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Compare pediatrician burnout when measured and categorized in different ways to better understand burnout and the association with satisfaction.We analyzed national survey data from a cohort study of early to midcareer pediatricians. In 2017, participants randomly received 1 of 3 question sets measuring burnout components (emotional exhaustion, depersonalization, and personal accomplishment): group A received the Maslach Burnout Inventory, group B received a previously used measure, and group C received a new severe measure. Repeated measures ANOVA tested differences across burnout categorizations: high emotional exhaustion and high depersonalization and low personal accomplishment; high emotional exhaustion and high depersonalization; and high emotional exhaustion or high depersonalization. Logistic regression tested relationships between burnout profiles (engaged, intermediate, and burnout) and satisfaction. Seventy-one percent of participants completed the survey (1279/1800).Burnout varied depending on measurement (groups A, B, and C) and categorization. For example, for group A, when categorized as high emotional exhaustion, high depersonalization, and low personal accomplishment, burnout was lower (4.8%) than categorized as high emotional exhaustion and depersonalization (15.2%) (P .001) or categorized as high emotional exhaustion or depersonalization (44.6%) (P .001). Most participants were satisfied with their career (83.6%). Using burnout profiles, 38.4%-85.1% fell in the engaged profile. For each group, burnout profiles were associated with satisfaction. For example, group A participants in the burnout or intermediate profile were less likely than those engaged to be satisfied with their careers (aOR, 0.08 [95% CI, 0.03-0.24]; and aOR, 0.23 [95% CI, 0.10-0.56], respectively).The way burnout is measured and categorized affects burnout prevalence and its association with satisfaction. Transparency in methodology used is critical to interpreting results.

Abstract Pediatric departments and children’s hospitals (hereafter pediatric academic settings) increasingly promote the tenets of diversity, equity, and inclusion (DEI) as guiding principles to shape the mission areas of clinical care, education, research, and advocacy. Integrating DEI across these domains has the potential to advance health equity and workforce diversity. Historically, initiatives toward DEI have been fragmented with efforts predominantly led by individual faculty or subgroups of faculty with little institutional investment or strategic guidance. In many instances, there is a lack of understanding or consensus regarding what constitutes DEI activities, who engages in DEI activities, how faculty feel about their engagement, and what is an appropriate level of support. Concerns also exist that DEI work falls disproportionately to racial and ethnic groups underrepresented in medicine, exacerbating what is termed the minority tax. Despite these concerns, current literature lacks quantitative data characterizing such efforts and their potential impact on the minority tax. As pediatric academic settings invest in DEI programs and leadership roles, there is imperative to develop and use tools that can survey faculty perspectives, assess efforts, and align DEI efforts between academic faculty and health systems. Our exploratory assessment among academic pediatric faculty demonstrates that much of the DEI work in pediatric academic settings is done by a small number of individuals, predominantly Black faculty, with limited institutional support or recognition. Future efforts should focus on expanding participation among all groups and increasing institutional engagement.

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...

Objective To determine the association between coronavirus disease 2019 (COVID-19) restrictions and paediatric mental health emergency department presentations. Methods Secondary analysis of Victorian Emergency Minimum Dataset data from 38 Victorian public hospital emergency departments. Paediatric patients (birth to

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.

IntroductionAustralia’s current healthcare system for children is neither sustainable nor equitable. As children (0–4 years) comprise the largest proportion of all primary care-type emergency department presentations, general practitioners (GPs) report feeling undervalued as an integral member of a child’s care, and lacking in opportunities for support and training in paediatric conditions. This Strengthening Care for Children (SC4C) randomised trial aims to evaluate a novel, integrated GP-paediatrician model of care, that, if effective, will improve GP quality of care, reduce burden to hospital services and ensure children receive the right care, at the right time, closer to home.Methods and analysisSC4C is a stepped wedge cluster randomised controlled trial (RCT) of 22 general practice clinics in Victoria and New South Wales, Australia. General practice clinics will provide control period data before being exposed to the 12-month intervention which will be rolled out sequentially each month (one clinic per state) until all 22 clinics receive the intervention. The intervention comprises weekly GP-paediatrician co-consultation sessions; monthly case discussions; and phone and email paediatrician support, focusing on common paediatric conditions. The primary outcome of the trial is to assess the impact of the intervention as measured by the proportion of children’s (0–Ethics and disseminationHuman research ethics committee (HREC) approval was granted by The Royal Children’s Hospital Ethics Committee in August 2020 (Project ID: 65955) and site-specific HRECs. The investigators (including Primary Health Network partners) will communicate trial results to stakeholders and participating GPs and general practice clinics via presentations and publications.Trial registration numberAustralia New Zealand Clinical Trials Registry 12620001299998.

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.

BackgroundWhile recent research efforts to reduce pressure ulcers in the clinical context have focused on key retrospective characteristics, little work has focused on creating real-time predictive models to prevent this avoidable hospital-acquired injury. Furthermore, existing machine learning heuristics often fail to surpass traditional statistical models or provide individual-level risk assessments with explanations for each patient. Thus, we sought to compare the predictive performance of five machine learning and traditional statistical modeling techniques to predict the occurrence of Hospital Acquired Pressure Injuries (HAPI).MethodsElectronic Medical Record (EMR) information was collected from 57,227 hospitalizations, containing 241 positive HAPI cases, acquired from Dartmouth Hitchcock Medical Center from April 2011 to December 2016. The five classifiers were trained to predict HAPI incidence and performance was assessed using the C-statistic or Area Under the Receiver Operating Curve (AUC).ResultsLogistic Regression was the best modeling approach (AUC=0.91±0.034). We report discordance between predictors deemed important by the machine learning models compared to traditional statistical model. We provide means to visually assess factors important to every patient’s prediction, regardless of the modeling approach, through Shapley Additive Explanations.ConclusionsMachine learning models will continue to inform decision making processes but should be compared to traditional modeling approaches to ensure proper utilization. Disagreements between important predictors found by traditional and machine learning modeling approaches can potentially confuse clinicians and as such need to be reconciled. Future efforts to analyze time-stamped, prospective medical record data will be enhanced by patient-specific details. These developments represent important steps forward in developing real-time predictive models that can be integrated and readily deployed in electronic medical record systems to reduce unnecessary harm.

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 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.