Data Sources
In conjunction with the American College
of Rheumatology, the Arthritis Foundation
created and fielded a survey of pediatric
rheumatologists and internist rheumatologists
in the United States. The survey was
not formally pilot tested and was fielded
using a Web-based format. All physician
members of the American College of Rheumatology
(n=3627) received an email message describing
the survey and providing a link to the
online survey. The email message was
sent on March 9, 2004 and a reminder on
March 23, 2004.
Data Cleaning
The Arthritis Foundation provided access
to a comma-delimited version of the survey
data. Raw data were converted to a usable
format by performing multiple data manipulations.
Observations that were obvious duplicates,
(i.e., observations that were identical
to another observation for all variables,
(n=22) were deleted). Observations from
non-physicians, non-rheumatologists, retired
physicians (n=38), fellows (n=21), physicians
practicing overseas (4), physicians with
missing data that prevented categorizing
them as pediatric or internist rheumatologists
(3), and records with no data (4) were
excluded. All impossible values for zip
code were recoded to missing; all non-US
zip codes to missing were recoded to missing.
For questions in a series (e.g., “How
much time do you spend on each of the
following activities?”), recoding of values
to missing was done only if all questions
in the series do not have data; otherwise,
blank values were recoded to zero. Reponses
of “don’t know” for percentage of Medicaid
and uninsured patients were considered
missing.
Several questions asked respondents to
report time amounts. If respondents reported
a range of values (e.g., 10-15 hours),
the lower end of the reported range was
used. If respondents report a value of
greater than or less than (e.g., >40
hours), the value reported was used, without
the greater than or less than qualifier.
If the total number of hours per week
summed to 100, it was assumed that the
provider had entered in percentages; these
were converted to hours using an assumed
workweek of 49 hours.
For questions that require a “Yes/No”
response, binary variables were created
to indicate an affirmative response.
For open-ended questions that requested
specification, categorical variables were
created that collapsed the responses into
a smaller number of categories.
Methods
Respondents were classified as either
adult or pediatric rheumatologists or
internist rheumatologist using data on
their Board certification status and/or
their self-description. Internist rheumatologists
were further classified as involved in
the care of children if they reported
that children represented at least some
of their patients. Internist rheumatologists
who specified that they did not treat
children with rheumatic diseases were
considered to not be involved in the care
of children.
Bivariate analyses were performed using
Pearson c2 for categorical
variables and two-sided, two-sample t-tests
for comparisons of means. In addition,
logit analyses were performed to assess
the independent association between distance
to the nearest pediatric rheumatologist
and the likelihood that an internist rheumatologist
treated children; distance data were derived
from the HRSA Bureau of Health Professions’
Area Resource File.
Results
Of the 3,637 emails sent, 300 failed
to reach the intended recipient; 3,337
individuals received the email message;
of this number, 706 unique survey responses
were received. Among the respondents
63 were ineligible due to: residence
outside the U.S. (4), retirement from
patient care or misclassification as a
rheumatologist (38), or current fellowship
status (21) yielding an effective sample
of 3,274. Of the 706 responses received,
633 were eligible and could be used in
the analyses; the effective response rate
was 19.3 percent. Given that approximately
224 physician members of the American
College of Rheumatology are pediatric
rheumatologists, a figure that includes
both fellows and practicing physicians,
it was estimated that the response rate
among pediatric rheumatologists was considerably
higher, closer to 55 percent.
Table
E.1. Provider Type,1 Arthritis
Foundation/American College of Rheumatology
Survey
|
All
Respondents |
N |
% |
Type
of provider: |
|
|
Pediatric
Rheumatologists |
110 |
17.4 |
Internist
rheumatologist who treat children |
289 |
45.7 |
Internist
rheumatologist who do not treat
children |
234 |
37.0 |
Total |
633 |
100.0 |
1Current fellows (n=21) excluded
from analyses
Of all respondents, 17.4 percent were
pediatric rheumatologists and 82.6 percent
were internist rheumatologists (Table
B.1). Of the internist rheumatologists
in patient care, 55.2 percent spent at
least some patient care time treating
children.
Bivariate
Analyses
Pediatric rheumatologists were compared
to internist rheumatologists who did and
did not treat children for all responses
(Table B.2). In addition, characteristics
of internist rheumatologists involved
in the care of children were compared
with those who did not treat children.
Pediatric rheumatologists spent significantly
more time than internist rheumatologists
in teaching and research and less time
in-patient care. Compared to internist
rheumatologists who did not treat children,
internist rheumatologists who treated
children spent significantly more time
in patient care and less in research.
Pediatric rheumatologists were, as expected,
significantly more likely to spend most
of the practice time caring for children.
Of those internist rheumatologists involved
in the care of children, the overwhelming
majority reported that children comprise
less than 10 percent of their patient
care time.
Pediatric rheumatologists were younger
than internist rheumatologists and more
likely to be women. Internist rheumatologists
who treated children were slightly more
likely to be men, however, than those
who did not treat children. Internist
rheumatologists who treated children were
more likely to be white and less likely
to be Asian than those who did not treat
children.
Table
E.2. Provider and Practice Characteristics
by Provider Type, Arthritis Foundation/American
College of Rheumatology Survey
|
Pediatric
Rheumatologists
(N=111) |
Internist
rheumatologists who treat children
(N=289) |
Internist
rheumatologists who do not treat
children
(N=234) |
Hours
per week spent in: |
Patient
care |
26.1*** |
34.3### |
27.0 |
Research |
13.4** |
6.4## |
10.0 |
Teaching |
6.2** |
4.5 |
4.6 |
Other
activities |
5.5 |
5.1 |
5.1 |
|
Percent
of time caring for children:
|
None
(%) |
1.0*** |
- |
100.0 |
Less
than 10% (%) |
1.9 |
86.4 |
- |
10%-50%
(%) |
9.3 |
7.5 |
- |
51%-90%
(%) |
11.1 |
1.8 |
- |
More
than 90% (%) |
76.9 |
4.3 |
- |
|
Age |
46.6* |
49.2 |
48.3 |
Male
(%) |
47.6*** |
76.0 |
68.5 |
Hispanic
(%) |
6.0 |
3.3# |
7.3 |
Race:
|
American
Indian (%) |
2.9* |
0.7* |
0.0 |
Asian
(%) |
7.8 |
8.6 |
16.1 |
African
American (%) |
0.0 |
1.1 |
1.8 |
White
(%) |
89.2 |
89.6 |
82.1 |
*
p<.05, ** p<0.01, *** p<0.001
comparison of pediatric rheumatologists
to all internist rheumatologists;
#
p<.05 ## p<0.01,
### p<0.001 comparison
of internist rheumatologists who
do and do not see kids
Significance
results are derived from Pearson
χ2 for categorical
variables or two-sided, two-sample
t-test of mean differences for continuous
variables |
Characteristics
of Pediatric Rheumatologists
Nearly 90 percent of responding pediatric
rheumatologists worked in an academic
setting or teaching hospital (Table B.3).
These providers received the majority
of their referrals from pediatricians
(61.7 percent); other physician specialties
contributed far less to referrals. Almost
two-thirds of responding pediatric rheumatologists
reported that the current wait time for
an appointment was greater than 2 weeks.
Table
E.3. Provider and Practice Characteristics:
Pediatric Rheumatologists Arthritis Foundation/American
College of Rheumatology Survey
|
N |
Percent |
Patients
and Insurance: |
Mean percentage of patients with
Medicaid/SCHIP |
|
32.5% |
Mean percentage of patients uninsured |
|
8.4% |
Primary
work setting: |
Academic/teaching
hospital |
92 |
89.3% |
Private
practice |
8 |
7.8% |
Other
setting |
3 |
2.9% |
Mean
wait time for a new patient:
|
Less
than 1 week |
7 |
6.8% |
1-2
weeks |
29 |
28.2% |
Greater
than 2 weeks |
67 |
65.1% |
Mean
percentage of referrals coming from:
|
Pediatricians |
-- |
61.7% |
Family
practitioners |
-- |
13.3% |
Internists |
-- |
3.0% |
Orthopedists |
-- |
10.9% |
Patient
self-referral |
-- |
4.6% |
Ophthalmologists |
-- |
3.3% |
Other
sources |
-- |
3.1% |
Has
a non-physician clinician in their
practice* |
47 |
45.6% |
Mean
percent of time non-physician clinicians
work with respondent |
|
54.0% |
Type:
|
Nurse
practitioner |
40 |
85.1% |
Physician’s
assistant |
3 |
6.4% |
Other
|
4 |
8.5% |
*Mean number of non-physician clinicians
per practice is 1.4.
About half of pediatric rheumatologists
used a non-physician clinician in their
practice; in most cases the non-physician
clinician was a nurse practitioner. Pediatric
rheumatologists with a non-physician clinician
in their practice spent about half of
their practice time working with this
person.
About one-third of pediatric rheumatologists
planed to decrease their time in clinical
care in the next 5 years, with 33.1 percent
the average planned decrease. The primary
reason for planning a decrease in time
was obtaining salary support from a research
source (45.5 percent); however, many also
report retirement (21.2 percent), salary
support from a business source (18.2 percent),
and other reasons (27.3 percent). Interestingly,
one-third of those who planned to decrease
their patient care time within the next
5 years also had reported already decreasing
their patient care time in the previous
5 years.
Just over one-fourth of pediatric rheumatologists
have decreased time in clinical care in
the preceding 5 years, with an average
reduction of 32.2 percent. The primary
reason reported was obtaining salary support
from a research source (39.3 percent).
Many providers also reported decreasing
their patient care time because another
pediatric rheumatologist joined their
practice (32.1 percent); they changed
employers or career (17.9 percent), or
other reasons (25.0 percent).
|