistant to associate professor reduced women's earning potential by a median (IQR) of $26 042 ($19 672-$35 671), but failure to be promoted at all reduced it by a median (IQR) of $218 724 ($176 317-$284 466). Equalizing starting salaries could increase women's earning potential by a median (IQR) of $250 075 ($161 299-$381 799) in the subspecialties for which starting salaries for women were lower than those for men. Equalizing annual salary growth rates could increase women's earning potential by a median (IQR) of $53 661 ($24 258-$102 892) in the subspecialties for which mean annual salary growth rates were lower for women than for men. Conclusions and Relevance: The findings of this study suggest that gender-based disparities in starting salary and early career earning potential are pervasive in academic medicine in the US. Equalizing starting salaries would address the majority of the differences in earning potential.

Telehealth: Opportunities to Improve Access, Quality, and Cost in Pediatric Care.

The use of telehealth technology to connect with patients has expanded significantly over the past several years, particularly in response to the global coronavirus disease 2019 pandemic. This technical report describes the present state of telehealth and its current and potential applications. Telehealth has the potential to transform the way care is delivered to pediatric patients, expanding access to pediatric care across geographic distances, leveraging the pediatric workforce for care delivery, and improving disparities in access to care. However, implementation will require significant efforts to address the digital divide to ensure that telehealth does not inadvertently exacerbate inequities in care. The medical home model will continue to evolve to use telehealth to provide high-quality care for children, particularly for children and youth with special health care needs, in accordance with current and evolving quality standards. Research and metric development are critical for the development of evidence-based best practices and policies in these new models of care. Finally, as pediatric care transitions from traditional fee-for-service payment to alternative payment methods, telehealth offers unique opportunities to establish value-based population health models that are financed in a sustainable manner.

The Association of the Childhood Opportunity Index on Pediatric Readmissions and Emergency Department Revisits.

OBJECTIVE: Reutilization following discharge is costly to families and the health care system. Singular measures of the social determinants of health (SDOH) have been shown to impact utilization; however, the SDOH are multifactorial. The Childhood Opportunity Index (COI) is a validated approach for comprehensive estimation of the SDOH. Using the COI, we aimed to describe the association between SDOH and 30-day revisit rates. METHODS: This retrospective study included children 0 to 17 years within 48 children's hospitals using the Pediatric Health Information System from 1/1/2019 to 12/31/2019. The main exposure was a child's ZIP code level COI. The primary outcome was unplanned readmissions and emergency department (ED) revisits within 30 days of discharge. Primary outcomes were summarized by COI category and compared using chi-square or Kruskal-Wallis tests. Adjusted analysis used generalized linear mixed effects models with adjustments for demographics, clinical characteristics, and hospital clustering. RESULTS: Of 728,997 hospitalizations meeting inclusion criteria, 30-day unplanned returns occurred for 96,007 children (13.2%). After adjustment, the patterns of returns were significantly associated with COI. For example, 30-day returns occurred for 19.1% (95% confidence interval [CI]: 18.2, 20.0) of children living within very low opportunity areas, with a gradient-like decrease as opportunity increased (15.5%, 95% CI: 14.5, 16.5 for very high). The relative decrease in utilization as COI increased was more pronounced for ED revisits. CONCLUSIONS: Children living in low opportunity areas had greater 30-day readmissions and ED revisits. Our results suggest that a broader approach, including policy and system-level change, is needed to effectively reduce readmissions and ED revisits.

Telehealth: Improving Access to and Quality of Pediatric Health Care.

All children and adolescents deserve access to quality health care regardless of their race/ethnicity, health conditions, financial resources, or geographic location. Despite improvements over the past decades, severe disparities in the availability and access to high-quality health care for children and adolescents continue to exist throughout the United States. Economic and racial factors, geographic maldistribution of primary care pediatricians, and limited availability of pediatric medical subspecialists and pediatric surgical specialists all contribute to inequitable access to pediatric care. Robust, comprehensive telehealth coverage is critical to improving pediatric access and quality of care and services, particularly for under-resourced populations.

Differences in Lifetime Earning Potential for Pediatric Subspecialists.

OBJECTIVES: Our 2011 report, reflecting data from 2007-2008, demonstrated that, for many pediatric subspecialties, pursuing fellowship training was a negative financial decision when compared with practicing as a general pediatrician. We provide an updated analysis on the financial impact of pediatric fellowship training and model interventions that can influence the results. METHODS: We estimated the financial returns a graduating pediatric resident might anticipate from fellowship training followed by a career as a pediatric subspecialist and compared them with the returns expected from starting a career as a general pediatrician immediately after residency. We evaluated the potential effects of eliminating medical school debt, shortening the length of fellowship training, and implementing a federal loan repayment program for pediatric subspecialists. We compared the financial returns of subspecialty training in 2018-2019 to those from our previous report. RESULTS: Pursuing fellowship training generated widely variable financial returns when compared with general pediatrics that ranged from +$852 129 for cardiology to -$1 594 366 for adolescent medicine. Twelve of 15 subspecialties analyzed yielded negative financial returns. The differences have become more pronounced over time: the spread between the highest and lowest earning subspecialties widened from >$1.4 million in 2007-2008 to >$2.3 million in 2018-2019. The negative financial impact of fellowship training could be partially ameliorated by shortening the length of training or by implementing pediatric subspecialist specific loan repayment programs. CONCLUSIONS: This report can be used to help guide trainees, educators, and policy makers. The interventions discussed could help maintain an adequate and balanced pediatric workforce.

Comparison of cost and resource utilization between firearm injuries and motor vehicle collisions at pediatric hospitals.

BACKGROUND/OBJECTIVES: Firearm injuries are converging with motor vehicle collisions (MVC) as the number one cause of death for children in the United States. Thus we examine differences in hospital cost and hospital resource utilization between motor vehicle and firearm injury. METHODS: This retrospective, cross-sectional study compares hospital costs and resource utilization of motor vehicle and firearm-injured children aged 0 to 19 years of age over a 5-year time frame (January 1, 2013-December 31, 2017) in 35 freestanding children's hospitals that submitted data to the Pediatric Health Information System. The primary outcome was hospital-adjusted comparative cost per patient presentation. Generalized linear mixed models were used to quantify the relationship between the type of injury and each outcome, adjusting for patient characteristics and hospital. RESULTS: There were 89,133 emergency department (ED) visits attributed to MVCs and 3,235 for firearm injury. Of the youths who presented for firearm injury, 49% were hospitalized versus 14% of youths presenting with MVC (adjusted odds ratio [aOR] = 6.6, 95% confidence interval [CI] = 6.1 to 7.2). Youths with firearm injury were more likely to be admitted to an intensive care unit (aOR = 6.7, 95% CI = 5.9 to 7.7) and had longer lengths of stays (aOR = 2.2, 95% CI = 1.9 to 2.6) compared to their MVC counterparts. Children admitted for firearm injury had more imaging and ED return visits, along with subsequent inpatient admission within 3 days (aOR = 3.4, 95% CI = 2.1 to 5.5) and 1 year (aOR = 2.5, 95% CI = 2.1 to 2.9). The mean relative per-patient costs were nearly fivefold higher for the firearm-injured group. CONCLUSIONS: Hospital costs and markers of resource utilization were higher for youths with firearm injury compared to MVC. High medical resource utilization is one of several important reasons to advocate for a comparable national focus and funding on firearm-related injury prevention.

Racial and Ethnic Differences in Emergency Department Diagnostic Imaging at US Children's Hospitals, 2016-2019.

Importance: Diagnostic imaging is frequently performed as part of the emergency department (ED) evaluation of children. Whether imaging patterns differ by race and ethnicity is unknown. Objective: To evaluate racial and ethnic differences in the performance of common ED imaging studies and to examine patterns across diagnoses. Design, Setting, and Participants: This cross-sectional study evaluated visits by patients younger than 18 years to 44 US children's hospital EDs from January 1, 2016, through December 31, 2019. Exposures: Non-Hispanic Black and Hispanic compared with non-Hispanic White race/ethnicity. Main Outcomes and Measures: The primary outcome was the proportion of visits for each race/ethnicity group with at least 1 diagnostic imaging study, defined as plain radiography, computed tomography, ultrasonography, and magnetic resonance imaging. The major diagnostic categories classification system was used to examine race/ethnicity differences in imaging rates by diagnoses. Results: A total of 13 087 522 visits by 6 230 911 children and adolescents (mean [SD] age, 5.8 [5.2] years; 52.7% male) occurred during the study period. Diagnostic imaging was performed during 3 689 163 visits (28.2%). Imaging was performed in 33.5% of visits by non-Hispanic White patients compared with 24.1% of visits by non-Hispanic Black patients (odds ratio [OR], 0.60; 95% CI, 0.60-0.60) and 26.1% of visits by Hispanic patients (OR, 0.66; 95% CI, 0.66-0.67). Adjusting for confounders, visits by non-Hispanic Black (adjusted OR, 0.82; 95% CI, 0.82-0.83) and Hispanic (adjusted OR, 0.87; 95% CI, 0.87-0.87) patients were less likely to include any imaging study compared with visits by non-Hispanic White patients. Limiting the analysis to only visits by nonhospitalized patients, the adjusted OR for imaging was 0.79 (95% CI, 0.79-0.80) for visits by non-Hispanic Black patients and 0.84 (95% CI, 0.84-0.85) for visits by Hispanic patients. Results were consistent in analyses stratified by public and private insurance groups and did not materially differ by diagnostic category. Conclusions and Relevance: In this study, non-Hispanic Black and Hispanic children were less likely to receive diagnostic imaging during ED visits compared with non-Hispanic White children. Further investigation is needed to understand and mitigate these potential disparities in health care delivery and to evaluate the effect of these differential imaging patterns on patient outcomes.

Application of the RE-AIM Framework for the Pediatric Mild Traumatic Brain Injury Evaluation and Management Intervention: A Study Protocol for Program Evaluation.

BACKGROUND: Children who experience a mild Traumatic Brain Injury (mTBI) may encounter cognitive and behavioral changes that often negatively impact school performance. Communication linkages between the various healthcare systems and school systems are rarely well-coordinated, placing children with an mTBI at risk for prolonged recovery, adverse impact on learning, and mTBI re-exposure. The objective of this study is to rigorously appraise the pediatric Mild Traumatic Brain Injury Evaluation and Management (TEaM) Intervention that was designed to enhance diagnosis and management of pediatric mTBI through enhanced patient discharge instructions and communication linkages between school and primary care providers. METHODS: This is a combined randomized and 2 × 2 quasi-experimental study design with educational and technology interventions occurring at the clinician level with patient and school outcomes as key endpoints. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework will be utilized as a mix methods approach to appraise a multi-disciplinary, multi-setting intervention with the intent of improving outcomes for children who have experienced mTBI. DISCUSSION: Utilization of the RE-AIM framework complemented with qualitative inquiry is suitable for evaluating effectiveness of the TEaM Intervention with the aim of emphasizing priorities regarding pediatric mTBI. This program evaluation has the potential to support the knowledge needed to critically appraise the impact of mTBI recovery interventions across multiple settings, enabling uptake of the best-available evidence within clinical practice.

Hunger: A Missed Opportunity for Screening in the Pediatric Emergency Department.

BACKGROUND: The American Academy of Pediatrics and pediatric community recognize the importance of addressing social determinants of health. There are limited data on the prevalence of food insecurity or literature establishing protocols assessing food insecurity in the emergency department (ED). METHODS: Two anonymous surveys were administered, one to families during their ED visit and another to ED staff to assess perceptions on the ED's role in providing social support. RESULTS: Thirty-three of 214 respondents (15.4%) reported food insecurity and are associated with economic risk factors ( P < .0001) and a lack of primary care ( P = .008). Overall, 83.2% of the ED staff believed knowing information about families' social risk factors would help patient care and 77.6% believed that the ED staff should address families' social needs. CONCLUSIONS: Food insecurity affects a significant portion of ED families across income ranges. Screening for food insecurity in the ED is important given association with lack of primary care. Hospital staff supports screening and intervention.

Predicting Low-Resource-Intensity Emergency Department Visits in Children.

OBJECTIVES: Interventions to reduce frequent emergency department (ED) use in children are often limited by the inability to predict future risk. We sought to develop a population-based model for predicting Medicaid-insured children at risk for high frequency (HF) of low-resource-intensity (LRI) ED visits. METHODS: We conducted a retrospective cohort analysis of Medicaid-insured children (aged 1-18 years) included in the MarketScan Medicaid database with ≥1 ED visit in 2013. LRI visits were defined as ED encounters with no laboratory testing, imaging, procedures, or hospitalization; and HF as ≥3 LRI ED visits within 365 days of the initial encounter. A generalized linear regression model was derived and validated using a split-sample approach. Validity testing was conducted examining model performance using 3 alternative definitions of LRI. RESULTS: Among 743,016 children with ≥1 ED visit in 2013, 5% experienced high-frequency LRI ED use, accounting for 21% of all LRI visits. Prior LRI ED use (2 visits: adjusted odds ratio = 3.5; 95% confidence interval, 3.3, 3.7; and ≥3 visits: adjusted odds ratio = 7.7; 95% confidence interval, 7.3, 8.1) and presence of ≥3 chronic conditions (adjusted odds ratio = 1.7; 95% confidence interval, 1.6, 1.8) were strongly associated with future HF-LRI ED use. A model incorporating patient characteristics and prior ED use predicted future HF-LRI ED utilization with an area under the curve of 0.74. CONCLUSIONS: Demographic characteristics and patterns of prior ED use can predict future risk of HF-LRI ED use in the following year. Interventions for reducing low-value ED use in these high-risk children should be considered.

Characteristics of Children Enrolled in Medicaid With High-Frequency Emergency Department Use.

BACKGROUND AND OBJECTIVES: Some children repeatedly use the emergency department (ED) at high levels. Among Medicaid-insured children with high-frequency ED use in 1 year, we sought to describe the characteristics of children who sustain high-frequency ED use over the following 2 years. METHODS: Retrospective longitudinal cohort study of 470 449 Medicaid-insured children appearing in the MarketScan Medicaid database, aged 1-16 years, with ≥1 ED discharges in 2012. Children with high ED use in 2012 (≥4 ED discharges) were followed through 2014 to identify characteristics associated with sustained high ED use (≥8 ED discharges in 2013-2014 combined). A generalized linear model was used to identify patient characteristics associated with sustained high ED use. RESULTS: A total of 39 945 children (8.5%) experienced high ED use in 2012, accounting for 25% of total ED visits in 2012. Sixteen percent of these children experienced sustained high ED use in the following 2 years. Adolescents (adjusted odds ratio [aOR]: 1.4 [95% confidence interval: 1.3-1.5]), disabled children (aOR: 1.3 [95% confidence interval: 1.1-1.5]), and children with 3 or more chronic conditions (aOR: 2.1, [95% confidence interval: 1.9-2.3]) experienced the highest likelihood for sustaining high ED use. CONCLUSIONS: One in 6 Medicaid-insured children with high ED use in a single year experienced sustained high levels of ED use over the next 2 years. Adolescents and individuals with multiple chronic conditions were most likely to have sustained high rates of ED use. Targeted interventions may be indicated to help reduce ED use among children at high risk.

Factors Influencing Pediatrician Retirement: A Survey of American Academy of Pediatrics Chapter Members.

OBJECTIVE: To assess the factors that may influence physicians' desire to retire through an analysis of data collected through the American Academy of Pediatrics (AAP) State Pediatrician Workforce Survey. STUDY DESIGN: An electronic survey was sent to retired and nonretired US pediatricians who held AAP membership. The respondents were asked about the importance of 12 factors that would influence or had influenced their decision to retire. The physicians who were not yet retired also were asked: "If you could afford to today, would you retire from medicine?" RESULTS: The survey was completed by 8867 pediatricians. Among the nonretired respondents, 27% reported that they would retire today if it were affordable. Increasing regulation of medicine, decreasing clinical autonomy, and insufficient reimbursement were rated as very important factors by >50% of these pediatricians. Among retired pediatricians, 26.9% identified the effort to keep up with clinical advances and changes in practice as a very important factor in their decision to retire. Younger physicians were significantly more likely to rate maintenance of certification requirements, insufficient reimbursement, lack of professional satisfaction, and family responsibilities as very important factors. Rural pediatricians were more interested in retiring than those working in academic settings. There were no sex differences. CONCLUSIONS: Twenty-seven percent of pediatricians in practice today would retire today if it were affordable. Identifying and addressing the important factors that influence a pediatrician's desire to retire can potentially reduce the retirement rate of pediatricians and thus increase access to care for children.

Children's Hospital Characteristics and Readmission Metrics.

BACKGROUND AND OBJECTIVE: Like their adult counterparts, pediatric hospitals are increasingly at risk for financial penalties based on readmissions. Limited information is available on how the composition of a hospital's patient population affects performance on this metric and hence affects reimbursement for hospitals providing pediatric care. We sought to determine whether applying different readmission metrics differentially affects hospital performance based on the characteristics of patients a hospital serves. METHODS: We performed a cross-sectional analysis of 64 children's hospitals from the Children's Hospital Association Case Mix Comparative Database 2012 and 2013. We calculated 30-day observed-to-expected readmission ratios by using both all-cause (AC) and Potentially Preventable Readmissions (PPR) metrics. We examined the association between observed-to-expected rates and hospital characteristics by using multivariable linear regression. RESULTS: We examined a total of 1 416 716 hospitalizations. The mean AC 30-day readmission rate was 11.3% (range 4.3%-19.6%); the mean PPR rate was 4.9% (range 2.9%-6.9%). The average 30-day AC observed-to-expected ratio was 0.96 (range 0.63-1.23), compared with 0.95 (range 0.65-1.23) for PPR; 59% of hospitals performed better than expected on both measures. Hospitals with higher volumes, lower percentages of infants, and higher percentage of patients with low income performed worse than expected on PPR. CONCLUSIONS: High-volume hospitals, those that serve fewer infants, and those with a high percentage of patients from low-income neighborhoods have higher than expected PPR rates and are at higher risk of reimbursement penalties.

Impact of Chronic Conditions on Emergency Department Visits of Children Using Medicaid.

OBJECTIVE: To assess the impact of chronic conditions on children's emergency department (ED) use. STUDY DESIGN: Retrospective analysis of 1 850 027 ED visits in 2010 by 3 250 383 children ages 1-21 years continuously enrolled in Medicaid from 10 states included in the Truven Marketscan Medicaid Database. The main outcome was the annual ED visit rate not resulting in hospitalization per 1000 enrollees. We compared rates by enrollees' characteristics, including type and number of chronic conditions, and medical technology (eg, gastrostomy, tracheostomy), using Poisson regression. To assess chronic conditions, we used the Agency for Healthcare Research and Quality's Chronic Condition Indicator system, assigning chronic conditions with ED visit rates ≥75th percentile as having the "highest" visit rates. RESULTS: The overall annual ED visit rate was 569 per 1000 enrollees. As the number of the children's chronic conditions increased from 0 to ≥3, visit rates increased by 180% (from 376 to 1053 per 1000 enrollees, P < .001). Rates were 174% higher in children assisted with vs without medical technology (1546 vs 565, P < .001). Sickle cell anemia, epilepsy, and asthma were among the chronic conditions associated with the highest ED visit rates (all ≥1003 per 1000 enrollees). CONCLUSIONS: The highest ED visit rates resulting in discharge to home occurred in children with multiple chronic conditions, technology assistance, and specific conditions such as sickle cell anemia. Future studies should assess the preventability of ED visits in these populations and identify opportunities for reducing their ED use.

Effects of immigration enforcement legislation on Hispanic pediatric patient visits to the pediatric emergency department.

OBJECTIVE: To compare the visits by Hispanic patients to the pediatric emergency department (PED) before and after passage of Georgia House Bill 87 (HB87). This bill grants local law enforcement the authority to enforce immigration laws. METHODS: A retrospective chart review of all Hispanic patients who presented to the PED in a 4-month period after implementation of HB87 in 2011 was conducted and compared with the same period in 2009 and 2010. Data compared included patient acuity score, disposition, payer status, and demographics. RESULTS: Fewer Hispanic patients presented to the ED after passage of the bill (18.3% vs 17.1%, P < .01), more patients were high acuity, and more patients were admitted to the hospital. CONCLUSION: The Hispanic population was the only group to see a decrease in visits and increase in acuity in the post-bill period. These results suggest potential adverse health effects on members of a specific group as a result of immigration legislation.

Resource burden at children's hospitals experiencing surge volumes during the spring 2009 H1N1 influenza pandemic.

OBJECTIVES: The objective was to describe the emergency department (ED) resource burden of the spring 2009 H1N1 influenza pandemic at U.S. children's hospitals by quantifying observed-to-expected utilization. METHODS: The authors performed an ecologic analysis for April through July 2009 using data from 23 EDs in the Pediatric Health Information System (PHIS), an administrative database of widely distributed U.S. children's hospitals. All ED visits during the study period were included, and data from the 5 prior years were used for establishing expected values. Primary outcome measures included observed-to-expected ratios for ED visits for all reasons and for influenza-related illness (IRI). RESULTS: Overall, 390,983 visits, and 88,885 visits for IRI, were included for Calendar Weeks 16 through 29, when 2009 H1N1 influenza was circulating. The subset of 106,330 visits and 31,703 IRI visits made to the 14 hospitals experiencing the authors' definition of ED surge during Weeks 16 to 29 was also studied. During surge weeks, the 14 EDs experienced 29% more total visits and 51% more IRI visits than expected (p < 0.01 for both comparisons). Of ED IRI visits during surge weeks, only 4.8% were admitted to non-intensive care beds (70% of expected, p < 0.01), 0.19% were admitted to intensive care units (44% of expected, p < 0.01), and 0.01% received mechanical ventilation (5.0% of expected, p < 0.01). Factors associated with more-than-expected visits included ages 2-17 years, payer type, and asthma. No factors were associated with more-than-expected hospitalizations from the ED. CONCLUSIONS: During the spring 2009 H1N1 influenza pandemic, pediatric EDs nationwide experienced a marked increase in visits, with far fewer than expected requiring nonintensive or intensive care hospitalization. The data in this study can be used for future pandemic planning.

Does fellowship pay: what is the long-term financial impact of subspecialty training in pediatrics?

OBJECTIVES: To (1) analyze the financial returns of fellowship training in pediatrics and to compare them with those generated from a career in general pediatrics and (2) evaluate the effects of including the newly enacted federal loan-repayment program and of changing the length of fellowship training. BACKGROUND: Although the choice to enter fellowship is based on many factors, economic considerations are important. We are not aware of any study that has focused on the financial impact of fellowship training in pediatrics. METHODS: Using standard financial techniques, we estimated the financial returns that a graduating pediatric resident might anticipate from additional fellowship training followed by a career as a pediatric subspecialist and compared them with the returns that might be expected from starting a career as a general pediatrician immediately after residency. RESULTS: The financial returns of pediatric fellowship training varied greatly depending on which subspecialty fellowship was chosen. Pursuing a fellowship in most pediatric subspecialties was a negative financial decision when compared with pursuing no fellowship at all and practicing as a general pediatrician. Incorporating the federal loan-repayment program targeted toward pediatric subspecialists and decreasing the length of fellowship training from 3 to 2 years would substantially increase the financial returns of the pediatric subspecialties. CONCLUSIONS: Pediatric subspecialization yielded variable financial returns. The results from this study can be helpful to current pediatric residents as they contemplate their career options. In addition, our study may be valuable to policy makers evaluating health care reform and pediatric workforce-allocation issues.

Practice characteristics that influence nonurgent pediatric emergency department utilization.

OBJECTIVE: The goal of this study was to determine what characteristics of a primary care pediatric practice are associated with nonurgent use of the pediatric emergency department (PED). METHODS: Primary care practice characteristics were prospectively collected from 33 practices. Nonurgent and urgent visits to the PED for patients from these practices were analyzed retrospectively. A discriminant analysis classification model was used to identify practice characteristics that were associated with nonurgent versus urgent utilization of the PED. RESULTS: Patients in the network of 33 practices accounted for 31 076 visits to the PED during the 12-month study period, 47% of which were classified as nonurgent. Based on the discriminant analysis classification model, discriminant patterns that predict the frequency of nonurgent utilization included the percentage of patients with Medicaid, total available sick slots to see patients per physician, closer distance to the PED, whether or not the nurse triage line notified all on-call physicians of disposition to the PED, whether it is practice policy to accept all walk-in sick visits, and ability of practice to have same-day turnaround of laboratory tests. CONCLUSIONS: Nonurgent utilization of the PED by patients in a specific primary care practice can be predicted based on discriminant practice characteristics, several of which may be modifiable. Use of these predictive rules can be used to optimize pediatric services and policy to help mitigate the high volume of PED nonurgent visitation. Focused interventions on practice characteristics of significance may help reduce PED overcrowding and improve continuity of care.