Scott A. Shipman

Screening and interventions for childhood overweight: a summary of evidence for the US Preventive Services Task Force.

Background. Childhood and adolescent overweight and obesity are related to health risks, medical conditions, and increased risk of adult obesity, with its attendant effects on morbidity and mortality rates. The prevalence of childhood overweight and obesity has more than doubled in the past 25 years. Purpose. This evidence synthesis examines the evidence for the benefits and harms of screening and early treatment of overweight among children and adolescents in clinical settings. Methods. We developed an analytic framework and 7 key questions representing the logical evidence connecting screening and weight control interventions with changes in overweight and behavioral, physiologic, and health outcomes in childhood or adulthood. We searched the Cochrane Library from 1996 to April 2004. We searched Medline, PsycINFO, DARE, and CINAHL from 1966 to April 2004. One reviewer abstracted relevant information from each included article into standardized evidence tables, and a second reviewer checked key elements. Two reviewers quality-graded each article with US Preventive Services Task Force criteria. Results. Although BMI is a measure of relative weight rather than adiposity, it is recommended widely for use among children and adolescents to determine overweight and is the currently preferred measure. The risk of adult overweight from childhood overweight provides the best available evidence to judge the clinical validity of BMI as an overweight criterion for children and adolescents. BMI measures in childhood track to adulthood moderately or very well, with stronger tracking seen for children with ≥1 obese parent and children who are more overweight or older. The probability of adult obesity (BMI of >30 kg/m2) is ≥50% among children >13 years of age whose BMI percentiles meet or exceed the 95th percentile for age and gender. BMI-based overweight categorization for individuals, particularly for racial/ethnic minorities with differences in body composition, may have limited validity because BMI measures cannot differentiate between increased weight for height attributable to relatively greater fat-free mass (muscle, bone, and fluids) and that attributable to greater fat. No trials of screening programs to identify and to treat childhood overweight have been reported. Limited research is available on effective, generalizable interventions for overweight children and adolescents that can be conducted in primary care settings or through primary care referrals. Conclusions. BMI measurements of overweight among older adolescents identify those at increased risk of developing adult obesity. Interventions to treat overweight adolescents in clinical settings have not been shown to have clinically significant benefits, and they are not widely available. Screening to categorize overweight among children under age 12 or 13 who are not clearly overweight may not provide reliable risk categorization for adult obesity. Screening in this age group is compromised by the fact that there is little generalizable evidence for primary care interventions. Because existing trials report modest short- to medium-term improvements (∼10–20% decrease in percentage of overweight or a few units of change in BMI), however, overweight improvements among children and adolescents seem possible.

Geographic Maldistribution of Primary Care for Children

OBJECTIVES: This study examines growth in the primary care physician workforce for children and examines the geographic distribution of the workforce. METHODS: National data were used to calculate the local per-capita supply of clinically active general pediatricians and family physicians, measured at the level of primary care service areas. RESULTS: Between 1996 and 2006, the general pediatrician and family physician workforces expanded by 51% and 35%, respectively, whereas the child population increased by only 9%. The 2006 per-capita supply varied by >600% across local primary care markets. Nearly 15 million children (20% of the US child population) lived in local markets with <710 children per child physician (average of 141 child physicians per 100 000 children), whereas another 15 million lived in areas with >4400 children per child physician (average of 22 child physicians per 100 000 children). In addition, almost 1 million children lived in areas with no local child physician. Nearly all 50 states had evidence of similar extremes of physician maldistribution. CONCLUSIONS: Undirected growth of the aggregate child physician workforce has resulted in profound maldistribution of physician resources. Accountability for public funding of physician training should include efforts to develop, to use, and to evaluate policies aimed at reducing disparities in geographic access to primary care physicians for children.

Primary Care Physician Supply and Children's Health Care Use, Access, and Outcomes: Findings From Canada

OBJECTIVES: To describe the relationship of primary care physician (PCP) supply for children and measures of health care access, use, and outcomes. METHODS: We conducted a population-based, cross-sectional study of all Ontario children from 2003 to 2005. We used health administrative data to calculate county-level supply (full-time equivalents [FTEs]) of PCPs. We modeled the relationship of supply to (1) recommended primary care visits, (2) emergency department (ED) use, and (3) ambulatory care–sensitive condition admissions and adjusted for neighborhood income. We used population-based surveys to describe access. RESULTS: The county-level PCP supply ranged from 1720 to 4720 children per FTE. Of the children, 45.4% live in the highest-supply areas (<2000 children per FTE) and 8% in the lowest-supply areas (>3000 children per FTE). Compared with high-supply counties, the lowest had significantly lower rates of primary care visits (2716 vs 7490 per 1000) and higher proportions of newborns without early follow-care (58.2% vs 14.5%). Low-supply areas had higher rates of ED visits (440 vs 179 per 1000) and admissions. A stepwise gradient existed for every decrease in supply for most measures. Self-reported access barriers were most evident in areas with >3500 children per FTE (32.8% without a physician). CONCLUSIONS: Under universal insurance there are differences in access to, and outcomes of, primary care related to local physician supply after controlling for neighborhood income. The most pronounced effect is on primary and ED care use, but there are implications for acute and chronic disease control. Physician distribution is a critical issue to address in policies to improve access to care.

Family Physicians in the Child Health Care Workforce: Opportunities for Collaboration in Improving the Health of Children

Pediatric workforce studies suggest that there may be a sufficient number of pediatricians for the current and projected US child population. These analyses do not fully consider the role of family medicine in the care of children. Family physicians provide 16% to 26% of visits for children, providing a medical home for one third of the child population, but face shrinking panels of children. Family medicines role in childrens health care is more stable in rural communities, for adolescents, and for underserved populations. For these populations, in particular, family medicines role remains important. The erosion of the proportion of visits to family medicine is likely caused by the rapid rise in the number of pediatricians relative to a declining birth rate. Between 1981 and 2004, the general pediatrician population grew at 7 times the rate of the US population, and the family physician workforce grew at nearly 5 times the rate. The number of clinicians caring for children meets or exceeds most estimates of sufficiency; however, the workforce distribution is skewed, leaving certain populations and settings underserved. More than 5 million children and adolescents live in counties with no pediatrician. Unmet need, addressing health in the context of families and communities, and tackling “millennial morbidities” represent common ground for both specialties that could lead to specific, collaborative training, research, intervention, and advocacy.

Pediatrician workforce statement

This statement discusses the importance of pediatrician-workforce issues and their relevance to the provision of pediatric health care. It reviews previous work in the health policy arena on physician and pediatrician workforce. Key pediatrician-workforce trends are described, including the growth in the number of pediatricians in relation to the child population, the increase in the number of female pediatricians, the role of international medical graduates, the diversity of the pediatrician workforce, the contributions of internal medicine-pediatrics physicians, the increasing number of nonpediatrician providers of pediatric care, geographic distribution of physicians, and the future of pediatric subspecialists. Methods of influencing the pediatrician workforce are also considered. In the concluding series of recommendations, the statement identifies both overarching policy goals for the pediatrician workforce and implementation strategies designed to ensure that all of Americas infants, children, adolescents, and young adults have access to appropriate pediatric health care.

Key characteristics of successful quality improvement curricula in physician education: a realist review

Purpose Quality improvement (QI) is a common competency that must be taught in all physician training programmes, yet, there is no clear best approach to teach this content in clinical settings. We conducted a realist systematic review of the existing literature in QI curricula within the clinical setting, highlighting examples of trainees learning QI by doing QI. Method Candidate theories describing successful QI curricula were articulated a priori. We searched MEDLINE (1 January 2000 to 12 March 2013), the Cochrane Library (2013) and Web of Science (15 March 2013) and reviewed references of prior systematic reviews. Inclusion criteria included study design, setting, population, interventions, clinical and educational outcomes. The data abstraction tool included categories for setting, population, intervention, outcomes and qualitative comments. Themes were iteratively developed and synthesised using realist review methodology. A methodological quality tool assessed the biases, confounders, secular trends, reporting and study quality. Results Among 39 studies, most were before–after design with resident physicians as the primary population. Twenty-one described clinical interventions and 18 described educational interventions with a mean intervention length of 6.58 (SD=9.16) months. Twenty-eight reported successful clinical improvements; no studies reported clinical outcomes that worsened. Characteristics of successful clinical QI curricula include attention to the interface of educational and clinical systems, careful choice of QI work for the trainees and appropriately trained local faculty. Conclusions This realist review identified success characteristics to guide training programmes, medical schools, faculty, trainees, accrediting organisations and funders to further develop educational and improvement resources in QI educational programmes.

Enhancing the diversity of the pediatrician workforce.

This policy statement describes the key issues related to diversity within the pediatrician and health care workforce to identify barriers to enhancing diversity and offer policy recommendations to overcome these barriers in the future. The statement addresses topics such as health disparities, affirmative action, recent policy developments and reports on workforce diversity, and research on patient and provider diversity. It also broadens the discussion of diversity beyond the traditional realms of race and ethnicity to include cultural attributes that may have an effect on the quality of health care. Although workforce diversity is related to the provision of culturally effective pediatric care, it is a discrete issue that merits separate discussion and policy formulation. At the heart of this policy-driven action are multiorganizational and multispecialty collaborations designed to address substantive educational, financial, organizational, and other barriers to improved workforce diversity.

Factors Influencing Family Physicians’ Contribution to the Child Health Care Workforce

PURPOSE We wanted to explore demographic and geographic factors associated with family physicians’ provision of care to children. METHODS We analyzed the proportion of family physicians providing care to children using survey data collected by the American Board of Family Medicine from 2006 to 2009. Using a cross-sectional study design and logistic regression analysis, we examined the association of various physician demographic and geographic factors and providing care of children. RESULTS Younger age, female sex, and rural location are positive predictors of family physicians providing care to children: odds ratio (OR) = 0.97 (95% CI, 0.97–0.98), 1.19 (1.12–1.25), and 1.50 (1.39–1.62), respectively. Family physicians practicing in a partnership are more likely to provide care to children than those in group practice: OR = 1.53 (95% CI, 1.40–1.68). Family physicians practicing in areas with higher density of children are more likely to provide care to children: OR = 1.04 (95% CI, 1.03–1.05), while those in high-poverty areas are less likely 0.10 (95% CI, 0.10–0.10). Family physicians located in areas with no pediatricians are more likely to provide care to children than those in areas with higher pediatrician density: OR = 1.80 (95% CI, 1.59–2.01). CONCLUSIONS Various demographic and geographic factors influence the likelihood of family physicians providing care to children, findings that have important implications to policy efforts aimed at ensuring access to care for children.

ADVANCING THE PRIMARY/SPECIALTY CARE INTERFACE THROUGH ECONSULTS AND ENHANCED REFERRALS

As academic health centers (AHCs) respond to valuebased purchasing, they are embracing a transformed role for primary care. As a case in point, 5 AHCs have formed a collaborative organized by the Association of American Medical Colleges (AAMC) to extend a model developed at the University of California, San Francisco (UCSF) that addresses the referral process between primary care and specialty care providers. This program, known as Coordinating Optimal Referral Experiences (CORE), incorporates 2 EMR-based innovations into the clinical workflow: (1) specialtyand problem-specific templates that provide prereferral decision support to the primary care physician and establish a co-management agreement between providers,1 and (2) “eConsults” which involve providerto-provider asynchronous messaging. With eConsults, the primary care physician sends a focused clinical question to a pre-identified subspecialist who then responds within 48 to 72 hours. The eConsult allows the primary care physician to provide care for the patient directly, provides specialist input in a convenient and timely manner for the patient, and reduces expensive specialty-driven care for minor issues, which in turn frees up the specialist for more complicated patients. Upon completion of each eConsult, both the primary care physician and the specialist receive a productivity (RVU) credit for their efforts. Overall, the model emphasizes and supports the role of the primary care physician as the primary provider for the patient, and emphasizes the rational use of services. The AAMC received a Health Care Innovations Award from the Center for Medicare and Medicaid Innovation (CMMI) to disseminate this model in partnership with UCSF across 5 partner institutions (University of Wisconsin, University of Iowa, University of California San Diego, University of Virginia, and Dartmouth-Hitchcock). With the 3-year grant, each AHC will implement the program in 15 or more medical and surgical specialties. Departments of Family Medicine are deeply involved in this program, and have identified several early learnings.

Exploring the workforce implications of a decade of medical school expansion: variations in medical school growth and changes in student characteristics and career plans.

Purpose To explore whether medical school enrollment growth may help address workforce priorities, including diversity, primary care, care for underserved populations, and academic faculty. Method The authors compared U.S. MD-granting medical schools, applicants, and matriculants immediately before expansion (1999–2001) and 10 years later (2009–2011). Using data from the American Medical Association Physician Masterfile and the Association of American Medical Colleges, they examined medical schools’ past production of physicians and changes in matriculant characteristics and practice intentions. Results Among the 124 schools existing in 1999–2001, growth varied substantially. Additionally, 11 new schools enrolled students by 2009–2011. Aggregate enrollment increased by 16.6%. Increases in applicants led to a lower likelihood of matriculation for all but those with rural backgrounds, racial/ethnic minorities, applicants >24 years old, and those with Medical College Admission Test scores > 33. The existing schools that expanded most had a history of producing the highest percentages of physicians practicing in primary care and in underserved and rural areas; those that expanded least had produced the greatest percentage of faculty. Compared with existing schools, new schools enrolled higher percentages of racial/ethnic minorities and of students with limited parental education or lower income. Matriculants’ interest in primary care careers showed no decline; interest in practicing with underserved populations increased, while interest in rural practice declined. Conclusions Despite expansion, the characteristics of matriculating medical students changed little, except at new schools. Further expansion may benefit from targeted consideration of workforce needs.