Financial Analysis of Pediatric Resident Physician Primary Care Longitudinal Outpatient Experience

Objective

To determine whether residency training represents a net positive or negative cost to academic medical centers, we analyzed the cost of a residency program and clinical productivity of residents and faculty in an outpatient primary care practice with or without residents.

Carbon dioxide monitoring in emergency medicine training programs

OBJECTIVES: Although the measurement of carbon dioxide (CO2) in breath is the standard of care for verification of endotracheal tube placement in all anesthesia practice and in the prehospital setting, there is currently no uniform consensus on the status of CO2 monitoring in emergency medicine. We conducted this survey to delineate practice patterns of CO2 monitoring in academic emergency medicine training programs and to describe the preference for type of CO2 monitoring device. METHODS: We surveyed the availability, presence, and types of CO2 monitoring in all general emergency medicine (GEM) residency programs and all pediatric emergency medicine (PEM) fellowship programs. A two-question survey was used, and data were collected from March 1998 to June 1998. The clinicians surveyed were asked whether their emergency department (ED) used CO2 monitoring for detection of endotracheal tube placement and, if so, what type of CO2 monitoring devices was used. Types of CO2 monitoring devices were categorized as colorimetric, capnometric, capnographic, or combinations of these. RESULTS: Of the 168 programs surveyed, all GEM and PEM programs responded, and the survey results showed that 136 of 168 (81%) used some form of CO2 monitoring, and 32 of 168 (19%) did not use CO2 monitoring. The majority of programs (115/168, 68%) used a single device. Colorimetric devices were used most frequently (76/168, 45%), and capnometry was used the least (9/168, 5%). PEM programs had a significant preference for quantitative CO2 monitoring, whereas GEM programs had a significant preference for qualitative CO2 monitoring. CONCLUSIONS: Although the majority of academic emergency medicine training programs used CO2 monitoring, 19% did not. Colorimetric devices were the most frequently used CO2 monitoring technology.     

Proposal for an administrative curriculum in pediatric emergency medicine fellowship training.

Administrative tasks make up a significant component of the practice of pediatric emergency medicine (PEM) physicians. Our survey of 10 academic pediatric emergency departments revealed that PEM physicians who are primarily clinical spent an average of 15% of their time on administrative tasks, and PEM physicians whose positions are administrative as well as clinical spent 30 to 60% of their time on administrative tasks. Of the 101 programs responding to our survey of 220 pediatric residency programs, 80% did not address hospital administrative issues, and many that did address these issues allowed these topics only one hour of presentation time per year. It is clear that there is a discrepancy between the demands placed upon PEM physicians to perform administrative tasks and the sparse or nonexistent opportunities for learning about administrative issues during residency training. It is incumbent upon pediatric emergency fellowship programs to provide an inclusive and well-structured administrative curriculum for their trainees. This article suggests a framework for such a curriculum.     

The status of academic general pediatrics: no longer endangered?

Our study objective was to assess the current state of general academic pediatrics in the United States. A confidential survey of division directors was conducted. At the beginning and end of the survey period, programs were called to verify the director's name. Of 199 divisions surveyed, 119 were returned. The number of physician and nonphysician division faculty has grown from a mean of 12.1 (+/-8.2) and 1.7 (+/-1.8), respectively, 5 years ago to 15.6 (+/-11.7) and 2.1 (+/-2.6). Over a 15- to 18-month period, 21% of programs had a change in division director leadership. Over 90% of divisions rated the clinical care and education missions as "very important," with research and advocacy thus rated by 29% and 50%. Ninety-five percent of divisions have primary responsibility for residency continuity clinics, 51% residency program, and 64% medical student clerkship. The mean number of annual outpatient visits was 29,821 (26,487). Academic general pediatrics divisions have grown and play a large role in clinical care, education, and research at their institutions. There is a need for continued focus on recruitment, fellowship training, faculty development, and leadership development. Although these divisions are now well established, many continue to feel "endangered" because of funding uncertainties in supporting their missions.     

The training of pediatric residents in the care of acutely ill and injured children

OBJECTIVES: To describe the current educational experience of pediatric residents in pediatric emergency care, to identify areas of variability between residency programs, and to distinguish areas in need of further improvement. DESIGN: A 63-item survey mailed to all accredited pediatric residency training program directors in the United States and Puerto Rico. SETTING AND PARTICIPANTS: Pediatric residency programs and their directors. MAIN OUTCOME MEASURES: Primary training settings, required and elective rotations related to the care of the acutely ill and injured child, supervision of care, procedural and technical training, and didactic curriculum in pediatric emergency medicine (PEM). RESULTS: One hundred fifty-three (72%) of 213 residency programs responded. One hundred nine (71%) were based at general or university hospitals, the remaining 44 (29%) were based at freestanding children's hospitals. Residents most commonly saw patients in pediatric emergency departments (54%), followed by acute care clinics (21%), general emergency departments (21%), and urgent care clinics (5%). The mean number of weeks of PEM training required was 11, but varied widely from 0 to 36 weeks. Forty programs (27%) required their residents to spend 4 or fewer weeks rotating in an emergency department setting. The best predictor of the number of weeks spent in emergency medicine was residency program size, with small programs requiring fewer weeks (7 weeks for small [1-8 postgraduate year 1 residents] vs 13 for medium [9-17 postgraduate year 1 residents] vs 15 for large [> or =18 postgraduate year 1 residents]). Pediatric surgery (18%), orthopedic (8%), anesthesia (6%), and toxicology (4%) rotations were rarely required. Ninety-two percent of the programs had 24-hour on-site attending physician coverage of the emergency department. Supervising physicians varied widely in their training and included PEM attendings and fellows, general emergency medicine attendings, and general pediatric attendings. Small programs were less likely to have PEM coverage (57% at small vs 95% at large) and more likely to have general emergency medicine coverage (79% at small vs 29% at large). Reported opportunities to perform procedures were uniformly high and did not differ by program size or affiliated fellowship. Residency program directors were uniformly confident in their residents' training in medical resuscitation, critical care, emergency care, airway management, and minor trauma. Thirty-seven percent of all respondents were not confident in their residents' training in major trauma. Most programs reported that they had a didactic PEM curriculum (77%), although the number of hours devoted to the lectures varied substantially. CONCLUSIONS: Wide variability exists in the amount of time devoted to emergency medicine within pediatric residency training curricula and in the training background of attendings used to supervise patient care and resident education. Nevertheless, pediatric residency training programs directors feel confident in their residents training in most topics related to PEM. Residents' training in major trauma resuscitation was the most frequently cited deficiency.     

Impact of X+Y Scheduling on Pediatric Resident and Faculty Perceptions of Education and Patient Care

PurposeTraditional half-day per week continuity clinic experiences can lead to fragmented education in both the inpatient and outpatient arenas. Five pediatric residency programs were granted the ability from the ACGME to create X+Y scheduling where residents have continuity clinic in “blocks” rather than half-day per week experiences. The aim of this study is to assess the impact X+Y scheduling has on pediatric resident and faculty perceptions of patient care and other educational experiences.MethodsElectronic surveys were sent to residents and faculty of the participating programs both prior to and 12 months after implementing X+Y scheduling. Survey questions measured resident and faculty perception of continuity clinic schedule satisfaction and the impact of continuity clinic schedules on inpatient and subspecialty rotation experiences using a 5-point Likert Scale. Data were analyzed using z-tests for proportion differences for those answering Agree or Strongly Agree between baseline and post-implementation respondents.ResultsHundred and twenty-six out of 186 residents (68%) responded preimplementation and 120 out of 259 residents (47%) responded post-implementation. 384 faculty members were sent the survey with 51% response pre-implementation and 26% response at 12 months. Statistically significant (P < .05) improvements were noted in resident and faculty perceptions of ability to have continuity with patients and inpatient workflow affected by clinic scheduling.ConclusionsFrom both resident and faculty perspectives, X+Y scheduling may improve several aspects of patient care and education. X+Y scheduling could be considered as a potential option by pediatric residency programs, especially if validated with more objective data.     

Race and gender differences in pediatricians' annual incomes.

OBJECTIVE: To determine the association between race, gender, and pediatricians' annual incomes after controlling for work effort, provider characteristics, and practice characteristics. METHODS: We conducted a retrospective analysis of 1172 actively practicing black and white male and female pediatricians who responded to the American Medical Association's annual survey of physicians between 1992 and 2001. We used linear regression modeling to calculate annual incomes adjusted for work effort, provider characteristics, and practice characteristics. RESULTS: White men reported annual incomes of $183,430. After adjusting incomes for work effort, provider characteristics, and practice characteristics, black male pediatricians' mean annual income was $175,640 (95 per cent confidence interval [95 per cent CI], $150,344-201,138). This was $7790 (4.2 per cent) lower, but not statistically different from that of white men (P = .5). However, compared with white male pediatricians' incomes, white female pediatricians' incomes were $150,636 (95 per cent CI, $140,975-$160,298), or $32,794 (18 per cent) lower (P < .001); and black female pediatricians' incomes were $133,018 (95 per cent CI, $108,736-$157,300), or $50,412 (27 per cent) lower (P < .001). CONCLUSIONS: During the 1990s, female gender was associated with lower annual incomes among pediatricians; differences were greatest for black women. These findings warrant further exploration to determine what factors might cause the gender-based income differences that we found.     

Coordination of specialty referrals and physician satisfaction with referral care

OBJECTIVES: To describe how physicians coordinate patient care for specialty referrals and to examine the effects of these activities on referring physicians' satisfaction with the specialty care their patients receive and referral completion. DESIGN AND METHODS: Prospective study of a consecutive sample of referrals (N = 963) made from the offices of 122 pediatricians in 85 practices in a national practice-based research network. Data sources included a physician survey completed when the referral was made (response rate, 99%) and a physician survey and medical record review conducted 3 months later (response rate, 85%). Referral completion was defined as receipt of written communication of referral results from the specialist. RESULTS: Pediatricians scheduled appointments with specialists for 39.3% and sent patient information to specialists for 50.8% of referrals. The adjusted odds of referral completion were increased 3-fold for those referrals for which the pediatrician scheduled the appointment and communicated with the specialist compared with those for which neither activity occurred. Referring physicians' satisfaction ratings were significantly increased by any type of specialist feedback and were highest for referrals involving specialist feedback by both telephone and letter. Elements of specialists' letters that significantly increased physician ratings of letter quality included presence of patient history, suggestions for future care, follow-up arrangements, and plans for comanaging care; only the inclusion of plans for comanaging patient care was significantly related to the referring physicians' overall satisfaction. CONCLUSIONS: Better coordination between referring physicians and specialists increases physician satisfaction with specialty care and enhances referral completion. Improvements in the referral process may be achieved through better communication and collaboration between primary care physicians and specialists.     

Pediatric integrative medicine: pediatrics¿ newest subspecialty?

ABSTRACT: BACKGROUND: Integrative medicine is defined as relationship-centered care that focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing, including evidence-based complementary and alternative medicine. Pediatric integrative medicine (PIM) develops and promotes this approach within the field of pediatrics. We conducted a survey to identify and describe PIM programs within academic children's hospitals across North America. Key barriers and opportunities were identified for the growth and development of academic PIM initiatives in the US and Canada. METHODS: Academic PIM programs were identified by email and eligible for inclusion if they had each of educational, clinical, and research activities. Program directors were interviewed by telephone regarding their clinical, research, educational, and operational aspects. RESULTS: Sixteen programs were included. Most (75%) programs provided both inpatient and outpatient services. Seven programs operated with less than 1 FTE clinical personnel. Credentialing of complementary and alternative medicine (CAM) providers varied substantially across the programs and between inpatient and outpatient services. Almost all (94%) programs offered educational opportunities for residents in pediatrics and/or family medicine. One fifth (20%) of the educational programs were mandatory for medical students. Research was conducted in a range of topics, but half of the programs reported lack of research funding and/or time. Thirty-one percent of the programs relied on fee-for-service income. CONCLUSIONS: Pediatric integrative medicine is emerging as a new subspecialty to better help address 21st century patient concerns.     

Home care cost-effectiveness for respiratory technology-dependent children

We evaluated home care costs and the cost-effectiveness of home care vs alternative institutional care for respiratory technology-dependent children in a Medicaid Model Waiver Program. "Cost-savings" was measured as the difference between the established Medicaid reimbursable charges to enact an individualized care plan at a long-term care institution and the actual Medicaid reimbursements for home care. Ten patients--six dependent on mechanical ventilation and four with a tracheostomy who were receiving oxygen--were included in the analysis. The mean (+/- SD) annual home care costs were $109,836 +/- $20,781 for ventilator-dependent children and $63,650 +/- $12,350 for oxygen-dependent patients with a tracheostomy, representing annual savings of approximately $79,000 per patient and $83,000 per patient, respectively. The largest portion of home care reimbursements was for nursing care, accounting for 69.0% and 59.0% of the two patient groups. The full program (50 patients) has the potential for a savings of $4 million per year.     

Three Years of X + Y Scheduling: Longitudinal Assessment of Resident and Faculty Perceptions

ObjectiveFive pediatric residency programs implemented true X + Y scheduling in 2018 where residents have continuity clinic in “blocks” rather than half-day per week experiences. We report the impact X + Y scheduling has on pediatric resident and faculty perceptions of patient care and other educational experiences over a 3-year timeframe.MethodsElectronic surveys were sent to residents and faculty of the participating programs prior to implementing X + Y scheduling and annually thereafter (2018–2021). Survey questions measured resident and faculty perception of continuity clinic schedule satisfaction and the impact of continuity clinic schedules on inpatient and subspecialty rotations. Data were analyzed using z-tests for proportion differences.ResultsOne hundred and eight six residents were sent the survey preimplementation and 254 to 289 postimplementation with response rates ranging from 47% to 69%. Three hundred and seventy-eight to 395 faculty members were sent the survey with response rates ranging from 26% to 51%. Statistically significant (P < .05) sustained perceived improvements over 3 years with X+Y were seen in outpatient continuity, inpatient workflow, and time for teaching both inpatient and in continuity clinic.ConclusionsX + Y scheduling can lead to perceived improvements in various aspects of pediatric residency programs. Our study demonstrates these improvements have been sustained over 3 years in the participating programs.     

Pediatric clinical faculty structure and teaching hospital function.

An organization of clinical faculty has been formed at Rainbow Babies and Childrens Hospital, Cleveland, Ohio, to help coordinate the mutual goals but sometimes conflicting needs of practicing pediatricians and a teaching hospital. The organization has been active in developing and conducting educational experiences for students, house officers, and practitioners. It has contributed to efforts to improve ambulatory and inpatient care. Collaborative clinical research projects involving practitioners and academicians are planned. We know of no other existing similar organization. We propose that other institutions with similar needs consider this mechanism to help improve their academic and patient care programs.     

Computerized pediatric telephone triage and advice programs at children's hospitals: operating and financial characteristics.

OBJECTIVE: To describe the operating characteristics, financial performance, and perceived value of computerized children's hospital-based telephone triage and advice (TTA) programs. DESIGN: A written survey of all 32 children's hospital-based TTA programs in the United States that used the same proprietary pediatric TTA software product for at least 6 months. MAIN OUTCOME MEASURES: The expense, revenues, and perceived value of children's hospital-based TTA programs. RESULTS: Of 30 programs (94%) responding, 27 (90%) were eligible for the study and reported on their experience with nearly 1.3 million TTA calls over a 12-month period. Programs provided pediatric TTA services for 1560 physicians, serving an average of 82 physicians (range, 10-340 physicians) and answering 38880 calls (range, 8500-140000 calls) annually. The mean call duration was 11.3 minutes and the estimated mean total expense per call was $12.45. Of programs charging fees for TTA services, 16 (59%) used a per-call fee and 7 (26%) used a monthly service fee. All respondents indicated that fees did not cover all associated costs. Telephone triage and advice programs, when examined on a stand-alone basis, were all operating with annual deficits (mean, $447000; median, $325000; range, $74000-$1.3 million), supported by the sponsoring children's hospitals and their companion programs. Using a 3-point Likert scale, the TTA program managers rated the value of the TTA program very highly as a mechanism for marketing to physicians (2.85) and increasing physician (2.92) and patient (2.80) satisfaction. CONCLUSIONS: Children's hospital-based TTA programs operate at substantial financial deficits. Ongoing support of these programs may derive from the perception that they are a valuable mechanism for marketing and increase patient and physician satisfaction. Children's hospitals should develop strategies to ensure the long-term financial viability of TTA programs or they may have to discontinue these services.     

Next steps for federal child care policy

In Mark Greenberg's view, a national child care strategy should pursue four goals. Every parent who needs child care to get or keep work should be able to afford care without having to leave children in unhealthy or dangerous environments; all families should be able to place their children in settings that foster education and healthy development; parental choice should be respected; and a set of good choices should be available. Attaining these goals, says Greenberg, requires revamping both federal child care subsidy programs and federal tax policy related to child care. Today subsidies are principally provided through a block grant structure in which states must restrict eligibility, access, or the extent of assistance because both federal and state funds are limited. Tax policy principally involves a modest nonrefundable credit that provides little or no assistance to poor and low-income families. Greenberg would replace the block grant with a federal guarantee of assistance for all families with incomes under 200 percent of poverty that need child care to enter or sustain employment. States would administer the federal assistance program under a federal-state matching formula with the federal government paying most of the cost. States would develop and implement plans to improve the quality of child care, coordinate child care with other early education programs, and ensure that child care payment rates are sufficient to allow families to obtain care that fosters healthy child development. Greenberg would also make the federal dependent care tax credit refundable, with the credit set at 50 percent of covered child care costs for the lowest-income families and gradually phasing down to 20 percent as family income increases. The combined subsidy and tax changes would lead to a better-coordinated system of child care subsidies that would assure substantial financial help to families below 200 percent of poverty, while tax-based help would ensure continued, albeit significantly reduced, assistance for families with higher incomes. Greenberg indicates that the tax credit expansions are estimated to cost about $5 billion a year, and the subsidy and quality expansions would cost about $18 billion a year.     

A comparison of tympanic and rectal temperatures in term NIGERIAN neonates

Background

Integrative medicine is defined as relationship-centered care that focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing, including evidence-based complementary and alternative medicine. Pediatric integrative medicine (PIM) develops and promotes this approach within the field of pediatrics. We conducted a survey to identify and describe PIM programs within academic children??s hospitals across North America. Key barriers and opportunities were identified for the growth and development of academic PIM initiatives in the US and Canada.

Methods

Academic PIM programs were identified by email and eligible for inclusion if they had each of educational, clinical, and research activities. Program directors were interviewed by telephone regarding their clinical, research, educational, and operational aspects.

Results

Sixteen programs were included. Most (75%) programs provided both inpatient and outpatient services. Seven programs operated with less than 1 FTE clinical personnel. Credentialing of complementary and alternative medicine (CAM) providers varied substantially across the programs and between inpatient and outpatient services. Almost all (94%) programs offered educational opportunities for residents in pediatrics and/or family medicine. One fifth (20%) of the educational programs were mandatory for medical students. Research was conducted in a range of topics, but half of the programs reported lack of research funding and/or time. Thirty-one percent of the programs relied on fee-for-service income.

Conclusions

Pediatric integrative medicine is emerging as a new subspecialty to better help address 21st century patient concerns.     

Substance abuse education in pediatrics

Historically, physicians have received little formal education related to alcohol or other drug abuse and dependence. A survey of all pediatric programs in the United States was conducted to assess the current status of alcohol/drug education in pediatrics. At the medical student and residency training levels, only 44% and 40% of programs, respectively, required any formal instruction, and only 27% and 34%, respectively, offered an elective for medical students or residents. Although most respondents endorsed the inclusion of both required and elective alcohol and drug education in the curriculum, few programs that did not include it already had a future plan for it. Major impediments identified were curriculum time constraints (86% medical student level, 68% resident level) and the lack of a qualified instructor (55% medical student level, 50% resident level). The survey results suggest a strong need for development of faculty and structured alcohol and drug abuse educational plans specific to pediatrics.