The Future Pediatric Subspecialty Physician Workforce Meeting the Needs of Infants, Children, and Adolescents (2023) / Chapter Skim
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3 Pediatric Subspecialty Use Data Analyses
3 Pediatric Subspecialty Use Data Analyses
Pages 81-100
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From page 81... ...
To fill this gap, the committee examined data analyses that used three complementary data sources.1 The first analysis by Carelon Research (formerly HealthCore) , the only analysis commissioned by the committee, examined commercially insured individuals enrolled in Elevance Health (formerly Anthem, Inc.)
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From page 82... ...
. Each of these three data sources provides a different assessment of children's use of subspecialty care: rates for those enrolled in commercial insurance products (Elevance Health)
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From page 83... ...
Lurie Children's Hospital of Chicago, Children's Hospital Colorado, Children's Hospital of Philadelphia, Cincinnati Children's Hospital Medical Center, Nationwide Children's Hospital, Nemours Children's Health, Seattle Children's Hospital, and Stanford Children's Health. Within the PEDSnet database, the study cohort included patients with at least one outpatient visit where the clinician specialty was general pediatrics in one of the academic pediatric medical centers during the time period of January 2010 to December 2021, and where the patient age was less than 21 years old at the end of the calendar year. The PEDSnet data also provided information on payer and patient race and ethnicity.
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From page 84... ...
The PEDSnet analysis included annual rates of patients seeing multiple types of subspecialties, defined as having at least one visit with more than one subspecialty type in that year. Both Elevance Health and PEDSnet cohorts were comprised of children and youth aged less than 21 years and computed annual specialty use rates from 2011 to 2021.
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From page 85... ...
The T-MSIS analysis also examined adult medical subspecialties that corresponded to the included pediatric subspecialties, excluding those with no adult counterpart (i.e., adolescent medicine, child abuse pediatrics, clinical genetics, developmental-behavioral pediatrics, and neonatal-perinatal medicine) as well as psychiatry, family medicine, internal medicine, obstetrics and gynecology, advanced practice nurses, and physician assistants.
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From page 86... ...
NOTES: The commercially insured data is based on the Carelon Research data analysis; the publicly insured data is based on the T-MSIS Medicaid/CHIP cohorts. The chart shows trends across an 11-year period from 2011 to 2021 for the commercially insured Elevance Health cohort and a 4-year period from 2016 to 2019 for the national Medicaid/CHIP cohort.
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From page 87... ...
NOTES: The chart shows trends in annual subspecialty use rates and the size of the eligible population (i.e., at least one visit to a general pediatricianat the academic medical health system in the index or prior year) across an 11-year period from 2011 to 2021 for children less than 21 years in the PEDSnet academic medical center cohort.
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From page 88... ...
In the Elevance Health data, the use rate for pediatric infectious diseases was stable until 2021 when it doubled, likely a result of care for children with COVID-19. TABLE 3-1 Change in the Annual Outpatient Subspecialist Use Rates, 2011 versus 2021, by Pediatric Medical Subspecialty, Elevance Health Data Subspecialty Use Rate per 1,000 Children Percentage Relative Pediatric Medical Subspecialty 2011 2021 Change Adolescent Medicine 34.2 35.6 4 Child Abuse Pediatrics <0.1 <0.1 n/a Child Neurology 7.2 9.9 38 Clinical Genetics 1.1 1.3 18 Developmental-Behavioral Pediatrics 2.8 2.4 –14 Hospice and Palliative Medicine 0.2 0.2 –27 Medical Toxicology <0.1 <0.1 n/a Obesity Medicine <0.1 <0.1 n/a Pediatric Allergy/Immunology 2.2 2.5 14 Pediatric Cardiology 10.6 15.2 43 Pediatric Dermatology 1.8 2.5 39 Pediatric Endocrinology 6.0 8.9 48 Pediatric Gastroenterology 7.0 10.4 49 Pediatric Hematology/Oncology 2.2 3.7 64 Pediatric Infectious Diseases 0.9 2.3 144 Pediatric Nephrology 1.2 1.9 58 Pediatric Pulmonology 4.0 5.0 25 Pediatric Rehabilitation Medicine 0.3 0.6 100 Pediatric Rheumatology 0.9 3.6 300 Pediatric Transplant Hepatology <0.1 <0.1 n/a Sleep Medicine 0.6 0.7 17 Sports Medicine 1.2 2.8 133 NOTES: Carelon Research data are from beneficiaries enrolled in an Elevance Health (formerly Anthem, Inc.) health plan (i.e., commercial insurance)
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From page 89... ...
PEDIATRIC SUBSPECIALTY USE DATA ANALYSES 89 TABLE 3-2 Change in the Annual Outpatient Subspecialist Use Rates, 2011 versus 2021, by Pediatric Medical Subspecialty, PEDSNet Subspecialist Use Rate per 1,000 Children Percentage Relative Pediatric Medical Subspecialty 2011 2021 Change Adolescent Medicine 14.5 17.0 18 Child Abuse Pediatrics 1.1 0.5 –53 Child Neurology 20.9 24.1 15 Dermatology 11.0 17.8 61 Developmental-Behavioral Pediatrics 19.4 27.4 41 Genetics 4.2 5.7 36 Hospice and Palliative Medicine 0.6 0.4 –35 Medical Toxicology <0.1 <0.1 n/a Obesity <0.1 <0.1 n/a Pediatric Allergy and Immunology 19.9 22.0 10 Pediatric Cardiology 28.7 32.1 12 Pediatric Endocrinology 17.6 22.0 25 Pediatric Gastroenterology 26.3 36.9 40 Pediatric Hematology/Oncology 11.4 12.4 9 Pediatric Infectious Diseases 3.2 2.5 –21 Pediatric Nephrology 5.6 12.8 127 Pediatric Pulmonology 15.7 18.3 17 Pediatric Rheumatology 4.0 5.0 26 Pediatric Transplant Hepatology <0.1 0.6 n/a Rehabilitation 15.1 10.8 –29 Sleep Medicine 1.5 1.0 –34 Sports Medicine 3.5 7.7 118 NOTES: PEDSnet data are from eight large pediatric academic medical centers. Annual subspecialist use rates were computed as the number of children with one or more visits to a pediatric subspecialist per 1,000 individuals with a general pediatrician visit during the index or prior calendar year.
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From page 90... ...
2019, by Pediatric Medical Subspecialty, T-MSIS Subspecialist Use Rate per 1,000 Children with Medicaid/CHIP Percentage Relative Pediatric Medical Subspecialty 2016 2019 Change Adolescent Medicine 28.2 26.6 –6% Child Abuse Pediatrics 0.4 0.4 –4% Child Neurology 6.4 7.2 13% Clinical Genetics 1.3 1.3 –2% Developmental-Behavioral Pediatrics 3.6 3.7 5% Pediatric Hospice and Palliative Medicine 0.3 0.3 –14% Pediatric Medical Toxicology <0.1 <0.1 n/a Pediatric Obesity Medicine 0.1 <0.1 n/a Pediatric Allergy/Immunology 0.8 1.0 26% Pediatric Cardiology 7.4 8.4 13% Pediatric Dermatology 8.3 8.7 5% Pediatric Endocrinology 5.8 6.4 11% Pediatric Gastroenterology 6.3 7.6 20% Pediatric Hematology/Oncology 4.2 4.5 6% Pediatric Infectious Diseases 2.2 2.3 8% Pediatric Nephrology 2.0 2.2 13% Pediatric Pulmonology 4.7 5.1 9% Pediatric Rehabilitation Medicine 0.3 0.4 5% Pediatric Rheumatology 0.7 0.9 26% Pediatric Transplant Hepatology <0.1 <0.1 n/a Pediatric Sleep Medicine 0.2 0.3 74% Pediatric Sports Medicine 0.8 1.1 28% NOTE: T-MSIS is a national dataset of Medicaid/CHIP claims. Annual subspecialist use rates were computed as the number of beneficiaries less than 19 years old insured by Medicaid/ CHIP with one or more visits to a pediatric subspecialist per 1,000 beneficiaries less than 19 years old insured by Medicaid/CHIP.
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From page 91... ...
A few patterns of use emerge across the three cohorts. For example, children insured by Medicaid/CHIP had higher subspecialist use rates to developmental-behavioral pediatrics compared with individuals in the commercially insured Elevance Health cohort, but lower use rates compared with the academic medical center PEDSnet cohort.
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From page 92... ...
NOTES: PEDSnet data are from eight large pediatric academic medical centers. Proportions for any subspecialist use represent the share of children with at least one visit to a subspecialist across the full study period.
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From page 93... ...
PEDIATRIC SUBSPECIALTY USE DATA ANALYSES 93 TABLE 3-4 Pediatric Medical Subspecialists' Three Most Commonly Diagnosed Health Conditions in Outpatient Settings, 2011–2021, PEDSnet Three Most Common Health Pediatric Subspecialty Conditions Rank Ordered Adolescent Medicine Obesity Sexually transmitted infection Contraception Child Abuse Pediatrics Child sexual abuse Foster care Possible victim of child abuse Child Neurology Seizure/epilepsy Headache, including migraine Developmental delay Clinical Genetics Developmental delay Autism spectrum disorder Poor muscle tone Developmental-Behavioral Pediatrics Developmental delay Autism spectrum disorder Attention deficit hyperactivity disorder Hospice and Palliative Medicine Palliative care Pain Hospice care Medical Toxicology Lead poisoning Abnormal blood chemistry Iron-deficiency anemia Obesity Medicine Obesity Obstructive sleep apnea, including snoring History of bariatric surgery Pediatric Allergy/Immunology Allergic rhinitis Allergies, including food allergies Atopic dermatitis Pediatric Cardiology Heart murmur Chest pain Palpitations Pediatric Dermatology Atopic dermatitis Warts and molluscum contagiosum Inflammatory dermatitis Pediatric Endocrinology Obesity Short stature Type 1 diabetes mellitus Pediatric Gastroenterology Constipation Gastroesophageal reflux Feeding problem (continued)
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From page 94... ...
It is also possible that common diagnoses like headache represent severe cases that have been intransigent to standard primary care treatment.
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From page 95... ...
However, the PEDSnet academic medical center data make it clear that these institutions have experienced an increase in demand for subspecialty care since 2010 due largely to an overall increased number of children receiving most of their care (primary and subspecialty) within their systems; that is, the rate per 1000 children has not increased, but the denominator has.
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From page 96... ...
96 THE FUTURE PEDIATRIC SUBSPECIALTY PHYSICIAN WORKFORCE TABLE 3-5 Adult and Pediatric Medical Subspecialty Outpatient Subspecialist Use Rates for Children Less Than 19 Years Covered by Medicaid/Children's Health Insurance Program, T-MSIS Calendar Year 2019 Use Rate per 1,000 Use Rate per 1,000 Children Children Insured Insured by Medicaid/CHIP, by Medicaid/CHIP by Age <1 1–11 12–18 Medical Subspecialty Age: All <19 Years Year Years Years Adult Neurology 2.8 0.9 2.4 3.9 Child Neurology 7.2 3.5 7.5 7.5 Adult Hospice and Palliative 0.3 0.4 0.3 0.3 Medicine Pediatric Hospice and Palliative 0.3 0.3 0.3 0.2 Medicine Adult Medical Toxicology <0.1 <0.1 <0.1 <0.1 Pediatric Medical Toxicology <0.1 <0.1 <0.1 <0.1 Adult Obesity Medicine 0.2 0.2 0.2 0.2 Pediatric Obesity Medicine <0.1 <0.1 <0.1 <0.1 Adult Allergy/Immunology 10.8 2.3 11.8 10.4 Pediatric Allergy/Immunology 1.0 0.5 1.2 0.8 Adult Cardiology 0.6 0.4 0.4 1.0 Pediatric Cardiology 8.4 16.1 8.0 7.9 Adult Dermatology 1.9 1.4 1.7 2.3 Pediatric Dermatology 8.7 3.4 6.5 13.4 Adult Emergency Medicine 18.7 12.5 20.0 17.3 Pediatric Emergency Medicine 6.9 10.0 8.1 4.4 Adult Endocrinology 0.3 0.1 0.2 0.7 Pediatric Endocrinology 6.4 3.0 5.0 9.3 Adult Gastroenterology 0.4 0.1 0.1 0.9 Pediatric Gastroenterology 7.6 8.5 7.7 7.3 Adult Hematology/Oncology 0.2 0.1 0.2 0.3 Pediatric Hematology/Oncology 4.5 4.7 4.7 4.2 Adult Infectious Disease 0.4 0.4 0.3 0.6 Pediatric Infectious Disease 2.3 4.5 2.6 1.6 Adult Nephrology 0.3 0.1 0.2 0.5 Pediatric Nephrology 2.2 2.4 2.1 2.4
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From page 97... ...
Carelon Research included data from one multistate health insurance company and was restricted to beneficiaries with commercial insurance. PEDSnet included patients insured by different commercial insurance plans as well as beneficiaries with Medicaid/CHIP insurance, but the analysis was limited to patients within eight large, pediatric academic medical centers. T-MSIS includes only the population insured by Medicaid/ CHIP. There are several reasons why the subspecialty use rates were lower in the Carelon Research and T-MSIS cohorts compared with the PEDSnet cohort.
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From page 98... ...
Children receiving care in academic medical centers may have higher acuity and thus more intense service use. Third, PEDSnet has devoted extensive effort to validating physician subspecialty, working with each member institution to examine and improve the quality of this data element.
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From page 99... ...
Conclusions Conclusion 3-1: The share of children using pediatric medical subspe cialty care increased somewhat from 2011 to 2021, but temporal trends varied significantly by subspecialty type and payer. Conclusion 3-2: In a select group of the nation's large pediatric aca demic medical centers, growth in the number of children cared for increased markedly from 2011 to 2021, although the share of children requiring pediatric medical subspecialty care remained constant.
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From page 100... ...
100 THE FUTURE PEDIATRIC SUBSPECIALTY PHYSICIAN WORKFORCE REFERENCE Yoon, P., J
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