Kara E. Lamarand

Pediatric Nurse Practitioners: Roles and Scope of Practice

BACKGROUND: There are ∼13 000 pediatric nurse practitioners (PNPs) in the United States. PNPs have been suggested as professionals who could provide care to the growing cadre of children with chronic illnesses and expand the pool of subspecialty care providers. Little is known about current roles of PNPs in primary or subspecialty care. OBJECTIVE: To gain a better understanding of the roles, focus of practice, professional setting, and professional responsibilities of PNPs. METHODS: We conducted a mail survey of a random national sample of 1200 PNPs stratified according to states that license NPs to practice independently. χ2 statistics were used to assess responses from PNPs in states that allow independent practice versus those that do not and on PNPs in primary versus specialty care. RESULTS: The overall response rate was 82.4%. Ninety-six percent (n = 636) of the PNPs were female. More than half of all the respondents (59% [n = 391]) worked in primary care, and almost two-thirds (64% [n = 394]) did not provide care in inpatient settings. Only 11% of the PNPs in states that allow independent practice, practiced independently. CONCLUSIONS: The majority of PNPs currently work in primary care, and most do not have any inpatient roles. It does not seem that independent PNP practices are responsible for a significant portion of pediatric visits. For those who posit that PNPs will help alleviate the currently perceived shortage of pediatric subspecialists, our findings indicate that it likely will not occur without a significant change in the PNP workforce distribution.

Measuring Family HRQoL Spillover Effects Using Direct Health Utility Assessment

Background. Applications of cost-effectiveness analysis do not typically incorporate effects on caregiver quality of life despite increasing evidence that these effects are measurable. Methods. Using a national sample of US adults, we conducted 2 cross-sectional surveys during December 2011 and January 2012. One version asked respondents to value their own experience as the family member of a person with a chronic illness (experienced sample), and the other version asked respondents to value hypothetical scenarios describing the experience of having a family member with a chronic illness (community sample). Conditions included Alzheimer’s disease/dementia, arthritis, cancer, and depression. Using standard gamble questions, respondents were asked to value the spillover effects of a family member’s illness. We used regression analysis to evaluate the disutility (loss in health-related quality of life) of having a family member with a chronic illness by condition and relationship type, controlling for the respondent’s own conditions and sociodemographic characteristics. Results. For the experienced sample (n = 1389), regression analyses suggested that greater spillover was associated with certain conditions (arthritis, depression) compared with other conditions (Alzheimer’s disease, cancer). For the community sample (n = 1205), regression analyses indicated that lower spillover was associated with condition (cancer) but not the type of relationship with the ill family member (parent, child, spouse). Conclusions. The effects of illness extend beyond the individual patient to include effects on caregivers of patients, parents of ill children, spouses, and other close family and household members. Cost-effectiveness analyses should consider the inclusion of health-related quality of life spillover effects in addition to caregiving time costs incurred by family members of ill individuals.

Hospitalists' involvement in pediatrics training: perspectives from pediatric residency program and clerkship directors.

Purpose To explore the use and perceived impact of pediatric hospitalists as teaching attendings among pediatric residency and clerkship programs. Method Between November 2007 and February 2008, the authors conducted a mail-based survey of all pediatric residency program directors (170) and pediatric clerkship directors (131) in the United States as identified by the Association of Pediatric Program Directors and Council on Medical Student Education in Pediatrics. The surveys focused on the responsibilities of pediatric hospitalists in training programs and their perceived impact on the roles of pediatric residents and medical students. Results The response rate for residency directors was 86% (146/170) and 87% (114/131) for clerkship directors. One hundred thirteen (77%) residency programs and 91 (80%) clerkship programs used hospitalists as teaching attendings. Among these programs, 65% (73) of residency program directors and 64% (58) of clerkship directors reported that pediatric hospitalists are responsible for all general inpatient services. The majority of residency (76%, 84) and clerkship directors (71%, 64) reported that hospitalists are more accessible to trainees than traditional attendings. A minority of residency program directors (36%, 39) reported that use of hospitalists has decreased senior resident autonomy. Conclusions The role of hospitalists in resident and student education will likely continueto evolve over the next decade.Additional refinement of the roles and responsibilities of hospitalists will address lingering concerns in some programs about resident autonomy.

Neonatal Nurse Practitioners: Distribution, Roles and Scope of Practice

OBJECTIVE: We sought to determine the distribution and scope of practice of the neonatal nurse practitioner (NNP) workforce across the United States. METHODS: To determine distribution, we used counts of certified NNPs from the National Certification Corp (Chicago, IL). We calculated state NNP/child population ratios as the number of NNPs divided by the state population 0 to 17 years of age. We calculated NNP/NICU bed ratios as the number of NNPs divided by the total number of NICU beds per state. To characterize roles and scope of practice, we conducted a mail survey of a random national sample of 300 NNPs in states that license nurse practitioners to practice independently and 350 NNPs in states that require physician involvement. RESULTS: The greatest concentrations of NNPs per capita were in the Midwest, South, and Mid-Atlantic region. Thirty-one states had <100 total NNPs. The survey response rate was 77.1%. More than one-half of NNP respondents (54% [n = 211]) reported that they spent the majority of their time in a community hospital, whereas more than one-third (37% [n = 144]) were in an academic health center. Only 2% (n = 7) reported that they engaged in independent practice. CONCLUSIONS: As with many health care professionals, the supply of NNPs may not be distributed according to need. With increasing concern regarding the availability of NNPs, comprehensive studies that examine the demand for NNPs and the roles of other clinicians in the NICU should provide a greater understanding of appropriate NICU workforce capacity and needs.

Pediatric physician assistants: Distribution and scope of practice

BACKGROUND: Physician assistants (PAs) are licensed to practice with physician supervision. PAs do not specialize or subspecialize as part of their formal standard training; consequently, their license is not limited to a specific specialty. As such, PAs can, and do, change their practice settings at will. Some researchers have projected plans for the future use of the pediatric PA workforce. However, the information on which those projections have been based is limited. OBJECTIVE: To provide information regarding the current status of pediatric PAs and to inform future workforce deliberations, we studied their current distribution and scope of practice. METHODS: Data from the American Association of Physician Assistants and the US Census Bureau were used to map the per-capita national distribution of pediatric PAs. We conducted a mail survey of a random sample of 350 PAs working in general pediatrics and 300 working in pediatric subspecialties. RESULTS: Most states have <50 pediatric PAs, and there is significant variation in their distribution across the nation. The overall survey response rate was 83.5%; 82% (n = 359) were female. More than half of the respondents (57% [n = 247]) reported that they currently are working in pediatric primary care, mostly in private-practice settings. CONCLUSIONS: PAs can, and do, play an important role in the care of children in the United States. However, the impact of that role is limited by the relative scarcity of PAs currently engaged in pediatric practice.

Using medicaid claims to identify children with asthma

OBJECTIVE To assess the accuracy of using administrative data from state-managed programs to identify children with asthma in a statewide immunization information system. We wished to understand the degree to which alternative asthma case definitions applied to administrative data influence the accuracy of cases identified in an immunization information system. DESIGN & SETTING Children aged 2 to 18 years were sequentially classified into 3-case definition groups on the basis of Michigan Department of Community Health administrative data (2005-2006): (1) children with a Childrens Special Health Care Services (CSHCS) Program qualifying diagnosis of asthma (CSHCS cases); (2) those having 1 or more asthma medication claims (Rx cases); or (3) those without asthma medications having 1 or more health services claim reporting an asthma diagnosis code (Dx cases). PARTICIPANTS Children were randomly selected from each asthma case definition group; parents were invited to participate in a telephone interview to document physician diagnosis of asthma, symptoms, activity limitations, medications, and asthma health services use. MAIN OUTCOME MEASURES The positive predictive value of parent report of a physician diagnosis of asthma; asthma severity, based on National Asthma Education and Prevention Program criteria. RESULTS : Of 440 completed interviews, 89% of parents confirmed the childs high-risk status, reporting physician diagnosis of asthma (83%), wheezy-cough (5%), or reactive airway disease (1%). The positive predictive value varied for CSHCS cases (100%), Rx cases (91%) and Dx cases (73%, P < .0001). Although reported asthma severity levels were similar among CSHCS and Rx cases (P = .9100), asthma severity was lower among Dx cases (P = .0218). CONCLUSIONS Medicaid administrative data can be used to accurately identify children with asthma and represents a feasible approach for Medicaid programs and health plans to identify priority groups for targeted influenza vaccination reminders.

Community-Based Values for 2009 Pandemic Influenza A H1N1 Illnesses and Vaccination-Related Adverse Events

Objective To evaluate community-based values for avoiding pandemic influenza (A) H1N1 (pH1N1) illness and vaccination-related adverse events in adults and children. Methods Adult community members were randomly selected from a nationally representative research panel to complete an internet survey (response rate = 65%; n = 718). Respondents answered a series of time trade-off questions to value four hypothetical health state scenarios for varying ages (1, 8, 35, or 70 years): uncomplicated pH1N1 illness, pH1N1 illness-related hospitalization, severe allergic reaction to the pH1N1 vaccine, and Guillain-Barré syndrome. We calculated descriptive statistics for time trade-off amounts and derived quality adjusted life year losses for these events. Multivariate regression analyses evaluated the effect of scenario age, as well as respondent socio-demographic and health characteristics on time trade-off amounts. Results Respondents were willing to trade more time to avoid the more severe outcomes, hospitalization and Guillain-Barré syndrome. In our adjusted and unadjusted analyses, age of the patient in the scenario was significantly associated with time trade-off amounts (p-value<0.05), with respondents willing to trade more time to prevent outcomes in children versus adults. Persons who had received the pH1N1 vaccination were willing to trade significantly more time to avoid hospitalization, severe allergic reaction, and Guillain-Barré syndrome, controlling for other variables in adjusted analyses.(p-value<0.05) Conclusions Community members placed the highest value on preventing outcomes in children, compared with adults, and the time trade-off values reported were consistent with the severity of the outcomes presented. Considering these public values along with other decision-making factors may help policy makers improve the allocation of pandemic vaccine resources.

Permanent pediatric diplomate awareness of and perspectives on maintenance of certification.

OBJECTIVE Since diplomates of the American Board of Pediatrics with permanent certificates will not be required to participate in the Maintenance of Certification (MOC) program, we determined the perceptions of permanent certificate holders about MOC and their degree of interest in participation. STUDY DESIGN We conducted a 12-item mail survey of 1693 diplomates with permanent certificates. Frequency distributions were calculated for all survey items. chi(2) statistics were used to explore associations between the variables. RESULTS The response rate was 77.7%. Less than one-third of generalist respondents (28%, n = 122) and 13% of subspecialists (n = 63) agreed that they would be willing to participate in general pediatrics MOC (P < .0001). However, approximately half the subspecialists (48%, n = 221) agreed that they would be willing to participate in subspecialty MOC. Approximately three-fourths of generalists (79%, n = 354) and subspecialists (74%, n = 338) disagreed that MOC is necessary for keeping up-to-date in clinical pediatrics. Few respondents believed that parents understand the MOC program. CONCLUSION A wide range of attitudes and perceptions about MOC exists among holders of permanent certificates. Concerns about the importance of MOC to parents and the usefulness of MOC participation in improving quality of care will need to be addressed.

Intracranial pressure monitoring in childhood meningitis with coma: a national survey of neurosurgeons in the United States.

Objectives: To describe the beliefs and attitudes of U.S. neurosurgeons regarding the use of intracranial pressure monitors among comatose children with meningitis. Design and Setting: A questionnaire was administered by mail between March and July 2009, to a random sample of 500 adult neurosurgeons and to all 228 pediatric neurosurgeons in the Congress of Neurologic Surgeons. Interventions: None. Measurements and Main Results: The response rate was 60%. Abnormal computed tomography scans, either with brain swelling or hydrocephalus, and older child age were likely to prompt neurosurgeons to consider monitoring intracranial pressure, whereas etiology of meningitis did not impact the decision to monitor intracranial pressure. Fifty-two percent of neurosurgeons believed computed tomography scans were inaccurate in detecting elevated intracranial pressure in comatose children with meningitis, 22% believed otherwise, and 26% were uncertain. Only 25% of neurosurgeons felt there was sufficient medical evidence to monitor intracranial pressure in comatose children with meningitis, with higher frequency among adult than pediatric (30% vs. 16%; p < .01) neurosurgeons. Eighty-one percent of neurosurgeons disagreed with the notion that comatose children with meningitis were too ill to benefit from placement of intracranial pressure monitors. Pediatric neurosurgeons reported a higher frequency than adult neurosurgeons of having placed more (more than five) intracranial pressure monitors in comatose children with meningitis (42% vs. 28%; p < .01). Conclusions: Most neurosurgeons are willing to consider monitoring intracranial pressure among comatose children with meningitis in the presence of abnormal findings on computed tomography scan and with older patient age. These findings are instructive in view of the current uncertainty and equipoise in clinical practice regarding intracranial pressure monitoring in these critically ill children.

Basis for immunization recommendations among countries of the World Health Organization European region

Despite World Health Organization (WHO) goals to reduce the incidence of several vaccine preventable diseases across the European region, the adoption of new vaccines has been slower than expected. To identify factors that influence the decision to recommend new vaccines, especially hepatitis B and Haemophilus influenzae, type b (Hib) vaccines, we studied the factors used in immunization decisionmaking across this region. A structured questionnaire was sent to the Immunization Program Manager of each country with the option to return the completed survey by e-mail, fax, or complete a web-based survey. Frequency distributions were explored for all survey items. Bivariate analysis was conducted to assess differences between countries by economic status. Of the 47 (89%) countries responding, the majority reported vaccine safety (91%), epidemiology of disease (85%), and the severity of disease prevented (74%) as very important factors when making immunization recommendations. Half of the countries reported the cost of disease burden and cost-effectiveness data were very important financial information when implementing vaccine recommendations. While no significant difference was seen by economic status in countries recommending hepatitis B vaccine (p=0.1129), high economic status countries were significantly more likely to report Hib vaccine is part of the country’s recommended schedule (p=0.0011). Understanding the importance of the factors considered by countries when making national immunization recommendation decisions can aid public health experts in providing countries with information needed to support these decisions.