The Importance of Subspecialty Pediatricians to the Health and Well-Being of the Nation’s Children
2023; Elsevier BV; Volume: 257; Linguagem: Inglês
10.1016/j.jpeds.2023.02.011
ISSN1097-6833
AutoresAngela Myers, Jill J. Fussell, Mary E. Moffatt, Debra Boyer, Robert Ross, Christiane E.L. Dammann, Laura Degnon, Pnina Weiss, Cary G. Sauer, Robert J. Vinci,
Tópico(s)Healthcare Systems and Technology
ResumoThe care of our nation's children requires a care delivery system embedded in a medical home under the direction of a primary care clinician. This home is augmented by a comprehensive network of subspecialty pediatricians leading to coordinated medical and social care across a multidisciplinary team that meets both the medical and nonmedical needs of the child and family.1Kash B.A. The pediatric medical home: what do evidence-based models look like?.Am Accountable Care. 2016; 4: 34-40Google Scholar Evidence suggests that primary care physicians are the best equipped for and have the most comfort in providing a medical home for children with special health care needs.2Okumura M.J. Knauer H.A. Calvin K.E. Takayama J.I. Pediatricians' comfort level in caring for children with special health care needs.Acad Pediatr. 2017; 17: 678-686Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Furthermore, a primary care physician's comfort level in providing a medical home is increased when pediatric subspecialty consultation is readily available for their patients. Access to pediatric subspecialists for children with medically complex conditions is vital to the health and well-being of children with and without chronic disease. There remain significant challenges to the delivery of subspecialty care to children. Disparate access to care has been highlighted by the American Board of Pediatrics (ABP) and the American Academy of Pediatrics, with recent data describing travel distances required to reach a pediatric subspecialist.3Turner A. Ricketts T. Leslie L.K. Comparison of number and geographic distribution of pediatric subspecialists and patient proximity to specialized care in the US between 2003 and 2019.JAMA Pediatr. 2020; 174: 852-860Crossref PubMed Scopus (43) Google Scholar,4American Board of PediatricsEstimated Driving distance to visit a pediatric subspecialist. ABP Certification Management System, 2022https://www.abp.org/content/estimated-driving-distance-visit-pediatric-subspecialistDate accessed: March 16, 2023Google Scholar These data show that there are significant variations to access subspecialty care. The limited supply of pediatric subspecialists is further exacerbated by their concentration in urban areas.5Ray K.N. Bogen D.L. Bertolet M. Forrest C.B. Mehrotra A. Supply and utilization of pediatric subspecialists in the United States.Pediatrics. 2014; 133: 1061-1069Crossref PubMed Scopus (40) Google Scholar These challenges contribute to the long wait times that currently exist for pediatric subspecialty appointments,6Pletcher B.A. Rimsza M.E. Cull W.L. Shipman S.A. Shugerman R.P. O'Connor K.G. Primary care pediatricians' satisfaction with subspecialty care, perceived supply, and barriers to care.J Pediatr. 2010; 156: 1011-1015.e1Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar a situation likely to worsen with an increased prevalence in the number of children living with chronic health conditions (eg, asthma, obesity, and mental health disorders).7Berry J.G. Hall M. Hall D.E. Kuo D.Z. Cohen E. Agrawal R. et al.Inpatient growth and resource use in 28 children's hospitals: a longitudinal, multi-institutional study.JAMA Pediatr. 2013; 167: 170-177Crossref PubMed Scopus (203) Google Scholar,8Basco W.T. Rimsza M.E. Committee on Pediatric Workforce, American Academy of PediatricsPediatrician workforce policy statement.Pediatrics. 2013; 132: 390-397Crossref PubMed Scopus (90) Google Scholar Families facing these access barriers may receive care from adult-trained specialists instead of pediatric-trained subspecialists,9Ray K.N. Kahn J.M. Miller E. Mehrotra A. Use of adult-trained medical subspecialists by children seeking medical subspecialty care.J Pediatr. 2016; 176: 173-181.e1Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar or children may not receive much needed pediatric subspecialty care for extended time periods.8Basco W.T. Rimsza M.E. Committee on Pediatric Workforce, American Academy of PediatricsPediatrician workforce policy statement.Pediatrics. 2013; 132: 390-397Crossref PubMed Scopus (90) Google Scholar What is less understood is the impact of these access barriers to pediatric subspecialty care on child health outcomes. Improved outcomes have been reported for specific diseases (eg, asthma) for children who were seen by a pediatric subspecialist compared with those who were not.10Slejko J.F. Ghushchyan V.H. Sucher B. Globe D.R. Lin S.L. Globe G. et al.Asthma control in the United States, 2008-2010: indicators of poor asthma control.J Allergy Clin Immunol. 2014; 133: 1579-1587Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar, 11Hasegawa K. Bittner J.C. Nonas S.A. Stoll S.J. Watase T. Gabriel S. et al.Children and adults with frequent hospitalizations for asthma exacerbation, 2012-2013: a multicenter observational study.J Allergy Clin Immunol Pract. 2015; 3: 751-758.e1Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 12Schatz M. Zeiger R.S. Mosen D. Apter A.J. Vollmer W.M. Stibolt T.B. et al.Improved asthma outcomes from allergy specialist care: a population-based cross-sectional analysis.J Allergy Clin Immunol. 2005; 116: 1307-1313Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 13Cloutier M.M. Salo P.M. Akinbami L.J. Cohn R.D. Wilkerson J.C. Diette G.B. et al.Clinician agreement, self-efficacy, and adherence with the guidelines for the diagnosis and management of asthma.J Allergy Clin Immunol Pract. 2018; 6: 886-894.e4Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar Outcomes also are better for children being seen in regional centers with immediate access to a full range of pediatric medical and surgical subspecialists, including pediatric anesthesiologists and ophthalmologists.14American Academy of Pediatrics Committee on the Fetus and NewbornLevels of neonatal care.Pediatrics. 2012; 130: 587-597Crossref PubMed Scopus (468) Google Scholar To our knowledge, health outcomes of children living with chronic disease have not been comprehensively reviewed to understand the importance of timely access to pediatric subspecialty care. Therefore, to confirm our hypothesis that children with ready access to pediatric subspecialty care have improved health outcomes, we surveyed the existing literature that describes the health outcomes when children are cared for by a pediatric subspecialist or an adult subspecialist, or receive no pediatric subspecialty care. All ABP-certified pediatric subspecialties, along with other subspecialties providing care for children that have representation within the Council of Pediatric Subspecialties (CoPS) were included in this review. CoPS is a national organization that "advances child health through communication and collaboration within its network of pediatric subspecialties and liaison organizations"15Council of Pediatric SubspecialtiesAbout the Council of pediatric subspecialties. 2022https://www.pedsubs.org/membership/representatives/Date accessed: March 16, 2023Google Scholar and provides a national network to conduct this collaboration. Subspecialist representative(s) from pediatric subspecialties within CoPS (Adolescent Medicine, Cardiology, Allergy & Immunology, Child Abuse, Critical Care, Dermatology, Developmental and Behavioral Pediatrics, Emergency Medicine, Endocrinology, Gastroenterology, Hematology-Oncology, Pediatric Hospital Medicine, Infectious Diseases, Neonatal-Perinatal Medicine, Nephrology, Child Neurology, Pulmonology, Rheumatology) searched the literature in their respective field, focusing on health outcomes of children with an acute or chronic medical condition(s) in which comparisons were made to the care provided by a pediatric vs an adult medicine specialist or no pediatric subspecialty care at all. Articles that compared type of subspecialty care (pediatric vs adult) highlighted outcomes related to delays in care, or compared costs of care were prioritized. A representative from each subspecialty reviewed articles included for their subspecialty for relevance and appropriateness. Descriptions of the outcomes are summarized for each subspecialty. Seventeen subspecialties are included in this summary, 15 of which are certified by the ABP. Allergy & Immunology is certified by the American Board of Allergy and Immunology, and Dermatology is certified by the American Board of Dermatology. Each subspecialty reported data regarding pediatric health outcomes resulting from subspecialty care in their specific field across a range of outcome variables (Table).10Slejko J.F. Ghushchyan V.H. Sucher B. Globe D.R. Lin S.L. Globe G. et al.Asthma control in the United States, 2008-2010: indicators of poor asthma control.J Allergy Clin Immunol. 2014; 133: 1579-1587Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar,11Hasegawa K. Bittner J.C. Nonas S.A. Stoll S.J. Watase T. Gabriel S. et al.Children and adults with frequent hospitalizations for asthma exacerbation, 2012-2013: a multicenter observational study.J Allergy Clin Immunol Pract. 2015; 3: 751-758.e1Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar,13Cloutier M.M. Salo P.M. Akinbami L.J. Cohn R.D. Wilkerson J.C. Diette G.B. et al.Clinician agreement, self-efficacy, and adherence with the guidelines for the diagnosis and management of asthma.J Allergy Clin Immunol Pract. 2018; 6: 886-894.e4Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar,14American Academy of Pediatrics Committee on the Fetus and NewbornLevels of neonatal care.Pediatrics. 2012; 130: 587-597Crossref PubMed Scopus (468) Google Scholar,16Trent M. Pelvic inflammatory disease.Pediatr Rev. 2013; 34: 163-172Crossref PubMed Scopus (15) Google Scholar, 17Trent M. Status of adolescent pelvic inflammatory disease management in the United States.Curr Opin Obstet Gynecol. 2013; 25: 350-356Crossref PubMed Scopus (21) Google Scholar, 18Goyal M. Hersh A. Luan X. Localio R. Trent M. Zaoutis T. Are emergency departments appropriately treating adolescent pelvic inflammatory disease?.JAMA Pediatr. 2013; 167: 672-673Crossref PubMed Scopus (15) Google Scholar, 19Schatz M. Improved asthma outcomes from allergy specialist care: a population-based cross-sectional analysis.J Allergy Clin Immunol. 2005; : 1307-1313Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 20Kogon B.E. Plattner C. Leong T. Kirshbom P.M. Kanter K.R. McConnell M. et al.Adult congenital heart surgery: adult or pediatric facility? Adult or pediatric surgeon?.Ann Thorac Surg. 2009; 87: 833-840Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar, 21Anderst J. Kellogg N. Jung I. Is the diagnosis of physical abuse changed when Child Protective Services consults a Child Abuse Pediatrics subspecialty group as a second opinion?.Child Abuse Negl. 2009; 33: 481-489Crossref PubMed Scopus (26) Google Scholar, 22Makoroff K.L. Brauley J.L. Brandner A.M. Myers P.A. Shapiro R.A. Genital examinations for alleged sexual abuse of prepubertal girls: findings by pediatric emergency medicine physicians compared with child abuse trained physicians.Child Abuse Negl. 2002; 26: 1235-1242Crossref PubMed Scopus (61) Google Scholar, 23Wallace G.H. Makoroff K.L. Malott H.A. Shapiro R.A. Hospital-based multidisciplinary teams can prevent unnecessary child abuse reports and out-of-home placements.Child Abuse Negl. 2007; 31: 623-629Crossref PubMed Scopus (30) Google Scholar, 24King M.A. Matos R.I. Hamele M.T. Borgman M.A. Zabrocki L.A. Gadepalli S.K. et al.PICU in the MICU: how adult ICUs can support pediatric care in public health emergencies.Chest. 2022; 161: 1297-1305Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 25Desrosiers A.S. Ibrahim J.M. Jacks S.K. A barrier to care: distance traveled affects adherence to treatment and follow-up plans for patients with infantile hemangioma.Pediatr Dermatol. 2019; 36: 402-403Crossref PubMed Scopus (11) Google Scholar, 26Moon A.T. Castelo-Soccio L. Yan A.C. Emergency department utilization of pediatric dermatology (PD) consultations.J Am Acad Dermatol. 2016; 74: 1173-1177Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 27Garza-Mayers A.C. Anderson L.E. Yu J. Huang J.T. Impact of dermatology consultation on the care of children with chronic graft-versus-host disease of the skin.J Am Acad Dermatol. 2019; 81: 627-629Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 28Feldman H.M. Blum N.J. Gahman A.E. Shults J. Committee D.B.S. Diagnosis of attention-deficit/hyperactivity disorder by developmental pediatricians in academic centers: a DBPNet study.Acad Pediatr. 2015; 15: 282-288Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 29Ames S.G. Davis B.S. Marin J.R. Fink E.L. Olson L.M. Gausche-Hill M. et al.Emergency department pediatric readiness and mortality in critically ill children.Pediatrics. 2019; 144: e20190568Crossref PubMed Scopus (83) Google Scholar, 30Michelson K.A. Hudgins J.D. Monuteaux M.C. Bachur R.G. Finkelstein J.A. Cardiac arrest survival in pediatric and general emergency departments.Pediatrics. 2018; 141: e20172741Crossref PubMed Scopus (41) Google Scholar, 31Newgard C.D. Lin A. Olson L.M. Cook J.N.B. Gausche-Hill M. Kuppermann N. et al.Evaluation of emergency department pediatric readiness and outcomes among US trauma centers.JAMA Pediatr. 2021; 175: 947-956Crossref PubMed Scopus (22) Google Scholar, 32Allen D.B. Aye T. Boney C.M. Eugster E.A. Misra M. Singer K. et al.Sustaining the pediatric Endocrinology workforce: recommendations from the Pediatric Endocrine Society Workforce Task Force.J Pediatr. 2021; 233: 4-7Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 33Nadeau K.J. Anderson B.J. Berg E.G. Chiang J.L. Chou H. Copeland K.C. et al.Youth-onset type 2 diabetes consensus report: current status, challenges, and priorities.Diabetes Care. 2016; 39: 1635-1642Crossref PubMed Scopus (237) Google Scholar, 34Ruemmele F.M. Turner D. Differences in the management of pediatric and adult onset ulcerative colitis--lessons from the joint ECCO and ESPGHAN consensus guidelines for the management of pediatric ulcerative colitis.J Crohns Colitis. 2014; 8: 1-4Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 35Howell D.L. Ward K.C. Austin H.D. Young J.L. Woods W.G. Access to pediatric cancer care by age, race, and diagnosis, and outcomes of cancer treatment in pediatric and adolescent patients in the state of Georgia.J Clin Oncol. 2007; 25: 4610-4615Crossref PubMed Scopus (78) Google Scholar, 36Bleyer A. The quid pro quo of pediatric versus adult services for older adolescent cancer patients.Pediatr Blood Cancer. 2010; 54: 238-241Crossref PubMed Scopus (42) Google Scholar, 37McCulloh R.J. Smitherman S. Adelsky S. Congdon M. Librizzi J. Koehn K. et al.Hospitalist and nonhospitalist adherence to evidence-based quality metrics for bronchiolitis.Hosp Pediatr. 2012; 2: 19-25Crossref PubMed Google Scholar, 38Conway P.H. Edwards S. Stucky E.R. Chiang V.W. Ottolini M.C. Landrigan C.P. Variations in management of common inpatient pediatric illnesses: hospitalists and community pediatricians.Pediatrics. 2006; 118: 441-447Crossref PubMed Scopus (53) Google Scholar, 39Barrett D.J. McGuinness G.A. Cunha C.A. Emans S.J. Gerson W.T. Hazinski M.F. et al.Pediatric hospital medicine: a proposed new subspecialty.Pediatrics. 2017; 139 (e20161823)Crossref PubMed Scopus (37) Google Scholar, 40Mussman G.M. Conway P.H. Pediatric hospitalist systems versus traditional models of care: effect on quality and cost outcomes.J Hosp Med. 2012; 7: 350-357Crossref PubMed Scopus (14) Google Scholar, 41Horikoshi Y. Suwa J. Higuchi H. Kaneko T. Furuichi M. Aizawa Y. et al.Sustained pediatric antimicrobial stewardship program with consultation to infectious diseases reduced carbapenem resistance and infection-related mortality.Int J Infect Dis. 2017; 64: 69-73Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 42Sunenshine R.H. Liedtke L.A. Jernigan D.B. Strausbaugh L.J. Infectious Diseases Society of America Emerging Infections NetworkRole of infectious diseases consultants in management of antimicrobial use in hospitals.Clin Infect Dis. 2004; 38: 934-938Crossref PubMed Scopus (65) Google Scholar, 43Cao B. Adler J.T. Bababekov Y.J. Markmann J.F. Chang D.C. Yeh H. Pediatric kidney transplantation and mortality: distance to transplant center matters.Pediatr Transplant. 2018; 22Crossref PubMed Scopus (11) Google Scholar, 44Khan M.S. Zhang W. Taylor R.A. Dean McKenzie E. Mallory G.B. Schecter M.G. et al.Survival in pediatric lung transplantation: the effect of center volume and expertise.J Heart Lung Transplant. 2015; 34: 1073-1081Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar,46Correll C.K. Spector L.G. Zhang L. Binstadt B.A. Vehe R.K. Barriers and alternatives to pediatric rheumatology referrals: survey of general pediatricians in the United States.Pediatr Rheumatol Online J. 2015; 13: 32Crossref PubMed Scopus (16) Google Scholar Outcome data reflect reduced hospitalization rates and improved satisfaction with care, as well as improved health outcomes across several subspecialty outcome metrics.TableSummary of data and outcomes for children receiving pediatric subspecialty careAdolescent•Comprehensive treatment for pelvic inflammatory disease is greater with multidisciplinary adolescent care compared with emergency department encounters.16Trent M. Pelvic inflammatory disease.Pediatr Rev. 2013; 34: 163-172Crossref PubMed Scopus (15) Google Scholar, 17Trent M. Status of adolescent pelvic inflammatory disease management in the United States.Curr Opin Obstet Gynecol. 2013; 25: 350-356Crossref PubMed Scopus (21) Google Scholar, 18Goyal M. Hersh A. Luan X. Localio R. Trent M. Zaoutis T. Are emergency departments appropriately treating adolescent pelvic inflammatory disease?.JAMA Pediatr. 2013; 167: 672-673Crossref PubMed Scopus (15) Google ScholarAllergy–immunology•Patients with asthma use fewer rescue medications and take more long-term controller medications with referral to an allergist.10Slejko J.F. Ghushchyan V.H. Sucher B. Globe D.R. Lin S.L. Globe G. et al.Asthma control in the United States, 2008-2010: indicators of poor asthma control.J Allergy Clin Immunol. 2014; 133: 1579-1587Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar,11Hasegawa K. Bittner J.C. Nonas S.A. Stoll S.J. Watase T. Gabriel S. et al.Children and adults with frequent hospitalizations for asthma exacerbation, 2012-2013: a multicenter observational study.J Allergy Clin Immunol Pract. 2015; 3: 751-758.e1Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar,13Cloutier M.M. Salo P.M. Akinbami L.J. Cohn R.D. Wilkerson J.C. Diette G.B. et al.Clinician agreement, self-efficacy, and adherence with the guidelines for the diagnosis and management of asthma.J Allergy Clin Immunol Pract. 2018; 6: 886-894.e4Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar,19Schatz M. Improved asthma outcomes from allergy specialist care: a population-based cross-sectional analysis.J Allergy Clin Immunol. 2005; : 1307-1313Abstract Full Text Full Text PDF PubMed Scopus (78) Google ScholarCardiology•Adults requiring surgery for congenital heart disease have lower mortality rates when performed by a pediatric heart surgeon.20Kogon B.E. Plattner C. Leong T. Kirshbom P.M. Kanter K.R. McConnell M. et al.Adult congenital heart surgery: adult or pediatric facility? Adult or pediatric surgeon?.Ann Thorac Surg. 2009; 87: 833-840Abstract Full Text Full Text PDF PubMed Scopus (61) Google ScholarChild abuse•Access ensures the correct diagnosis (abuse vs not abuse) is made.21Anderst J. Kellogg N. Jung I. Is the diagnosis of physical abuse changed when Child Protective Services consults a Child Abuse Pediatrics subspecialty group as a second opinion?.Child Abuse Negl. 2009; 33: 481-489Crossref PubMed Scopus (26) Google Scholar, 22Makoroff K.L. Brauley J.L. Brandner A.M. Myers P.A. Shapiro R.A. Genital examinations for alleged sexual abuse of prepubertal girls: findings by pediatric emergency medicine physicians compared with child abuse trained physicians.Child Abuse Negl. 2002; 26: 1235-1242Crossref PubMed Scopus (61) Google Scholar, 23Wallace G.H. Makoroff K.L. Malott H.A. Shapiro R.A. Hospital-based multidisciplinary teams can prevent unnecessary child abuse reports and out-of-home placements.Child Abuse Negl. 2007; 31: 623-629Crossref PubMed Scopus (30) Google ScholarCritical care•Critically ill children with medical complexity or young age ( 7 times more likely to be nonadherent to treatment compared with those who traveled ≤10 miles.25Desrosiers A.S. Ibrahim J.M. Jacks S.K. A barrier to care: distance traveled affects adherence to treatment and follow-up plans for patients with infantile hemangioma.Pediatr Dermatol. 2019; 36: 402-403Crossref PubMed Scopus (11) Google Scholar•Children evaluated by a pediatric dermatologist have a change to the correct diagnosis up to 40% of the time when seen in the pediatric emergency department and therapy is changed in most (80%) children diagnosed with chronic skin graft vs host disease.26Moon A.T. Castelo-Soccio L. Yan A.C. Emergency department utilization of pediatric dermatology (PD) consultations.J Am Acad Dermatol. 2016; 74: 1173-1177Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar,27Garza-Mayers A.C. Anderson L.E. Yu J. Huang J.T. Impact of dermatology consultation on the care of children with chronic graft-versus-host disease of the skin.J Am Acad Dermatol. 2019; 81: 627-629Abstract Full Text Full Text PDF PubMed Scopus (1) Google ScholarDevelopmental–behavioral•Developmental Behavioral Pediatricians complete comprehensive assessments and recognize coexisting developmental and learning diagnoses in children with attention deficit hyperactivity syndrome and autism spectrum disorder.28Feldman H.M. Blum N.J. Gahman A.E. Shults J. Committee D.B.S. Diagnosis of attention-deficit/hyperactivity disorder by developmental pediatricians in academic centers: a DBPNet study.Acad Pediatr. 2015; 15: 282-288Abstract Full Text Full Text PDF PubMed Scopus (9) Google ScholarEmergency medicine•There is decreased mortality and improved outcomes for critically ill children in pediatric emergency departments and in hospitals with higher pediatric readiness scores.29Ames S.G. Davis B.S. Marin J.R. Fink E.L. Olson L.M. Gausche-Hill M. et al.Emergency department pediatric readiness and mortality in critically ill children.Pediatrics. 2019; 144: e20190568Crossref PubMed Scopus (83) Google Scholar, 30Michelson K.A. Hudgins J.D. Monuteaux M.C. Bachur R.G. Finkelstein J.A. Cardiac arrest survival in pediatric and general emergency departments.Pediatrics. 2018; 141: e20172741Crossref PubMed Scopus (41) Google Scholar, 31Newgard C.D. Lin A. Olson L.M. Cook J.N.B. Gausche-Hill M. Kuppermann N. et al.Evaluation of emergency department pediatric readiness and outcomes among US trauma centers.JAMA Pediatr. 2021; 175: 947-956Crossref PubMed Scopus (22) Google ScholarEndocrine•The number of trainees choosing pediatric endocrinology is declining and type 1 and 2 diabetes in youth is increasing, resulting in large referral volumes and reduced access to care.32Allen D.B. Aye T. Boney C.M. Eugster E.A. Misra M. Singer K. et al.Sustaining the pediatric Endocrinology workforce: recommendations from the Pediatric Endocrine Society Workforce Task Force.J Pediatr. 2021; 233: 4-7Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,33Nadeau K.J. Anderson B.J. Berg E.G. Chiang J.L. Chou H. Copeland K.C. et al.Youth-onset type 2 diabetes consensus report: current status, challenges, and priorities.Diabetes Care. 2016; 39: 1635-1642Crossref PubMed Scopus (237) Google ScholarGastroenterology•Ulcerative colitis in children is typically more aggressive than adult-onset disease. Treatment algorithms for children with ulcerative colitis have an expanded focus, to include growth, puberty, emotional development, and body image.34Ruemmele F.M. Turner D. Differences in the management of pediatric and adult onset ulcerative colitis--lessons from the joint ECCO and ESPGHAN consensus guidelines for the management of pediatric ulcerative colitis.J Crohns Colitis. 2014; 8: 1-4Abstract Full Text Full Text PDF PubMed Scopus (54) Google ScholarHematology–oncology•Adolescents and young adults with pediatric cancers treated at Children's Oncology Group centers have greater survival rates compared with those treated at non-Children's Oncology Group institutions.35Howell D.L. Ward K.C. Austin H.D. Young J.L. Woods W.G. Access to pediatric cancer care by age, race, and diagnosis, and outcomes of cancer treatment in pediatric and adolescent patients in the state of Georgia.J Clin Oncol. 2007; 25: 4610-4615Crossref PubMed Scopus (78) Google Scholar,36Bleyer A. The quid pro quo of pediatric versus adult services for older adolescent cancer patients.Pediatr Blood Cancer. 2010; 54: 238-241Crossref PubMed Scopus (42) Google ScholarHospital medicine•Hospitalized children cared for by pediatric hospitalists have shorter lengths of stay, lower costs, and greater adherence to evidence-based therapies than children cared for by nonhospitalist physicians.37McCulloh R.J. Smitherman S. Adelsky S. Congdon M. Librizzi J. Koehn K. et al.Hospitalist and nonhospitalist adherence to evidence-based quality metrics for bronchiolitis.Hosp Pediatr. 2012; 2: 19-25Crossref PubMed Google Scholar, 38Conway P.H. Edwards S. Stucky E.R. Chiang V.W. Ottolini M.C. Landrigan C.P. Variations in management of common inpatient pediatric illnesses: hospitalists and community pediatricians.Pediatrics. 2006; 118: 441-447Crossref PubMed Scopus (53) Google Scholar, 39Barrett D.J. McGuinness G.A. Cunha C.A. Emans S.J. Gerson W.T. Hazinski M.F. et al.Pediatric hospital medicine: a proposed new subspecialty.Pediatrics. 2017; 139 (e20161823)Crossref PubMed Scopus (37) Google Scholar, 40Mussman G.M. Conway P.H. Pediatric hospitalist systems versus traditional models of care: effect on quality and cost outcomes.J Hosp Med. 2012; 7: 350-357Crossref PubMed Scopus (14) Google ScholarInfectious diseases•Antimicrobial stewardship programs with ID consult led to decreased carbapenem use and decreased Pseudomonas resistance, lengths of stay, and mortality.41Horikoshi Y. Suwa J. Higuchi H. Kaneko T. Furuichi M. Aizawa Y. et al.Sustained pediatric antimicrobial stewardship program with consultation to infectious diseases reduced carbapenem resistance and infection-related mortality.Int J Infect Dis. 2017; 64: 69-73Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar•Survey data have shown the importance of ID physician involvement in antimicrobial restriction policies and approval processes.42Sunenshine R.H. Liedtke L.A. Jernigan D.B. Strausbaugh L.J. Infectious Diseases Society of America Emerging Infections NetworkRole of infectious diseases consultants in management of antimicrobial use in hospitals.Clin Infect Dis. 2004; 38: 934-938Crossref PubMed Scopus (65) Google ScholarNeonatal–perinatal medicine•Facilities should be uniformly classified by their capabilities, which includes required equipment, trained specialty personnel, variety of available services, and transport capabilities. This allows for standardization of which neonates a facility is equipped to provide care, leading to improved patient outcomes particularly for very low birth weight infants.14American Academy of Pediatrics Committee on the Fetus and NewbornLevels of neonatal care.Pediatrics. 2012; 130: 587-597Crossref PubMed Scopus (468) Google ScholarNephrology•Mortality is 2 times greater in children with end-stage kidney disease who live ≥78 miles from a transplant center compared with those who live closer.43Cao B. Adler J.T. Bababekov Y.J. Markmann J.F. Chang D.C. Yeh H. Pediatric kidney transplantation and mortality: distance to transplant center matters.Pediatr Transplant. 2018; 22Crossref PubMed Scopus (11) Google ScholarPulmonology•Posttransplant survival is greater for older children and adolescents treated at pediatric centers compared with adult centers.44Khan M.S. Zhang W. Taylor R.A. Dean McKenzie E. Mallory G.B. Schecter M.G. et al.Survival in pediatric lung transplantation: the effect of center volume and expertise.J Heart Lung Transplant. 2015; 34: 1073-1081Abstract Full Text Full Text PDF PubMed Scopus (28) Google ScholarRheumatology•Barriers to access lead to more invasive procedures and missed uveitis, as well as increased joint damage and involvement of more joints with diagnostic delays.45Foster H.E. Eltringham M.S. Kay L.J. Friswell M. Abinun M. Myers A. Delay in access to appropriate care for children presenting with musculoskeletal symptoms and ultimately diagnosed with juvenile idiopathic arthritis.Arthritis Rheum. 2007; 57: 921-927Crossref PubMed Scopus (91) Google Scholar•Children with a suspected rheumatologic diagnosis are often referred to alternative specialists (eg, pediatric ID or adult rheumatologist) or not referred because of distance to travel to a pediatric rheumatologist.46Correll C.K. Spector L.G. Zhang L. Binstadt B.A. Vehe R.K. Barriers and alternatives to pediatric rheumatology referrals: survey
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