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The Current Landscape of US Pediatric Anesthesiologists: Demographic Characteristics and Geographic Distribution

Muffly, Matthew K. MD; Muffly, Tyler M. MD; Weterings, Robbie PhD; Singleton, Mark MD, FAAP; Honkanen, Anita MD, MS, FAAP

doi: 10.1213/ANE.0000000000001266
Pediatric Anesthesiology: Research Report
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BACKGROUND: There is no comprehensive database of pediatric anesthesiologists, their demographic characteristics, or geographic location in the United States.

METHODS: We endeavored to create a comprehensive database of pediatric anesthesiologists by merging individuals identified as US pediatric anesthesiologists by the American Board of Anesthesiology, National Provider Identifier registry, Healthgrades.com database, and the Society for Pediatric Anesthesia membership list as of November 5, 2015. Professorial rank was accessed via the Association of American Medical Colleges and other online sources. Descriptive statistics characterized pediatric anesthesiologists’ demographics. Pediatric anesthesiologists’ locations at the city and state level were geocoded and mapped with the use of ArcGIS Desktop 10.1 mapping software (Redlands, CA).

RESULTS: We identified 4048 pediatric anesthesiologists in the United States, which is approximately 8.8% of the physician anesthesiology workforce (n = 46,000). The median age of pediatric anesthesiologists was 49 years (interquartile range, 40–57 years), and the majority (56.4%) were men. Approximately two-thirds of identified pediatric anesthesiologists were subspecialty board certified in pediatric anesthesiology, and 33% of pediatric anesthesiologists had an identified academic affiliation. There is substantial heterogeneity in the geographic distribution of pediatric anesthesiologists by state and US Census Division with urban clustering.

CONCLUSIONS: This description of pediatric anesthesiologists’ demographic characteristics and geographic distribution fills an important gap in our understanding of pediatric anesthesia systems of care.

Published ahead of print April 5, 2016

From the *Stanford University Medical Center, Stanford, California; Denver Health Medical Center, Denver, Colorado; and Department of Natural Resources and Environment, Naresuan University, Phitsanulok, Thailand.

Accepted for publication January 22, 2016.

Published ahead of print April 5, 2016

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Matthew K. Muffly, MD, Stanford University Health Center, 300 Pasteur Dr. H3580, Stanford, CA 94305. Address e-mail to mmuffly@stanford.edu.

In 1997, the Accreditation Council for Graduate Medical Education (ACGME) recognized pediatric anesthesiology as a subspecialty within anesthesiology.1 Nearly 20 years later, there are 56 ACGME-accredited pediatric anesthesiology fellowship programs in the United States, with >230 yearly pediatric anesthesiology fellowship positions, and advanced second-year pediatric anesthesiology fellowships increasingly are required for academic positions.2,a In 2011, pediatric anesthesiology fellowship programs entered the National Resident Matching Program, and in 2013, the American Board of Anesthesiology (ABA) offered the first annual pediatric anesthesiology subspecialty written board examination.2,b,c

Perhaps as a result of the rapid growth and changes within this evolving subspecialty, there is no comprehensive list of pediatric anesthesiologists in the United States.3,d The American Medical Association Physician Masterfile does not identify anesthesiologists at this subspecialty level, and neither the Society for Pediatric Anesthesia (SPA) nor the American Academy of Pediatrics maintains a list of all pediatric anesthesiologists. Therefore, a useful understanding of pediatric anesthesiologists’ demographic characteristics and geographic locations has been elusive. Without accurate demographic and geographic distribution data, it is impossible to assess the geographic distribution of pediatric anesthesiologists relative to the pediatric population, to conduct pediatric anesthesia workforce analyses, or to make informed policy and training decisions. In addition, the American College of Surgeons’ (ACS) guidelines for the optimal care of pediatric surgical patients specify that pediatric anesthesiologists shall directly care for patients at advanced and comprehensive pediatric surgical centers for pediatric patients younger than 2 years old to meet its certification requirements.4,e The geographic availability of pediatric anesthesiologists to care for these patients, as defined by these new guidelines, currently is unknown.

To address this important knowledge gap, we sought to create a comprehensive database of pediatric anesthesiologists and define their demographic characteristics and geographic distributions in the United States. We then described the association between anesthesiologists’ demographic characteristics and geographic location with successful subspecialty board certification in pediatric anesthesia.

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METHODS

Pediatric Anesthesiologist Definition

A pediatric anesthesiologist is defined by the ABA as an individual, board certified in anesthesia by the ABA or equivalent, and board certified or eligible to be certified in the subspecialty of pediatric anesthesia by the ABA or equivalent organization.f Eligibility criteria for pediatric anesthesiology written board examination registration include one of the following: (1) satisfactory completion of an ACGME-accredited, 1-year pediatric anesthesiology fellowship or (2) the physician’s clinical practice must demonstrate a focus and current expertise in pediatrics either by having been devoted primarily to pediatric anesthesiology for the last 2 years or having ≥30% of the diplomate’s clinical practice averaged over the last 5 years devoted to pediatric anesthesiology, and the practice must include neonates and children younger than 2 years of age and undertake procedures considered high risk. Those meeting the second criteria had 3 years (2013–2015) to enter the certification process after which, although their practices of pediatric anesthesiology may continue without change, they will not have an opportunity to attain ABA certification as such.g

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Data Sources

A comprehensive database of US-based pediatric anesthesiologists was compiled by hand searching and merging pediatric anesthesiologists from 4 sources with the following information recorded from each database as of November 5, 2015: (1) ABA pediatric anesthesiology written board examination registrants,g name, geographic location (city and state), medical degree, and primary board and pediatric written board certification date; (2) National Provider Identifier (NPI) registry,h name, and geographic location (city and state); (3) Healthgrades database,i name, geographic location (city and state), demographic, and other information (age, sex, location of medical training, and medical degree); and (4) SPA physician membership list, name, and geographic location (city and state) (Fig. 1).

Figure 1

Figure 1

Eligibility requirements for the pediatric anesthesiology written board examination have been outlined previously in this paper. The assignment of a pediatric anesthesiology taxonomy code in the NPI database requires self-identification as a pediatric anesthesiologist. Active SPA members consist of physicians who have an interest in pediatric anesthesia and meet membership eligibility requirements of the American Society of Anesthesiologists. To minimize the effect of society membership fluctuation, we combined SPA membership lists from 2 consecutive years (October 2014 and November 2015). Finally, Healthgrades uses a proprietary algorithm to surface information from government, commercially available sources, and physicians themselves to identify physician specialty, demographic data, and geographic location.j The information used likely includes state medical licensing information, board certification, the American Medical Association Physician Masterfile data, NPI taxonomy, and other publicly available data.

An important subset of pediatric anesthesiologists includes those who completed residency training outside the United States, or osteopaths, both of whom may not participate in the ABA system. Individuals identified as pediatric anesthesiologists by the aforementioned methodology but not located in the ABA system were included in the database. Individuals located outside the United States or designated as military personnel were excluded from the database. We then cross-referenced the database with known pediatric anesthesiology departmental rosters from 6 major academic centers across the United States, consisting of approximately 400 pediatric anesthesiologists. This methodology identified >99% of department members. The relative contributions from each data source to the final database of pediatric anesthesiologists are shown in Figure 2.

Figure 2

Figure 2

The following demographic variables were recorded if available: age, sex, year of primary board certification in anesthesiology, location of medical training, medical degree, and academic affiliation. We defined international medical graduates as physicians who graduated from medical school outside the United States, without additional completion of medical school in the United States. Academic affiliation and professorial rank was retrieved from the Association of American Medical Colleges (AAMC) Faculty Roster provided by Faculty Roster representatives at the individual medical schools to establish academic status.k In October 2015, the AAMC Faculty Roster was no longer available, so we used online sources for individuals not identified via the AAMC Faculty Roster.

Pediatric anesthesiologists’ geographic practice locations at the city and state level were recorded and grouped by US region according to the 9 US Census Divisions.l In cases in which there was geographic discordance between NPI, SPA, Healthgrades, and ABA lists, online sources were used to confirm current practice location. Because sources allowed reporting of either home or work address, we assumed that anesthesiologists lived and worked in the same county for the purpose of this analysis.

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Statistical Considerations

Descriptive statistics captured pediatric anesthesiologists’ demographics. Statistical analysis was performed using JMP 11.0 (Cary, NC). Geographic mapping was performed using ArcGIS Desktop 10.1 mapping software (Redlands, CA). County and state boundaries were retrieved from DIVA-GIS (www.diva-gis.com). Addresses of pediatric anesthesiologists were geocoded to coordinates via use of the Bing Map API (Microsoft Corporation, Redmond, WA) and loaded into ArcGIS. The Stanford Hospital IRB designated this analysis as exempt from IRB review (Protocol #33830).

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RESULTS

Pediatric Anesthesiologist Demographics

Table 1

Table 1

Table 2

Table 2

We identified 4048 pediatric anesthesiologists in the United States, which was approximately 0.5% of the total physician workforce (n = 838,453) and 8.8% of the physician anesthesiologist workforce (n = 46,000).3,m,n Approximately two-thirds of pediatric anesthesiologists were subspecialty board certified in pediatric anesthesiology (BCPA). Pediatric anesthesiologists’ demographics for the total cohort and stratified by subspecialty board certification are detailed in Table 1. The median age of pediatric anesthesiologists was 49 years (interquartile range, 40–57 years), and 56.4% were men; however, women now comprise the majority of pediatric anesthesiologists 35 years and younger (Table 2). The rates of board certification in pediatric anesthesia were similar between men and women in each age group. The majority (54.7%) of pediatric anesthesiologists older than 55 years were not subspecialty BCPA; conversely, the majority (78.2%) of anesthesiologists age 45 years and younger were BCPA. One-third of pediatric anesthesiologists had an identified academic affiliation, which was associated with a greater likelihood of BCPA (73.9% vs 61.8%).

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Pediatric Anesthesiologist Geographic Distribution

Table 3

Table 3

Figure 3

Figure 3

The geographic location and distribution of pediatric anesthesiologists in the United States is displayed in Figure 3. There is substantial heterogeneity in the geographic distribution of pediatric anesthesiologists by US Census Division and state with urban clustering. The vast majority (>90%) of pediatric anesthesiologists worked in counties with a pediatric population >50,000. The numbers of pediatric anesthesiologists by state and US Census Division, stratified by subspecialty board certification, are shown in Table 3.

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DISCUSSION

Historically, there has been no comprehensive database of pediatric anesthesiologists in the United States. The reasons are multifactorial; the rapid growth in pediatric anesthesiology training programs and positions, the abundance of practicing pediatric anesthesiologists who completed training before the 1997 ACGME accreditation of pediatric anesthesia fellowships, nonmandatory SPA membership, and the ability to practice pediatric anesthesiology without subspecialty board certification all have contributed. This description of pediatric anesthesiologists’ demographic characteristics and geographic distribution in the United States fills an important gap in our understanding of the subspecialty.

The creation of this database is particularly timely. In March 2014, the ACS outlined recommendations for the optimal care of pediatric surgical patients to address a mismatch between individual patient needs and available clinical resources.4 Thereafter, a voluntary Children’s Surgery Verification Program was initiated that will designate as basic, advanced, and comprehensive, facilities where pediatric surgery is performed, and specify that pediatric anesthesiologists administer or directly oversee the anesthetic for patients younger than 2 years old at advanced and comprehensive centers.4 The American Society of Anesthesiologists raised concerns about the impact of these recommendations on the pediatric population’s access to care given a predictable shift of pediatric patients to pediatric referral centers from community hospitals.5 To assess the feasibility of implementing the ACS recommendations, we must understand the geographic distribution of pediatric anesthesiologists relative to the pediatric population. To effectively plan for future workforce needs, we must know the baseline number of pediatric anesthesiologists in the workforce and their demographic characteristics to predict workforce dynamics such as location preferences, work-hour choices, and retirement rates. Understanding the demographic characteristics and geographic distribution of pediatric anesthesiologists in the United States will help researchers, policymakers, and those directly involved in pediatric anesthesia care address these important issues.

Approximately two-thirds of identified pediatric anesthesiologists have successfully completed subspecialty board certification in pediatric anesthesia and those who did tended to be younger and in academic practice. These findings may reflect the growing recognition that subspecialty board certification increasingly is encouraged or required to secure hospital credentialing as a pediatric anesthesiologist and that academic departments may require pediatric anesthesiologists to obtain subspecialty certification. Individuals with shorter time frames until projected retirement may not have a strong incentive to pursue subspecialty board certification in pediatric anesthesiology.

The urban clustering seen with pediatric anesthesiologists is consistent with reports of other physician specialists and likely reflects the locations of underlying systems of care.6,7 Although pediatric anesthesiologists are an integral component of the surgical care of pediatric patients, they function as members of a complex team. The underlying cause of anesthesiologist urban clustering may be the predominantly urban location of systems that are required to care for pediatric patients. The presence of established systems for the care of pediatric patients is clearly an important determinant in a pediatric anesthesiologist’s practice location. The significance of urban clustering and paucity of anesthesiologists in certain areas require further investigation.

This study has potential limitations that must be considered. Identification of pediatric anesthesiologists by ABA pediatric anesthesiology examination registration, NPI database, SPA physician membership list, and Healthgrades database requires that the physician self-identify as a pediatric anesthesiologist; therefore, some pediatric anesthesiologists may not be included in the database. In addition, pediatric anesthesiologists’ practice characteristics were not assessed in this investigation and may vary substantially. Pediatric anesthesiologists practice part-time or full-time and encompass heterogeneous case mixes and may include a significant percentage of adult patients.8 Last, this is a dynamic cohort, influenced by recent fellowship graduates, retirees, deaths, name-changes, and geographic relocation, which will affect the accuracy of the database. Nevertheless, despite these potential limitations, we feel confident that this work is a significant step forward in our understanding of the pediatric anesthesiology workforce.

This description of pediatric anesthesiologists’ demographic characteristics and geographic distribution addresses an important knowledge gap and creates the foundation upon which future studies may address workforce issues facing anesthesiologists and the needs of the pediatric population.

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DISCLOSURES

Name: Matthew K. Muffly, MD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Matthew K. Muffly has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Name: Tyler M. Muffly, MD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Tyler M. Muffly has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Robbie Weterings, PhD.

Contribution: This author helped conduct the study, analyze the data, and write the manuscript.

Attestation: Robbie Weterings has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Mark Singleton, MD, FAAP.

Contribution: This author helped write the manuscript.

Attestation: Mark Singleton has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Anita Honkanen, MD, MS, FAAP.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Anita Honkanen has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

This manuscript was handled by: James A. DiNardo, MD.

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FOOTNOTES

a Accreditation Council on Graduate Medical Education website. Available at: https://apps.acgme.org/ads/Public/Reports/ReportRun?ReportId=1&CurrentYear=2015&SpecialtyId=4&IncludePreAccreditation=false. Accessed December 16, 2015.
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b National Resident Matching Program website. Available at: http://www.nrmp.org. Accessed November 5, 2015.
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c The American Board of Anesthesiology website. Available at: http://www.theaba.org. Accessed June 23, 2015.
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d Robertson C, Sharma A. Workforce Survey of Fellowship Program Directors. Abstract: Society for Pediatric Anesthesia Winter 2011.
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e Available at: https://www.facs.org/quality-programs/childrens-surgery-verification/standards. Accessed February 28, 2016.
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f The American Society of Anesthesiologists website. Available at: http://www.asahq.org/resources/publications/newsletter-articles/2015/march-2015/aba-pediatric-anesthesiology-certification. Accessed August 2, 2015.
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g Available at: Theaba.org.
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h Available at: https://nppes.cms.hhs.gov, pediatric anesthesiology taxonomy code: 207LP3000X.
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i Available at: Healthgrades.com.
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j Healthgrades website. Available at: https://update.healthgrades.com/frequently-asked-questions. Accessed December 1, 2014.
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k Association of American Medical Colleges Faculty Lookup website. Available at: https://apps.aamc.org/aamc-faculty-search/#/. Accessed June 23, 2015.
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l US Census Bureau website. Available at: https://www.census.gov/geo/reference/gtc/gtc_census_divreg.html. Accessed June 23, 2015.
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m US Census Bureau. Statistical Abstract of the United States: 2012. Table 165. Active Physicians and Nurses by State: 2009. Available at: http://www.census.gov/compendia/statab/2012/tables/12s0164.pdf.
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n American Medical Association: Physician Characteristics and Distribution in the US, 2015.
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