Pediatric Medical Subspecialist Use in Outpatient Settings.

Importance: A first step toward understanding whether pediatric medical subspecialists are meeting the needs of the nation's children is describing rates of use and trends over time. Objectives: To quantify rates of outpatient pediatric medical subspecialty use. Design, Setting, and Participants: This repeated cross-sectional study of annual subspecialist use examined 3 complementary data sources: electronic health records from PEDSnet (8 large academic medical centers [January 1, 2010, to December 31, 2021]); administrative data from the Healthcare Integrated Research Database (HIRD) (14 commercial health plans [January 1, 2011, to December 31, 2021]); and administrative data from the Transformed Medicaid Statistical Information System (T-MSIS) (44 state Medicaid programs [January 1, 2016, to December 31, 2019]). Annual denominators included 493 628 to 858 551 patients younger than 21 years with a general pediatric visit in PEDSnet; 5 million beneficiaries younger than 21 years enrolled for at least 6 months in HIRD; and 35 million Medicaid or Children's Health Insurance Program beneficiaries younger than 19 years enrolled for any amount of time in T-MSIS. Exposure: Calendar year and type of medical subspecialty. Main Outcomes and Measures: Annual number of children with at least 1 completed visit to any pediatric medical subspecialist in an outpatient setting per population. Use rates excluded visits in emergency department or inpatient settings. Results: Among the study population, the proportion of girls was 51.0% for PEDSnet, 51.1% for HIRD, and 49.3% for T-MSIS; the proportion of boys was 49.0% for PEDSnet, 48.9% for HIRD, and 50.7% for T-MSIS. The proportion of visits among children younger than 5 years was 37.4% for PEDSnet, 20.9% for HIRD, and 26.2% for T-MSIS; most patients were non-Hispanic Black (29.7% for PEDSnet and 26.1% for T-MSIS) or non-Hispanic White (44.9% for PEDSnet and 43.2% for T-MSIS). Annual rates for PEDSnet ranged from 18.0% to 21.3%, which were higher than rates for HIRD (range, 7.9%-10.4%) and T-MSIS (range, 7.6%-8.6%). Subspecialist use increased in the HIRD commercial health plans (annual relative increase of 2.4% [95% CI, 1.6%-3.1%]), but rates were essentially flat in the other data sources (PEDSnet, -0.2% [95% CI, -1.1% to 0.7%]; T-MSIS, -0.7% [95% CI, -6.5% to 5.5%]). The flat PEDSnet growth reflects a balance between annual use increases among those with commercial insurance (1.2% [95% CI, 0.3%-2.1%]) and decreases in use among those with Medicaid (-0.9% [95% CI, -1.6% to -0.2%]). Conclusions and Relevance: The findings of this cross-sectional study suggest that among children, 8.6% of Medicaid beneficiaries, 10.4% of those with commercial insurance, and 21.3% of those whose primary care is received in academic health systems use pediatric medical subspecialty care each year. There was a small increase in rates of subspecialty use among children with commercial but not Medicaid insurance. These data may help launch innovations in the primary-specialty care interface.

Estimation and Comparison of Current and Future Racial/Ethnic Representation in the US Health Care Workforce.

Importance: The COVID-19 pandemic coupled with health disparities have highlighted the disproportionate burden of disease among Black, Hispanic, and Native American (ie, American Indian or Alaska Native) populations. Increasing transparency around the representation of these populations in health care professions may encourage efforts to increase diversity that could improve cultural competence among health care professionals and reduce health disparities. Objective: To estimate the racial/ethnic diversity of the current health care workforce and the graduate pipeline for 10 health care professions and to evaluate whether the diversity of the pipeline suggests greater representation of Black, Hispanic, and Native American populations in the future. Design, Setting, and Participants: This cross-sectional study used weighted data from the 2019 American Community Survey (ACS) to compare the diversity of 10 health care occupations (advanced practice registered nurses, dentists, occupational therapists, pharmacists, physical therapists, physician assistants, physicians, registered nurses, respiratory therapists, and speech-language pathologists) with the diversity of the US working-age population, and 2019 data from the Integrated Postsecondary Education Data System (IPEDS) were used to compare the diversity of graduates with that of the US population of graduation age. Data from the IPEDS included all awards and degrees conferred between July 1, 2018, and June 30, 2019, in the US. Main Outcomes and Measures: A health workforce diversity index (diversity index) was developed to compare the racial/ethnic diversity of the 10 health care professions (or the graduates in the pipeline) analyzed with the racial/ethnic diversity of the current working-age population (or average student-age population). For the current workforce, the index was the ratio of current workers in a health occupation to the total working-age population by racial/ethnic group. For new graduates, the index was the ratio of recent graduates to the population aged 20 to 35 years by racial/ethnic group. A value equal to 1 indicated equal representation of the racial/ethnic groups in the current workforce (or pipeline) compared with the working-age population. Results: The study sample obtained from the 2019 ACS comprised a weighted total count of 148 358 252 individuals aged 20 to 65 years (White individuals: 89 756 689; Black individuals: 17 916 227; Hispanic individuals: 26 953 648; and Native American individuals: 1 108 404) who were working or searching for work and a weighted total count of 71 608 009 individuals aged 20 to 35 years (White individuals: 38 995 242; Black individuals: 9 830 765; Hispanic individuals: 15 257 274; and Native American individuals: 650 221) in the educational pipeline. Among the 10 professions assessed, the mean diversity index for Black people was 0.54 in the current workforce and in the educational pipeline. In 5 of 10 health care professions, representation of Black graduates was lower than representation in the current workforce (eg, occupational therapy: 0.31 vs 0.50). The mean diversity index for Hispanic people was 0.34 in the current workforce; it improved to 0.48 in the educational pipeline but remained lower than 0.50 in 6 of 10 professions, including physical therapy (0.33). The mean diversity index for Native American people was 0.54 in the current workforce and increased to 0.57 in the educational pipeline. Conclusions and Relevance: This study found that Black, Hispanic, and Native American people were underrepresented in the 10 health care professions analyzed. Although some professions had greater diversity than others and there appeared to be improvement among graduates in the educational pipeline compared with the current workforce, additional policies are needed to further strengthen and support a workforce that is more representative of the population.