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.

Children with severe sepsis: relationship between community level income and morbidity and mortality.

BACKGROUND: Health disparities surrounding pediatric severe sepsis outcomes remains unclear. We aimed to measure the relationship between indicators of socioeconomic status and mortality, hospital length of stay (LOS), and readmission rates among children hospitalized with severe sepsis. METHODS: Children 0-18 years old, hospitalized with severe sepsis in the Nationwide Readmissions Database (2016-2018) were included. The primary exposure was median household income by ZIP Code of residence, divided into quartiles. RESULTS: We identified 15,214 index pediatric severe sepsis hospitalizations. There was no difference in hospital mortality rate or readmission rate across income quartiles. Among survivors, patients in Q1 (lowest income) had a 2 day longer LOS compared to those in Q4 (Median 10 days [IQR 4-21] vs 8 days [IQR 4-18]; p < 0.0001). However, there was no difference after adjusting for multiple covariates. CONCLUSIONS: Children living in Q1 had a 2 day longer LOS versus their peers in Q4. This was not significant on multivariable analysis, suggesting income quartile is not driving this difference. As pediatric severe sepsis remains an important source of morbidity and mortality in critically ill children, more sensitive metrics of socioeconomic status may better elucidate any disparities. IMPACT: Children with severe sepsis living in the lowest income ZIP Codes may have longer hospital stays compared to peers in higher income communities. More precise metrics of socioeconomic status are needed to better understand health disparities in pediatric severe sepsis.

Is this child suitable to be seen in primary care? Poor agreement between caregiver/family perception and definitions of a 'primary care-type' patient.

AIMS: To compare and evaluate the number of paediatric patients classified as 'suitable for primary care' using the Australian Institute of Health and Welfare (AIHW) method, the Australasian College for Emergency Medicine (ACEM) method, and parental judgement. METHODS: This was a prospective observational study enrolling parents/carers presenting with their children to two Victorian EDs in Victoria, Australia over a 1-week period. Trained research assistants were posted within both EDs and surveyed all eligible parents/carers whether they agreed with the statement 'I think a GP would be able to look after my child's current illness/injury'. Survey responses were linked to clinical outcomes and length of stay. Each presentation was classified as suitable for primary care using the AIHW method, the ACEM method and parental survey. Agreement between definitions was assessed using Cohen's kappa statistic. RESULTS: During the study (June 2016), 1069 patients presented to the two EDs; 677 patients were able to be classified under all three definitions (AIHW: 1069, ACEM: 991, survey: 677 patients). Only 80/677 (12%) patients met all three criteria. Agreement was slight between the parent survey and the ACEM method (K = 0.14, 95% confidence interval (CI) 0.06-0.21), and the parent survey and the AIHW method (K = 0.12, 95% CI 0.05-0.19). There was moderate agreement between the ACEM and AIHW methods (K = 0.45, 95% CI 0.39-0.51). CONCLUSIONS: There is very poor agreement on what defines a 'primary care-type' paediatric patient between the definitions used by government, professional bodies and caregivers.

Prevalence and associated skills of Australian general practice registrars seeing children with functional bowel and bladder problems.

AIM: Functional bowel (constipation and faecal incontinence) and bladder (urinary incontinence and enuresis) problems in children are often treated by paediatricians yet should mostly be managed by general practitioners (GPs). To understand whether the necessary skills and knowledge are being built in general practice, this study aimed to establish the prevalence and associated skills of Australian general practice registrars managing children with functional bowel and bladder problems. Together as paediatricians and GPs, we use these data to determine how best to ensure high quality, equitable care for children. METHODS: We drew on 16 rounds of data collection from the Registrar Clinical Encounters in Training (ReCEnT) multi-site cohort study (2010-2017) of general practice registrars' in-consultation experience. It included a measure of paediatric consultations in which a functional bowel or bladder problem was managed, as well as demographic information. RESULTS: Out of 62 721 problems/diagnoses for paediatric patients (0-17 years), 844 (1.4%) were coded as functional bowel (n = 709; 1.13% (95% confidence interval, CI: 1.05-1.22)) and/or bladder (n = 135; 0.22% (95% CI: 0.18-0.25)) presentations. Registrars were more likely to prescribe medication for bowel problems (odds ratio (OR) = 2.22 (95% CI: 1.86-2.64)) than for all other problems, but less likely to prescribe medication (OR = 0.31 (95% CI: 0.18-0.52)) for night-time wetting and more likely to make a specialist referral (OR = 1.99 (95% CI: 1.22-3.25)) compared to all other problems. CONCLUSIONS: Only a small proportion of children with functional bowel and bladder problems were seen by registrars despite high prevalence in the community and amenability to management in the general practice setting (i.e. generally low morbidity and low complexity) versus need for specialists. Registrars appeared to be managing functional bowel and bladder problems according to evidence-based guidelines, but with relatively high levels of referral. Given the inequitable access to specialist care, paediatricians should support local general practice management of these problems. This might include (i) engaging with training programs to ensure appropriate education and (ii) liaising with individual registrars/practices to provide management advice for individual or example cases.

Comparative Effectiveness of Coronavirus Disease 2019 (COVID-19) Vaccines Against the Delta Variant.

BACKGROUND: There is a lack of data regarding how the Delta variant of coronavirus disease 2019 (COVID-19) has impacted the effectiveness of the BNT162b2 (Pfizer-BioNTech), mRNA-1273 (Moderna), and Ad26.COV2.S (Johnson & Johnson-Janssen) vaccines at preventing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and COVID-19 hospitalization. METHODS: We compared the effectiveness of the three vaccines during the pre- and post-Delta variant period (before and after 1 July 2021) in a large cohort of vaccinated and unvaccinated patients in the Michigan Medicine healthcare system. We assessed vaccine effectiveness (VE) using 2 analyses: an inverse propensity weighted (IPW) Kaplan-Meier (KM) analysis based on time from vaccination, and a Cox model based on calendar time with vaccination as a time-varying covariate. RESULTS: Compared to Ad26.COV2.S recipients, the risk of hospitalization for COVID-19 in the post-Delta variant period was lower for BNT162b2 recipients (hazard ratio [HR] = 0.37; 95% confidence interval [CI]: [.14-.98]; P = .05) and mRNA-1273 recipients (HR = 0.21; 95% CI: [.07-.64]; P = .006). Recipients of the mRNA-1273 vaccine had a lower risk of SARS-CoV-2 infection than Ad26.COV2.S recipients (HR = 0.6; 95% CI: [.43-.83]; P = .003) and BNT162b2 recipients (HR = 0.64; 95% CI: [.54-.76]; P < .001). After 1 July, efficacy against SARS-CoV-2 infection declined for Ad26.COV2.S recipients (VE = 76% before; VE = 49% after; P = .02), BNT162b2 recipients (VE = 87% before; VE = 52% after; P < .001), and mRNA-1273 recipients (VE = 92% before; VE = 70% after; P < .001). Waning immunity and the Delta variant contributed independently and significantly to this decline. CONCLUSIONS: Although there is a substantial decline in effectiveness, the approved COVID-19 vaccines remain effective against infection and hospitalization due to the Delta variant. The mRNA-based vaccines are more effective than the Ad26.COV2.S vaccine.

Efficacy of COVID-19 vaccines in patients taking immunosuppressants.

OBJECTIVES: We intended to assess the effectiveness of all three US Food and Drug Administration approved COVID-19 vaccines at preventing SARS-CoV-2 infection and COVID-19 hospitalisation in a large cohort of individuals on immunosuppressants for a diverse range of conditions. METHODS: We studied the effectiveness of BNT162b2 (Pfizer-BioNTech), mRNA-1273 (Moderna) and Ad26.COV2.S (Johnson & Johnson-Janssen) vaccines among individuals who take immunosuppressants (including disease-modifying antirheumatic drugs and glucocorticoids) by comparing vaccinated (n=97688) and unvaccinated (n=42094) individuals in the Michigan Medicine healthcare system from 1 January to 7 December 2021, using Cox proportional hazards modelling with time-varying covariates. RESULTS: Among vaccinated and unvaccinated individuals, taking immunosuppressants increased the risk of SARS-CoV-2 infection (adjusted HR (aHR)=2.17, 95% CI 1.69 to 2.79 for fully vaccinated and aHR=1.40, 95% CI 1.07 to 1.83 for unvaccinated). Among individuals taking immunosuppressants, we found: (1) vaccination reduced the risk of SARS-CoV-2 infection (aHR=0.55, 95% CI 0.39 to 0.78); (2) the BNT162b2 and mRNA-1273 vaccines were highly effective at reducing the risk of SARS-CoV-2 infection (n=2046, aHR=0.59, 95% CI 0.38 to 0.91 for BNT162b2; n=2064, aHR=0.52, 95% CI 0.33 to 0.82 for mRNA-1273); (3) with a smaller sample size (n=173), Ad26.COV2.S vaccine protection did not reach statistical significance (aHR=0.34, 95% CI 0.09 to 1.30, p=0.17); and (4) receiving a booster dose reduced the risk of SARS-CoV-2 infection (aHR=0.42, 95% CI 0.24 to 0.76). CONCLUSIONS: The mRNA-1273 and BNT162b2 vaccines are effective in individuals who take immunosuppressants. However, individuals who are vaccinated but on immunosuppressants are still at higher risk of SARS-CoV-2 infection and COVID-19 hospitalisation than the broader vaccinated population. Booster doses are effective and crucially important for individuals on immunosuppressants.

Different Measures and Ways to Categorize Pediatrician Burnout and the Association with Satisfaction.

OBJECTIVE: Compare pediatrician burnout when measured and categorized in different ways to better understand burnout and the association with satisfaction. STUDY DESIGN: We analyzed national survey data from a cohort study of early to midcareer pediatricians. In 2017, participants randomly received 1 of 3 question sets measuring burnout components (emotional exhaustion, depersonalization, and personal accomplishment): group A received the Maslach Burnout Inventory, group B received a previously used measure, and group C received a new severe measure. Repeated measures ANOVA tested differences across burnout categorizations: high emotional exhaustion and high depersonalization and low personal accomplishment; high emotional exhaustion and high depersonalization; and high emotional exhaustion or high depersonalization. Logistic regression tested relationships between burnout profiles (engaged, intermediate, and burnout) and satisfaction. Seventy-one percent of participants completed the survey (1279/1800). RESULTS: Burnout varied depending on measurement (groups A, B, and C) and categorization. For example, for group A, when categorized as high emotional exhaustion, high depersonalization, and low personal accomplishment, burnout was lower (4.8%) than categorized as high emotional exhaustion and depersonalization (15.2%) (P < .001) or categorized as high emotional exhaustion or depersonalization (44.6%) (P < .001). Most participants were satisfied with their career (83.6%). Using burnout profiles, 38.4%-85.1% fell in the engaged profile. For each group, burnout profiles were associated with satisfaction. For example, group A participants in the burnout or intermediate profile were less likely than those engaged to be satisfied with their careers (aOR, 0.08 [95% CI, 0.03-0.24]; and aOR, 0.23 [95% CI, 0.10-0.56], respectively). CONCLUSIONS: The way burnout is measured and categorized affects burnout prevalence and its association with satisfaction. Transparency in methodology used is critical to interpreting results.

Trends in quality of care among children with sickle cell anemia.

INTRODUCTION: For decades, it has been recommended that children with sickle cell anemia (SCA) receive antibiotic prophylaxis to prevent serious infections and undergo transcranial Doppler (TCD) screening to identify those at highest risk of overt stroke. We assessed recent temporal trends in antibiotic prophylaxis prescription fills and TCD screening among children with SCA using validated quality measures. PROCEDURE: Using validated claims-based definitions, we identified children with SCA who were enrolled in Michigan or New York State (NYS) Medicaid programs (2011-2018). Among recommended age groups, two outcomes were assessed yearly: (a) filling of ≥300 days of antibiotics, and (b) receipt of greater than or equal to one TCD. The proportion of children with each outcome was calculated by state. Temporal trends in each preventive service were assessed using generalized linear models. RESULTS: A total of 1784 children were eligible for antibiotic prophylaxis (Michigan: 384; NYS: 1400), contributing 3322 person-years. Annual rates of filling ≥300 days of antibiotics ranged from 16% to 22% and were similar by state. There was no change in rates of antibiotic filling over time in Michigan (p-value: .10), but there was a decrease in NYS (p-value: .02). A total of 3439 children with SCA were eligible for TCD screening (Michigan: 710; NYS: 2729), contributing 10,012 person-years. Annual rates of TCD screening ranged from 39% to 45%, were similar by state, and did not change over time (p-values >.05). CONCLUSIONS: Most children with SCA do not receive recommended antibiotic prophylaxis and/or TCD screening. New, sustainable, and coordinated interventions across preventive services are urgently needed.

Nonindicated Brain Computed Tomography Scans for Children: Adaptation of an American Measurement Tool and Contrast of Current Practice in an Australian Hospital.

OBJECTIVES: Clinical guidelines state brain computed tomography (CT) for atraumatic headache or first generalized afebrile, atraumatic seizure as nonindicated in neurologically normal children. We aimed to adapt 2 rigorously validated United States-based measures that examine overuse of CT in children with these conditions, and to determine whether these measures can be used in an Australian setting to determine rates of CT scanning in current practice. METHODS: Within an Australian tertiary pediatric hospital, we successfully adapted the measures from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding system of the United States measures to the International Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) coding system used in Australia. We conducted a retrospective audit of electronic medical record data from April 1, 2017, to March 31, 2018. Eligible patients were children aged 4 to 17 years who attended one of the hospital outpatient clinics and/or emergency department and/or were admitted to an inpatient ward. The conditions of interest were (1) atraumatic headache and (2) first generalized afebrile, atraumatic seizure. RESULTS: The measure for afebrile seizure was found to have low accuracy and low feasibility in this setting and was not tested further. The adapted measure for atraumatic headache was highly accurate in determining the encounters of interest; however, manual chart review was required to identify nonindicated brain CTs. Using this measure, 601 encounters for atraumatic headache were identified, of which 98 (16.3%) received at least 1 brain CT. We found that 14.1% of these scans were nonindicated, meaning 2% all atraumatic headache encounters received a nonindicated scan; lower than rates reported in international literature. CONCLUSIONS: Using the tool developed in this study, rigorous measurement of the overuse of CT scans in other settings may determine the reasons for the lower rates observed in this study; inform future interventions to minimize overuse; and provide safer, higher quality care to children.

Growth and changes in the pediatric medical subspecialty workforce pipeline.

BACKGROUND: To inform discussions of pediatric subspecialty workforce adequacy and characterize its pipeline, we examined trends in first-year fellows in the 14 American Board of Pediatrics (ABP)-certified pediatric medical subspecialties, 2001-2018. METHODS: Data were obtained from the ABP Certification Management System. We determined, within each subspecialty, the annual number of first-year fellows. We assessed for changes in the population using variables available throughout the study period (gender, medical school location, program region, and program size). We fit linear trendlines and calculated χ2 statistics. RESULTS: The number of first-year pediatric medical subspecialty fellows increased from 751 in 2001 to 1445 in 2018. Fields with the growth of 3 or more fellows per year were Cardiology, Critical Care, Emergency Medicine, Gastroenterology, Neonatology, and Hematology Oncology (P value <0.05 for all). The number of fellows entering Adolescent Medicine, Child Abuse, Infectious Disease, and Nephrology increased at a rate of 0.5 fellows or fewer per year. Female American Medical Graduates represented the largest and growing proportions of several subspecialties. Distribution of programs by region and size were relatively consistent over time, but varied across subspecialties. CONCLUSIONS: The number of pediatricians entering medical subspecialty fellowship training is uneven and patterns of growth differ between subspecialties. IMPACT: The number of individuals entering fellowship training has increased between 2001 and 2018. Growth in the number of first-year fellows is uneven. Fields with the greatest growth: Critical Care, Emergency Medicine, and Neonatology. Fields with limited growth: Adolescent Medicine, Child Abuse, Infectious Disease, and Nephrology. Concerns about the pediatric medical subspecialty workforce are not explained by the number of individuals entering the fellowship.

How long and how much? Wait times and costs for initial private child mental health appointments.

AIM: To determine: (i) wait times and out-of-pocket costs for children attending private specialists for initial mental health appointments; and (ii) whether these differed between specialists working in metropolitan versus rural areas and in low, medium and high socio-economic areas. METHODS: Prospective secret shopper study whereby a researcher posed as a parent seeking an appointment for her child with anxiety or attention-deficit/hyperactivity disorder. We contacted 317 private paediatrician, psychiatrist and psychologist practices in Victoria and South Australia between 12 March and 5 May 2019. RESULTS: One third (29.8%) of private practices were closed to new referrals. The average wait times for paediatricians, psychiatrists, and psychologists were 44, 41 and 34 days, respectively. Average out-of-pocket costs quoted were AU$120 for paediatricians, AU$176 for psychiatrists and AU$85 for psychologists. CONCLUSION: Parents face extensive wait times and substantial out-of-pocket costs when seeking private mental health services for their child.

Engagement in research among pediatric subspecialists at the time of enrollment in maintenance of certification, 2009-2016.

BACKGROUND: Amid concerns about the pediatrician-scientist workforce, we hypothesized that declining numbers of pediatric subspecialists devote at least 25% of their professional time to research with fewer younger and female pediatricians engaged in research over the study period. METHODS: Board-certified pediatricians enrolling online in the American Board of Pediatrics (ABP's) Maintenance of Certification (MOC) program October 2009 through 2016 were invited to complete a survey with questions about the allocation of their professional time. Responses from individuals in the 14 ABP-certified subspecialties were analyzed. The number and proportions of respondents devoting 25-49% and 50% or more of professional time to research were calculated over time. Age and gender were also examined. RESULTS: We analyzed 21,367 responses over 8 years. A small number of pediatric subspecialists engaged in research with 5.2-6.7% devoting 25-49% and 5.6-8.4% at least 50% of their professional time to research across subspecialties. There was no discernable increase or decrease over time or pattern by age or gender. CONCLUSION: Less than 10% of pediatric medical subspecialists devote at least 50% of their professional time to research. Efforts to promote research among pediatric subspecialists have not increased the size of the population that reports engaging in research at this level.

Designing a Multistakeholder Collaboration to Improve Preventive Care for Children With Sickle Cell Anemia.

Newly developed measures of health care quality for children with sickle cell anemia (SCA) have revealed significant performance gaps in recommended care. Historically, health systems, Medicaid health plans, and state Medicaid programs have not partnered with patients and families to improve SCA care delivery. We organized 2 novel multistakeholder design meetings to identify potential interventions to deliver high-quality preventive care for children with SCA. Invitees included patients with SCA, families, and representatives from pediatric hematology clinics, Medicaid health plans, community organizations, and a state Medicaid program. Participants identified some barriers to care through presentations and facilitated discussions. Over 35 potential interventions and 6 drivers of high-quality SCA preventive care delivery were organized into a key driver diagram. Many barriers to SCA care delivery could be addressed by Medicaid health plan resources to support members with chronic disease; however, these resources are infrequently used in the pediatric SCA population. Bridging gaps between stakeholder groups identified many potential interventions to improve SCA preventive care delivery at all levels of the health care system. Similar multistakeholder discussions may be useful for other communities interested in improving preventive care for children with SCA or other chronic pediatric diseases.

Analgesic Use Following Bilateral Breast Reduction.

The opioid epidemic in the United States resulted in 42,000 deaths in 2016, 40% of which involved a prescription opioid. It is estimated that 2 million patients become opioid-dependent after elective, ambulatory surgery each year. There has been increased interest in quantifying the need for postoperative narcotic pain medications for a variety of surgical procedures. However, studies have been limited. We sought to quantify the analgesic usage after one of the most common operations performed in plastic surgery, bilateral breast reduction.In this prospective, observational study, sequential breast reduction patients were contacted by telephone on the evening of postoperative days 3 and 7. Patients were queried as to which analgesic medications were used on the day of the phone call. Data relating to dosage, frequency, and satisfaction with pain control were sought. Patients taking chronic narcotics, postoperative complications requiring surgical intervention, and those unable to be reached after multiple attempts were excluded.Complete data were obtained for 40 patients. Narcotic prescriptions were written for oxycodone, hydromorphone and tramadol, with the number prescribed ranging from 0 to 20 tablets. The median total number used was 6 tablets. Eighty percent of patients used a total of 10 tablets or less. Fifty percent of patients were using only nonnarcotic analgesia by postoperative day 3. Patient-reported satisfaction with pain control was overwhelmingly positive, with 95% being either somewhat satisfied or very satisfied with postoperative pain control. Of those taking any medication on postoperative day 3, only half were using a nonsteroidal anti-inflammatory drug (NSAID) as part of their pain regimen.The number of tablets prescribed after breast reduction surgery varies considerably, and there is no consensus regarding the appropriate number to prescribe. Currently, few patients use all the medication prescribed to them, indicating a high rate of overprescribing. The overwhelming majority are satisfied with their pain control. Most patients use less than 10 tablets of narcotic pain medication after surgery. Acetaminophen is widely used as an adjunct but NSAIDs remain underutilized. Based on these data, we recommend that breast reduction patient's pain is best managed with acetaminophen, NSAIDs, and expectation management.

Incidence of Thyroid Disease in Adolescent Females Presenting with Heavy Menstrual Bleeding.

The incidence of thyroid disease in adolescents with heavy menstrual bleeding is unknown. A retrospective cross-sectional study of 427 adolescents presenting with heavy menstrual bleeding found 0.23% (95% CI 0%-0.7%) had thyroid disease, lower than that expected in the general population. Thyroid testing should only be considered when other symptomatology is present.

Timing and Stability of Fellowship Choices during Pediatric Residency: A Longitudinal Survey.

OBJECTIVES: To determine, among pediatric residents, the timing and stability of decisions to pursue fellowship training and select a specific subspecialty, which can be used to inform strategies to better match the distribution of pediatric subspecialist with the needs of children. STUDY DESIGN: A longitudinal survey administered with the General Pediatrics In-training Exam to pediatric residents in the US and Canada, 2010-2014. The study included residents who responded in each of their first 3 years of residency and indicated plans to enter fellowship or matriculated, 2013-2016, into 1 of the 14 medical subspecialty fellowships for which the American Board of Pediatrics grants a certificate. Descriptive and χ2 statistics were calculated. RESULTS: Of the 7580 residents who completed 3 annual surveys (response rate 99%) 4963 (65.5%) indicated plans to pursue fellowship training and 2843 (37.5%) matriculated into fellowship. Residents who did not enter fellowship were in smaller residency programs and programs with less interest in fellowship among interns. Most residents who matriculated into fellowship (68.4%) planned to do so as interns and maintained that plan throughout residency. In contrast, 22.7% had selected a specific subspecialty as interns. Fellowship decisions were made later in residency by female residents, American Medical Graduates, and residents in programs where <50% of interns planned to pursue fellowship training. Timing and stability of decisions varied across subspecialty fields. CONCLUSIONS: Understanding the timing of pediatric medical subspecialty fellowship decisions could be used to shape medical education and, ultimately, the pediatric workforce.

Variation in Part-Time Work among Pediatric Subspecialties.

OBJECTIVE: To assess the part-time workforce and average hours worked per week among pediatric subspecialists in the 15 medical subspecialties certified by the American Board of Pediatrics. STUDY DESIGN: We examined data from pediatric subspecialists who enrolled in Maintenance of Certification with the American Board of Pediatrics from 2009 to 2015. Data were collected via an online survey. Providers indicated whether they worked full time or part time and estimated the average number of hours worked per week in clinical, research, education, and administrative tasks, excluding time on call. We calculated and compared the range of hours worked by those in full- and part-time positions overall, by demographic characteristics, and by subspecialty. RESULTS: Overall, 9.6% of subspecialists worked part time. There was significant variation in part-time employment rates between subspecialties, ranging from 3.8% among critical care pediatricians to 22.9% among developmental-behavioral pediatricians. Women, American medical graduates, and physicians older than 70 years of age reported higher rates of part-time employment than men, international medical graduates, and younger physicians. There was marked variation in the number of hours worked across subspecialties. Most, but not all, full-time subspecialists reported working at least 40 hours per week. More than one-half of physicians working part time in hematology and oncology, pulmonology, and transplant hepatology reported working at least 40 hours per week. CONCLUSIONS: There are unique patterns of part-time employment and hours worked per week among pediatric medical subspecialists that make simple head counts inadequate to determine the effective workforce. Our findings are limited to the 15 American Board of Pediatrics-certified medical subspecialties.

Paediatric mental and physical health presentations to emergency departments, Victoria, 2008-15.

OBJECTIVES: To identify trends in presentations to Victorian emergency departments (EDs) by children and adolescents for mental and physical health problems; to determine patient characteristics associated with these presentations; to assess the relative clinical burdens of mental and physical health presentations. DESIGN: Secondary analysis of Victorian Emergency Minimum Dataset (VEMD) data. Participants, setting: Children and young people, 0-19 years, who presented to public EDs in Victoria, 2008-09 to 2014-15. MAIN OUTCOME MEASURES: Absolute numbers and proportions of mental and physical health presentations; types of mental health diagnoses; patient and clinical characteristics associated with mental and physical health presentations. RESULTS: Between 2008-09 and 2014-15, the number of mental health presentations increased by 6.5% per year, that of physical health presentations by 2.1% per year; the proportion of mental health presentations rose from 1.7% to 2.2%. Self-harm accounted for 22.5% of mental health presentations (11 770 presentations) and psychoactive substance use for 22.3% (11 694 presentations); stress-related, mood, and behavioural and emotional disorders together accounted for 40.3% (21 127 presentations). The rates of presentations for self-harm, stress-related, mood, and behavioural and emotional disorders each increased markedly over the study period. Patients presenting with mental health problems were more likely than those with physical health problems to be triaged as urgent (2014-15: 66% v 40%), present outside business hours (36% v 20%), stay longer in the ED (65% v 82% met the National Emergency Access Target), and be admitted to hospital (24% v 18%). CONCLUSIONS: The number of children who presented to Victorian public hospital EDs for mental health problems increased during 2008-2015, particularly for self-harm, depression, and behavioural disorders.