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Background: A significant gap persists between evidence from research and its use in practice. Research funders, important actors in the health research system, can help reduce this gap by initiating dissemination and implementation (D&I) activities. The specific types of D&I activities funders currently lead have not been explored thoroughly. The Ensuring Value in Research (EViR) Funders' Forum-an international collaboration of health-related research funders-was established in 2017 to address research waste issues and increase the value of research. The Forum surveyed funders to learn about their D&I practices and challenges., Methods: We distributed a five-item exploratory survey to participating funders in August 2018. The results informed the development of a survey instrument, distributed in June 2019. The survey instrument contained 15 items prompting respondents to categorize and describe their level of effort in six practice areas: release of findings, dissemination, knowledge exchange/partnering, implementation, building capacity, and implementation research. In addition, funders were asked to describe examples of their practices in detail. Thirty-one funders completed the survey instrument, a 58% response rate., Results: Most funders regard D&I as a high priority, but funders vary in levels of activity per practice area. Over half of respondents reported that they have at least some activity in all D&I practice areas surveyed, with the exception of implementation research. The vast majority indicated some or significant activity in release of findings (97%) and dissemination (87%). Nearly one-fifth of funders (19%) indicated that implementation is outside their remit, and 26% indicated that implementation research is outside their remit. Survey respondents shared a broad range of examples of activities in each practice area. Lack of evidence for successful approaches and measuring impact were named frequently as challenges and as potential areas for collaboration., Conclusions: Although models of dissemination and implementation vary across organizations, the majority of funders indicated that D&I of research findings is a priority. Funders indicated a need for evidence on effectiveness of various approaches to D&I. Increased collaboration between funders, including sharing good practices, will increase our collective learning and knowledge development., (© 2022. The Author(s).)

International experts have recommended actions that funders can take to improve the value of research investments. They state that self-assessment and public sharing are the basis for accountability and improvement. We examined our policies and practice to determine the extent to which the Patient-Centered Outcomes Research Institute's (PCORI) policies and practices as a research funder align with international best practice recommendations. A self-audit of current policies and practice against 17 recommendations and 35 sub-recommendations representing five major stages of research production, based on adapted methods used for self-assessment by another funder, was performed.  Fit of existing PCORI policies and practices with 35 sub-recommendations, qualitative assessment of adequacy (area of strength; area of partial strength; area of growth; not applicable) for 17 recommendations for five stages of research production was assessed. Of the 17 recommendations, 15 were applicable to PCORI's research mission and focus.  PCORI has policies and practices in place for all elements of six recommendations ("area of strength") and policies that address each element but with some still in active development for three ("area of partial strength"). PCORI is partially addressing six of the 15 relevant recommendations ("area of growth"). Areas for growth include making study protocols publicly available, improving policies on data sharing, and enhancing collaboration with other funders to reduce redundant funding. A voluntary consortium of international funders is underway to encourage further progress, including additional self-assessment and public sharing for accountability. These findings indicate PCORI has undertaken efforts to align its funding practices with international recommendations to ensure the value of public dollars invested in research.  Further efforts will likely require additional coordination and collaboration between funders and stakeholders., Competing Interests: Competing interests: Because we are employees of PCORI and this is a self-audit, it could be perceived as potentially biased. We utilized the methods used by a separate funding agency (NIHR) for a similar exercise to the extent possible. We engaged both internal staff (for knowledge and completeness of data generation) as well as Board members (for an outside informed but more objective view when rating these). For the overall self-rating, we used several rounds of feedback after independent ratings were conducted to come to a consensus. We have acknowledged this as a self-audit and that potential limitation, while also promoting the transparency and accountability it represents for a funding agency. The authors have no other relationships, circumstances, or financial activities to disclose.

International experts have recommended actions that funders can take to improve the value of research investments. They state that self-assessment and public sharing are the basis for accountability and improvement. We examined our policies and practice to determine the extent to which the Patient-Centered Outcomes Research Institute's (PCORI) policies and practices as a research funder align with international best practice recommendations. A self-audit of current policies and practice against 17 recommendations and 35 sub-recommendations representing five major stages of research production, based on adapted methods used for self-assessment by another funder, was performed.  Fit of existing PCORI policies and practices with 35 sub-recommendations, qualitative assessment of adequacy (area of strength; area of partial strength; area of growth; not applicable) for 17 recommendations for five stages of research production was assessed. Of the 17 recommendations, 15 were applicable to PCORI's research mission and focus.  PCORI has policies and practices in place for all elements of six recommendations ("area of strength") and policies that address each element but with some still in active development for three ("area of partial strength"). PCORI is partially addressing six of the 15 relevant recommendations ("area of growth"). Areas for growth include making study protocols publicly available, improving policies on data sharing, and enhancing collaboration with other funders to reduce redundant funding. A voluntary consortium of international funders is underway to encourage further progress, including additional self-assessment and public sharing for accountability. These findings indicate PCORI has undertaken efforts to align its funding practices with international recommendations to ensure the value of public dollars invested in research.  Further efforts will likely require additional coordination and collaboration between funders and stakeholders., Competing Interests: Competing interests: Because we are employees of PCORI and this is a self-audit, it could be perceived as potentially biased. We utilized the methods used by a separate funding agency (NIHR) for a similar exercise to the extent possible. We engaged both internal staff (for knowledge and completeness of data generation) as well as Board members (for an outside informed but more objective view when rating these). For the overall self-rating, we used several rounds of feedback after independent ratings were conducted to come to a consensus. We have acknowledged this as a self-audit and that potential limitation, while also promoting the transparency and accountability it represents for a funding agency. The authors have no other relationships, circumstances, or financial activities to disclose.

Importance: Incomplete information about existing research is an underlying cause of research waste. National and international initiatives and requirements have been launched to address this issue., Objectives: To characterize current clinical trial transparency policies among the largest noncommercial US funders and examine whether the policies are concordant with international funders., Design, Setting, and Participants: This retrospective review of public information used methods developed for documenting funder policies internationally; 2 researchers searched each funder's website and Google between May and November 2018 to locate trial transparency policies for 10 top US funders. Key informants at each funding organization were contacted by email and given 3 or more weeks to review and confirm or correct the findings. Nonresponders were contacted 2 or more additional times. Descriptive statistics were calculated to summarize the findings. The study was conducted using publicly available policy information with findings confirmed by funder representatives where possible. Participants included top 10 noncommercial US health research funders with the highest reported investment in health research (2013 dollars) who fund clinical trials. Data analysis was conducted from November 6, 2018, to November 23, 2018., Exposures: Availability of policies addressing each of the 3 key trial transparency domains as specified by the World Health Organization in 2017., Main Outcomes and Measures: Independent assessment by 2 investigators of availability (yes or no) of a policy addressing registration for trials, sharing of summary results, and individual participant data sharing activities; requirements (yes, no, or supportive statement) of these policies in terms of completeness, timeliness, public access, and provision of additional technical or financial support to meet data sharing requirements; description (yes or no) of internal monitoring for policy adherence., Results: All 10 funders acknowledged the outreach. One funder who indicated that less than 1% of their research funding goes to clinical trials was removed. Six (67%) of the remaining 9 top US funders have a publicly available written policy for all 3 major trial transparency domains. The most comprehensive trial transparency practice among US funders addresses summary results sharing as follows: 8 of 9 US funders (89%) have a policy, 5 of 9 US funders (56%) require reporting of summary results within 1 year, and 6 of 9 US funders (67%) monitor compliance with their summary results sharing policy. For clinical trial registration, 7 of 9 US funders (78%) have a policy and 5 of 9 US funders (56%) require registration and monitor trial registration to measure adherence to the policy., Conclusions and Relevance: In this study, overall the proportion of US funders with policies and practices to support trial transparency in this sample was similar or compared favorably with the larger international sample of noncommercial funders recently reported.

To successfully implement a pragmatic clinical trial, investigators need access to numerous resources, including financial support, institutional infrastructure (e.g. clinics, facilities, staff), eligible patients, and patient data. Gatekeepers are people or entities who have the ability to allow or deny access to the resources required to support the conduct of clinical research. Based on this definition, gatekeepers relevant to the US clinical research enterprise include research sponsors, regulatory agencies, payers, health system and other organizational leadership, research team leadership, human research protections programs, advocacy and community groups, and clinicians. This article provides a framework to help guide gatekeepers' decision-making related to the use of resources for pragmatic clinical trials. Relevant ethical considerations for gatekeepers include (1) concern for the interests of individuals, groups, and communities affected by the gatekeepers' decisions, including protection from harm and maximization of benefits; (2) advancement of organizational mission and values; and (3) stewardship of financial, human, and other organizational resources. Separate from these ethical considerations, gatekeepers' actions will be guided by relevant federal, state, and local regulations. This framework also suggests that to further enhance the legitimacy of their decision-making, gatekeepers should adopt transparent processes that engage relevant stakeholders when feasible and appropriate. We apply this framework to the set of gatekeepers responsible for making decisions about resources necessary for pragmatic clinical trials in the United States, describing the relevance of the criteria in different situations and pointing out where conflicts among the criteria and relevant regulations may affect decision-making. Recognition of the complex set of considerations that should inform decision-making will guide gatekeepers in making justifiable choices regarding the use of limited and valuable resources., (© The Author(s) 2015.)

Background: Studies have demonstrated a dramatic increase in the number of new nurse practitioners (NPs) overall completing NP education each year. However, NPs who provide specialized care to children have not experienced increases in their pipeline at all. This has resulted in shortages of neonatal nurse practitioners (NNPs)., Purpose: The aim of this study was to gain a greater understanding of the NNP pipeline and potential for increasing the number of new NNPs graduating each year., Methods: Telephone survey of all NNP educational programs., Discussion: Approximately one fourth of all NNP education programs had closed over the past several years. This is despite a strong job market, planned increases in hiring NNPs, and a seemingly growing shortage of NNPs., Conclusion: Problems with the NNP pipeline are not due to a lack of capacity of existing programs, but rather to difficulties in increasing the enrollment demand., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: In contrast to family nurse practitioners and other adult nurse practitioners, the percentage of new pediatric nurse practitioners (PNPs) graduating each year has not increased., Purpose: The aim of this study was to determine whether the marginal increase in the pipeline for PNPs is related to a limit in the capacity of educational programs or whether unfilled student openings exist., Methods: Self-administered survey of program directors at all recognized PNP educational programs in the United States., Results: Approximately 10% of PNP programs in the United States were either closed, put on hold, or did not have new graduates in the last 3 years. Even with these closures, over 25% of active programs did not fill all available positions for the class entering in 2012., Conclusion: Despite evidence that demonstrates plans by employers to hire a greater number of PNPs in a variety of clinical venues including pediatric hospitals, primary care and subspecialty pediatric practices, the PNP pipeline has remained relatively stagnant. More than one third of program directors do not believe that their PNP program is currently at capacity, indicating that underutilized capacity to educate PNPs is a hindrance to meeting the current and future demands for these professionals., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: The demand for hiring pediatric nurse practitioners (PNPs) is strong. However, the number of newly educated PNPs has remained relatively flat during the past several years. Understanding the rationale and timing for the decision to pursue this profession is essential to having a positive impact on increasing the future workforce., Methods: A mail survey of all new PNPs certified between January 2009 and July 2011 (N = 1040) was conducted., Results: The response rate was 79.9%. Nearly half of all respondents (45%, N = 314) reported that they work in outpatient general pediatrics, 26% (N = 184) in outpatient subspecialty pediatrics, and 22% (N = 152) in inpatient settings. More than one third (36%, N = 253) spend most of their time in a private practice. Forty percent (N = 307) reported that they decided to pursue education as an advanced practice nurse while in practice as a registered nurse (RN), and 38% (N = 289) made the decision before pursuing RN education., Conclusions: Efforts to increase the PNP pipeline will need to be directed both to students during their RN education and to creating opportunities for current RNs to pursue advanced practice nurse education that is focused on children., (Copyright © 2014 National Association of Pediatric Nurse Practitioners. Published by Mosby, Inc. All rights reserved.)

Objective: In 2005, we conducted a study of the prevalence of board certification requirements for hospital privileging and found that one-third of hospitals did not require pediatricians to be board certified. In 2010, the American Board of Pediatrics implemented the Maintenance of Certification (MOC) program. To examine changes in the policies of hospitals regarding requirements for board certification, we surveyed privileging personnel at hospitals across the country., Study Design: Telephone survey between April 2010 and June 2010 of privileging personnel at a random sample of 220 hospitals., Results: Of the 220 hospitals, 23 were ineligible because they had no pediatricians on staff, and 26 hospitals refused to participate. The remaining 154 hospitals completed the survey, resulting in a 78% participation rate. Compared with our findings in 2005, in 2010 a greater proportion of hospitals now require board certification for general pediatricians (80% vs 67%, P = 0.141) and pediatric subspecialists (86% vs 71%, P = 0.048). Among these hospitals, a larger proportion (24% vs 4%) now requires board certification for all pediatricians at the point of initial privileging. However, a greater proportion of hospitals reported that they make exceptions to their board certification policies (99% vs 41%)., Conclusion: In the 5 years since our previous study, a larger proportion of hospitals now require pediatricians to be board certified, although the proportion of hospitals that make exceptions to this policy has increased twofold. Hospitals appear to be incorporating the MOC program into their privileging policies., (Copyright © 2013 Society of Hospital Medicine.)

Background and Objective: Changes to the structure and nature of resident duty hour assignments can create compensatory workforce needs in hospital or outpatient settings to ensure appropriate patient care. The objective of this study was to understand what, if any, adjustments children's hospitals have made in staffing and assignments of specific duties during the past 2 years as a result of residency duty hour changes, and what changes are anticipated in the upcoming 2 years., Methods: Mail survey to chief executive officers and chief operating officers of 114 freestanding children's hospitals or children's hospitals within a larger hospital., Results: Response rate was 65.4%. Respondents from more than half of hospitals (57%, N = 36) reported increasing the overall full-time equivalent (FTE) of hospitalists in response to the 2011 resident work hour changes. Forty-eight percent (N = 30) increased the overall FTE of pediatric nurse practitioners (PNPs), and 42% (N = 27) increased the FTE of neonatal nurse practitioners (NNPs). Most hospitals plan to increase the number of hospitalists (69%, N = 44), PNPs (59%, N = 37), or pediatric attending physicians (56%, N = 35) over the next 2 years. Forty-three percent (N = 27) of hospitals plan to increase the number of NNPs over the next 2 years, and a quarter plan to increase physician assistants (25%, N = 16) or pediatric house staff (24%, N = 15)., Conclusions: Changes in work hours for pediatric residents appear to have an impact on workforce planning within pediatric hospitals. Decreases in available resident work hours will create an increasing demand, primarily for nonresident physicians, PNPs, and NNPs.

Objective: Historically, most pediatric subspecialists have conducted their clinical work in academic health centers. However, increases in the absolute numbers of pediatric subspecialists in past decades, combined with greater concentrations of children in urban and suburban settings, might result in more opportunities for pediatric subspecialists to enter private practice. Our goal was to assess the proportions of subspecialists in private practice., Methods: We surveyed a stratified, random, national sample of 1696 subspecialists from 5 subspecialties and assessed the ownership of their current clinical practice settings., Results: The response rate was 77%. Two-thirds of respondents (65% [n = 705]) reported that they work in academic hospitals or outpatient clinics. Compared with other subspecialists, greater proportions of neonatologists (38% [n = 92]) and critical care physicians (19% [n = 44]) reported that they work in community hospitals. Larger proportions of cardiologists (27% [n = 58]) and gastroenterologists (24% [n = 47]) reported that they work in private outpatient practices., Conclusions: There were significant proportions of pediatric subspecialists in private practice in most of the 5 subspecialties studied. Ensuring children's access to pediatric subspecialists likely will require a robust workforce in both academic and private clinical settings. Ongoing studies of the career trajectories of pediatric subspecialists with respect to their venues of practice will be essential for future workforce planning.

Objective: There is little nationally representative information describing the current manner in which nurse practitioners (NPs) and physician assistants (PAs) work in pediatric practices and their professional activities. To understand better the current NP and PA workforce in pediatric primary and subspecialty care, we conducted a national survey of pediatricians., Methods: A survey study of a random national sample of 498 pediatric generalists and 1696 subspecialists in the United States was performed by using a structured questionnaire administered by mail. The survey focused on practice settings, employment, and scope of work of NPs and PAs., Results: Response rates were 72% for generalists and 77% for subspecialists. More than one-half (55%) of generalists reported that they do not currently work with NPs or PAs, compared with only one-third of subspecialists who do not. Many generalists and subspecialists intend to increase the number of NPs and PAs in their practices in the next 5 years. More generalist and subspecialty practices work with NPs than with PAs. There was great variability between generalists and subspecialists and among different subspecialties in the proportions that worked with NPs and PAs. The scope of work of NPs and PAs also varied between generalists and subspecialists., Conclusions: Planned increases in the number of NPs hired and expansion of their scope of work might put subspecialists and general pediatricians in competition with regard to recruitment and hiring of a limited pool of new pediatric NPs. Similar issues might arise with PAs.

Background: Pandemic influenza A(H1N1) (pH1N1) was first identified in North America in April 2009. Vaccination against pH1N1 commenced in the U.S. in October 2009 and continued through January 2010. The objective of this study was to evaluate the cost-effectiveness of pH1N1 vaccination., Methodology: A computer simulation model was developed to predict costs and health outcomes for a pH1N1 vaccination program using inactivated vaccine compared to no vaccination. Probabilities, costs and quality-of-life weights were derived from emerging primary data on pH1N1 infections in the US, published and unpublished data for seasonal and pH1N1 illnesses, supplemented by expert opinion. The modeled target population included hypothetical cohorts of persons aged 6 months and older stratified by age and risk. The analysis used a one-year time horizon for most endpoints but also includes longer-term costs and consequences of long-term sequelae deaths. A societal perspective was used. Indirect effects (i.e., herd effects) were not included in the primary analysis. The main endpoint was the incremental cost-effectiveness ratio in dollars per quality-adjusted life year (QALY) gained. Sensitivity analyses were conducted., Results: For vaccination initiated prior to the outbreak, pH1N1 vaccination was cost-saving for persons 6 months to 64 years under many assumptions. For those without high risk conditions, incremental cost-effectiveness ratios ranged from $8,000-$52,000/QALY depending on age and risk status. Results were sensitive to the number of vaccine doses needed, costs of vaccination, illness rates, and timing of vaccine delivery., Conclusions: Vaccination for pH1N1 for children and working-age adults is cost-effective compared to other preventive health interventions under a wide range of scenarios. The economic evidence was consistent with target recommendations that were in place for pH1N1 vaccination. We also found that the delays in vaccine availability had a substantial impact on the cost-effectiveness of vaccination.

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

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

Objective: The goal was to characterize the pediatric role and scope of practice of family nurse practitioners (FNPs)., Methods: A mail survey of a random national sample of 1000 FNPs, stratified according to states that license nurse practitioners to practice independently, was performed. Frequencies were calculated and bivariate analyses were performed to determine the level of association between practice characteristics and practice state, practice location (urban versus rural), and type of care provided (primary versus specialty)., Results: The overall response rate was 75.9%. Sixty-six percent of respondents (n = 416) reported that they currently provided care to children, and 18% (n = 110) reported that they had never provided care to children. Fifty-four percent of FNPs who provided care to children (n = 222) reported that children represented ≤ 25% of their current patient populations. Few FNPs (9% [n = 39]) reported that children represented >75% of their total patient populations., Conclusions: Among FNPs who provide care to children, pediatric patients represent only a small fraction of their patient populations. FNPs are unlikely to have a significant impact on the availability of either primary or subspecialty care for children in the near future.

Background: There are ∼ 13,000 pediatric nurse practitioners (PNPs) in the United States. PNPs have been suggested as professionals who could provide care to the growing cadre of children with chronic illnesses and expand the pool of subspecialty care providers. Little is known about current roles of PNPs in primary or subspecialty care., Objective: To gain a better understanding of the roles, focus of practice, professional setting, and professional responsibilities of PNPs., Methods: We conducted a mail survey of a random national sample of 1200 PNPs stratified according to states that license NPs to practice independently. χ(2) statistics were used to assess responses from PNPs in states that allow independent practice versus those that do not and on PNPs in primary versus specialty care., Results: The overall response rate was 82.4%. Ninety-six percent (n = 636) of the PNPs were female. More than half of all the respondents (59% [n = 391]) worked in primary care, and almost two-thirds (64% [n = 394]) did not provide care in inpatient settings. Only 11% of the PNPs in states that allow independent practice, practiced independently., Conclusions: The majority of PNPs currently work in primary care, and most do not have any inpatient roles. It does not seem that independent PNP practices are responsible for a significant portion of pediatric visits. For those who posit that PNPs will help alleviate the currently perceived shortage of pediatric subspecialists, our findings indicate that it likely will not occur without a significant change in the PNP workforce distribution.

Objective: To determine the timing of and key factors in resident decision making to pursue either a career in general pediatrics or subspecialty training., Design: We used a 10-item fixed-choice questionnaire that focused on exploring how and when pediatric residents make career choices., Setting: The survey was administered to all categorical pediatric residents in the United States and Canada as part of the General Pediatrics In-Training Examination in 2007 and 2009. The 2007 level 1 residents and 2009 level 3 residents were matched by a unique person identifier to create a longitudinal data set., Participants: A total of 2305 individuals completed the survey as level 1 residents in 2007 and level 3 residents in 2009, representing a retention rate of 83.5%., Main Outcome Measures: Change in individual and aggregate pediatric resident response over time., Results: A similar number of individuals planned to pursue fellowship training in 2007 and 2009 (1026 vs 1062). Among this group, 745 (72.6%) of the 2009 residents were the same individuals who had indicated that they planned to pursue fellowship training in 2007. A total of 258 (71.9%) of all residents who reported in 2007 that they intended to pursue careers in general pediatrics with little or no inpatient care were still planning to do so in 2009., Conclusions: Most pediatricians make their decisions regarding pursuit of a career in primary care or to complete a fellowship before they ever enter residency training. It is unknown whether a similar timeline of decision making is consistent across specialties.

Objective: To assess the current distribution and training patterns of pediatric nurse practitioners (PNPs)., Study Design: Secondary data analysis from the National Association of Pediatric Nurse Practitioners and the 2008 US Census Bureau were used to estimate the distribution of PNPs per 100,000 children. Data on nurse practitioner (NP) graduation and specialty education programs were obtained from the American Association of Colleges of Nursing., Results: PNPs have the greatest concentration in the New England and mid-Atlantic regions and a narrow band of Midwestern states. States that allow PNPs to practice or prescribe independently do not consistently have a higher density of PNPs per child population. There has been a slight decrease in the proportion of programs that offer PNP training. In the last decade, the proportion of NP graduates pursuing family nurse practitioner education has increased, and the proportion pursuing PNP education has decreased., Conclusion: Workforce planning for the health care of children will require improved methods of assessment of the role of PNPs and the volume of care they provide. Increased use of PNPs in pediatrics will likely require greater effort at recruitment of NPs into the PNP specialty., (Copyright (c) 2010 Mosby, Inc. All rights reserved.)

Objective: To determine the current proportion of pediatric primary care and specialty visits being conducted by pediatricians versus other providers., Study Design: We used data from 1980-2006 National Ambulatory Medical Care Surveys (NAMCS) to examine trends in office visits by patients 0 to 17 years of age. During our years of interest, the total number of visits in NAMCS by children ranged from 2597 to 9220 per year., Results: Overall, the percentage of all nonsurgical physician office visits for children 0 to 17 years of age made to general pediatricians increased from 61% in 1996 to 71% in 2006 and those to nonpediatric generalists fell from 28% to 22%. The greatest changes between 2000 and 2006 occurred in the adolescent age group where the proportion of visits to general pediatricians increased from 38% to 53%., Conclusions: Pediatricians continue to provide most primary care visits for children in the United States. For the first time, pediatricians now provide most visits for adolescents., (Copyright (c) 2010 Mosby, Inc. All rights reserved.)

Objectives: To characterize parental attitudes regarding board certification and other factors that influence selection of physicians to care for children., Study Design: A web-based survey administered in 2008 to a random sample of 3621 adults >or=18 years of age stratified by parents and non-parents. Proportion of respondents who view board certification and other measures of quality as important factors in selecting a physician to care for children., Results: Survey completion rate was 62%. Almost all (95%) believe it is important or very important for doctors who care for children to be assessed on their quality of care, receive high ratings from patients (91%), and pass a written test at regular intervals (88%). Most reported that recommendations from friends or family (84%) and board certification (82%) were important or very important factors in choosing a physician for their child. Seventy-seven percent of parents stated that they would be likely to change their child's physician if he/she did not maintain board certification., Conclusion: Parents report a preference for board-certified physicians and expect them to participate in Maintenance of Certification. Greater understanding of quality measures and the board certification process would empower consumers to make more informed decisions in selecting a physician for their children.

Historically, the specialties classified as "primary care" have been pediatrics, internal medicine, and family medicine. Often, primary care disciplines are aggregated in workforce or career-preference studies, and any differences among them are not assessed or reported. However, such aggregation is likely unwarranted and may actually lead to false or misguided policy direction in the name of "primary care disciplines" when, in fact, there may be substantive differences among these specialties. We examine here the data available to assess whether the physicians who make up 2 of the primary care specialties are necessarily the same with regard to their perspectives on the economic aspects of medicine in general, or their own personal economic preferences regarding career choice in particular. Recent research has demonstrated that there are substantive differences among internal medicine trainees and pediatric trainees. As such, we must be cautious when using data from 1 primary care specialty to suggest structural and/or policy changes regarding the economic structure of training for the others.

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

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

Objectives: To better understand the relationship between board certification and credentialing policies for surgeons and nonsurgical subspecialists and to examine possible variation in use of board certification among different types of hospitals., Design, Setting, and Participants: Telephone survey conducted from November 14, 2006, through March 16, 2007, of the privileging personnel among a random sample of 235 nonchildren's hospitals stratified by teaching status, bed size, metropolitan statistical area, system affiliation, and tax status., Main Outcome Measures: Proportion of hospitals that require specialty board certification to gain privileges and hospital requirements for recertification., Results: Of 235 hospitals, 11 were ineligible and 183 completed the telephone interview, resulting in an overall response rate of 82%. Approximately one-third of hospitals did not require surgeons and nonsurgical subspecialists ever to be board certified to receive hospital privileges. Among the 109 hospitals that required certification at some point, only 5 (5%) required surgeons and 3 (3%) required nonsurgical subspecialists to be board certified at the point of initial privileging. More than three-fourths of hospitals had exceptions to their certification policies for surgeons and 84 (77%) had them for nonsurgical subspecialists. Eighty-two percent of all hospitals and two-thirds of hospitals whose policies required recertification allowed surgeons and nonsurgical subspecialists to retain privileges when their board certification expired., Conclusion: Most hospitals do not consistently use board certification to ensure physician competence at their institutions.

Objectives: To characterize the role of board certification in general surgeon, surgical specialist, and nonsurgical subspecialist credentialing and contracting policies and to examine possible variation among different types of health plans., Design: Telephone survey conducted from October 27, 2006, through March 30, 2007., Setting: Health plans across the United States., Participants: Health plan credentialing personnel from a random sample of 223 health plans stratified by enrollment size, plan type, Medicaid enrollment, and tax status., Main Outcome Measures: Proportion of health plans that require specialty board certification at initial contract or at some point during association with the plan and health plan requirements for recertification., Results: Of 223 health plans, 9 were ineligible, and credentialing personnel completed the telephone survey in 176, which resulted in an overall response rate of 82%. More than 60% of the health plans in this study did not require surgical specialists, general surgeons, or nonsurgical subspecialists ever to be board certified to contract with the plan. Approximately two-thirds of respondents reported that they did not require surgeons (65%) or nonsurgical subspecialists (63%) with time-limited board certification to recertify in their specialty. More than half of the health plans reported that they made exceptions to their board certification policies based on geographic or network need., Conclusions: Most health plans did not use specialty board certification to assess surgeon and nonsurgical subspecialist competence.

Objective: There has been a rapid increase in the number of pediatric hospitalist programs in the United States. As most pediatric hospitalist services are believed to be subsidized by hospitals, gaining a better understanding of the rationale for these subsidies is critical to the future success and existence of these programs. Our objective was to determine the rationale for pediatric hospitalist program subsidies from the perspective of hospital leaders., Methods: A survey was mailed to hospital executives from a national sample of 112 hospitals between October 2007 and February 2008., Results: The overall response rate was 69% (N = 77). Twelve hospitals no longer used hospitalists to provide care for children, leaving 65 hospitals for the analysis. The majority of hospital leaders indicated they subsidize their pediatric hospitalist program (78%, n = 51) and the average proportion subsidized was 49% of program costs. The majority of hospitals (82%, n = 40) do not plan to phase out the subsidy of hospitalists over time, as they do not anticipate their program will be able to cover its costs. Hospital leaders provided a broad rational for this subsidization but most commonly cited the nonmonetary benefits of patient (83%, n = 39) and referring physician satisfaction (81%, n = 38) as reason for their investment., Conclusions: Despite the fact that most pediatric hospitalist programs are unable to cover their costs, the majority of hospitals plan to continue subsidizing these programs. Discussions of the value added by hospitalists should not presume that hospital investment in hospitalist programs is based on monetary benefits alone.

Objective: To determine the range and frequency of experiences, clinical and nonclinical roles, training, work expectations, and career plans of practicing pediatric hospitalists., Design: Mail survey study of a national sample of 530 pediatric hospitalists of whom 67% (N = 338) were from teaching hospitals, 71% (N = 374) were from children's hospitals, 43% (N = 230) were from freestanding children's hospitals, and 69% (N = 354) were from hospitals with >or=250 beds., Results: The response rate was 84%. The majority (54%; N = 211) had been practicing as hospitalists for at least 3 years. Most reported that the pediatric inpatient unit (94%) and inpatient consultation service (51%) were a part of their regular clinical assignment. Most did not provide service in the normal newborn nursery (58%), subspecialty inpatient service (52%), transports (85%), outpatient clinics (66%), or as part of an emergency response team (53%). Many participated in quality improvement (QI) initiatives (84%) and practice guideline development (81%)., Conclusions: This study provides the most comprehensive information available regarding the clinical and nonclinical roles, training, work expectations, and career plans of pediatric hospitalists. However, the field is currently a moving target; there is significant flux in the hospitalist workforce and variation in the roles of these professionals in their clinical and nonclinical work environment., ((c) 2009 Society of Hospital Medicine.)

Objective: To explore the structure, components, and training goals of pediatric hospitalist fellowship programs in North America., Design: We constructed a 17-item structured questionnaire to be administered by phone. Questionnaire items focused on documenting goals, training, requirements, and clinical duties of pediatric hospitalist training programs. From February through June 2007, research staff contacted directors of the programs. Responses were analyzed to determine program characteristics, including goals, formal training requirements, clinical rotations, and participation in hospital administrative activities., Results: All 8 training programs completed the survey. There appear to be 2 distinct tracks for pediatric hospitalist training programs: clinical or academic specialization. Currently there are no standards or requirements for fellowship training from an external accrediting body and the curriculum for these programs is likely driven by service requirements and speculation on the needs of a future generation of pediatric hospitalists. The stated goals of the programs were quite similar. Seven reported that the provision of advanced training in the clinical care of hospitalized patients, quality improvement (QI), and hospital administration are central goals of their training program. Six reported training in the education of medical students and residents to be a primary goal, while 5 indicated training in health services research as a primary goal., Conclusions: Pediatric hospitalist fellowships are in the very early stages of their development. In time, greater structure across institutions will need to be put in place if they are to succeed in becoming a necessary prerequisite to the practice of hospital medicine., ((c) 2009 Society of Hospital Medicine.)

Introduction: During their careers, physicians may have periods of clinical inactivity for a variety of reasons. Concerns have been raised about the impact of clinical inactivity on the growing physician workforce shortage. It is unknown how these periods of clinical inactivity impact physician competence and patient safety. With this study we sought to determine the rates of clinical inactivity, the duration of periods of inactivity, professional activities during those periods, and the perspective of pediatricians regarding future requirements of competency for return to clinical practice., Patients and Methods: A random sample of 6757 American Board of Pediatrics diplomates aged < or =65 years received a structured questionnaire by mail. The survey explored the prevalence of and reasons for clinical inactivity and perspectives on the return to clinical practice. Clinical inactivity was defined as a period of absence of > or =12 months from any direct or consultative clinical care., Results: The response rate was 74%. Of respondents, 88% (n = 4176) were currently engaged in pediatric clinical care. Twelve percent (n = 554) indicated that they had experienced a period of clinical inactivity lasting > or =12 months. Women were more likely than men (16% vs 7%) to have had periods of clinical inactivity. Controlling for gender, generalists were no more likely than subspecialists to report a past period of clinical inactivity. More than one third of the respondents (n = 1672 [36%]) agreed that pediatricians who return from clinical inactivity after >1 year should undergo a competency evaluation., Conclusions: Almost 1 in 8 pediatricians has suspended clinical care for > or =1 year, and a similar proportion of respondents were inactive at the time of our survey. Currently, all of these physicians may maintain both their licensure and board certification during these periods. The impact of clinical inactivity on patient care and patient safety is unknown.

Objective: The purpose of this research was to explore state physician licensing board policies and regulation of active, inactive, and retired licenses., Methods: We conducted structured telephone interviews from January to March 2007 with representatives of all 64 state allopathic and osteopathic medical licensing boards in the United States. All of the licensing boards participated., Results: Only 34% of state licensing boards query physicians regarding clinical activity at both initial licensure and renewal. The majority of boards allow physicians to hold or renew an unrestricted active license to practice medicine, although they may not have cared for a patient in years. Only 1 board requires a minimum number of patient visits to maintain an active license. Five boards allow physicians with inactive licenses to practice some form of medicine, whereas 7 boards allow physicians with retired licenses to practice. Few states have any mechanism to assess the competency of clinically inactive physicians who return to active practice., Conclusions: The number of inactive physicians in the United States is growing. Currently, state medical board policies do not address the issue of continuing competence in license renewal. Greater medical safety concerns on the part of the public will likely lead to calls for greater accountability by state licensing authorities.

Objective: Little is known regarding at what point during the training period residents in pediatrics make decisions on their future career choices. As part of a dedicated process of reexamining the structure of residency training in pediatrics, the American Board of Pediatrics sought information to better understand the influences, process, and sequencing of both residency program selection and career decision-making among residents., Methods: All pediatrics resident physicians in all training programs in the United States and Canada (N = 8290) received the survey as part of the general pediatrics in-training examination. The survey focused on exploring how and when pediatrics residents make career choices and assessed perceived flexibility of their individual pediatrics residency program., Results: The response rate was 95%. Location was the most important factor in selecting a residency program for 42% of all residents. Almost half of the pediatrics residents planned to pursue fellowship training after residency, a proportion that changed little across the 3 training years (level 1: 47%; level 2: 49%; level 3: 47%). Those who planned to pursue a general pediatrics career (either with or without inpatient care) were more likely than those who intended to pursue fellowship training to report that lifestyle was the most important factor in their career choice (63% vs 21%)., Conclusions: Not surprisingly, different priorities motivate pediatricians to pursue specific programs for training and specific career options. The finding that those with the highest priority regarding lifestyle are more likely to pursue generalist training has implications for the generalist workforce, because those persons may also be more likely to seek part-time employment. Lifestyle concerns may need to be addressed in subspecialty training and subsequent subspecialty careers to ensure a continued flow of residents into fellowship training.

Ambulatory surgical centers (ASCs) play a considerable role in providing surgical care in the United States. However, compared to hospitals, ASCs may have less oversight and less-well-developed policies for credentialing and privileging. Specialty board certification is one metric for measuring physician competence. What proportion of ASCs currently requires board certification for privileging is unknown. This article examines the relationship between board certification and privileging policies at ASCs in the United States. A telephone survey of privileging personnel among a convenience sample of 139 freestanding ASCs with two or more specialty services was conducted between February and May 2007. Fifty out of 81 eligible ASCs completed the survey, resulting in a cooperation rate of 62 percent. More than half of ASCs surveyed require that surgical specialists (54 percent, N=27), nonsurgical specialists (56 percent, N=22), and non-American Board of Medical Specialties (ABMS) specialists (56 percent, N=24) be board certified at some point during their tenure. Among ASCs that call for board certification during physician tenure, 11 percent (N=3) require surgical specialists, 5 percent (N=1) require nonsurgical specialists, and 12 percent (N=3) require non-ABMS specialists to hold current board certification at the point of initial privileging. Twenty-nine ASCs (59 percent) allow physicians to retain their privileges after certification expires. Ensuring safe medical care necessitates coordination across healthcare organizations and regulatory agencies. Nevertheless, our results indicate that almost half of multispecialty ASCs are not using this measure of physician competence issued by specialty boards as part of their privileging process.

Objective: Training for pediatric residents who intend to pursue fellowship differs little from training for residents who intend to practice general pediatrics. It is unknown how well residents who intend to pursue subspecialty training believe that residency prepares them for subspecialty fellowships or future careers. To characterize the strengths and weaknesses of residency training and the factors influencing subspecialty choice from the perspective of subspecialty fellows, we conducted a survey of current fellows on these issues., Methods: A random sample of 1000 physicians who were entering their second or third year of fellowship in the United States in 2007 received a structured questionnaire by mail. The survey focused on decision-making in selection of residency and fellowship programs, strength of residency training in preparation for fellowship, and plans for future practice., Results: The overall response rate was 81%. A majority of the fellows would not have shortened their general pediatrics residency before fellowship if given the option (64% [n = 482]). However, more than half (52% [n = 390]) of the fellows would have chosen a 2-year fellowship without research or scholarly activity over the current 3-year structure. Few current fellows believed they could have used any additional training in the areas of patient safety, coordination of care for children with complex illnesses, or patient communication., Conclusions: The finding that a large proportion of fellows would opt for shortened subspecialty training should prompt discussion and debate within the profession regarding the skills necessary for a pediatric subspecialist. Patient safety, physician-parent communication, and care coordination are emphasized primarily through informal training during residency. Although most clinicians believe themselves to be adequately prepared, research has identified gaps in clinician skills and understanding of these issues of great importance to patients and their families.

Objective: Because of the increase in both the prevalence and complexity of chronic diseases in children, there is heightened awareness of the need for general pediatricians to be prepared to comanage their patients with chronic disorders with subspecialists. It is not known currently how well prepared general pediatricians believe themselves to be for these roles after residency training. This study was conducted to determine the perspectives of recently trained general pediatricians in practice regarding their decisions on residency choice, career choice, and adequacy of training., Methods: A random sample of 600 generalists whose initial application for general pediatric certification occurred between 2002 and 2003 (4-5 years out of training) and 600 generalists who applied for board certification between 2005 and 2006 and who were not currently enrolled in or had completed subspecialty training (1-2 years out of training) received a structured questionnaire by mail. The survey focused on decision-making in selection of residency programs, strength of residency training in preparation for clinical care, and scope of practice., Results: The overall response rate was 76%. The majority of generalists reported that their residency training was adequate in most subspecialty areas. However, a large proportion of generalists indicated that they could have used additional training in mental health (62% [n = 424]), sports medicine (51% [n = 345]), oral health (52% [n = 356]), and developmental/behavioral pediatrics (48% [n = 326]). Most generalist respondents reported that they are comfortable comanaging cases requiring subspecialty care with a subspecialist. However, generalist respondents without local access to subspecialists were more likely to report that they are comfortable managing patients who require subspecialty care., Conclusions: The training of general pediatricians, and the needs for their adequate preparation to care for patients, should be a dynamic process. As the nature and epidemiology of pediatric care change, our educational system must change as well.

Objectives: Little is known regarding the factors influencing the decision to pursue pediatric subspecialty fellowship training and the timing of when such a decision is made. In addition, there is no information regarding whether the general pediatrics training received in residency is perceived as valuable by subspecialists. This study was conducted to characterize the strengths and weaknesses of residency and fellowship training from the perspective of recently trained pediatric subspecialists and to assess their current and future career goals and intended scope of practice., Methods: A random sample of 550 subspecialists whose initial application for pediatric subspecialty certification occurred between 2002 and 2003 (4-5 years out of training) and 550 subspecialists who applied for board certification between 2005 and 2006 (1-2 years out of training) received a structured questionnaire by mail. The survey focused on decision-making in selection of residency and fellowship programs, strength of residency training in preparation for clinical care provision, and scope of current practice., Results: The overall response rate was 77%. More than half (54%) of the recently trained subspecialists would have shortened either their pediatric residency or fellowship training if given the opportunity, and 7% were unsure. More than one third of the respondents made the decision to pursue subspecialty training before the start of residency (36% [n = 198]), whereas approximately half of them made this decision during the first (19% [n = 106]) or second (27% [n = 150]) year of residency., Conclusions: Many subspecialists would have been interested in modifications to their pediatric residency and fellowship training programs, which may reflect changing patterns of professional activities or the preferences of a younger generation of subspecialists. Given that a substantial proportion of subspecialists decide to pursue subspecialty training before or early in residency, greater flexibility in configuring some residency experiences to meet their career goals would be feasible.

Objective: The goal was to determine the reasons given for nonparticipation in maintenance of certification by general pediatricians and pediatric subspecialists whose board certification had expired., Methods: All United States-based pediatricians whose board certification had expired and who had not recertified as a generalist or subspecialist in 2004 or 2005 were surveyed. The total sample included 1001 pediatric generalists and 1237 subspecialists. We conducted a mail survey study, with a total of 3 mailings to nonrespondents. Analyses initially were conducted separately for generalists with expired certificates, subspecialists with active subspecialty but expired general pediatrics certificates, and subspecialists with expired subspecialty certificates (regardless of their general pediatrics certification status)., Results: The overall response rates were 68% for generalists and 76% for subspecialists. Of pediatricians who had allowed their certificates to expire, the majority still intended to recertify (65% of the generalists and 86% of the subspecialists, in their primary subspecialty). The most common reasons cited by the 35% of generalists with expired certificates who were not planning to participate in maintenance of certification were the expense, the time required to complete maintenance of certification, and the perceived lack of relevance to their current practice. The 14% of subspecialists who were not planning to recertify in their primary subspecialty most commonly cited the expense, a change in career path making recertification unnecessary, and the time required., Conclusions: Although the physicians in this study had allowed their certificates to expire, they still overwhelmingly believed that physicians who provide direct patient care should maintain their certification. There was general consensus among our respondents regarding the professional value to patients and peers of participation in the maintenance of certification program.

Potent and selective inhibition of matrix metalloproteinases was demonstrated for a series of sulfonamide-based hydroxamic acids. The design of the heterocyclic sulfonamides incorporates a six- or seven-member central ring with a P2' substituent that can be modified. Binding interactions of this substituent at the S2' site are believed to contribute to high inhibitory potency against stromelysin, collagenase-3 and gelatinases A and B, and to provide selectivity against collagenase-1 and matrilysin. An X-ray structure of a stromelysin inhibitor complex was obtained to provide insights into the SAR and selectivity trends observed for the series.

Matrix metalloproteinases are believed to play an important role in pathological conditions such as osteoarthritis, rheumatoid arthritis and tumor invasion. Stromelysin is a zinc-dependent proteinase and a member of the matrix metalloproteinase family. We have solved the crystal structure of an active uninhibited form of truncated stromelysin and a complex with a hydroxamate-based inhibitor. The catalytic domain of the enzyme of residues 83-255 is an active fragment. Two crystallographically independent molecules, A and B, associate as a dimer in the crystals. There are three alpha-helices and one twisted, five-strand beta-sheet in each molecule, as well as one catalytic Zn, one structural Zn and three structural Ca ions. The active site of stromelysin is located in a large, hydrophobic cleft. In particular, the S1' specificity site is a deep and highly hydrophobic cavity. The structure of a hydroxamate-phosphinamide-type inhibitor-bound stromelysin complex, formed by diffusion soaking, has been solved as part of our structure-based design strategy. The most important feature we observed is an inhibitor-induced conformational change in the S1' cavity which is triggered by Tyr223. In the uninhibited enzyme structure, Tyr223 completely covers the S1' cavity, while in the complex, the P1' group of the inhibitor displaces the Tyr223 in order to fit into the S1' cavity. Furthermore, the displacement of Tyr223 induces a major conformational change of the entire loop from residue 222 to residue 231. This finding provides direct evidence that Tyr223 plays the role of gatekeeper of the S1' cavity. Another important intermolecular interaction occurs at the active sit of molecule A, in which the C-terminal tail (residues 251-255) from molecule B inserts. The C-terminal tail interacts extensively with the active site of molecule A, and the last residue (Thr255) coordinated to the catalytic zinc as the fourth ligand, much like a product inhibitor would. The inhibitor-induced conformational change and the intermolecular C-terminal-zinc coordination are significant in understanding the structure-activity relationships of the enzyme., (Copyright 1999 Academic Press.)