Kristin N. Ray

Supply and Utilization of Pediatric Subspecialists in the United States

OBJECTIVE: The wide geographic variation in pediatric subspecialty supply in the United States has been a source of concern. Whether children in areas with decreased supply receive less subspecialty care or have worse outcomes has not been adequately evaluated. Among children with special health care needs, we examined the association between pediatric subspecialty supply and subspecialty utilization, need, child disease burden, and family disease burden. METHODS: We measured pediatric subspecialist supply as pediatric subspecialists per capita in each residential county. By using the 2009–2010 National Survey of Children With Special Health Care Needs and controlling for many potential confounders, we examined the association between quintile of pediatric subspecialty supply and parent-reported subspecialty utilization, perceived subspecialty need, and child and family disease burden. RESULTS: County-level pediatric subspecialty supply ranged from a median of 0 (lowest quintile) to 59 (highest quintile) per 100 000 children. In adjusted results, compared with children in the highest quintile, children in the lowest quintile of supply were 4.8% less likely to report ambulatory subspecialty visits (P < .001), 5.3% less likely to perceive subspecialty care needs (P < .001), and 2.3% more likely to report emergency department visits (P = .018). There were no meaningful differences between pediatric subspecialty supply quintiles for other measures of child or family disease burden. CONCLUSIONS: Children living in counties with the lowest supply of pediatric subspecialists had both decreased perceived need for subspecialty care and decreased utilization of subspecialists. However, the differences in supply were not associated with meaningful differences in child or family disease burden.

Premature Infants Born to Adolescent Mothers: Health Care Utilization After Initial Discharge

OBJECTIVE Premature infants have increased health care utilization after initial discharge compared with term infants. Young maternal age has been shown to impact health care utilization among term infants, but little is known about the impact of maternal age on health care utilization among premature infants. We compared health care utilization among premature infants of adolescent (aged < or = 19 years) and young adult (aged 20-29 years) mothers, hypothesizing that premature infants of adolescent mothers would have increased acute care utilization, while having decreased preventive care utilization. METHODS In this retrospective cohort study, we analyzed health care utilization of premature infants born to adolescent mothers (n = 76) compared with premature infants born to young adult mothers (n = 587) within a cohort of premature infants born between 1998 and 2001 in an integrated health care delivery system. RESULTS After controlling for illness severity, premature infants born to adolescent mothers had significantly increased odds of medical rehospitalizations (odds ratio 3.57, 95% confidence interval, 1.81-7.05) and emergency department visits (odds ratio 3.67, 95% confidence interval, 2.11-6.39) during the first year after initial discharge compared with premature infants born to young adult mothers. Differences in rehospitalization rates were significant within the first 3 months after discharge (P < .001). Frequency of preventive care visits was not significantly different between the two groups. CONCLUSIONS Despite similar severity of chronic illness and similar preventive care utilization, premature infants born to adolescent mothers had significantly increased rates of rehospitalizations and emergency department visits compared with premature infants born to young adult mothers.

Disparities in Time Spent Seeking Medical Care in the United States

recommendation for their use. Despite the lack of guidelinebased recommendations and little evidence to support IABP use, the study by Inohara et al2 finds that IABPs continue to be used frequently and that their use is associated with increased inhospital mortality. Although there has been enthusiasm about newer PVADs (eg, Impella LP2.5 [Abiomed Europe GmbH] and TandemHeart [Cardiac Assist]), initial studies regarding their use to treat cardiogenic shock have not shown any significant survival benefit compared with IABPs and observed increased bleeding and a tendency toward more limb ischemia from the use of larger sheaths with PVADs.7 Similar to IABPs, no net benefit was demonstrated in hemodynamically stable patients with an implanted PVAD undergoing high-risk angioplasty, another common clinical scenario for the use of PVADs.8 Why is there reluctance to abandon these invasive, expensive, and seemingly ineffective therapies? The answer might be multifactorial. Cardiogenic shock complicating myocardial infarction remains a formidable foe and is associated with 40% to 50% in-hospital mortality.9 In this setting, only early revascularization has shown improved survival. In some of these critically ill patients, it may seem reasonable to use mechanical circulatory support devices as salvage therapy. However, they offer little benefit in reducing clinical events, and have high costs and significant complication rates. Inohara et al2 confirm previous findings that IABPs and PVADs are being increasingly used in patients without indications for their use. Although the precise reasons for such excessive use remain to be established, misaligned financial incentives might have a role. Furthermore, continued use of IABPs may be due to established routines or treatment protocols, with commission bias tending toward action rather than inaction.10 Based on available data, the use of these invasive and expensive mechanical circulatory support devices should be critically appraised and limited because of significant complication rates associated with their use and a lack of evidence demonstrating any benefit. In the use of IABPs and PVADs, it seems appropriate to conclude that perhaps less is more.

Hospitalization of Rural and Urban Infants During the First Year of Life

OBJECTIVES: To examine hospitalizations and length of stay (LOS) for infants aged <1 year in rural and urban counties, hypothesizing that infants living in rural counties experience significantly different hospital use compared with urban infants. METHODS: Birth certificates for infants born in California hospitals between 1993 and 2005 and surviving to discharge were linked to hospital discharge records and death certificates during the first year of life, resulting in a study population of >6.4 million. Hospitalizations, cumulative LOS, readmission rates, and mortality were compared by using univariate and multivariable analysis for infants living in small rural, large rural, small urban, and large urban counties. Odds of hospitalization and cumulative LOS were also examined for common infant diagnoses. RESULTS: Infants living in increasingly rural counties experienced decreasing rates of hospitalization and decreasing number of hospitalized days during the first year of life. Infants living in small rural counties experienced 370 hospital days per 1000 infants compared with 474 hospital days per 1000 infants living in large urban counties. In multivariable analysis, infants in large urban counties experienced increased odds of hospitalization (odds ratio: 1.20 [95% confidence interval: 1.06–1.36]) and increased hospitalized days (incidence risk ratio: 1.17 [95% confidence interval: 1.06–1.29]) compared with infants in small rural counties. For most common diagnoses, urban residence was associated with either increased odds of hospitalization or increased cumulative LOS. CONCLUSIONS: Infants living in rural California counties experienced decreased hospital utilization, including decreased hospitalization and decreased LOS, compared with infants living in urban counties.

Access to High Pediatric-Readiness Emergency Care in the United States

Objective To determine the geographic accessibility of emergency departments (EDs) with high pediatric readiness by assessing the percentage of US children living within a 30‐minute drive time of an ED with high pediatric readiness, as defined by collaboratively developed published guidelines. Study design In this cross‐sectional analysis, we examined geographic access to an ED with high pediatric readiness among US children. Pediatric readiness was assessed using the weighted pediatric readiness score (WPRS) of US hospitals based on the 2013 National Pediatric Readiness Project (NPRP) survey. A WPRS of 100 indicates that the ED meets the essential guidelines for pediatric readiness. Using estimated drive time from ZIP code centroids, we determined the proportions of US children living within a 30‐minute drive time of an ED with a WPRS of 100 (maximum), 94.3 (90th percentile), and 83.6 (75th percentile). Results Although 93.7% of children could travel to any ED within 30 minutes, only 33.7% of children could travel to an ED with a WPRS of 100, 55.3% could travel to an ED with a WPRS at or above the 90th percentile, and 70.2% could travel to an ED with a WPRS at or above the 75th percentile. Among children within a 30‐minute drive of an ED with the maximum WPRS, 90.9% lived closer to at least 1 alternative ED with a WPRS below the maximum. Access varied across census divisions, ranging from 14.9% of children in the East South Center to 56.2% in the Mid‐Atlantic for EDs scoring a maximum WPRS. Conclusion A significant proportion of US children do not have timely access to EDs with high pediatric readiness.

Clinician Attitudes Toward Adoption of Pediatric Emergency Telemedicine in Rural Hospitals.

Objective Although there is growing evidence regarding the utility of telemedicine in providing care for acutely ill children in underserved settings, adoption of pediatric emergency telemedicine remains limited, and little data exist to inform implementation efforts. Among clinician stakeholders, we examined attitudes regarding pediatric emergency telemedicine, including barriers to adoption in rural settings and potential strategies to overcome these barriers. Methods Using a sequential mixed-methods approach, we first performed semistructured interviews with clinician stakeholders using thematic content analysis to generate a conceptual model for pediatric emergency telemedicine adoption. Based on this model, we then developed and fielded a survey to further examine attitudes regarding barriers to adoption and strategies to improve adoption. Results Factors influencing adoption of pediatric emergency telemedicine were identified and categorized into 3 domains: contextual factors (such as regional geography, hospital culture, and individual experience), perceived usefulness of pediatric emergency telemedicine, and perceived ease of use of pediatric emergency telemedicine. Within the domains of perceived usefulness and perceived ease of use, belief in the relative advantage of telemedicine was the most pronounced difference between telemedicine proponents and nonproponents. Strategies identified to improve adoption of telemedicine included patient-specific education, clinical protocols for use, decreasing response times, and simplifying the technology. Conclusions More effective adoption of pediatric emergency telemedicine among clinicians will require addressing perceived usefulness and perceived ease of use in the context of local factors. Future studies should examine the impact of specific identified strategies on adoption of pediatric emergency telemedicine and patient outcomes in rural settings.

Family Perspectives on High-Quality Pediatric Subspecialty Referrals

OBJECTIVE Although children are frequently referred to subspecialist physicians, many inadequacies in referral processes have been identified from physician and system perspectives. Little is known, however, about how to comprehensively measure or improve the quality of the referral systems from a family-centered perspective. To foster family-centered improvements to pediatric subspecialty referrals, we sought to develop a framework for high-quality, patient-centered referrals from the perspectives of patients and their families. METHODS We used stakeholder-informed qualitative analysis of parent, caregiver, and patient interviews to identify outcomes, processes, and structures of high-quality pediatric subspecialty referrals as perceived by patients and their family members. RESULTS We interviewed 21 informants. Informants identified 5 desired outcomes of subspecialty referrals: improved functional status or symptoms; improved long-term outcomes; improved knowledge of their disease; informed expectations; and reduced anxiety about the childs health status. Processes that informants identified as supporting these outcomes centered around 6 key steps in subspecialty referrals, including the referral decision, previsit information transfer, appointment scheduling, subspecialist visit, postvisit information transfer, and ongoing care integration and communication. Health care delivery structures identified by informants as supporting these processes included physical infrastructure, human resources, and information technology systems. CONCLUSIONS We identified family-centered outcomes, processes, and structures of high-quality pediatric subspecialty referrals. These domains can be used not only to improve measurement of the quality of existing referral systems but also to inform future interventions to improve patient-centered outcomes for children in need of specialty care.

Optimizing Telehealth Strategies for Subspecialty Care: Recommendations from Rural Pediatricians

BACKGROUND Telehealth offers strategies to improve access to subspecialty care for children in rural communities. Rural pediatrician experiences and preferences regarding the use of these telehealth strategies for childrens subspecialty care needs are not known. We elicited rural pediatrician experiences and preferences regarding different pediatric subspecialty telehealth strategies. MATERIALS AND METHODS Seventeen semistructured telephone interviews were conducted with rural pediatricians from 17 states within the United States. Interviewees were recruited by e-mails to a pediatric rural health listserv and to rural pediatricians identified through snowball sampling. Themes were identified through thematic analysis of interview transcripts. Institutional Review Board approval was obtained. RESULTS Rural pediatricians identified several telehealth strategies to improve access to subspecialty care, including physician access hotlines, remote electronic medical record access, electronic messaging systems, live video telemedicine, and telehealth triage systems. Rural pediatricians provided recommendations for optimizing the utility of each of these strategies based on their experiences with different systems. Rural pediatricians preferred specific telehealth strategies for specific clinical contexts, resulting in a proposed framework describing the complementary role of different telehealth strategies for pediatric subspecialty care. Finally, rural pediatricians identified additional benefits associated with the use of telehealth strategies and described a desire for telehealth systems that enhanced (rather than replaced) personal relationships between rural pediatricians and subspecialists. CONCLUSIONS Rural pediatricians described complementary roles for different subspecialty care telehealth strategies. Additionally, rural pediatricians provided recommendations for optimizing individual telehealth strategies. Input from rural pediatricians will be crucial for optimizing specific telehealth strategies and designing effective telehealth systems.

Strengthening stakeholder-engaged research and research on stakeholder engagement

Stakeholder engagement is an emerging field with little evidence to inform best practices. Guidelines are needed to improve the quality of research on stakeholder engagement through more intentional planning, evaluation and reporting. We developed a preliminary framework for planning, evaluating and reporting stakeholder engagement, informed by published conceptual models and recommendations and then refined through our own stakeholder engagement experience. Our proposed exploratory framework highlights contexts and processes to be addressed in planning stakeholder engagement, and potential immediate, intermediate and long-term outcomes that warrant evaluation. We use this framework to illustrate both the minimum information needed for reporting stakeholder-engaged research and the comprehensive detail needed for reporting research on stakeholder engagement.

Trends in Visits to Specialist Physicians Involving Nurse Practitioners and Physician Assistants, 2001 to 2013

enance data (eg, physical examination). Future analysis will examine how copied and imported text is used to fulfill the various functions of a note, such as billing or clinical history recall. This finding could spur EHR design that makes copied and imported information readily visible to clinicians as they are writing a note but, ultimately, does not store that information in the note. For example, copied text used as a hospital course record to facilitate the creation of a discharge summary may represent an opportunity for the EHR to provide an alternative space for discharge information. Alternately, copied text that represents a belief that more text leads to higher billing suggests an opportunity for educating clinicians in how notes are coded. As mentioned, this study’s limitations included its singlecenter, single-service focus and inability to access sectionspecific provenance data. Clinicians spend time every day writing progress notes. Understanding their practice and the needs of their audience could spur improvements that restore the utility of this documentation.