Child Health Needs and the Pediatric Infectious Diseases Workforce: 2020-2040.

Pediatric infectious diseases (PID) physicians prevent and treat childhood infections through clinical care, research, public health, education, antimicrobial stewardship, and infection prevention. This article is part of an American Board of Pediatrics Foundation-sponsored supplement investigating the future of the pediatric subspecialty workforce. The article offers context to findings from a modeling analysis estimating the supply of PID subspecialists in the United States between 2020 and 2040. It provides an overview of children cared for by PID subspecialists, reviews the current state of the PID workforce, and discusses the projected headcount and clinical workforce equivalents of PID subspecialists at the national, census region, and census division levels over this 2-decade period. The article concludes by discussing the education and training, clinical practice, policy, and research implications of the data presented. Adjusting for population growth, the PID workforce is projected to grow more slowly than most other pediatric subspecialties and geographic disparities in access to PID care are expected to worsen. In models considering alternative scenarios, decreases in the number of fellows and time spent in clinical care significantly affect the PID workforce. Notably, model assumptions may not adequately account for potential threats to the PID workforce, including a declining number of fellows entering training and the unknown impact of the COVID-19 pandemic and future emerging infections on workforce attrition. Changes to education and training, clinical care, and policy are needed to ensure the PID workforce can meet the future needs of US children.

Exploring Factors for Implementation of EPAs in Pediatric Subspecialty Fellowships: A Qualitative Study of Program Directors.

OBJECTIVE: To understand fellowship program directors' (FPDs) perspectives on facilitators and barriers to using entrustable professional activities (EPAs) in pediatric subspecialty training. METHODS: We performed a qualitative study of FPDs, balancing subspecialty, program size, geographic region and current uses of EPAs. A study coordinator conducted 1-on-1 interviews using a semistructured approach to explore EPA use or nonuse and factors supporting or preventing their use. Investigators independently coded transcribed interviews using an inductive approach and the constant comparative method. Group discussion informed code structure development and refinement. Iterative data collection and analysis continued until theoretical sufficiency was achieved, yielding a thematic analysis. RESULTS: Twenty-eight FPDs representing 11 pediatric subspecialties were interviewed, of whom 16 (57%) reported current EPA use. Five major themes emerged: (1) facilitators including the intuitive nature and simple wording of EPAs; (2) barriers such as workload burden and lack of a regulatory requirement; (2) variable knowledge and training surrounding EPAs, leading to differing levels of understanding; (3) limited current use of EPAs, even among self-reported users; and (4) complementary nature of EPAs and milestones. FPDs acknowledged the differing strengths of both EPAs and milestones but sought additional knowledge about the value added by EPAs for assessing trainees, including the impact on outcomes. CONCLUSIONS: Identified themes can inform effective and meaningful EPA implementation strategies: Supporting and educating FPDs, ongoing assessment of the value of EPAs in training, and practical integration with current workflow. Generating additional data and engaging stakeholders is critical for successful implementation for the pediatric subspecialties.

Impact of the COVID-19 pandemic on pediatric faculty: a report from nine academic institutions.

BACKGROUND: The COVID-19 pandemic affected home and work routines, which may exacerbate existing academic professional disparities. Objectives were to describe the impact of the pandemic on pediatric faculty's work productivity, identify groups at risk for widening inequities, and explore mitigation strategies. METHODS: A cross-sectional study of faculty members was conducted at nine U.S. pediatric departments. Responses were analyzed by demographics, academic rank, and change in home caregiving responsibility. RESULTS: Of 5791 pediatric faculty members eligible, 1504 (26%) completed the survey. The majority were female (64%), over 40 years old (60%), and assistant professors (47%). Only 7% faculty identified as underrepresented in medicine. Overall 41% reported an increase in caregiving during the pandemic. When comparing clinical, administrative, research, and teaching activities, faculty reported worse 1-year outlook for research activities. Faculty with increased caregiving responsibilities were more likely to report concerns over delayed promotion and less likely to have a favorable outlook regarding clinical and research efforts. Participants identified preferred strategies to mitigate challenges. CONCLUSIONS: The COVID-19 pandemic negatively impacted pediatric faculty productivity with the greatest effects on those with increased caregiving responsibilities. COVID-19 was particularly disruptive to research outlook. Mitigation strategies are needed to minimize the long-term impacts on academic pediatric careers. IMPACT: The COVID-19 pandemic most negatively impacted work productivity of academic pediatric faculty with caregiving responsibilities. COVID-19 was particularly disruptive to short-term (1-year) research outlook among pediatric faculty. Faculty identified mitigation strategies to minimize the long-term impacts of the pandemic on academic pediatric career pathways.

Relationship between epa level of supervision with their associated subcompetency milestone levels in pediatric fellow assessment.

BACKGROUND: Entrustable Professional Activities (EPA) and competencies represent components of a competency-based education framework. EPAs are assessed based on the level of supervision (LOS) necessary to perform the activity safely and effectively. The broad competencies, broken down into narrower subcompetencies, are assessed using milestones, observable behaviors of one's abilities along a developmental spectrum. Integration of the two methods, accomplished by mapping the most relevant subcompetencies to each EPA, may provide a cross check between the two forms of assessment and uncover those subcompetencies that have the greatest influence on the EPA assessment. OBJECTIVES: We hypothesized that 1) there would be a strong correlation between EPA LOS ratings with the milestone levels for the subcompetencies mapped to the EPA; 2) some subcompetencies would be more critical in determining entrustment decisions than others, and 3) the correlation would be weaker if the analysis included only milestones reported to the Accreditation Council for Graduate Medical Education (ACGME). METHODS: In fall 2014 and spring 2015, the Subspecialty Pediatrics Investigator Network asked Clinical Competency Committees to assign milestone levels to each trainee enrolled in a pediatric fellowship for all subcompetencies mapped to 6 Common Pediatric Subspecialty EPAs as well as provide a rating for each EPA based upon a 5-point LOS scale. RESULTS: One-thousand forty fellows were assessed in fall and 1048 in spring, representing about 27% of all fellows. For each EPA and in both periods, the average milestone level was highly correlated with LOS (rho range 0.59-0.74; p < 0.001). Correlations were similar when using a weighted versus unweighted milestone score or using only the ACGME reported milestones (p > 0.05). CONCLUSIONS: We found a strong relationship between milestone level and EPA LOS rating but no difference if the subcompetencies were weighted, or if only milestones reported to the ACGME were used. Our results suggest that representative behaviors needed to effectively perform the EPA, such as key subcompetencies and milestones, allow for future language adaptations while still supporting the current model of assessment. In addition, these data provide additional validity evidence for using these complementary tools in building a program of assessment.

Pediatric Infectious Diseases Milestones: A Step in the Right Direction to Evaluate Subspecialty Learners.

We share the work of the ACGME Pediatric Infectious Diseases Working Group in creating the Pediatric Infectious Diseases-Specific Milestones and discuss key considerations that lead to the reformation of competencies to better assess learners in Pediatric Infectious Diseases.

Clinical competency committee perceptions of entrustable professional activities and their value in assessing fellows: A qualitative study of pediatric subspecialty program directors.

OBJECTIVES: To examine the composition and processes of Clinical Competency Committees (CCCs) assigning entrustable professional activity (EPA) levels of supervision for pediatric subspecialty fellows and to examine fellowship program director (FPD) perspectives about using EPAs to determine fellows' graduation readiness. METHODS: A qualitative study was performed using one-on-one interviews with a purposeful sample of pediatric subspecialty FPDs to yield a thematic analysis. Semi-structured interview guides were used for participants who self-identified as EPA users or non-users. Inductive analysis and coding were performed on transcripts until theoretical sufficiency was attained. RESULTS: Twenty-eight FPDs were interviewed. There was significant variability in the composition and processes of CCCs across subspecialties. FPDs felt that CCCs intuitively understand what entrustment means, allowing for ease of application of level of supervision (LOS) scales and consensus. FPDs perceived that EPAs provided a global assessment of fellows and are one tool to determine graduation readiness. CONCLUSIONS: Although there was variability in the makeup and processes of CCCs across subspecialties, FPDs believe EPAs are intuitive and relatively easy to implement. Consensus can be reached easily using EPA-specific LOS scales focusing on entrustment. FPDs desire a better understanding of how EPAs should be used for graduation.

Rapid Development and Testing of a COVID-19 Vaccine Curriculum for Pediatricians.

BACKGROUND AND OBJECTIVES: As the coronavirus disease 2019 (COVID-19) pandemic evolves and vaccines become available to children, pediatricians must navigate vaccination discussions in the setting of rapidly changing vaccine recommendations and approvals. We developed and evaluated an educational curriculum for pediatricians to improve their knowledge about COVID-19 vaccines and confidence in communicating with patients and families about COVID-19 vaccines. METHODS: Five institutions collaborated to develop an online educational curriculum. Utilizing the collaboration's multidisciplinary expertise, we developed a 3-module curriculum focused on the SARS-CoV-2 virus and vaccine basics, logistics and administration of COVID-19 vaccine, and COVID-19 vaccine communication principles. Surveys administered to clinician participants before and after completion of the curriculum assessed knowledge and confidence; a follow-up survey 1 month after the post-survey assessed persistence of initial findings. RESULTS: A total of 152 pediatric providers participated; 72 completed both pre- and post-surveys. The median knowledge score improved from the pre-survey to the post-survey (79%-93%, P < .001). There was an increase in providers' confidence after completing the curriculum, which persisted in the follow-up survey. In the post-survey, 98% of participants had had the opportunity to discuss the COVID-19 vaccine with patients, and most clinicians reported that the modules decreased apprehension some or significantly. CONCLUSIONS: This project demonstrates rapid and feasible deployment of a curriculum providing up-to-date information to front-line clinicians responsible for having complex conversations about COVID-19 vaccine decision-making. Clinicians who completed this curriculum had sustained increased confidence and decreased levels of apprehension when discussing the COVID-19 vaccine.

Let's Talk About Antibiotics: a randomised trial of two interventions to reduce antibiotic misuse.

BACKGROUND: Children with acute respiratory tract infections (ARTIs) receive ≈11.4 million unnecessary antibiotic prescriptions annually. A noted contributor is inadequate parent-clinician communication, however, efforts to reduce overprescribing have only indirectly targeted communication or been impractical. OBJECTIVES: Compare two feasible (higher vs lower intensity) interventions for enhancing parent-clinician communication on the rate of inappropriate antibiotic prescribing. DESIGN: Multisite, parallel group, cluster randomised comparative effectiveness trial. Data collected between March 2017 and March 2019. SETTING: Academic and private practice outpatient clinics. PARTICIPANTS: Clinicians (n=41, 85% of eligible approached) and 1599 parent-child dyads (ages 1-5 years with ARTI symptoms, 71% of eligible approached). INTERVENTIONS: All clinicians received 20 min ARTI diagnosis and treatment education. Higher intensity clinicians received an additional 50 min communication skills training. All parents viewed a 90 second antibiotic education video. MAIN OUTCOMES AND MEASURES: Inappropriate antibiotic treatment was assessed via blinded medical record review by study clinicians and a priori defined as prescriptions for the wrong diagnosis or use of the wrong agent. Secondary outcomes were revisits, adverse drug reactions (both assessed 2 weeks after the visit) and parent ratings of provider communication, shared decision-making and visit satisfaction (assessed at end of the visit on Likert-type scales). RESULTS: Most clinicians completed the study (n=38, 93%), were doctors (n=25, 66%), female (n=30, 78%) and averaged 8 years in practice. All parent-child dyad provided data for the main outcome (n=855 (54%) male, n=1043 (53%) <2 years). Inappropriate antibiotic prescribing was similar among patients who consulted with a higher intensity (54/696, 7.8%) versus a lower intensity (85/904, 9.4%) clinician. A generalised linear mixed effect regression model (adjusted for the two-stage nested design, clinician type, clinic setting and clinician experience) revealed that the odds of receiving inappropriate antibiotic treatment did not significantly vary by group (AOR 0.99, 95% CI: 0.52 to 1.89, p=0.98). Secondary outcomes of revisits and adverse reactions did not vary between arms, and parent ratings of satisfaction with quality of parent-provider communication (5/5), shared decision making (9/10) and visit satisfaction (5/5) were similarly high in both arms. CONCLUSIONS AND RELEVANCE: Rate of inappropriate prescribing was low in both arms. Clinician education coupled with parent education may be sufficient to yield low inappropriate antibiotic prescribing rates. The absence of a significant difference between groups indicates that communication principles previously thought to drive inappropriate prescribing may need to be re-examined or may not have as much of an impact in practices where prescribing has improved in recent years. TRIAL REGISTRATION NUMBER: NCT03037112.

Differences in pediatric SARS-CoV-2 symptomology and Co-infection rates among COVID-19 Pandemic waves.

An estimated 12.8 million pediatric SARS-CoV-2 infections have occurred within the United States as of March 1 2022, with multiple epidemic waves due to emergence of several SARS-CoV-2 variants. The aim of this study was to compare demographics, clinical presentation, and detected respiratory co-infections during COVID-19 waves to better understand changes in pediatric SARS-CoV-2 epidemiology over time.

Fellow Entrustment for the Common Pediatric Subspecialty Entrustable Professional Activities Across Subspecialties.

OBJECTIVE: To determine the relationship between level of supervision (LOS) ratings for the Common Pediatric Subspecialty Entrustable Professional Activities (EPAs) with their associated subcompetency milestones across subspecialties and by fellowship training year. METHODS: Clinical Competency Committees (CCCs) in 14 pediatric subspecialties submitted LOS ratings for 6 Common Subspecialty EPAs and subcompetency milestone levels mapped to these EPAs. We examined associations between these subcompetency milestone levels and LOS ratings across subspecialty training year by fitting per-EPA linear mixed effects models, regressing LOS rating on milestone level and on training year. RESULTS: CCCs from 211 pediatric fellowship programs provided data for 369 first, 336 second, and 331 third year fellows. Mean subcompetency milestone levels increased similarly among subspecialties for most EPAs compared with the reference, Adolescent Medicine. Mean subcompetency milestones mapped to each EPA and mean EPA LOS ratings generally increased by training year across all subspecialties. CONCLUSIONS: Subcompetency milestones levels mapped to each Common Subspecialty EPA and the EPA LOS ratings increase similarly across subspecialties and by training year, providing validity evidence for using EPA LOS to assess pediatric subspecialty trainee performance. This study supports the development of tools to facilitated the CCC evaluation process across all pediatric subspecialties.

Diagnostic Yield of Saliva for SARS-CoV-2 Molecular Testing in Children.

Pediatric saliva specimen demonstrated high sensitivity (93%) and specificity (96.2%) compared to paired nasopharyngeal swabs (NPS) by Aptima SARS-CoV-2 Assay (Aptima). Viral loads were comparable in both specimen types. Saliva is a safe, noninvasive, and acceptable alternative specimen for SARS-CoV-2 detection in children.

Integration of a Lean Daily Management System into an Antimicrobial Stewardship Program.

Growing demands and limited guidance on efficient use of resources to advance stewardship initiatives challenge antimicrobial stewardship programs (ASP). METHODS: The primary aim was to incorporate a Lean Readiness and Metrics Board (RMB) into ASP and assess team member accountability and satisfaction with weekly 15-minute huddle participation within 1 year of implementation. ASP team survey data were analyzed for comments regarding Lean integration, team communication, and productivity. The second aim was to develop 5 shared metrics associated with quality, people, delivery, safety, and stewardship and evaluate ASP team productivity by assessing the impact of projects targeted at each specific metric. Pharmacist-physician ASP scheduling conflicts were addressed through identified rounding times under the "People" metric. The "Quality" metric assessed ASP intervention disagreement rate and collaborations that occurred to reduce disagreement. ASP tracked the number of individuals educated by ASP monthly through the "Delivery" metric. RESULTS: Since August 2018, ASP replaced hour-long monthly meetings with weekly huddles at the RMB. On average, 14 members (88%) of the ASP participate weekly. Team members report improvement in communication and satisfaction with Lean integration. Metric utilization enhanced productivity. For the metrics under "People," "Quality," and "Delivery," reduced scheduling conflicts occurred, the ASP intervention disagreement rate decreased (37.0%-25.6%; P < 0.001), and the ASP educated an average of 79 learners per month. CONCLUSIONS: Weekly huddles at the RMB enhanced communication and team accountability while visually displaying program needs, progress, and achievements. The RMB helps to ensure ongoing institutional commitment, and Lean methods show promise for evaluating and improving ASP productivity.

Agreement of Program Directors With Clinical Competency Committees for Fellow Entrustment.

OBJECTIVES: Fellowship program directors (FPD) and Clinical Competency Committees (CCCs) both assess fellow performance. We examined the association of entrustment levels determined by the FPD with those of the CCC for 6 common pediatric subspecialty entrustable professional activities (EPAs), hypothesizing there would be strong correlation and minimal bias between these raters. METHODS: The FPDs and CCCs separately assigned a level of supervision to each of their fellows for 6 common pediatric subspecialty EPAs. For each EPA, we determined the correlation between FPD and CCC assessments and calculated bias as CCC minus FPD values for when the FPD was or was not a member of the CCC. In addition, we examined the effect of program size, FPD understanding of EPAs, and subspecialty on the correlations. Data were obtained in fall 2014 and spring 2015. RESULTS: A total of 1040 fellows were assessed in the fall and 1048 in the spring. In both periods and for each EPA, there was a strong correlation between FPD and CCC supervision levels (P < .001). The correlation was somewhat lower when the FPD was not a CCC member (P < .001). Overall bias in both periods was small. CONCLUSIONS: The correlation between FPD and CCC assignment of EPA supervision levels is strong. Although slightly weaker when the FPD is not a CCC member, bias is small, so this is likely unimportant in determining fellow entrustment level. The similar performance ratings of FPDs and CCCs support the validity argument for EPAs as competency-based assessment tools.

Reductions in Parent Interest in Receiving Antibiotics following a 90-Second Video Intervention in Outpatient Pediatric Clinics.

OBJECTIVES: To assess the impact of a 90-second animated video on parents' interest in receiving an antibiotic for their child. STUDY DESIGN: This pre-post test study enrolled English and Spanish speaking parents (n = 1051) of children ages 1-5 years presenting with acute respiratory tract infection symptoms. Before meeting with their provider, parents rated their interest in receiving an antibiotic for their child, answered 6 true/false antibiotic knowledge questions, viewed the video, and then rated their antibiotic interest again. Parents rated their interest in receiving an antibiotic using a visual analogue scale ranging from 0 to 100, with 0 being "I definitely do not want an antibiotic," 50 "Neutral," and 100 "I absolutely want an antibiotic." RESULTS: Parents were 84% female, with a mean age of 32 ± 6.0, 26.0% had a high school education or less, 15% were black, and 19% were Hispanic. After watching the video, parents' average antibiotic interest ratings decreased by 10 points (mean, 57.0 ± 20 to M ± 21; P < .0001). Among parents with the highest initial antibiotic interest ratings (≥60), even greater decreases were observed (83.0 ± 12.0 to 63.4 ± 22; P < .0001) with more than one-half (52%) rating their interest in the low or neutral ranges after watching the video. CONCLUSIONS: A 90-second video can decrease parents' interest in receiving antibiotics, especially among those with higher baseline interest. This scalable intervention could be used in a variety of settings to reduce parents' interest in receiving antibiotics. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03037112.

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.

Measuring shared decision-making in the pediatric outpatient setting: Psychometric performance of the SDM-Q-9 and CollaboRATE among English and Spanish speaking parents in the US Midwest.

OBJECTIVE: Shared decision-making (SDM) measures have never been assessed for validity and feasibility in pediatric outpatient settings. We compared psychometric performance of parent adaptations of a well-established measure (SDM-Q-9) to a newer measure focusing on provider effort in facilitating SDM (CollaboRATE) in two clinics. METHODS: English (n = 955) and Spanish (n = 58) speaking parents of children ages 1-5 years with symptoms of acute respiratory tract infections (ARTI) completed post-visit SDM-Q-9, CollaboRATE, satisfaction items (visit, provider communication, and study participation), and qualitative feedback. RESULTS: Parents felt CollaboRATE was more comprehensible and relevant than SDM-Q-9, which refers to decision-making actions difficult to define in ARTI visits. Among English-speakers, both measures showed high internal consistency (α = 0.91, α = 0.97). SDM-Q-9 reliability was strong (split-half, r = 0.83) and CollaboRATE weak-to-moderate (two-week test-retest, ρ = 0.41-0.66). Convergent validity with communication and visit satisfaction was poor for SDM-Q-9 (r=0.38, r=0.34) but higher for CollaboRATE (r=0.59, r = 0.52). Both showed divergent validity with study participation satisfaction (r=0.08, r=0.13). Spanish versions demonstrated similar results. CONCLUSIONS: Parent preference and correlations with satisfaction support CollaboRATE over SDM-Q-9, however psychometrics were borderline acceptable. PRACTICE IMPLICATIONS: Tools like CollaboRATE that focus on provider effort appear more appropriate for routine pediatric visits where SDM outcomes may be difficult to identify, yet additional validation research is needed.

Competencies, Milestones, and a Level of Supervision Scale for Entrustable Professional Activities for Scholarship.

PROBLEM: Scholarship is an important element of both undergraduate and graduate medical education, and scholarly activity is required for all pediatric fellows. However, despite the creation of entrustable professional activities (EPAs) for scholarship, the specific progressive levels of performance and the appropriate level of supervision for a given performance level have not been defined. The authors developed competencies and milestones for the scholarship EPA to provide a framework for assessment across the continuum; a level of supervision scale was also developed. APPROACH: The Vitae Researcher Development Framework served as a template to create the competencies and milestones for the scholarship EPA. Beginning in September 2015 and using a modified Delphi approach, three drafts were circulated to individuals with expertise in various types of scholarship until broad agreement was achieved. Then, in October 2016, the Steering Committee of the Subspecialty Pediatrics Investigator Network created a level of supervision scale, modeled after one it had previously developed. OUTCOMES: Eight competencies were identified as important in making entrustment decisions related to scholarship. For each competency, five milestone levels that span the continuum from novice to expert were created. A supervision scale with five progressive levels of entrustment was also created. NEXT STEPS: Next steps include a study to obtain validity evidence for the supervision scale and determine the correlation between milestone and supervision levels. These competencies, milestones, and supervision levels can potentially serve as a road map for trainees and junior faculty and also play a role in the assessment of physician-scientists.