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.

Workforce Trends and Analysis of Selected Pediatric Subspecialties in the United States.

OBJECTIVE: To update pediatric subspecialty workforce data to support evidence-based legislation and public policy decisions by replicating the American Academy of Pediatrics' 1998 Future of Pediatric Education (FOPE II) workforce survey. METHODS: A descriptive and comparative analysis of survey responses from 9950 US pediatric subspecialists who completed an electronic survey. RESULTS: Pediatric subspecialists are working fewer hours and spending less of their time in direct patient care than they did in 1998 but the mean hours worked differs significantly according to subspecialty. Most subspecialists continue to be board-certified, white, non-Hispanic men, although the percentage who are women and from minority groups has increased. The proportion of subspecialists practicing in an academic medical center has increased since 1998. Thirty percent of pediatric subspecialists reported appointment wait times of >2 weeks and pediatric subspecialists in developmental pediatrics, endocrinology, and neurology identified much longer wait times than other subspecialists. CONCLUSION: The demographic and practice characteristics of pediatric subspecialists have changed since the FOPE II survey and access to subspecialty care in a family's community remains a challenge. However, pediatric subspecialties are not monolithic and solutions to workforce shortages will need to take into account these differences to improve access to subspecialty care.

Diversity and inclusion training in pediatric departments.

BACKGROUND AND OBJECTIVE: The diversifying US population of children necessitates assessing the diversity of the pediatric academic workforce and its level of cultural competency training. Such data are essential for workforce and educational policies. METHODS: An 8-question survey was sent to 131 US pediatric chairs to assess plans for diversity, targeted groups, departmental diversity, diversity measures, perceived success in diversity, and presence and type of cultural competency training. RESULTS: In all, 49.6% of chairs responded, and three-quarters of them reported having a plan for diversity, which targeted racial; ethnic; gender; lesbian, gay, bisexual, and transgender; disabled; and social class groups. Of the residents, 75% were women, as compared with 54% of faculty and 26% of chairs. Racial and ethnic diversity was limited among trainees, faculty, and leaders; <10% of each group was African American, Hispanic, or Native American. Asian Americans were more common among trainees (15%-33%) but were less common in faculty and leadership positions (0%-14%). Lesbian, gay, bisexual, and transgender physicians were represented in some groups. Measures of diversity included the number of trainees and faculty, promotion success, climate assessments, and exit interviews. Overall, 69% of chairs reported being successful in diversity efforts. A total of 90% reported cultural competency training for trainees, and 74% reported training for faculty and staff. Training in cultural competency included linguistic training, primarily in Spanish. CONCLUSIONS: Pipeline issues for minorities are ongoing challenges. Pediatric leadership needs more representation of racial and ethnic minorities, women, and LGBT. Suggestions for workforce and educational policies are made.

Pediatrician workforce policy statement.

This policy statement reviews important trends and other factors that affect the pediatrician workforce and the provision of pediatric health care, including changes in the pediatric patient population, pediatrician workforce, and nature of pediatric practice. The effect of these changes on pediatricians and the demand for pediatric care are discussed. The American Academy of Pediatrics (AAP) concludes that there is currently a shortage of pediatric medical subspecialists in many fields, as well as a shortage of pediatric surgical specialists. In addition, the AAP believes that the current distribution of primary care pediatricians is inadequate to meet the needs of children living in rural and other underserved areas, and more primary care pediatricians will be needed in the future because of the increasing number of children who have significant chronic health problems, changes in physician work hours, and implementation of current health reform efforts that seek to improve access to comprehensive patient- and family-centered care for all children in a medical home. The AAP is committed to being an active participant in physician workforce policy development with both professional organizations and governmental bodies to ensure a pediatric perspective on health care workforce issues. The overall purpose of this statement is to summarize policy recommendations and serve as a resource for the AAP and other stakeholders as they address pediatrician workforce issues that ultimately influence the quality of pediatric health care provided to children in the United States.

Unexpected infant deaths associated with use of cough and cold medications.

OBJECTIVE: The objective of this study was to determine whether caregivers had given infants who died unexpectedly over-the-counter cough and cold medications before the infant deaths to identify sociodemographic risk factors for their use. METHODS: The Arizona Child Fatality Review Program reviews the circumstances surrounding every child death that occurs in the state each year. By statute, the multidisciplinary review teams have access to all medical charts, autopsy reports, law enforcement reports, and other records for their review and use these data to determine the cause of death and its preventability. The data on all infants who died unexpectedly in 2006 and had an autopsy and postmortem toxicologic studies were reviewed for this analysis. RESULTS: Ten unexpected infant deaths that were associated with cold-medication use were identified. The infants ranged in age from 17 days to 10 months. Postmortem toxicology testing found evidence of recent administration of pseudoephedrine, antihistamine, dextromethorphan, and/or other cold-medication ingredients in these infants. The families who used these medications were poor and publicly insured, and 50% of them had limited English proficiency. Only 4 of these infants had received medical care for their current illness before their death. The over-the-counter cough and cold medication had been prescribed by a clinician for only 1 of these infants. CONCLUSIONS: Review of these infants' deaths raises concern about the role of the over-the-counter cough and cold medications in these deaths. These findings support the recommendation that such medications not be given to infants. In addition, these findings suggest that warnings on these medications "to consult a clinician" before use are not being followed by parents. Educational campaigns to decrease the use of over-the-counter cough and cold medications in infants need to be increased.

Physician practice revenues and use of information technology in patient care.

OBJECTIVES: Although information technology (IT) may improve efficiency and quality of patient care, the adoption of clinical IT by physicians has been limited. This study investigates the relationships between physician practice revenue and use of clinical IT. RESEARCH DESIGN: We undertook a cross-sectional analysis of data on 6849 U.S. physicians in physician-owned practices who responded to the 2000-2001 Community Tracking Study Physician Survey. Physician practice revenues, measured as the percentage of total revenues, is defined along 2 dimensions: type (capitation, noncapitated managed care, or fee-for-service) and source (Medicare, Medicaid, or private/other). Analyses were adjusted for physician and practice characteristics and geographic location. MEASURES: The proportion of physicians using IT for 5 functions of patient care: treatment guidelines, formularies, patient notes or lists, electronic prescriptions, and data exchange with other physicians. RESULTS: Practice revenues are associated with differences in physicians' use of IT in patient care. Above-average Medicaid revenue was associated with 20% higher use of IT overall (incidence density ratio = 1.20, 95% confidence interval [CI] = 1.12-1.30). Above-average capitation revenue corresponds to higher use of IT overall (incidence density ratio = 1.10, 95% CI = 1.02-1.19) and greater odds of using IT for guidelines (odds ratio = 1.26, 95% CI = 1.05-1.53). Above-average noncapitated managed care revenue, however, has no apparent relationship with IT use. CONCLUSIONS: Differences in the type and source of physician revenues were associated with differences in the use of IT in patient care in 2000-2001. The relationships between practice revenues and IT use varied across clinical IT functions.

Impact of Medicaid disenrollment on health care use and cost.

OBJECTIVE: The objective of this study was to compare the health care use of children who are covered by public insurance and uninsured children who live in a large urban area and the potential impact of disenrollment on health care use and costs if these children become uninsured. METHODS: The 2004 health care transactions for 43,313 uninsured children and 168,722 children who were insured by Medicaid/State Children's Health Insurance Program and living in the Phoenix metropolitan area were analyzed using a community-wide administrative health database (Arizona HealthQuery). Using a multivariate model of health care use by currently uninsured children, we examined the effect of 10% disenrollment of the children who were currently insured by Medicaid/State Children's Health Insurance Program. RESULTS: A 10% disenrollment would increase the costs of health care in the community by $3,460,398 annually, or $2121 for each child disenrolled. This increase in costs is attributed to a shift of care from ambulatory settings to more expensive emergency departments and an increase in hospital days. We determined that 69% of the change in emergency department visits, 58% of the change in hospital stays, and 74% of the change in ambulatory visits would be attributable to the change in insurance status. CONCLUSIONS: Programmatic changes that result in disenrollment from public insurance programs will increase the number of emergency department visits and hospital days as well as the total community costs of health care. These increases in health care use can be expected to aggravate community problems of emergency department overcrowding and inpatient bed shortages. The majority of the changes in use are attributable to changes in insurance status, which results in a shift of care from less expensive ambulatory settings to emergency departments and increases in hospital days when children lose Medicaid/State Children's Health Insurance Program coverage.

The effects of access to pediatric care and insurance coverage on emergency department utilization.

OBJECTIVE: To compare children who used the emergency department (ED) in a rural, border community with those who did not over a 1-year period to estimate the effects of access to pediatric care, insurance coverage, ethnicity, gender, age, and area of residence on ED utilization. DESIGN: Multivariate logit models are used to estimate the independent influence of demographic characteristics, insurance coverage, and access to pediatric care on ED utilization during 1999 by children 0 to 19 years of age. RESULTS: Controlling for age, gender, ethnicity, and area of residence, children who received care from a private practice pediatric group were 73% less likely to utilize the ED if insured and 93% less likely if uninsured to use the ED than children who had not visited a pediatrician. Uninsured children were nearly 4 times more likely to use the ED than insured children. Among insured children, those covered by Medicaid were 54% less likely to use the ED than children with private insurance. Compared with white, non-Hispanic children, Asian or Hispanic children were no more likely to use the ED. Insured Native American children were more than twice as likely as white, non-Hispanic children to utilize the ED. CONCLUSIONS: Access to pediatric care is associated with a marked decrease in ED utilization regardless of insurance status. This decrease in ED utilization is especially large for uninsured children.

Can child deaths be prevented? The Arizona Child Fatality Review Program experience.

OBJECTIVE: To determine the causes and preventability of child deaths; to assess the accuracy of death certificate information; and to assess the number of child abuse deaths that are misdiagnosed as deaths attributable to natural or accidental causes. METHODS: Analysis of deaths of children <18 years old that occurred between 1995-1999 using the data collected by the Arizona Child Fatality Review Program (ACFRP). RESULTS: From 1995-1999, local multidisciplinary child fatality review teams (CFRTs) have reviewed 95% of all deaths of children <18 years old in Arizona. Each team has access to the child's death certificate, autopsy report, hospital records, child protective services records, law enforcement reports, and any other relevant documents that provide insight into the cause and preventability of a child's death. After reviewing these documents, the team determines the cause of death, its preventability, and the accuracy of the death certificate. The ACFRP defines a child's death as preventable if an individual or the community could reasonably have done something that would have changed the circumstances that led to the child's death. The ACFRP determined that 29% (1416/4806) of these deaths could have been prevented, and preventability increased with the age of the child. Only 5% (81/1781) of neonatal deaths were considered preventable, whereas the deaths of 38% of all children older than 28 days were considered preventable. By 9 years of age, the majority of child deaths (56%) were considered preventable. Deaths attributable to medical conditions were far less likely to be considered preventable than deaths attributable to unintentional injuries. Although 62% of all deaths in Arizona during the 5-year period were attributable to medical conditions, only 8% (253/2983) of these deaths were considered preventable. In contrast, 91% (852/934) of the deaths attributable to unintentional injuries were considered preventable. Motor vehicle crashes accounted for 634 of the deaths resulting from injuries, and drowning accounted for 187 deaths. Motor vehicle crashes were the leading cause of death for all children in Arizona over 1 year of age. Only 18% of child passengers and 3% of adolescent drivers who died were known to be appropriately restrained. The typical drowning victim was a young child who drowned in the family's backyard pool. Indeed, 70% (131/187) of the drowning victims were <5 years old, and 62% (81/131) of these children died in a backyard pool. Supervision of the child and pool fencing could have prevented 90% of these deaths. Most deaths attributable to medical conditions occurred in the first year of life. Prematurity was the most common medical condition (1036 deaths) followed by congenital anomalies (662 deaths) and infectious diseases (470 deaths). Some of the reasons why CFRTs believed a medical death was preventable included inadequate emergency medical services, poor continuity of care, and delay in seeking care because of lack of health insurance. There were 4 deaths resulting from infections that were vaccine-preventable. There were 263 deaths attributable to sudden infant death syndrome. Only 38 of these infants were found lying on their back; 35 were found lying on their side. The death rate from sudden infant death syndrome decreased from 1.1 per 1000 infants <1 year of age in 1995 to 0.5 in 1999. There were 33 deaths that the CFRTs concluded were attributable to unsafe sleeping arrangements that resulted in unintentional suffocation. From 1995-1999, 317 Arizona children died from gun shot wounds. Most of these deaths were homicides (175) or suicides (109). All suicide deaths occurred in children >9 years old, and 77% of these children were >14 years old. The typical suicide victim was male (83%) and used a gun (70%) to kill himself. After review by the CFRTs, it was determined that 5 of the 67 child abuse deaths were misdiagnosed as attributable to natural or accidental causes on the death certificate. In 3 of these 5 cases, the child was in a persistent vegetative state and died many years after the episode of child abuse. Although inaction or inappropriate action by Child Protective Services (CPS) is often thought to be the cause of child abuse deaths, the ACFRP determined that in 79% of child abuse deaths, there had been no previous CPS involvement with the child's family. Although 61% of child abuse deaths were considered to be preventable, much of the responsibility for preventing these deaths rests with community members (eg, relatives, neighbors) who were aware of the abuse but failed to report the family to CPS. The CFRTs, who had received training in the proper completion of death certificates, reported that the cause of death was incorrect on 13% of all death certificates and in 16 cases, the CFRTs disagreed with the medical examiner on the manner of death (eg, natural, accidental, undetermined). Because CFRTs have access to additional information that may not have been available to the physician who completes a child's death certificate, CFRTs may be able to more accurately determine the cause and manner of death than the physician who completed the death certificate. CONCLUSIONS: Arizona's child death rate is above the national average (82.16/100 000), but the ACFRP determined that many of these deaths could have been prevented by using known prevention strategies (eg, child safety restraints, pool fencing). Most child mortality data are based on death certificate information that often is incorrect and cannot be used to assess preventability. Although most states have child fatality review programs that review suspected child abuse deaths, <3% of all preventable deaths in Arizona were attributable to child abuse. If all child deaths in the United States were reviewed from a prevention/needs assessment perspective, targeted and data-driven recommendations for prevention could be developed for each community, and potentially 38% of all child deaths that occur after the first month of life could be prevented. The ACFRP is an excellent example of a statewide system with a public health focus. To assist other states in developing similar programs, national support is needed. The establishment of a public health focused federally funded national program would provide us with the opportunity to standardize data collection among states and better utilize this data at a national level.