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BACKGROUND AND OBJECTIVES: In 2016, the American Board of Medical Specialties (ABMS) approved pediatric hospital medicine (PHM) as the newest pediatric subspecialty. To characterize development of the field, this article aims to: (1) describe the responsibilities and practice settings of US pediatricians self-identifying as hospitalists; and (2) determine how exclusive PHM practice, compared with PHM practice in combination with general or subspecialty care, was associated with professional development interests. METHODS: Pediatricians enrolling in the 2017-2018 American Board of Pediatrics (ABP) Maintenance of Certification program were offered a voluntary survey about their responsibilities, interests, and practice settings. Logistic regression was employed to characterize associations between exclusive PHM practice and: (1) interest in quality improvement (QI) leadership; (2) intention to take the PHM certifying exam; (3) satisfaction with allocation of professional time; and (4) intention to maintain more than one ABP certification. RESULTS: The survey response rate was 70.0%; 1662 (13.1%) self-reported PHM practice. Four-hundred ninety-one (29.5%) practiced PHM exclusively, 518 (31.1%) practiced PHM and general pediatrics, and 653 (39.3%) practiced PHM and one or more subspecialties. Respondents reporting exclusive PHM practice were significantly more likely to report interest in QI leadership or consultation (adjusted odds ratio [OR], 1.39; 95% CI, 1.09-1.79), PHM exam certification (adjusted OR, 7.10; 95% CI, 5.45-9.25), and maintenance of more than one ABP certification (adjusted OR, 2.64; 95% CI, 1.89-3.68). CONCLUSIONS: Hospitalists reported diverse clinical and nonclinical responsibilities. Those practicing PHM exclusively expressed high levels of interest in board certification and QI leadership. Ongoing monitoring of PHM responsibilities and practice settings will be important to support the professional development of the PHM workforce.

Children with sickle cell disease are at increased risk of serious infections, many of which can be prevented by receipt of recommended immunizations. Study objectives were to (1) assess the primary immunization series coverage among children with sickle cell disease and (2) compare the coverage with that of those without sickle cell disease.The Michigan Care Improvement Registry was used to obtain primary immunization series doses and sickle cell disease status for all eligible children in Michigan born in 2001-2016 (analysis was conducted in 2019). Completion of series and each individual vaccine were assessed for every child at ages 19 and 35 months. Proportions were stratified by sickle cell disease status and compared using chi-square tests. Logistic regression was used to model the odds of completing the series at each age, as predicted by sickle cell disease status and adjusting for the presence of Medicaid identification number.The proportion of children who completed the immunization series was higher for those with sickle cell disease than for those without sickle cell disease at 19 months (58.5% vs 48.0%) and 35 months (74.7% vs 59.6%) (both p0.0001). The odds of completing the series were 1.4 times higher at 19 months (95% CI=1.2, 1.6) and 1.7 times higher at 35 months (95% CI=1.5, 2.0) for children with sickle cell disease than for those without, adjusting for the presence of Medicaid identification number.Although children with sickle cell disease had higher immunization rates than those without sickle cell disease,40% of children with sickle cell disease did not receive all recommended immunizations by age 19 months. Immunization information systems should be utilized to improve routine immunization coverage of children with sickle cell disease.

To assess receipt of annual flu immunization among children living with sickle cell disease (SCD).Receipt of flu immunization (2014-2019) by SCD status was assessed among all Michigan children18 years of age using the statewide immunization registry. Logistic regression was used to estimate the odds of annual flu immunization by SCD status and age.Annual flu immunization coverage was higher among children with SCD (46.9%; n = 751) than without (23.2%; n = 2,012,846). The annual adjusted odds of flu immunization for those with SCD were 2.8 (95% CI: 2.5-3.1) times higher than for those without SCD; there were no significant differences by age among children with SCD. Among those without SCD, adolescents aged 13-17 were 2.2 (95% CI: 2.2-2.2) times less likely to receive annual flu immunization than children 6-35 months.Children with SCD had higher annual flu immunization rates than those without SCD, but50% remain unimmunized.

BACKGROUND The BREAST-Q is the only questionnaire specific to bilateral breast reduction that was developed according to federal and international standards. Many payors mandate minimum resection weights for preapproval, despite lacking supportive evidence for this practice. This study aimed to assess changes in BREAST-Q scores after bilateral breast reduction, and determine whether compliance with Schnur requirements impacts improvement in patient-reported outcomes. METHODS Patients presenting for bilateral breast reduction from 2011 to 2017 were asked to complete the BREAST-Q preoperatively and postoperatively. Multivariate regression analysis was performed to isolate factors associated with favorable outcomes. RESULTS Complete data were available for 238 patients. Mean time to postoperative BREAST-Q was 213 days. Complications occurred in 31 patients (13.0 percent). Mean preoperative BREAST-Q scores were below normative values (p < 0.001), and mean postoperative scores were above normative values (p < 0.001 for Satisfaction with Breasts, Psychosocial Well-being, and Sexual Well-being; and p = 0.05 for Physical Well-being). Postoperative Physical Well-being scores were similar to normative values for resections less than Schnur (p = 0.32), but below norms for resections greater than Schnur (p < 0.0001). On multivariate regression (n = 230), complication and surgeon experience were the only independent predictors of lesser improvement on the Satisfaction with Breasts subscale. CONCLUSIONS This study is the largest to include both preoperative and postoperative bilateral breast reduction BREAST-Q scores, and to compare multiple subscales to normative data. Scores overwhelmingly increased, regardless of age or Schnur compliance. Complications negatively impacted degree of BREAST-Q improvement. Interestingly, postoperative Physical Well-being was slightly higher in women with non-Schnur-compliant resections. Bilateral breast reduction substantially improves patient welfare, and our data question the validity of insurer-mandated minimum resections. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

BACKGROUND To inform discussions of pediatric subspecialty workforce adequacy and characterize its pipeline, we examined trends in first-year fellows in the 14 American Board of Pediatrics (ABP)-certified pediatric medical subspecialties, 2001-2018. METHODS Data were obtained from the ABP Certification Management System. We determined, within each subspecialty, the annual number of first-year fellows. We assessed for changes in the population using variables available throughout the study period (gender, medical school location, program region, and program size). We fit linear trendlines and calculated χ2 statistics. RESULTS The number of first-year pediatric medical subspecialty fellows increased from 751 in 2001 to 1445 in 2018. Fields with the growth of 3 or more fellows per year were Cardiology, Critical Care, Emergency Medicine, Gastroenterology, Neonatology, and Hematology Oncology (P value

Abdominoperineal resection (APR) in patients with anorectal carcinomas may involve flap-based perineal reconstruction techniques, such as rectus abdominis, myocutaneous, gracilis, and gluteal flaps. There is no consensus on the optimal approach. We evaluated the outcomes of perineal reconstruction following APR in the literature and identified a predominance of abdominal-based approaches, though overall outcomes were similar compared with thigh or perineal-based options. Statistical power to detect small differences in outcomes is limited, however, due to the retrospective design, relatively short-term follow-up, and potential selection bias based on morbidities associated with reconstructive techniques. Lacking randomized studies to define optimum approaches to perineal reconstruction, clinicians should individualize surgical strategy.

The opioid epidemic in the United States resulted in 42,000 deaths in 2016, 40% of which involved a prescription opioid. It is estimated that 2 million patients become opioid-dependent after elective, ambulatory surgery each year. There has been increased interest in quantifying the need for postoperative narcotic pain medications for a variety of surgical procedures. However, studies have been limited. We sought to quantify the analgesic usage after one of the most common operations performed in plastic surgery, bilateral breast reduction.In this prospective, observational study, sequential breast reduction patients were contacted by telephone on the evening of postoperative days 3 and 7. Patients were queried as to which analgesic medications were used on the day of the phone call. Data relating to dosage, frequency, and satisfaction with pain control were sought. Patients taking chronic narcotics, postoperative complications requiring surgical intervention, and those unable to be reached after multiple attempts were excluded.Complete data were obtained for 40 patients. Narcotic prescriptions were written for oxycodone, hydromorphone and tramadol, with the number prescribed ranging from 0 to 20 tablets. The median total number used was 6 tablets. Eighty percent of patients used a total of 10 tablets or less. Fifty percent of patients were using only nonnarcotic analgesia by postoperative day 3. Patient-reported satisfaction with pain control was overwhelmingly positive, with 95% being either somewhat satisfied or very satisfied with postoperative pain control. Of those taking any medication on postoperative day 3, only half were using a nonsteroidal anti-inflammatory drug (NSAID) as part of their pain regimen.The number of tablets prescribed after breast reduction surgery varies considerably, and there is no consensus regarding the appropriate number to prescribe. Currently, few patients use all the medication prescribed to them, indicating a high rate of overprescribing. The overwhelming majority are satisfied with their pain control. Most patients use less than 10 tablets of narcotic pain medication after surgery. Acetaminophen is widely used as an adjunct but NSAIDs remain underutilized. Based on these data, we recommend that breast reduction patient's pain is best managed with acetaminophen, NSAIDs, and expectation management.

Retrospective, parent‐reported data suggest that 50% of Australian children with mental health disorders miss out on care. In a national sample, we aimed to determine the proportion receiving menta...

INTRODUCTION For decades, it has been recommended that children with sickle cell anemia (SCA) receive antibiotic prophylaxis to prevent serious infections and undergo transcranial Doppler (TCD) screening to identify those at highest risk of overt stroke. We assessed recent temporal trends in antibiotic prophylaxis prescription fills and TCD screening among children with SCA using validated quality measures. PROCEDURE Using validated claims-based definitions, we identified children with SCA who were enrolled in Michigan or New York State (NYS) Medicaid programs (2011-2018). Among recommended age groups, two outcomes were assessed yearly: (a) filling of ≥300 days of antibiotics, and (b) receipt of greater than or equal to one TCD. The proportion of children with each outcome was calculated by state. Temporal trends in each preventive service were assessed using generalized linear models. RESULTS A total of 1784 children were eligible for antibiotic prophylaxis (Michigan: 384; NYS: 1400), contributing 3322 person-years. Annual rates of filling ≥300 days of antibiotics ranged from 16% to 22% and were similar by state. There was no change in rates of antibiotic filling over time in Michigan (p-value: .10), but there was a decrease in NYS (p-value: .02). A total of 3439 children with SCA were eligible for TCD screening (Michigan: 710; NYS: 2729), contributing 10,012 person-years. Annual rates of TCD screening ranged from 39% to 45%, were similar by state, and did not change over time (p-values >.05). CONCLUSIONS Most children with SCA do not receive recommended antibiotic prophylaxis and/or TCD screening. New, sustainable, and coordinated interventions across preventive services are urgently needed.

Objective The aim of this study was to assess the acceptability of a novel, integrated general practitioner (GP)–paediatrician model of care, aiming to reduce referrals to hospitals and improve primary care quality. Methods A pre-post study was conducted with five general practice clinics in north-west Melbourne. Over 12 months, 49 GPs and 896 families participated in the intervention that included weekly to fortnightly paediatrician–GP co-consultation sessions at the general practice, monthly case discussions and telephone or email clinical support for GPs. GPs and families completed surveys or interviews at three time points (before the intervention, after running the model for 4 months and at the end of the implementation). Non-identifiable consultation data were extracted from general practice medical records. Results All GPs found the model acceptable. Although not significant, there was a trend towards a lower proportion of referrals to private paediatricians after the intervention (from 34% to 20%) and emergency departments (from 19% to 12%). Outpatient clinic referrals remained steady, and then increased as the paediatrician left the clinics (31% vs 47% before and after the intervention respectively). Unnecessary prescribing of acid suppression medications decreased by 20% (from 29% to 9%). GPs reported improved confidence in paediatric care (88% vs 100% before and after the intervention respectively). Families reported increased confidence in GP care (78% vs 94% before and after the intervention respectively). Model cost estimates were A$172 above usual care per child seen in the co-consultations. Conclusions This novel model of care is acceptable to GPs and families and may improve access and quality of paediatric care. What is known about the topic? A GP–paediatrician integrated model of care appears effective in reducing hospital burden in England, but has not been implemented in Australia. What does this paper add? This pilot, an Australian first, found that a GP–paediatrician integrated model of care is feasible and acceptable in Australia’s primary healthcare system, improves GP confidence and quality of paediatric care, may reduce paediatric referrals to outpatient clinics and emergency departments and improves family confidence in, and preference for, GP care. What are the implications for practitioners? This model may reduce hospital burden and improve quality in GP paediatric care while potentially producing cost savings for families and the healthcare system.

OBJECTIVE: To develop, test, and validate the performance of ICD‐10‐CM claims‐based case definitions for identifying children with sickle cell anemia (SCA). DATA SOURCES: Medicaid administrative claims (2016) for children

BACKGROUND Amid concerns about the pediatrician-scientist workforce, we hypothesized that declining numbers of pediatric subspecialists devote at least 25% of their professional time to research with fewer younger and female pediatricians engaged in research over the study period. METHODS Board-certified pediatricians enrolling online in the American Board of Pediatrics (ABP's) Maintenance of Certification (MOC) program October 2009 through 2016 were invited to complete a survey with questions about the allocation of their professional time. Responses from individuals in the 14 ABP-certified subspecialties were analyzed. The number and proportions of respondents devoting 25-49% and 50% or more of professional time to research were calculated over time. Age and gender were also examined. RESULTS We analyzed 21,367 responses over 8 years. A small number of pediatric subspecialists engaged in research with 5.2-6.7% devoting 25-49% and 5.6-8.4% at least 50% of their professional time to research across subspecialties. There was no discernable increase or decrease over time or pattern by age or gender. CONCLUSION Less than 10% of pediatric medical subspecialists devote at least 50% of their professional time to research. Efforts to promote research among pediatric subspecialists have not increased the size of the population that reports engaging in research at this level.

Hospital-acquired pressure injuries (HAPIs) are a major source of unintended patient harm and unnecessary costs. The Braden Scale is widely used for risk assessment, yet it lacks specificity and clinical applications. This study used the electronic health record to examine associations between patient-specific factors and pressure injury. Adult patients (age >18) with 3-day length of stay from April 2011 to December 2016 were included. Pressure injuries were identified by ICD-9/ICD-10 codes. Longitudinal multivariate logistic regression was used to evaluate the association between patient-specific factors and HAPIs. This included 57,227 hospital encounters and 241 HAPIs. We observed 2–3 times increased likelihood of acquiring a pressure injury among patients who were malnourished or who had increased intraoperative time. The Braden subscales of nutrition, mobility, and friction showed significant predictive value. Future work is needed to assess the clinical applicability of this work.

Objectives Clinical guidelines state brain computed tomography (CT) for atraumatic headache or first generalized afebrile, atraumatic seizure as nonindicated in neurologically normal children. We aimed to adapt 2 rigorously validated United States-based measures that examine overuse of CT in children with these conditions, and to determine whether these measures can be used in an Australian setting to determine rates of CT scanning in current practice. Methods Within an Australian tertiary pediatric hospital, we successfully adapted the measures from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding system of the United States measures to the International Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) coding system used in Australia. We conducted a retrospective audit of electronic medical record data from April 1, 2017, to March 31, 2018. Eligible patients were children aged 4 to 17 years who attended one of the hospital outpatient clinics and/or emergency department and/or were admitted to an inpatient ward. The conditions of interest were (1) atraumatic headache and (2) first generalized afebrile, atraumatic seizure. Results The measure for afebrile seizure was found to have low accuracy and low feasibility in this setting and was not tested further. The adapted measure for atraumatic headache was highly accurate in determining the encounters of interest; however, manual chart review was required to identify nonindicated brain CTs. Using this measure, 601 encounters for atraumatic headache were identified, of which 98 (16.3%) received at least 1 brain CT. We found that 14.1% of these scans were nonindicated, meaning 2% all atraumatic headache encounters received a nonindicated scan; lower than rates reported in international literature. Conclusions Using the tool developed in this study, rigorous measurement of the overuse of CT scans in other settings may determine the reasons for the lower rates observed in this study; inform future interventions to minimize overuse; and provide safer, higher quality care to children.

1. Introduction In Victoria, the healthcare system for children is overburdened by increasing general practitioner (GP) referrals to hospital emergency departments (EDs) and outpatient clinics. GPs could be supported to manage children closer to home. 2. Practice change implemented We co-designed and implemented a GP-paediatrician integrated care model comprising: weekly paediatrician-GP co-consultation sessions at the GP practice; monthly case discussions; and phone and email support for GPs. 3. Aim and theory of change The model was designed to support GPs to deliver higher quality of care, with greater confidence for a broader range of childhood health concerns. We measured: model feasibility and acceptability; GP confidence, referrals and care quality; family experience and preference for care; and costs. 4. Targeted population and stakeholders Population: 49 participating GPs from 5 GP practices (2 metropolitan and 3 regional); and their patients aged 0 – 17 years, and families; and 2 Paediatricians. Stakeholders: The Royal Children’s Hospital; Sunshine and Werribee Mercy Hospitals; North Western Melbourne Primary Health Network (PHN); and the Victorian Department of Health and Human Services. 5. Timeline 12-month intervention. 6. Highlights (innovation, Impact and outcomes) The model was feasible and acceptable to GPs, families and paediatricians with 624 children seen in the co-consultations and 50 case discussions conducted. In pre-post testing, there was a 7% absolute reduction in ED referrals, 20% reduction in GP low value care; increased GP confidence in paediatric care (88% to 100%); and family confidence in GP care (78% to 94%). Families reported ease and comfort of receiving paediatric care closer to home. Model costs as implemented were $172 over and above usual care, per child seen in the co-consults. However, in an idealised implementation scenario, the model has the potential to be cost saving for families, state/federal governments and hospitals. 7. Comments on sustainability Sustainability planning was completed in partnership with the PHN and the practices; two have hired paediatricians, with others exploring options for access to paediatric support and learning (e.g. webinar program). The research team plan to complete a larger, multi-site multi-state trial to rigorously evaluate effectiveness and cost-effectiveness of the model in high referral areas. 8. Comments on transferability This integrated care model could be replicated for chronic complex care that burdens the hospital system, or implemented in service hubs with co-located paediatricians, or extended to include telehealth for rural/regional hubs. 9. Conclusions (key findings) Developing and embedding a GP-paediatrician integrated model of care in Australia’s primary health care system is feasible and acceptable; improves GP confidence and quality of paediatric care; benefits families and children; and may reduce referrals to hospital services. 10. Discussions Truly integrated care, delivered as a collaboration between hospitals, health networks, GPs and their practices has the potential to shape a health system in which children can receive higher quality, timelier care, closer to home. 11. Lessons learned Co-design and initial onsite-support were crucial e.g. billing; data collection; co-consult structure and purpose. The drive and desire to provide better care for children is the strongest motivator for change.

* Abbreviation: URiM — : underrepresented in medicine Medicine in the United States has been hampered by a lack of diversity for centuries. Over the past few decades, greater attention and efforts have been focused on tackling this problem. A diverse workforce is important for many reasons, including a commitment toward a representative workforce in the name of social justice, improved patient care in the form of increased access and patient satisfaction,1 and service to communities for whom we provide care.2 Programs aimed at increasing diversity exist at every level of medical training, from premedical programs to the subspecialty match. Programs throughout are important because structural and individual racism impede minority success at every level, but the earliest interventions are the most likely to succeed. Efforts aimed at increasing diversity will not succeed by simply targeting subspecialty trainees alone. In essence, at the subspecialty level, this is a zero-sum game. The gains made by any one program are exactly balanced by the losses borne by others. A significant impact on increasing the pool of underrepresented in medicine (URiM) candidates for fellowship positions requires that efforts begin early and continue throughout the entire educational journey. The Association of American Medical Colleges defines URiM as “racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.” This … Address correspondence to Angela C. Weyand, MD, Division of Pediatric Hematology and Oncology, Department of Pediatrics, Medical School, University of Michigan, 1150 W Medical Center Dr, Medical Sciences Research Building III, Room 8220E, Ann Arbor, MI 48109. E-mail: acweyand{at}med.umich.edu

AIM: To determine: (i) wait times and out-of-pocket costs for children attending private specialists for initial mental health appointments; and (ii) whether these differed between specialists working in metropolitan versus rural areas and in low, medium and high socio-economic areas. METHODS: Prospective secret shopper study whereby a researcher posed as a parent seeking an appointment for her child with anxiety or attention-deficit/hyperactivity disorder. We contacted 317 private paediatrician, psychiatrist and psychologist practices in Victoria and South Australia between 12 March and 5 May 2019. RESULTS: One third (29.8%) of private practices were closed to new referrals. The average wait times for paediatricians, psychiatrists, and psychologists were 44, 41 and 34 days, respectively. Average out-of-pocket costs quoted were AU$120 for paediatricians, AU$176 for psychiatrists and AU$85 for psychologists. CONCLUSION: Parents face extensive wait times and substantial out-of-pocket costs when seeking private mental health services for their child.

Newly developed measures of health care quality for children with sickle cell anemia (SCA) have revealed significant performance gaps in recommended care. Historically, health systems, Medicaid health plans, and state Medicaid programs have not partnered with patients and families to improve SCA care delivery. We organized two novel multi-stakeholder design meetings to identify potential interventions to deliver high quality preventive care for children with SCA. Invitees included patients with SCA, families, and representatives from pediatric hematology clinics, Medicaid health plans, community organizations, and a state Medicaid program. Participants identified some barriers to care through presentations and facilitated discussions. Over 35 potential interventions and six drivers of high-quality SCA preventive care delivery were organized into a key driver diagram. Many barriers to SCA care delivery could be addressed by Medicaid health plan resources to support members with chronic disease, however these resources are infrequently used in the pediatric SCA population. Bridging gaps between stakeholder groups identified many potential interventions to improve SCA preventive care delivery at all levels of the health care system. Similar multi-stakeholder discussions may be useful for other communities interested in improving preventive care for children with SCA or other chronic pediatric diseases.

Objective: To determine: 1) the mean, median and range of fees for initial and subsequent private outpatient consultations with a general paediatrician in Australia; 2) any variation in fees and bulk billing rates between states/territories; and 3) volume of outpatient general paediatric specialist consultations relative to child population. Methods: Analysis of Medicare claims data from the years 2011 and 2014 for initial consultations (items 110 and 132), subsequent consultations (items 116 and 133), and autism or pervasive developmental disorder (PDD) initial consultation (item 135) with a general paediatrician. Results: Fees for initial and subsequent general paediatric outpatient consultations varied within, and between, states and territories. Fees increased slightly from 2011 to 2014, after accounting for inflation. The volume of consultations relative to child population varied markedly across states and territories, as did bulk billing rates. Use of item codes for patients with multiple morbidities (132 and 133) increased significantly from 2011 to 2014. Autism/PDD consultation service use (item 135) and fees remained relatively stable. Conclusions: There was variation in service use, fees and bulk billing within, and between, states and territories, and across time and consultation types. Implications for public health: Future studies should assess the impact of such variation on access to paediatric services and the relationship, if any, to variation in state investment in public paediatric outpatient services.

Objective To assess adults' perceptions regarding the health and well-being of children today relative to their own health and well-being as youth and the potential for intergenerational differences in those perceptions. Methods A cross-sectional, Internet-based survey of a nationally representative household sample was conducted using GfK Custom Research's Web-enabled KnowledgePanel, a probability-based panel representative of the US population. We assessed perceptions of children's health and well-being today compared to when respondents were growing up, including physical and mental health; and children's education, exercise, diet, health care, safety of communities, and emotional support from families, groups, and organizations. Results Overall, 1330 (65%) of 2047 adult respondents completed the survey. Only 26% of respondents believed that the current physical health of children, and 14% that the current mental health of children, is better today than when they were growing up. There was a significant trend among generations, with a greater proportion of older generations perceiving the physical health of children to be better today. Only 15% of respondents reported the chances for a child to grow up with good mental health in the future are "better" now than when they were growing up. Conclusions Adults across all generations in the United States today view children's health as unlikely to meet the goals of the American Dream of continuous improvement. Although demographic changes require continued focus on our aging population, we must equally recognize the importance of advancing a healthy future for our nation's children, who will assume the mantle of our future.

Objectives To identify trends in presentations to Victorian emergency departments (EDs) by children and adolescents for mental and physical health problems; to determine patient characteristics associated with these presentations; to assess the relative clinical burdens of mental and physical health presentations. Design Secondary analysis of Victorian Emergency Minimum Dataset (VEMD) data. Participants, setting: Children and young people, 0-19 years, who presented to public EDs in Victoria, 2008-09 to 2014-15. Main outcome measures Absolute numbers and proportions of mental and physical health presentations; types of mental health diagnoses; patient and clinical characteristics associated with mental and physical health presentations. Results Between 2008-09 and 2014-15, the number of mental health presentations increased by 6.5% per year, that of physical health presentations by 2.1% per year; the proportion of mental health presentations rose from 1.7% to 2.2%. Self-harm accounted for 22.5% of mental health presentations (11 770 presentations) and psychoactive substance use for 22.3% (11 694 presentations); stress-related, mood, and behavioural and emotional disorders together accounted for 40.3% (21 127 presentations). The rates of presentations for self-harm, stress-related, mood, and behavioural and emotional disorders each increased markedly over the study period. Patients presenting with mental health problems were more likely than those with physical health problems to be triaged as urgent (2014-15: 66% v 40%), present outside business hours (36% v 20%), stay longer in the ED (65% v 82% met the National Emergency Access Target), and be admitted to hospital (24% v 18%). Conclusions The number of children who presented to Victorian public hospital EDs for mental health problems increased during 2008-2015, particularly for self-harm, depression, and behavioural disorders.

Objective To assess the part-time workforce and average hours worked per week among pediatric subspecialists in the 15 medical subspecialties certified by the American Board of Pediatrics. Study design We examined data from pediatric subspecialists who enrolled in Maintenance of Certification with the American Board of Pediatrics from 2009 to 2015. Data were collected via an online survey. Providers indicated whether they worked full time or part time and estimated the average number of hours worked per week in clinical, research, education, and administrative tasks, excluding time on call. We calculated and compared the range of hours worked by those in full- and part-time positions overall, by demographic characteristics, and by subspecialty. Results Overall, 9.6% of subspecialists worked part time. There was significant variation in part-time employment rates between subspecialties, ranging from 3.8% among critical care pediatricians to 22.9% among developmental-behavioral pediatricians. Women, American medical graduates, and physicians older than 70 years of age reported higher rates of part-time employment than men, international medical graduates, and younger physicians. There was marked variation in the number of hours worked across subspecialties. Most, but not all, full-time subspecialists reported working at least 40 hours per week. More than one-half of physicians working part time in hematology and oncology, pulmonology, and transplant hepatology reported working at least 40 hours per week. Conclusions There are unique patterns of part-time employment and hours worked per week among pediatric medical subspecialists that make simple head counts inadequate to determine the effective workforce. Our findings are limited to the 15 American Board of Pediatrics-certified medical subspecialties.

The incidence of thyroid disease in adolescents with heavy menstrual bleeding is unknown. A retrospective cross-sectional study of 427 adolescents presenting with heavy menstrual bleeding found 0.23% (95% CI 0%-0.7%) had thyroid disease, lower than that expected in the general population. Thyroid testing should only be considered when other symptomatology is present.

Aim To determine (i) the proportion of different referral sources for new referrals to paediatric specialist outpatient clinics and (ii) any association of referral source with utilisation of additional health services. Methods Survey of parents presenting with their child at five paediatric specialist outpatient clinics at two Melbourne public hospitals. Results Just over half (52%) of the respondents were referred by a general practitioner (GP). The remainder were referred by a paediatrician (27%) at hospital discharge (16%) or from the ED (6%). Most respondents (71%) reported that their child also has a referral to see another specialist for the same health concern but had not yet had the consultation; 44% had consulted another doctor for the same health concern between receiving the referral and the appointment. Paediatrician referrals were more likely to see another specialist for the same health concern compared to other referral sources (P = 0.032). Conclusion Only half of the referrals of new patients to paediatric specialist outpatient clinics come from GPs. Future research should investigate whether multiple referral sources have a negative impact on the co-ordination and cost of paediatric health care.

Aim To assess a national sample of Australian parental confidence in general practitioner (GP) care for illness and injury for their children. Methods Cross-sectional, internet-based survey of a national, representative sample of parents of children birth – 17 years in Australia was used. Purposeful recruitment was used to achieve a national, representative sample of 2100 Australian parents, reflective of demographic and geographic distribution based on census data. Parents were asked to indicate their degree of confidence in a GP to handle medical problems as well as their preference for, and use of, paediatric speciality care for their children. Results Fewer than half of parents (44%) reported that they were completely confident in a GP to provide general care as defined as ‘can handle almost all general health issues for my child’. A slightly greater proportion of parents (56%) were completely confident in a GP to provide care for minor injuries, defined as injuries not requiring an X-ray. Greater confidence in general care was seen among parents >40 years of age and those whose GP is always bulk billed. Conclusions Parental confidence in GPs is an important issue. Our findings that fewer than half of parents are completely confident in their GP to provide general care to their child may be an influencing factor on current health-care utilisation trends. The potential implications of low parental confidence in GPs are greater numbers of emergency department presentations for children with lower urgency conditions and increased referrals of children for specialty care.

The aims of this study were to estimate the proportion of emergency department presentations attributable to children with cerebral palsy (CP), investigate the frequency of emergency department presentations in a CP cohort, and compare emergency department presentations among children with CP with those of other children.This was a retrospective cohort study. The Victorian Cerebral Palsy Register was linked to the Victorian Emergency Minimum Dataset. Data on emergency department presentations for the CP cohort occurring between 2007 and 2014 and population control data were obtained.The CP cohort (n=1748) had 7015 emergency department presentations during the 7-year period, accounting for 0.4% of the 1.69 million age-specific presentations during that time. The number of annual presentations per 1000 children rose with increasing CP severity. Compared with presentations among the general population, higher proportions of presentations among the CP cohort were preceded by ambulance arrivals (27% vs 8%), triaged as urgent (66% vs 32%), and required hospital admission (38% vs 12%).The marked differences in presentations between the CP cohort and the general population in the proportions that were urgent and required ambulance arrivals and hospital admissions was an important finding. Strategies to ensure appropriate use of services, including encouragement to seek earlier assistance from primary care providers, may prevent problems escalating to the need for urgent care.Children with cerebral palsy (CP) account for 0.4% of childhood emergency department presentations. More emergency department presentations among children with CP require ambulance arrival. More CP emergency department presentations are urgent and require hospital admission. Traditional emergency department triage scales seem less accurate for this group.

OBJECTIVES To determine the mean, median and 10th and 90th percentile levels of fees and out-of-pocket costs to the patient for an initial consultation with a consultant physician; to determine any differences in fees and bulk-billing rates between specialties and between states and territories. DESIGN, PARTICIPANTS AND SETTING Analysis of 2015 Medicare claims data for an initial outpatient appointment with a consultant physician (Item 110) in 11 medical specialties representative of common adult non-surgical medical care (cardiology, endocrinology, gastroenterology, geriatric medicine, haematology, immunology/allergy, medical oncology, nephrology, neurology, respiratory medicine and rheumatology). MAIN OUTCOME MEASURES Mean, median, 10th and 90th percentile levels for consultant physician fees and out-of-pocket costs, by medical specialty and state or territory; bulk-billing rate, by medical specialty and state/territory. RESULTS Bulk-billing rates varied between specialties, with only haematology and medical oncology bulk-billing more than half of initial consultations. Bulk-billing rates also varied between states and territories, with rates in the Northern Territory (76%) nearly double those elsewhere. Most private consultations require a significant out-of-pocket payment by the patient, and these payments varied more than fivefold in some specialties. CONCLUSION Without data on quality of care in private outpatient services, the rationale for the marked variations in fees within specialties is unknown. As insurers are prohibited from providing cover for the costs of outpatient care, the impact of out-of-pocket payments on access to private specialist care is unknown.

BACKGROUND: Physicians must balance career and home responsibilities, yet previous studies on work-life balance are focused primarily on work-based tasks. We examined gender discrepancies and factors related to household responsibilities and work-life balance among pediatricians. METHODS: We used 2015 data from the American Academy of Pediatrics Pediatrician Life and Career Experience Study, a longitudinal study of early-career pediatricians. χ2 tests and multivariable logistic regression were used to examine the effects of gender on household responsibilities, satisfaction, and work-life balance attainment. We formally reviewed responses from 2 open-ended questions on work-life balance challenges and strategies for common themes. RESULTS: Seventy-two percent of participants completed the survey (1293 of 1801). Women were more likely than men to report having primary responsibility for 13 of 16 household responsibilities, such as cleaning, cooking, and routine care of children (all P < .001). All gender differences except budget management remained significant when controlling for part-time work status and spouse or partner work status (P < .05). Women were less satisfied with their share of responsibilities relative to others (52% vs 62%; P < .001), and few women and men report being very successful at achieving balance between their job and other life areas (15% vs 19%, respectively; P = .05). Open-ended responses (n = 1145) revealed many barriers to achieving work-life balance. Strategies to increase work-life balance included reducing work hours, outsourcing household-related work, and adjustments to personal responsibilities and relationships. CONCLUSIONS: Female pediatricians spend more time on household responsibilities than male pediatricians, and gender is a key factor associated with work-life balance satisfaction.

Introduction: Over the past two decades, Australia’s child population has grown by 12%, yet fewer children are seen by General Practitioners (GP) (Freed, 2011) and more present to emergency departments (Freed, 2015) and hospital outpatient clinics for relatively simple conditions that could be managed in primary care. We therefore aimed to co-develop and pilot an innovative, integrated GP-paediatrician care model and test its feasibility and acceptability to GPs, families and paediatricians, across 5 Victorian (Australia) general practices. Theory/Methods: GP and paediatrician co-design of an integrated care model comprising: weekly GP-paediatrician co-consulting sessions and monthly hour-long case discussions at each practice led by GPs and facilitated by a paediatrician, and email/telephone support to GPs by paediatricians. Paediatricians recorded data on numbers of children and types of cases seen in co-consults and number and topics and number of attendees in the case discussions. We extracted data on quality of GP care for common conditions and pre/post referral patterns of GPs via GHRANITE electronic medical record data extraction software. GP and paediatrician satisfaction with model of care and family satisfaction with GP care for their child were collected via surveys. Results: After 9 months of implementation, 447 children were seen in co-consults and 27 case discussion sessions were conducted with 206 attendees. GPs report high satisfaction with the model and changes in their knowledge and confidence with paediatric care. GPs referred 9% fewer children to hospital and families reported improved confidence in thier GP's care (complete confidence from 78% to 94%) and increased first preference for followup care with a GP (65.4% to 82.8%). Discussion: A novel, integrated model of care between GPs, paediatricians and families is feasible and acceptable to GPs, general practice staff, paediatricians and families. Challenges include ensuring accurate and complete data on GP referral patterns, payment for the co-consulting sessions, and clear communication to practice staff and parents about the role of the paediatrician as a co-consultant with the GP rather than a stand-alone specialist care provider. Conclusions: Developing and embedding a GP-paediatrician model of integrated care in Australia’s primary health care system is feasible and acceptable. Pilot data suggest that the model improves GP confidence to manage paediatric care, streamlines specialist care for child developmental/behavioural problems and may reduce referrals to hospital outpatient clinics and emergency departments. Lessons learned: Intervention design must involve paediatricians, GPs, practice managers and practice administrative staff from the outset. Mutual expectations and clear roles and responsibilities of GPs and paediatricians in co-consultations must be established. Careful attention to messaging to families about the nature of co-consultations will avoid families seeking a paediatrician without a GP. Limitations: pilot study Future research: controlled trial to test the costs and effectiveness of this model in improving GP quality of care for common paediatric health conditions, reducing referrals to outpatient specialist clinics and emergency departments, improving GP confidence in paediatric care, and family satisfaction with primary care for their child.

BACKGROUND: The US physician workforce includes an increasing number of women, with pediatrics having the highest percentage. In recent research on physicians, it is indicated that men earn more than women. It is unclear how this finding extends to pediatricians. METHODS: We examined cross-sectional 2016 data on earnings from the American Academy of Pediatrics Pediatrician Life and Career Experience Study, a longitudinal study of early- and midcareer pediatricians. To estimate adjusted differences in pediatrician earnings between men and women, we conducted 4 ordinary least squares regression models. Model 1 examined gender, unadjusted; model 2 controlled for labor force characteristics; model 3 controlled for both labor force and physician-specific job characteristics; and model 4 controlled for labor force, physician-specific job, and work-family characteristics. RESULTS: Sixty-seven percent of Pediatrician Life and Career Experience Study participants completed the 2016 surveys (1213 out of 1801). The analytic sample was restricted to participants who completed training and worked in general pediatrics, hospitalist care, or subspecialty care (n = 998). Overall pediatrician-reported mean annual income was $189 804. Before any adjustment, women earned ∼76% of what men earned, or ∼$51 000 less. Adjusting for common labor force characteristics such as demographics, work hours, and specialty, women earned ∼87% of what men earned, or ∼$26 000 less. Adjusting for a comprehensive set of labor force, physician-specific job, and work-family characteristics, women earned ∼94% of what men earned, or ∼$8000 less. CONCLUSIONS: Early- to midcareer female pediatricians earned less than male pediatricians. This difference persisted after adjustment for important labor force, physician-specific job, and work-family characteristics. In future work, researchers should use longitudinal analyses and further explore family obligations and choices.

The transition from ICD-9-CM to ICD-10-CM diagnosis codes has potentially significant implications for quality measurement. Challenges include translating each measure by manual review, and reassessing the validity of each measure. Without this effort, all claims-based quality measures have unknown accuracy, affecting their use by providers, patients, and insurers.

Physician workforce research often generates marked interest across multiple specialties and policy makers. Data are used to argue for or against proposed changes in funding for undergraduate or graduate medical education, to define areas of shortage or surplus in the health care delivery system, and to forecast future needs. In my experience, investigators or policy makers may present workforce research results, for which they may be unaware of their data sources and accuracy, to describe the current workforce or make inferences or predictions of the future workforce. Often, little is known regarding the methods of how the data were obtained or analyzed nor what standards of rigor are needed to achieve validity of the results presented. Usually, flaws in methodology create uncertainty regarding the accuracy and validity of results. Recognition of these flaws can help place results in context and temper tendencies of researchers and/or advocates to draw strong inferences. Determining the precise degree of inaccuracy requires the use of >1 data source, preferably with one that can function as a gold standard. For example, a data source commonly used by the federal government and the Dartmouth Atlas Project to determine counts and distributions of physicians was shown to have a misattribution rate of ∼30% for a specific pediatric subspecialty.1 Regardless, for those who either produce or use workforce research, it is important to be aware of and understand common methodologic pitfalls that can affect the accuracy of both the results and the inferences deduced from them. These problems fall into 5 basic categories: (1) selection bias, (2) nonresponse bias, (3) aggregation bias, (4) designation bias, and (5) head-count bias. When >1 type of bias is present at the same time, they can act in an additive or multiplicative fashion, making the results more suspect. Understanding the potential biases … Address correspondence to Gary L. Freed, MD, MPH, Child Health Evaluation and Research Center, University of Michigan, 300 North Ingalls Building, Room 6D21, Ann Arbor, MI 48109-0456. E-mail: gfreed{at}med.umich.edu

This survey study investigates whether the perceived gender of a child is associated with how medical students assess a pediatric patient’s pain displayed and pain experienced.

Background: Whether general practitioner (GP) registrars have adequate exposure to, and feel confident in, managing children's health during training is unknown. Objectives: To determine the prevalence and associations of GP registrars' paediatric vs. non-paediatric consultations. Methods: Cross-sectional analysis from a cohort study of Australian GP registrars' 2010-2014 consultations. Results: 889 registrars contributed details for 26,427 (21.8% (95% CI: 21.4-22.2) paediatric consultations. Paediatric patients were more likely to be male and new to the practice. Although paediatric patients were less likely to have a chronic disease (OR 0.38, 95% CI 0.36, 0.40) and presented with fewer problems (OR 0.59, 95% CI 0.57, 0.61), registrars were more likely to seek in-consultation advice (OR 1.25, 95% CI 1.19, 1.31) and generate learning goals (OR 1.12, 95% CI 1.07, 1.18) for paediatric consultations. Discussion: GP registrars appear to feel less confident in managing paediatric compared with adult consultations, suggesting an unmet training need.

Aim The overall aim was to investigate the feasibility and utility of linking a cerebral palsy (CP) register to an administrative data set for health services research purposes. We sought to compare CP hospital admissions to general childhood population admissions, and identify factors associated with type and frequency of admissions in a CP cohort. Method The CP register for Victoria, Australia was linked to the state's hospital admissions database. Data pertaining to the admissions of a CP cohort (n=1748) that took place between 2007 and 2014 were extracted. Population data were also obtained. Results Overall, 80% of the CP cohort (n=1401) had at least admission between 2007 and 2014, accounting for 11 012 admissions or 1.5% of all admissions in their age group. Compared to general population admissions, CP admissions were more costly and more likely to be elective (66% vs 57%; p

The treatment of complex wounds is commonplace for plastic surgeons. Standard management is debridement of infected and devitalized tissue and systemic antibiotic therapy. In cases where vital structures are exposed within the wound, coverage is obtained with the use of vascularized tissue using both muscle and fasciocutaneous flaps. The use of nondissolving polymethylmethacrylate and absorbable antibiotic-impregnated beads has been shown to deliver high concentrations of antibiotics with low systemic levels of the same antibiotic. We present a multicenter retrospective review of all cases that used absorbable antibiotic-impregnated beads for complex wound management from 2003 to 2013. A total of 104 cases were investigated, flap coverage was used in 97 cases (93.3%). Overall, 15 patients (14.4%) required reoperation with the highest groups involving orthopedic wounds and sternal wounds. The advantages of using absorbable antibiotic-impregnated beads in complex infected wounds have been demonstrated with minimal disadvantages. The utilization of these beads is expanding to a variety of complex infectious wounds requiring high concentrations of local antibiotics.

Aim Over the last decade, there has been a dramatic increase in the number of referrals for paediatric subspecialty care and in overall appointments (new and review) to these doctors. We sought to determine the perspective of parents regarding their role in the initiation of referrals, their preferences for follow-up and the role of general practitioners (GPs) in care co-ordination. Methods Self-completed survey in outpatient paediatric clinics (general paediatrics and four subspecialties) at two children's hospitals in Victoria. Recruitment targets were 100 parents in each of the general paediatrics clinics and 50 parents in each subspecialty clinic, equally divided between new and review visits (total n = 600). Results A total of 606 parents provided responses, with a decline rate of 9%. Many (52%) new patients were referred by a GP with the remainder from a variety of other sources. With specific regard to providing general care to their child, only 45% were completely confident in a GP. Most (76%) agreed with the statement that a GP would give their child a referral to see a paediatrician whenever they ask. Approximately, a third of parents reported that a GP rarely or never co-ordinates the care of their child with other doctors. Conclusions Parents play an important role in both the initiation of paediatric specialty referrals and the patterns of follow-up care provided. Parent perspectives, preferences and motivations on both the referral process and the patterns for ongoing care are essential to develop policies that provide the best and most efficient care for children.

Aim In adult medicine, rates of investigation and prescribing appear to be increasing. Such information is lacking for paediatrics. We audited Australian paediatricians’ practices in 2013 to determine changes since 2008 in: (i) conditions seen; (ii) consultation duration; (iii) imaging and pathology ordered; and (iv) prescribing. Methods This is a patient-level prospective audit of paediatricians’ secondary care practice. Between November and December 2013, members of the Australian Paediatric Research Network were invited to complete standardised forms for 100 consecutive patients or all patients seen over 2 weeks, whichever was completed first. Main measures: diagnoses, consultation duration, pathology and/or imaging investigations ordered, rate of medication prescription. Analyses: hierarchical linear modelling clustered at the paediatrician level. Results One hundred and eighty paediatricians (48% of those eligible) contributed 7102 consultations. The proportion of developmental/behavioural conditions rose from 48% (SD 31%) to 60% (SD 30%) in new and 54% (SD 28%) to 66% (SD 28%) in review consultations in 2013 compared with 2008. More paediatricians reported diagnoses of autism spectrum disorder (39–56%, P = 0.002), attention-deficit/hyperactivity disorder (47–55%, P = 0.05) and intellectual disability (18–36%, P = 0.001) in first consultations. Mean consultation duration and pathology/imaging ordering rates were stable. Prescribing rates increased from 39 to 45% of consultations for the top 10 new diagnoses and from 57 to 68% of consultations for the top 10 review diagnoses. Conclusions Paediatricians are seeing more children with developmental–behavioural conditions, prescribing more and demonstrating wide variation in their practice. The latter suggests both over- and under-treatment.

Objectives Injuries are a significant proportion of lower urgency (triage category 4 or 5) child presentations to the EDs in metropolitan Melbourne. The purpose of the present study was to assess parental preferences and experiences regarding the treatment of lower urgency child injuries and the role of general practitioners (GPs) in such care. Methods A self-administered survey study of 1150 parents of children ≤9 years of age attending the ED at one of four Victorian hospitals triaged with a lower urgency condition (triage category 4 or 5) looked at whether children with lower urgency injuries are frequently referred by their GP to the ED and parent preferences for the care of lower urgency child injuries. Parents were recruited by time of day and weekday/weekend. Descriptive and bivariate analyses were performed. Results Fewer parents of injured children, compared with illness, attempted to make a GP appointment prior to attending ED (35% vs 46%; P

Aim The aim of the study was to investigate the patterns of medical service use in children with cerebral palsy (CP), taking into account child and family characteristics. Methods Nine hundred and one parents and carers of children registered with the Victorian CP Register were invited to complete a survey. Participants were asked about their child's appointments with general practitioners and public and private paediatric medical specialists over the preceding 12 months. Information on family characteristics and finances was also collected. Data on CP severity and complexity were extracted from the CP Register. Results Three hundred and fifty parents and carers (39%) participated. Of these, 83% reported that their child had ≥1 appointment with a general practitioner over the preceding 12 months, while 84% had ≥1 appointment with a public or private paediatric medical specialist. Overall, 58% of children saw 2–5 different paediatric medical specialists, while 9% had appointments with ≥6 clinicians. Children with severe and complex CP were more likely to have had ≥1 appointment with a publically funded paediatric medical specialist and had seen a greater number of different clinicians over the study period. Family characteristics were not associated with service use. Conclusions Children with CP are managed by a number of paediatric medical specialists, and they continue to see a range of specialists throughout adolescence. In Victoria, differences in service use are not based on family characteristics; instead the highest service users are those with severe and complex CP. For this group, care co-ordination and information sharing between treating clinicians are important, if gaps in care are to be avoided.

Despite recommendations to limit the use of neuroimaging for evaluation of minor head injury and atraumatic headache in children, many children receive unnecessary imaging without clear history or physical exam indications in the emergency department (ED) or other outpatient settings. This overuse of neuroimaging has not previously been explored across clinical settings, nor for the diagnosis of atraumatic headache. We convened a multi-stakeholder design meeting to discuss reasons for overuse of neuroimaging in children and brainstorm potential interventions to reduce overuse. The meeting included didactic sessions on the risks and benefits of neuroimaging and quality improvement methodology. There were also small group discussions of challenges and potential interventions. Participants included ED physicians and nurses, radiologists, Medicaid health plan representatives, a pediatric neurologist, a pediatric primary care provider and a parent. Reasons for overuse included family anxiety and expectations for neuroimaging, pediatric phone triage protocols directing patients to the ED for evaluation, time pressures within primary care and the ED clinics, and reluctance among payers to institute prior authorization for ED-based imaging studies. Several potential interventions were identified and organized into three key driver diagrams: one each for primary care, the ED, and Medicaid health plans. Convening a multi-stakeholder meeting was feasible and resulted in the identification of common reasons for overuse of neuroimaging in children and many potential interventions across clinical settings. Similar multidisciplinary approaches may be helpful for others interested in reducing the overuse of imaging in children. Discussions from a multi-stakeholder meeting with representation from primary care, pediatric emergency departments, and Medicaid health plans resulted in the identification of common reasons for overuse of neuroimaging in children and many potential interventions across clinical settings.

Objective Explore pediatric residents’ experiences and confidence with quality improvement (QI). Methods Pediatric residents were surveyed nationally in July 2017 about their demographic characteristics, experiences with QI projects over the previous year, and confidence with QI skills. Descriptive statistics and distributions of each individual demographic and QI variable, as well as training program size, were calculated for each variable. QI question responses were compared to demographic characteristics of the respondents, and chi-square statistics were calculated. Results In total, 11,137 out of 11,304 (98.5%) residents completed the survey. Half of residents had participated in a QI project over the previous academic year, and 78% of third-year residents reported having done so. However, few of these residents self-reported moderate or high confidence in their ability to design a QI project (28.9%), use QI tools (23.1%), use QI methodologies (24.0%), or use data to track changes in their personal practice over time (28.9%). Residents in small or medium programs were statistically more likely to rate their confidence in certain QI abilities higher than those in large programs. Conclusions Although recent pediatric residents appear to be participating in QI activities during training, their self-perception of their QI skills development remains low. Residents in small and medium programs provide more favorable reports.