General and subspecialist pediatrician perspectives on barriers and strategies for referral: a latent profile analysis.

BACKGROUND: Children in need of pediatric subspecialty care may encounter multiple barriers, and multiple strategies have been suggested to improve access. The purpose of this study was to describe the perceptions of general and subspecialty pediatric physicians regarding barriers to subspecialty care and the value of strategies to improve subspecialty access. METHODS: We surveyed a national sample of 1680 general pediatricians and pediatric subspecialists in May and June 2020 regarding 11 barriers to subspecialty care and 9 strategies to improve access to subspecialty care, selected from recent literature. Using latent profile analysis, respondents were grouped according to the degree to which they believed each of the barriers impacted access to subspecialty care. Using chi-squared tests, we compared the profiles based on respondent characteristics and perspectives on strategies to improve access. RESULTS: The response rate was 17%. In 263 responses completed and eligible for inclusion, the barriers most frequently described as "major problems" were wait times (57%), lack of subspecialists (45%) and difficulty scheduling (41%). Respondents were classified into 4 profiles: "Broad concerns," "Subspecialist availability concerns," "Clinician communication concerns," and "Few concerns." These profiles varied significantly by respondent specialty (p < .001, with medical subspecialists overrepresented in the "Clinician communication" profile, psychiatrists in the "subspecialist availability" profile, and surgeons in the "few concerns" profile); and by respondents' typical wait time for appointments (p < .001, with physicians with the longest wait times overrepresented in the "subspecialist availability" profile). CONCLUSIONS: We found specific profiles in clinician views regarding barriers to subspecialty care which were associated with perspectives on strategies aimed at overcoming these barriers. These results suggest that health systems aiming to improve subspecialty access should first identify the barriers and preferences specific to local clinicians.

Healthcare Utilization Among Children Receiving Permanent Supportive Housing.

BACKGROUND AND OBJECTIVES: Permanent supportive housing (PSH) integrates long-term housing and supports for families and individuals experiencing homelessness. Although PSH is frequently provided to families with children, little is known about the impacts of PSH among children. We examined changes in health care visits among children receiving PSH compared with similar children who did not receive PSH. METHODS: We analyzed Pennsylvania Medicaid administrative data for children entering PSH between 2011 and 2016, matching to a comparison cohort with similar demographic and clinical characteristics who received non-PSH housing services. We conducted propensity score-weighted difference-in-differences (DID) analyses to compare changes in health care visits 3 years before and after children entered PSH versus changes in the comparison cohort. RESULTS: We matched 705 children receiving PSH to 3141 in the comparison cohort. Over 3 years following PSH entry, dental visits among children entering PSH increased differentially relative to the comparison cohort (DID: 12.70 visits per 1000 person-months, 95% confidence interval: 3.72 to 21.67). We did not find differential changes in preventive medicine visits, hospitalizations, or emergency department (ED) visits overall. When stratified by age, children ≤5 years old at PSH entry experienced a greater decrease in ED visits relative to the comparison cohort (DID: -13.16 visits per 1000 person-months, 95% confidence interval: -26.23 to -0.10). However, emergency visit trends before PSH entry differed between the cohorts. CONCLUSIONS: Children in PSH had relatively greater increases in dental visits, and younger children entering PSH may have experienced relative reductions in ED visits. Policymakers should consider benefits to children when evaluating the overall value of PSH.

Use of telemedicine for initial outpatient subspecialist consultative visit: A national survey of general pediatricians and pediatric subspecialists.

BACKGROUND: Evidence-based strategies are needed to support appropriate use of telemedicine for initial outpatient subspecialty consultative visits. To inform such strategies we performed a survey of general pediatricians and pediatric subspecialists about use of telemedicine for patients newly referred for pediatric subspecialty care. METHODS: We developed and fielded an e-mail and postal survey of a national sample of 840 general pediatricians and 840 pediatric subspecialists in May and June 2020. RESULTS: Of 266 completed surveys (17% response rate), 204 (76%) thought telemedicine should be offered for some and 29 (11%) thought telemedicine should be offered for all initial subspecialist visits. Most respondents who indicated telemedicine should be offered for some initial consultations believed this decision should be made by subspecialty attendings (176/204, 86%). Respondents prioritized several data elements to inform this decision, including clinical information and family-based contextual information (e.g., barriers to in-person care, interest in telemedicine, potential communication barriers). Factors perceived to reduce appropriateness of telemedicine for subspecialty consultation included need for interpreter services and prior history of frequent no-shows. Responses from generalists and subspecialists rarely differed significantly. CONCLUSIONS: Survey results suggest potential opportunities to support the appropriate use of telemedicine for initial outpatient pediatric subspecialty visits through structured transfer of specific clinical and contextual information at the time of referral and through strategies to mitigate perceived communication or engagement barriers. IMPLICATION: Pediatric physician beliefs about telemedicine for initial outpatient subspecialty consultative visits may inform future interventions to support appropriate telemedicine use. LEVEL OF EVIDENCE: Survey of a national sample of clinicians.

Unscheduled Referrals and Unattended Appointments After Pediatric Subspecialty Referral.

OBJECTIVES: Incomplete subspecialty referrals, whether unscheduled or unattended, represent unmet patient needs and an opportunity to improve patient safety and experiences. Our objectives were to describe the rates of appointment scheduling and visit attendance after pediatric subspecialty referral and to examine patient and systems factors associated with scheduled referrals and attended appointments. METHODS: We conducted a retrospective review of referrals within a network of 52 primary and urgent care sites from November 2016 to October 2017. We included referrals for children ≤17 years old referred to medical or surgical subspecialists. We examined patient and health systems factors associated with (1) appointment scheduling and (2) visit attendance. RESULTS: Of 20 466 referrals, 13 261 (65%) resulted in an appointment scheduled within 90 days and 10 514 (51%) resulted in a visit attended within 90 days. In adjusted analyses, referral to surgical subspecialists was associated with an increased likelihood of appointment scheduling but a decreased likelihood of visit attendance. Compared with appointments scheduled within 7 days, appointments with intervals from referral to scheduled appointment exceeding 7 days were associated with decreasing likelihood of visit attendance (adjusted odds ratio 8-14 days 0.48; 95% confidence interval 0.37-0.61). Patient factors associated with decreased likelihood of both appointment scheduling and visit attendance included African American race, public insurance, and lower zip code median income. CONCLUSIONS: Patient and system factors were associated with variation in appointment scheduling and visit attendance. Decreased interval to appointment was significantly associated with visit attendance. These factors represent targets for interventions to improve referral completion.

Failure by fatigue in the field: a model of fatigue breakage for the macroalga Mazzaella, with validation.

Seaweeds inhabiting the extreme hydrodynamic environment of wave-swept shores break frequently. However, traditional biomechanical analyses, evaluating breakage due to the largest individual waves, have perennially underestimated rates of macroalgal breakage. Recent laboratory testing has established that some seaweeds fail by fatigue, accumulating damage over a series of force impositions. Failure by fatigue may thus account, in part, for the discrepancy between prior breakage predictions, based on individual not repeated wave forces, and reality. Nonetheless, the degree to which fatigue breaks seaweeds on wave-swept shores remains unknown. Here, we developed a model of fatigue breakage due to wave-induced forces for the macroalga Mazzaella flaccida. To test model performance, we made extensive measurements of M. flaccida breakage and of wave-induced velocities experienced by the macroalga. The fatigue-breakage model accounted for significantly more breakage than traditional prediction methods. For life history phases modeled most accurately, 105% (for female gametophytes) and 79% (for tetrasporophytes) of field-observed breakage was predicted, on average. When M. flaccida fronds displayed attributes such as temperature stress and substantial tattering, the fatigue-breakage model underestimated breakage, suggesting that these attributes weaken fronds and lead to more rapid breakage. Exposure to waves had the greatest influence on model performance. At the most wave-protected sites, the model underpredicted breakage, and at the most wave-exposed sites, it overpredicted breakage. Overall, our fatigue-breakage model strongly suggests that, in addition to occurring predictably in the laboratory, fatigue-induced breakage of M. flaccida occurs on wave-swept shores.