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Background: Federal regulations allow exception from informed consent (EFIC) to study emergent conditions when obtaining prospective consent is not feasible. Little is known about public views on including children in EFIC studies. The Pediatric Dose Optimization for Seizures in EMS (PediDOSE) trial implements age-based, standardized midazolam dosing for pediatric seizures. The primary objective of this study was to determine public support for and concerns about the PediDOSE EFIC trial. The secondary objective was to assess how support for PediDOSE varied by demographics., Methods: We conducted a mixed-methods study in 20 U.S. communities. Participants reviewed information about PediDOSE before completing an online survey. Descriptive data were generated. Univariable and multivariable logistic regression analysis identified factors associated with support for PediDOSE. Reviewers identified themes from free-text response data regarding participant concerns., Results: Of 2450 respondents, 79% were parents/guardians, and 20% had a child with previous seizures. A total of 96% of respondents supported PediDOSE being conducted, and 70% approved of children being enrolled without prior consent. Non-Hispanic Black respondents were less likely than non-Hispanic White respondents to support PediDOSE with an adjusted odds ratio (aOR) of 0.57 (95% CI 0.42-0.75). Health care providers were more likely to support PediDOSE, with strongest support among prehospital emergency medicine clinicians (aOR 5.82, 95% CI 3.19-10.62). Age, gender, parental status, and level of education were not associated with support of PediDOSE. Common concerns about PediDOSE included adverse effects, legal and ethical concerns about enrolling without consent, and potential racial bias., Conclusions: In communities where this study will occur, most respondents supported PediDOSE being conducted with EFIC and most approved of children being enrolled without prior consent. Support was lowest among non-Hispanic Black respondents and highest among health care providers. Further research is needed to determine optimal ways to address the concerns of specific racial and ethnic groups when conducting EFIC trials., (© 2024 Society for Academic Emergency Medicine.)

Background: Firearm-related suicide is the second leading cause of pediatric firearm death. Lethal means counseling (LMC) can improve firearm safe-storage practices for families with youth at risk of suicide., Objectives: This study aims to evaluate the feasibility of pediatric emergency department (ED) behavioral mental health (BMH) specialists providing LMC to caregivers of youth presenting with BMH complaints and to test for changes in firearm safety practices, pre-post ED LMC intervention, as measures of preliminary efficacy., Methods: Prospective pilot feasibility study of caregivers of youth presenting to a pediatric ED with BMH complaints. Caregivers completed an electronic survey regarding demographics and firearm safe-storage knowledge/practices followed by BMH specialist LMC. Firearm owners were offered a free lockbox and/or trigger lock. One-week follow-up surveys gathered self-reported data on firearm safety practices and intervention acceptability. One-month interviews with randomly sampled firearm owners collected additional firearm safety data. Primary outcomes were feasibility measures, including participant accrual/attrition and LMC intervention acceptability. Secondary outcomes included self-reported firearm safety practice changes. Feasibility benchmarks were manually tabulated, and Likert-scale acceptability responses were dichotomized to strongly agree/agree vs. neutral/disagree/strongly disagree. Descriptive statistics were used for univariate and paired data responses., Results: In total, 81 caregivers were approached; of which, 50 (81%) caregivers enrolled. A total of 44% reported having a firearm at home, 80% completed follow-up at one week. More than 80% affirmed that ED firearm safety education was useful and that the ED is an appropriate place for firearm safety discussions. In total, 58% of participants reported not having prior firearm safety education/counseling. Among firearm owners ( n  = 22), 18% reported rarely/never previously using a safe-storage device, and 59% of firearm owners requested safe storage devices.At 1-week follow-up ( n  = 40), a greater proportion of caregivers self-reported asking about firearms before their child visited other homes (+28%). Among firearm owners that completed follow-up ( n  = 19), 100% reported storing all firearms locked at one week (+23% post-intervention). In total, 10 caregivers reported temporarily/permanently removing firearms from the home., Conclusion: It is feasible to provide LMC in the pediatric ED via BMH specialists to families of high-risk youth. Caregivers were receptive to LMC and reported finding this intervention useful, acceptable, and appropriate. Additionally, LMC and device distribution led to reported changes in safe storage practices., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationship that could be construed as a potential conflict of interest. The handling editor DE declared a shared affiliation with the author(s) at the time of review., (Copyright © 2024 Chaudhary, Doh, Morris, Chivily, Washington, Gillespie, Jergel, Lazarus, Costa, Call, Rupp and Simon.)

Background: In the United States, 33% of households with children contain firearms, however only one-third reportedly store firearms securely. It's estimated that 31% of unintentional firearm injury deaths can be prevented with safety devices. Our objective was to distribute safe storage devices, provide safe storage education, evaluate receptivity, and assess impact of intervention at follow-up., Method: At five independent, community safety events, parents received a safe storage device after completing a survey that assessed firearms storage methods and parental comfort with discussions regarding firearm safety. Follow-up surveys collected 4 weeks later. Data were evaluated using descriptive analysis., Result: 320 participants completed the surveys, and 288 participants were gunowners living with children. Most participants were comfortable discussing safe storage with healthcare providers and were willing to talk with friends about firearm safety. 54% reported inquiring about firearm storage in homes their children visit, 39% stored all their firearms locked-up and unloaded, 32% stored firearms/ammunition separately. 121 (37%0.8) of participants completed the follow-up survey, 84% reported using the distributed safety device and 23% had purchased additional locks for other firearms., Conclusion: Participants were receptive to firearm safe storage education by a healthcare provider and distribution of a safe storage device. Our follow up survey results showed that pairing firearm safety education with device distribution increased overall use of safe storage devices which in turn has the potential to reduce the incidence of unintentional and intentional self-inflicted firearm injuries. Providing messaging to promote utilization of safe storage will impact a firearm safety culture change., Competing Interests: JJ was employed by Medically Home. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationship that could be construed as potential conflict of interest., (Copyright © 2024 Fraser Doh, Bishop, Gillings, Johnson, Boy, Waris, Bhatia, Santore and Simon.)

Objectives: In 2020, firearm injuries surpassed automobile collisions as the leading cause of death in US children. Annual automobile fatalities have decreased during 40 years through a multipronged approach. To develop similarly targeted public health interventions to reduce firearm fatalities, there is a critical need to first characterize firearm injuries and their outcomes at a granular level. We sought to compare firearm injuries, outcomes, and types of shooters at trauma centers in four pediatric health systems across the USA., Methods: We retrospectively extracted data from each institution's trauma registry, paper and electronic health records. Study included all patients less than 19 years of age with a firearm injury between 2003 and 2018. Variables collected included demographics, intent, resources used, and emergency department and hospital disposition. Descriptive statistics were reported using medians and IQRs for continuous data and counts with percentages for categorical data. χ 2 test or Fisher's exact test was conducted for categorical comparisons., Results: Our cohort (n=1008, median age 14 years) was predominantly black and male. During the study period, there was an overall increase in firearm injuries, driven primarily by increases in the South (S) site (β=0.11 (SE 0.02), p=<0.001) in the setting of stable rates in the West and decreasing rates in the Northeast and Mid-Atlantic sites (β=-0.15 (SE 0.04), p=0.002; β=-0.19 (SE0.04), p=0.001). Child age, race, insurance type, resource use, injury type, and shooter type all varied by regional site., Conclusion: The incidence of firearm-related injuries seen at four sites during 15 years varied by site and region. The overall increase in firearm injuries was predominantly driven by the S site, where injuries were more often unintentional. This highlights the need for region-specific data to allow for the development of targeted interventions to impact the burden of injury.Level of Evidence: II, retrospective study., Competing Interests: Competing interests: KFD discloses an honorarium received to discuss gun violence for a medical education podcast., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Government and commercial health insurers have recently enacted policies to discourage nonemergent emergency department (ED) visits by reducing or denying claims for such visits using retrospective claims algorithms. Low-income Black and Hispanic pediatric patients often experience worse access to primary care services necessary for preventing some ED visits, raising concerns about the uneven impact of these policies., Objective: To estimate potential racial and ethnic disparities in outcomes of Medicaid policies for reducing ED professional reimbursement based on a retrospective diagnosis-based claims algorithm., Design, Setting, and Participants: This simulation study used a retrospective cohort of pediatric ED visits (aged 0-18 years) for Medicaid-insured children and adolescents appearing in the Market Scan Medicaid database between January 1, 2016, and December 31, 2019. Visits missing date of birth, race and ethnicity, professional claims data, and Current Procedural Terminology codes of billing level of complexity were excluded, as were visits that result in admission. Data were analyzed from October 2021 to June 2022., Main Outcomes and Measures: Proportion of ED visits algorithmically classified as nonemergent and simulated per-visit professional reimbursement after applying a current reimbursement reduction policy for potentially nonemergent ED visits. Rates were calculated overall and compared by race and ethnicity., Results: The sample included 8 471 386 unique ED visits (43.0% by patients aged 4-12 years; 39.6% Black, 7.7% Hispanic, and 48.7% White), of which 47.7% were algorithmically identified as potentially nonemergent and subject to reimbursement reduction, resulting in a 37% reduction in ED professional reimbursement across the study cohort. More visits by Black (50.3%) and Hispanic (49.0%) children were algorithmically identified as nonemergent when compared with visits by White children (45.3%; P < .001). Modeling the impact of the reimbursement reductions across the cohort resulted in expected per-visit reimbursement that was 6% lower for visits by Black children and 3% lower for visits by Hispanic children relative to visits by White children., Conclusions and Relevance: In this simulation study of over 8 million unique ED visits, algorithmic approaches for classifying pediatric ED visits that used diagnosis codes identified proportionately more visits by Black and Hispanic children as nonemergent. Insurers applying financial adjustments based on these algorithmic outputs risk creating uneven reimbursement policies across racial and ethnic groups.

Objectives: Compare lifetime earning potential (LEP) for developmental and behavioral pediatrics (DBP) to general pediatrics and other pediatric subspecialties. Evaluate association between LEP for DBP and measures of workforce distribution., Methods: Using compensation and debt data from 2018 to 2019 and a net present value analysis, we estimated LEP for DBP compared to general pediatrics and other pediatric subspecialties. We evaluated potential effects of eliminating educational debt, shortening length of fellowship training, and implementing loan repayment or forgiveness programs for pediatric subspecialists. We evaluated the association between LEP for DBP and measures of workforce distribution, including distance to subspecialists, percentage of hospital referral regions (HRRs) with a subspecialist, ratio of subspecialists to regional child population, and fellowship fill rates., Results: LEP was lower for DBP than for general private practice pediatrics ($1.9 million less), general academic pediatrics ($1.1 million less), and all other pediatric subspecialties. LEP of DBP could be improved by shortening fellowship training or implementing loan repayment or forgiveness programs. LEP for subspecialists, including DBP, was associated with distance to subspecialists (-0.5 miles/$100,000 increase in LEP, 95% confidence interval [CI] -0.98 to -0.08), percentage of HRRs with a subspecialist (+1.1%/$100,000 increase in LEP, 95% CI 0.37-1.83), ratio of subspecialists to regional child population (+0.1 subspecialists/100,000 children/$100,000 increase in LEP, 95% CI 0.04-0.17), and average 2014 to 2018 fellowship fill rates (+1% spots filled/$100,000 increase in LEP, 95% CI 0.25-1.65)., Conclusions: DBP has the lowest LEP of all pediatric fields and this is associated with DBP workforce shortages. Interventions to improve LEP may promote workforce growth., (Copyright © 2022 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: For children, the post-concussion return to school process is a critical step towards achieving positive health outcomes. The process requires integration between healthcare professionals, parents, and school personnel., Objective: This research team conducted focus groups with stakeholders including parents, education personnel, school nurses, external healthcare providers (nurses) and athletic trainers to identify communication patterns between healthcare providers outside of the school setting and school personnel., Methods: Data from focus groups were analyzed using a Thematic Analysis approach. Researchers used an inductive (bottom-up) coding process to describe semantic themes and utilized a critical realist epistemology., Results: We identified four key themes within focus group data: (1) lack of effective communication between hospital and outpatient healthcare providers to school personnel; (2) parents who were strong advocates had improved communication with healthcare professionals and garnered more accommodations for their children; (3) non-school professionals and families were often confused about who the point of contact was at a given school; and (4) differing experiences for athletes vs. non-athletes., Conclusion: This study suggests gaps in communication between healthcare and school professionals when children return to school following a concussion. Improving communication between healthcare providers and school staff will require a multi-faceted approach.

Objective: Examine the relationship between the gender distribution of the pediatric subspecialty workforce and lifetime earning potential., Methods: We estimated lifetime earning potential for pediatric academic subspecialists using mean debt and compensation data from national physician surveys for 2019 to 2020 and examined the relationship between the workforce gender composition and lifetime earning potential across the pediatric subspecialties using linear regression analysis., Results: Subspecialties with a higher proportion of women had lower lifetime earning potential (-$55,215 in lifetime earning potential/1% increase in the percentage of female subspecialists; P value .002, 95% CI -$24,429 to -$86,000). Similarly, a higher proportion of female first-year fellows was associated with lower lifetime earning potential (-$61,808 in lifetime earning potential/1% increase in the percentage of female first-year fellows; P value .026, 95% CI -$9,210 to -$114,405)., Conclusions: Consistent with patterns seen in other areas of adult medicine and surgery, pediatric subspecialties with higher proportions of women, such as adolescent medicine and endocrinology, tended to have lower lifetime earning potentials than subspecialties with higher proportions of men, such as cardiology and critical care. Lower earning subspecialties also tended to train higher proportions of women, suggesting that this trend may worsen over time as pediatrics in general and individual subspecialties in particular become increasingly female predominant., (Copyright © 2022 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: Despite extensive efforts, overall readmission rates at US children's hospitals have not materially declined over the past decade, raising questions about how to direct future efforts. Using measures of prevalence and performance variation we describe readmission rates by condition and identify priority conditions for future intervention., Methods: Retrospective cohort study of 49 US children's hospitals in the Pediatric Health Information System in 2017. Conditions were classified using All Patients Refined Diagnosis Related Groups. 30-day unadjusted and risk-adjusted readmission rates were calculated for each hospital/condition using the Pediatric All Cause Readmission measure. We ranked the highest volume conditions by rate variation (RV, interquartile range divided by the median) for each condition across hospitals., Results: The sample included 811,434 index hospitalizations with 50,196 (6.2%) 30-day readmissions. The RV across hospitals/conditions was between 0 and 2.8 (median = 0.7). Common reasons for admission had low RVs across hospitals, for example, bronchiolitis (readmission rate = 5.6%, RV = 0.4), seizure (readmission rate = 6.6%, RV = 0.3), and asthma (readmission rate = 3.1%, RV = 0.4). We identified 33 conditions with high variation in readmission rates across hospitals, which accounted for 18% of all discharges and 11% of all pediatric readmissions. These conditions may serve as candidates for future readmission reduction activities., Conclusions: Many common childhood conditions have little variation in readmission rates across children's hospitals, suggesting limited future improvement opportunities. Conditions with high rate variation may provide opportunities for quality improvement; however, these conditions account for a relatively small share of total discharges suggesting modest potential impacts on national rates., (Copyright © 2022 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Importance: Lower rates of diagnostic imaging have been observed among Black children compared with White children in pediatric emergency departments. Although the racial composition of the pediatric population served by each hospital differs, it is unclear whether this is associated with overall imaging rates at the hospital level, and in particular how it may be associated with the difference in imaging rates between Black and White children at a given hospital., Objective: To examine the association between the diversity of the pediatric population seen at each pediatric ED and variation in diagnostic imaging., Design, Setting, and Participants: Cross-sectional analysis of ED visits by patients younger than 18 years at 38 children's hospitals from January 1, 2016, through December 31, 2019, using data from the Pediatric Health Information System. Data were analyzed from April to September 2021., Exposures: Proportion of patients from minoritized groups cared for at each hospital., Main Outcomes and Measures: The primary outcome was receipt of an imaging test defined as radiography, ultrasonography, computed tomography, or magnetic resonance imaging; adjusted odds ratios (aORs) were calculated to measure differences in imaging by race and ethnicity by hospital, and the correlation between the proportion of patients from minoritized groups cared for at each hospital and the aOR for receipt of diagnostic imaging by race and ethnicity was examined., Results: There were 12 310 344 ED visits (3 477 674 [28.3%] among Hispanic patients; 3 212 915 [26.1%] among non-Hispanic Black patients; 4 415 747 [35.9%] among non-Hispanic White patients; 6 487 660 [52.7%] among female patients) by 5 883 664 pediatric patients (mean [SD] age, 5.84 [5.23] years) to the 38 hospitals during the study period, of which 3 527 866 visits (28.7%) involved at least 1 diagnostic imaging test. Diagnostic imaging was performed in 1 508 382 visits (34.2%) for non-Hispanic White children, 790 961 (24.6%) for non-Hispanic Black children, and 907 222 (26.1%) for Hispanic children (P < .001). Non-Hispanic Black patients were consistently less likely to receive diagnostic imaging than non-Hispanic White patients at each hospital, and for all imaging modalities. There was a significant correlation between the proportion of patients from minoritized groups cared for at the hospital and greater imaging difference between non-Hispanic White and non-Hispanic Black patients (correlation coefficient, -0.37; 95% CI, -0.62 to -0.07; P = .02)., Conclusions and Relevance: In this cross-sectional study, hospitals with a higher percentage of pediatric patients from minoritized groups had larger differences in imaging between non-Hispanic Black and non-Hispanic White patients, with non-Hispanic White patients consistently more likely to receive diagnostic imaging. These findings emphasize the urgent need for interventions at the hospital level to improve equity in imaging in pediatric emergency medicine.

Objective: Reutilization following discharge is costly to families and the health care system. Singular measures of the social determinants of health (SDOH) have been shown to impact utilization; however, the SDOH are multifactorial. The Childhood Opportunity Index (COI) is a validated approach for comprehensive estimation of the SDOH. Using the COI, we aimed to describe the association between SDOH and 30-day revisit rates., Methods: This retrospective study included children 0 to 17 years within 48 children's hospitals using the Pediatric Health Information System from 1/1/2019 to 12/31/2019. The main exposure was a child's ZIP code level COI. The primary outcome was unplanned readmissions and emergency department (ED) revisits within 30 days of discharge. Primary outcomes were summarized by COI category and compared using chi-square or Kruskal-Wallis tests. Adjusted analysis used generalized linear mixed effects models with adjustments for demographics, clinical characteristics, and hospital clustering., Results: Of 728,997 hospitalizations meeting inclusion criteria, 30-day unplanned returns occurred for 96,007 children (13.2%). After adjustment, the patterns of returns were significantly associated with COI. For example, 30-day returns occurred for 19.1% (95% confidence interval [CI]: 18.2, 20.0) of children living within very low opportunity areas, with a gradient-like decrease as opportunity increased (15.5%, 95% CI: 14.5, 16.5 for very high). The relative decrease in utilization as COI increased was more pronounced for ED revisits., Conclusions: Children living in low opportunity areas had greater 30-day readmissions and ED revisits. Our results suggest that a broader approach, including policy and system-level change, is needed to effectively reduce readmissions and ED revisits., (Copyright © 2022 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

The use of telehealth technology to connect with patients has expanded significantly over the past several years, particularly in response to the global coronavirus disease 2019 pandemic. This technical report describes the present state of telehealth and its current and potential applications. Telehealth has the potential to transform the way care is delivered to pediatric patients, expanding access to pediatric care across geographic distances, leveraging the pediatric workforce for care delivery, and improving disparities in access to care. However, implementation will require significant efforts to address the digital divide to ensure that telehealth does not inadvertently exacerbate inequities in care. The medical home model will continue to evolve to use telehealth to provide high-quality care for children, particularly for children and youth with special health care needs, in accordance with current and evolving quality standards. Research and metric development are critical for the development of evidence-based best practices and policies in these new models of care. Finally, as pediatric care transitions from traditional fee-for-service payment to alternative payment methods, telehealth offers unique opportunities to establish value-based population health models that are financed in a sustainable manner., Competing Interests: CONFLICT OF INTEREST DISCLOSURES: Dr Hackell is an expert reviewer and provides testimony to various law firms; the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2022 by the American Academy of Pediatrics.)

Purpose: Institutions are adopting the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) guidelines for pediatric esophageal button battery ingestion (EBBI). Our objective was to evaluate the guidelines' impact on in-hospital resource utilization and short-term clinical outcomes in hemodynamically stable patients after endoscopic battery removal., Methods: A single-center retrospective review of all EBBI admissions from 2010 to 2020. Patients were divided into two groups based on adoption of national guidelines: pre-guideline (2010-2015) and post-guideline (2016-2020)., Results: Sixty-five patients were studied (pre-guideline n = 23; post-guideline n = 42). Compared with pre-guideline, post-guideline use of magnetic resonance imaging (MRI) increased (2/23 [8.7%]; 30/42 [71.4%]; p < 0.001). Post-guideline increases resulted for median days (IQR) receiving antibiotics (0 [0, 4]; 6 [3, 8]; p = 0.01), total pediatric intensive care unit admission (0 [0, 1]; 3 [0, 6]; p < 0.001), and total hospital length of stay (5 [2, 11]; 11.5 [4, 17]; p = 0.02). Two patients in the post-guideline group had delayed presentations despite normal imaging: one with TEF and one with aorto-esophageal fistula. All survived to discharge., Conclusion: In EBBI cases managed using the consensus based NASPHAGN guidelines, we report increased resource utilization without improved patient outcomes. Further research should evaluate post-guideline costs and resource utilization., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Competing Interests: Declaration of Competing Interest Dr. Kiesha Fraser Doh discloses an honorarium received to discuss gun violence for a medical education podcast-Hippo Peds Rap-January 2021. The other authors (EKS, MW, YX, CRM, HKS) have indicated they have no financial relationships relevant to this article to disclose.

Background: Children who experience a mild Traumatic Brain Injury (mTBI) may encounter cognitive and behavioral changes that often negatively impact school performance. Communication linkages between the various healthcare systems and school systems are rarely well-coordinated, placing children with an mTBI at risk for prolonged recovery, adverse impact on learning, and mTBI re-exposure. The objective of this study is to rigorously appraise the pediatric Mild Traumatic Brain Injury Evaluation and Management (TEaM) Intervention that was designed to enhance diagnosis and management of pediatric mTBI through enhanced patient discharge instructions and communication linkages between school and primary care providers., Methods: This is a combined randomized and 2 × 2 quasi-experimental study design with educational and technology interventions occurring at the clinician level with patient and school outcomes as key endpoints. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework will be utilized as a mix methods approach to appraise a multi-disciplinary, multi-setting intervention with the intent of improving outcomes for children who have experienced mTBI., Discussion: Utilization of the RE-AIM framework complemented with qualitative inquiry is suitable for evaluating effectiveness of the TEaM Intervention with the aim of emphasizing priorities regarding pediatric mTBI. This program evaluation has the potential to support the knowledge needed to critically appraise the impact of mTBI recovery interventions across multiple settings, enabling uptake of the best-available evidence within clinical practice., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Tucker, Bull, Hall, Moran, Jain, Sathian, Simon, Gioia, Ratcliff and Wright.)

Importance: Gender-based disparities in compensation in academic medicine are recognized, but their estimated impacts on early career earning potential and strategies to mitigate them have not been well studied., Objectives: To compare earning potential between female and male academic physicians in the first 10 years of posttraining employment and to evaluate the estimated impact of promotion timing, starting salary, and salary growth rate on earning potential., Design, Setting, and Participants: Using publicly available mean debt and compensation data for full-time employed academic physicians in the US from 2019 to 2020, starting salary, salary in year 10 of employment, annual salary growth rate, and overall earning potential in the first 10 years of employment were estimated for each gender by subspecialty. The estimated impacts of promotion timing and potential interventions, including equalizing starting salaries and annual salary growth rates, were modeled. Data analysis was performed from March to May 2021., Exposures: Gender and subspecialty., Main Outcomes and Measures: Starting salary, annual salary growth rate, year-10 salary, and earning potential in first 10 years of employment., Results: This cross-sectional study included compensation data from 24 593 female and 29 886 male academic physicians across 45 subspecialties. Women had lower starting salaries in 42 of 45 subspecialties (93%), year-10 salaries in 43 of 45 subspecialties (96%), mean annual salary growth rates in 22 of 45 subspecialties (49%), and earning potential in 43 of 45 subspecialties (96%) (median [IQR], $214 440 [$130 423-$384 954], or 10%, less). A 1-year delay in promotion from assistant to associate professor reduced women's earning potential by a median (IQR) of $26 042 ($19 672-$35 671), but failure to be promoted at all reduced it by a median (IQR) of $218 724 ($176 317-$284 466). Equalizing starting salaries could increase women's earning potential by a median (IQR) of $250 075 ($161 299-$381 799) in the subspecialties for which starting salaries for women were lower than those for men. Equalizing annual salary growth rates could increase women's earning potential by a median (IQR) of $53 661 ($24 258-$102 892) in the subspecialties for which mean annual salary growth rates were lower for women than for men., Conclusions and Relevance: The findings of this study suggest that gender-based disparities in starting salary and early career earning potential are pervasive in academic medicine in the US. Equalizing starting salaries would address the majority of the differences in earning potential.

Pediatric primary health care (PPHC) is of principal importance to the health and development of all children, helping them reach their true potential. Pediatricians, as the clinicians most intensively trained and experienced in child health, are the natural leaders of PPHC within the context of the medical home. Given the rapidly evolving models of pediatric health care delivery, including the explosion of telehealth in the wake of the COVID-19 pandemic, pediatricians, together with their representative national organizations such as the American Academy of Pediatrics (AAP), are the most capable clinicians to guide policy innovations on both the local and national stage., Competing Interests: FINANCIAL DISCLOSURE: The authors have indicated they do not have a financial relationship relevant to this article to disclose., (Copyright © 2022 by the American Academy of Pediatrics.)

Objectives: High-flow nasal cannula (HFNC) is an oxygen delivery device that provides heated humidified air with higher flow rates. The purpose of this survey is to look at institutional practice patterns of HFNC initiation, weaning, and disposition for pediatric patients across the United States., Methods: Survey was sent via electronic listservs to pediatric physicians in emergency medicine, hospital medicine, critical care, and urgent care. The questionnaire was divided into demographics and HFNC practices (initiation, management, and weaning). One response per institution was included in the analysis., Results: Two hundred twenty-four responses were included in the analysis, composed of 40% pediatric emergency medicine physicians, 46% pediatric hospitalists, 13% pediatric intensive care unit (PICU) physicians, and 1% pediatric urgent care physicians. Ninety-eight percent of the participants have HFNC at their institution. Thirty-seven percent of the respondents had a formal guideline for HFNC initiation. Nearly all guideline and nonguideline institutions report HFNC use in bronchiolitis. Guideline cohort is more likely to have exclusion criteria for HFNC (42% in the guideline cohort vs 17% in the nonguideline cohort; P < 0.001) and less frequently mandates PICU admissions once on HFNC (11% in the guideline cohort vs 56% in the nonguideline cohort; P < 0.001). Forty-six percent of guideline cohort had an objective scoring system to help determine the need for HFNC, and 73% had a weaning guideline., Conclusions: Although there is general agreement to use HFNC in bronchiolitis, great practice variation remains in the initiation, management, and weaning of HFNC across the United States. There is also a discordance on PICU use when a patient is using HFNC., Competing Interests: Disclosure: The authors declare no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Differences in lifetime earning potential between pediatric subspecialties may contribute to shortages in the subspecialty workforce., Objectives: To evaluate the association between lifetime earning potential and workforce distribution and to investigate the potential role of a pediatric subspecialist-specific loan repayment program (LRP) in workforce expansion., Design, Setting, and Participants: This study was performed on publicly available mean debt and compensation data from national physician surveys from 2018 to 2019 of pediatric subspecialists in academic practice. Linear regression analysis was used to evaluate the association between lifetime earning potential and measures of workforce distribution in 2019, including distance to subspecialists, percentage of hospital referral regions with a subspecialist, and ratio of subspecialists to the regional child population as well as between lifetime earning potential in 2018 to 2019 and mean subspecialty fellowship fill rates between 2014 and 2018. The association between the change in lifetime earning potential from 2007 to 2018 and the change in workforce distribution metrics from 2003 to 2019 was also examined. The potential role of a pediatric subspecialist-specific LRP was modeled., Exposures: Lifetime earning potential by subspecialty., Main Outcomes and Measures: Measures of workforce distribution and fellowship fill rates., Results: This study included mean compensation data representing 7539 pediatric subspecialists, workforce distribution data representing 24 375 pediatric subspecialists, and fellowship fill rates representing a mean of 1344 pediatric subspecialty fellows per year. Higher lifetime earning potential was associated with shorter distance to subspecialists (-0.59 miles/$100 000 increase in lifetime earning potential; 95% CI, -1.10 to -0.09), higher percentage of hospital referral regions with a subspecialist (+1.17%/$100 000 increase in lifetime earning potential; 95% CI, 0.34-2.00), and higher ratio of subspecialists to regional child population (+0.11 subspecialists/100 000 children/$100 000 increase in lifetime earning potential; 95% CI, 0.04-0.19). The subspecialties for which lifetime earning potential increased the least between 2007 and 2018 experienced the least growth in the ratio of subspecialists to regional child population from 2003 to 2019 (+0.11 subspecialists/100 000 children/$100 000 increase in lifetime earning potential; 95% CI, 0.07-0.16). Higher lifetime earning potential was associated with higher mean fellowship fill rates (+0.96% spots filled/$100 000 increase in lifetime earning potential; 95% CI, 0.15-1.77). Implementing a pediatric subspecialist-specific LRP could increase fellowship fill rates and improve workforce distribution., Conclusions and Relevance: Lifetime earning potential based on subspecialty may contribute to imbalances in both the current and future pediatric subspecialty workforce. Pediatric subspecialist-specific LRPs, especially for underfilled subspecialties, are potential tools for policy makers to target workforce shortages.

All children and adolescents deserve access to quality health care regardless of their race/ethnicity, health conditions, financial resources, or geographic location. Despite improvements over the past decades, severe disparities in the availability and access to high-quality health care for children and adolescents continue to exist throughout the United States. Economic and racial factors, geographic maldistribution of primary care pediatricians, and limited availability of pediatric medical subspecialists and pediatric surgical specialists all contribute to inequitable access to pediatric care. Robust, comprehensive telehealth coverage is critical to improving pediatric access and quality of care and services, particularly for under-resourced populations., Competing Interests: POTENTIAL CONFLICTS OF INTEREST: Dr Hackell is an expert reviewer and provides testimony to various law firms; the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)