The Pediatric Nephrology Workforce Crisis: A Call to Action

Child Health Needs and the Pediatric Nephrology Subspecialty Workforce: 2020-2040

Pediatric nephrology is dedicated to caring for children with kidney disease, a unique blend of acute care and chronic longitudinal patient relationships. Though historically a small field, trainee interest has declined over the past 2 decades. This has led to growing alarm about the health of the pediatric nephrology workforce, although concerns have been hampered by a lack of available data to enable feasible projections. This article is part of a supplement that anticipates the future pediatric subspecialty workforce supply. It draws on existing literature, data from the American Board of Pediatrics, and findings from a model that estimates the future supply of pediatric subspecialists developed by the Carolina Health Workforce Research Center at the University of North Carolina Chapel Hill's Cecil G. Sheps Center for Health Services Research and Strategic Modeling Analytics & Planning Ltd. The workforce projections from 2020 to 2040 incorporate population growth, clinical effort, and geographic trends and model alternate scenarios adjusting for changes in trainee interest, clinical efforts, and workforce attrition. The baseline model predicts growth of clinical work equivalents by 26% by 2040, but further widening geographic disparities worsen the existing mismatch between supply, clinical need, and market demand. The worst-case scenario projects 13% growth by 2040 which, at best, maintains the status quo of an already strained workforce. The models do not account for many factors expected to heighten demand over the coming decades. Urgent reforms are necessary now. Proposed solutions require multipronged changes in education and training pathways, remuneration, clinical practice models, and government policy.

Forecasting the Future Supply of Pediatric Subspecialists in the United States: 2020-2040

Concerns persist about whether the United States has an adequate supply of pediatric subspecialists and whether they are appropriately distributed across the nation to meet children's health needs. This article describes the data and methods used to develop a workforce projection model that estimates the future supply of 14 pediatric subspecialities certified by the American Board of Pediatrics at the national and US census region and division levels from 2020 to 2040. The 14 subspecialties include adolescent medicine, pediatric cardiology, child abuse pediatrics, pediatric critical care medicine, developmental-behavioral pediatrics, pediatric emergency medicine, pediatric endocrinology, pediatric gastroenterology, pediatric hematology-oncology, pediatric infectious diseases, neonatal-perinatal medicine, pediatric nephrology, pediatric pulmonology, and pediatric rheumatology. Hospital medicine was excluded because of the lack of historical data needed for the model. This study addresses the limitations of prior models that grouped adult and pediatric physician subspecialty workforces together and aggregated pediatric subspecialties. The model projects supply at national and subnational levels while accounting for geographic moves that pediatric subspecialists make after training and during their career. Ten "what if" scenarios included in the model simulate the effect of changes in the number of fellows entering training, the rate at which subspecialists leave the workforce, and changes in hours worked in direct and indirect clinical care. All model projections and scenarios are available on a public, interactive Web site. The model's projections can also be examined with other data to provide insight into the possible future of the pediatric subspecialty workforce and offer data to inform decision-making.

Child Health and the US Pediatric Subspecialty Workforce: Planning for the Future

This article opens a multi-article Pediatrics supplement that provides a rigorous analysis of the projected pediatric subspecialty workforce in the United States. Congenital variations, epigenetics, exposures, lifestyle, preventive care, and medical interventions from conception through young adulthood set the stage for health and wellbeing in adulthood. Although care provided by pediatric subspecialists is associated with better outcomes and lower costs compared with adult providers, the authors of recent articles in the lay and medical literature have questioned the capacity of pediatric subspecialists to meet children's health care needs. This article highlights that, despite numerous advances in prevention, diagnosis, and treatment, the last decade has witnessed increasing numbers of children with acute or chronic physical and mental health disorders, including medical complexity, obesity, type 2 diabetes, anxiety, depression, and suicidality, all of which are exacerbated by poverty, racism, and other social drivers of health. In this article, we then describe the variability in the demographics, practice characteristics, and geographic distribution of the 15 core pediatric subspecialties certified by the American Board of Pediatrics. We then discuss the rationale and approach to the development of a pediatric subspecialty workforce model that forecasts subspecialist supply from 2020 to 2040 for 14 subspecialties at the national and subnational levels (not including the newest subspecialty, pediatric hospital medicine), accounting for US Census Bureau child population projections. The model does not account for the unique physical and mental needs of individual children, nor does it address the increasingly precarious commitment to, and financing of, pediatric subspecialty care in the US health care system impacting market demand.

Safety and timeliness of telemedicine initiation of continuous kidney replacement therapy

BACKGROUND

During the COVID-19 pandemic, some continuous kidney replacement therapy (CKRT) initiations were transitioned to telemedicine to improve the timeliness of initiation, and minimize COVID-19 transmission. While telemedicine would appear acceptable for many clinical settings, safety and timeliness of telemedicine CKRT initiation is undescribed.

METHODS

We conducted a single-center retrospective cohort study of pediatric patients on CKRT from January 2021-September 2022. Information on patient characteristics and CKRT therapy was extracted from the electronic health record. Multidisciplinary team provider attitudes and perspectives were assessed using survey.

RESULTS

During the study period, there were 101 CKRT circuit initiations in patients not previously receiving CKRT, with 33% (33/101) initiated by telemedicine. There were no differences in patient characteristics, including age, weight at initiation, severity of illness, nor degree of fluid overload between the in-person and telemedicine initiation cohorts. CKRT telemedicine initiations were timelier, occurring on average 3.0 h after decision to initiate therapy compared to 5.8 h for all in-person CKRT starts (p < 0.001) and 5.5 h for night and weekend in-person starts (p < 0.001). Complications did not differ between telemedicine and in-person starts (15% vs. 15%, p = 0.99) and initial circuit life was similar. There were no differences in likelihood of death or duration of CKRT therapy. Telemedicine initiations were widely acceptable to multidisciplinary providers.

CONCLUSION

In appropriately selected patients, telemedicine initiation of CKRT is a timely and safe option. Further standardization of telemedicine initiation of CKRT should be considered to improve the timely delivery of CKRT and may improve nephrology workforce wellness. A higher resolution version of the Graphical abstract is available as Supplementary information.

Association Between Dialysis Facility Ownership and Mortality Risk in Children With Kidney Failure

Importance

In adults, treatment at profit dialysis facilities has been associated with a higher risk of death.

Objective

To determine whether profit status of dialysis facilities is associated with the risk of death in children with kidney failure treated with dialysis and whether any such association is mediated by differences in access to transplant.

Design, Setting, and Participants

This retrospective cohort study reviewed US Renal Data System records of 15 359 children who began receiving dialysis for kidney failure between January 1, 2000, and December 31, 2019, in US dialysis facilities. The data analysis was performed between May 2, 2022, and June 15, 2023.

Exposure

Time-updated profit status of dialysis facilities.

Main Outcomes and Measures

Adjusted Fine-Gray models were used to determine the association of time-updated profit status of dialysis facilities with risk of death, treating kidney transplant as a competing risk. Cox proportional hazards regression models were also used to determine time-updated profit status with risk of death regardless of transplant status.

Results

The final cohort included 8465 boys (55.3%) and 6832 girls (44.7%) (median [IQR] age, 12 [3-15] years). During a median follow-up of 1.4 (IQR, 0.6-2.7) years, with censoring at transplant, the incidence of death was higher at profit vs nonprofit facilities (7.03 vs 4.06 per 100 person-years, respectively). Children treated at profit facilities had a 2.07-fold (95% CI, 1.83-2.35) higher risk of death compared with children at nonprofit facilities in adjusted analyses accounting for the competing risk of transplant. When follow-up was extended regardless of transplant status, the risk of death remained higher for children treated in profit facilities (hazard ratio, 1.47; 95% CI, 1.35-1.61). Lower access to transplant in profit facilities mediated 67% of the association between facility profit status and risk of death (95% CI, 45%-100%).

Conclusions and Relevance

Given the higher risk of death associated with profit dialysis facilities that is partially mediated by lower access to transplant, the study's findings indicate a need to identify root causes and targeted interventions that can improve mortality outcomes for children treated in these facilities.

Evaluating Kidney Function Decline in Children with Chronic Kidney Disease Using a Multi-Institutional Electronic Health Record Database

BACKGROUND

The objectives of this study were to use electronic health record data from a US national multicenter pediatric network to identify a large cohort of children with CKD, evaluate CKD progression, and examine clinical risk factors for kidney function decline.

METHODS

This retrospective cohort study identified children seen between January 1, 2009, to February 28, 2022. Data were from six pediatric health systems in PEDSnet. We identified children aged 18 months to 18 years who met criteria for CKD: two eGFR values <90 and ≥15 ml/min per 1.73 m2 separated by ≥90 days without an intervening value ≥90. CKD progression was defined as a composite outcome: eGFR <15 ml/min per 1.73 m2, ≥50% eGFR decline, long-term dialysis, or kidney transplant. Subcohorts were defined based on CKD etiology: glomerular, nonglomerular, or malignancy. We assessed the association of hypertension (≥2 visits with hypertension diagnosis code) and proteinuria (≥1 urinalysis with ≥1+ protein) within 2 years of cohort entrance on the composite outcome.

RESULTS

Among 7,148,875 children, we identified 11,240 (15.7 per 10,000) with CKD (median age 11 years, 50% female). The median follow-up was 5.1 (interquartile range 2.8-8.3) years, the median initial eGFR was 75.3 (interquartile range 61-83) ml/min per 1.73 m2, 37% had proteinuria, and 35% had hypertension. The following were associated with CKD progression: lower eGFR category (adjusted hazard ratio [aHR] 1.44 [95% confidence interval (95% CI), 1.23 to 1.69], aHR 2.38 [95% CI, 2.02 to 2.79], aHR 5.75 [95% CI, 5.05 to 6.55] for eGFR 45-59 ml/min per 1.73 m2, 30-44 ml/min per 1.73 m2, 15-29 ml/min per 1.73 m2 at cohort entrance, respectively, when compared with eGFR 60-89 ml/min per 1.73 m2), glomerular disease (aHR 2.01 [95% CI, 1.78 to 2.28]), malignancy (aHR 1.79 [95% CI, 1.52 to 2.11]), proteinuria (aHR 2.23 [95% CI, 1.89 to 2.62]), hypertension (aHR 1.49 [95% CI, 1.22 to 1.82]), proteinuria and hypertension together (aHR 3.98 [95% CI, 3.40 to 4.68]), count of complex chronic comorbidities (aHR 1.07 [95% CI, 1.05 to 1.10] per additional comorbid body system), male sex (aHR 1.16 [95% CI, 1.05 to 1.28]), and younger age at cohort entrance (aHR 0.95 [95% CI, 0.94 to 0.96] per year older).

CONCLUSIONS

In large-scale real-world data for children with CKD, disease etiology, albuminuria, hypertension, age, male sex, lower eGFR, and greater medical complexity at start of follow-up were associated with more rapid decline in kidney function.

Psychosocial supports within pediatric nephrology practices: A pediatric nephrology research consortium survey

BACKGROUND

The landscape of available psychosocial services within pediatric nephrology care is poorly characterized. However, the effects of kidney disease on emotional health and health-related quality of life are well documented, as is the impact of social determinants of health on kidney disease outcomes. The objectives of this study were to assess pediatric nephrologists' perceptions of available psychosocial services and to elucidate inequities in access to psychosocial care.

METHODS

A web-based survey was distributed to members of the Pediatric Nephrology Research Consortium (PNRC). Quantitative analyses were performed.

RESULTS

We received responses from 49 of the 90 PNRC centers. With regards to dedicated services, social work was most commonly available (45.5-100%), followed by pediatric psychology (0-57.1%) and neuropsychology (0-14.3%), with no centers having embedded psychiatry. Availability of psychosocial providers was positively associated with nephrology division size, such that as center size increased, access to various psychosocial providers increased. Notably, the majority of respondents indicated that perceived need for psychosocial support exceeds that which is currently available, even at centers with higher levels of current support.

CONCLUSIONS

Within the US, there is wide variability in the availability of psychosocial services within pediatric nephrology centers despite a well-documented necessity for the provision of holistic care. Much work remains to better understand the variation in funding for psychosocial services and in utilization of psychosocial professionals in the pediatric nephrology clinic, and to inform key best practices for addressing the psychosocial needs of patients with kidney disease.

Association Between Dialysis Facility Ownership and Access to the Waiting List and Transplant in Pediatric Patients With End-stage Kidney Disease in the US

IMPORTANCE

Care of adults at profit vs nonprofit dialysis facilities has been associated with lower access to transplant. Whether profit status is associated with transplant access for pediatric patients with end-stage kidney disease is unknown.

OBJECTIVE

To determine whether profit status of dialysis facilities is associated with placement on the kidney transplant waiting list or receipt of kidney transplant among pediatric patients receiving maintenance dialysis.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study reviewed the US Renal Data System records of 13 333 patients younger than 18 years who started dialysis from 2000 through 2018 in US dialysis facilities (followed up through June 30, 2019).

EXPOSURES

Time-updated profit status of dialysis facilities.

MAIN OUTCOMES AND MEASURES

Cox models, adjusted for clinical and demographic factors, were used to examine time to wait-listing and receipt of kidney transplant by profit status of dialysis facilities.

RESULTS

A total of 13 333 pediatric patients who started receiving maintenance dialysis were included in the analysis (median age, 12 years [IQR, 3-15 years]; 6054 females [45%]; 3321 non-Hispanic Black patients [25%]; 3695 Hispanic patients [28%]). During a median follow-up of 0.87 years (IQR, 0.39-1.85 years), the incidence of wait-listing was lower at profit facilities than at nonprofit facilities, 36.2 vs 49.8 per 100 person-years, respectively (absolute risk difference, -13.6 (95% CI, -15.4 to -11.8 per 100 person-years; adjusted hazard ratio [HR] for wait-listing at profit vs nonprofit facilities, 0.79; 95% CI, 0.75-0.83). During a median follow-up of 1.52 years (IQR, 0.75-2.87 years), the incidence of kidney transplant (living or deceased donor) was also lower at profit facilities than at nonprofit facilities, 21.5 vs 31.3 per 100 person-years, respectively; absolute risk difference, -9.8 (95% CI, -10.9 to -8.6 per 100 person-years) adjusted HR for kidney transplant at profit vs nonprofit facilities, 0.71 (95% CI, 0.67-0.74).

CONCLUSIONS AND RELEVANCE

Among a cohort of pediatric patients receiving dialysis in the US from 2000 through 2018, profit facility status was associated with longer time to wait-listing and longer time to kidney transplant.

Burnout Syndrome among Pediatric Nephrologists—Report on Its Prevalence, Severity, and Predisposing Factors

Background and Objectives: Burnout is an occupation-related syndrome comprising emotional exhaustion, depersonalization, and reduced feelings of work-related personal accomplishments. There are reports on burnout among adult nephrologists and general pediatricians, but little is known about burnout among pediatric nephrologists. The aim of our study was to assess the prevalence and severity of burnout syndrome among Polish pediatric nephrologists. Materials and Methods: A 25-item study survey consisting of abbreviated Maslach Burnout Inventory and additional self-created questions about work-related factors was completed by 97 physicians affiliated with the Polish Society of Pediatric Nephrology. Women comprised 75.3%, with median time of professional experience in the study group was 15 years. Results: A high level of emotional exhaustion, depersonalization, and reduced feeling of personal accomplishments were observed in 39.2%, 38.1%, and 21.6% of the participants, respectively. At least a medium level of burnout in all three dimensions were observed in 26.8% of the participants and 8.2% of them presented high three-dimensional burnout. About 41.2% of the participants stated that they would like to take part in burnout prevention and support programs. According to the study participants, excessive bureaucracy in healthcare systems, rush at work, and overtime work were the main job-related problems that could influence burnout intensity. Conclusions: Burnout is an important factor in the professional landscape of pediatric nephrology. Actions aimed at reducing the risk of occupational burnout among pediatric nephrologists should be applied, both at the personal and institutional levels.

Improving the identification of acute kidney injury in the neonatal ICU: three centers' experiences

OBJECTIVE

To describe three different standardized approaches to improving neonatal acute kidney injury (AKI) identification and the impact on AKI identification, incidence, and nephrology consultation and referral.

STUDY DESIGN

A retrospective cohort study in three academic NICUs. We compared AKI identification, AKI incidence, nephrology consultation, and nephrology follow-up before and after implantation of local protocols to standardize neonatal AKI identification.

RESULT

Neonatal AKI identification improved in all three NICUs following protocol implementation (26-85%, P < 0.0001). Each center also saw increases in nephrology consultation (15-83%, P < 0.0001) and nephrology follow-up (7-73%, P < 0.0001). AKI incidence decreased significantly (21-12%, P < 0.0001).

CONCLUSION

Multiple strategies can be successfully operationalized to improve neonatal AKI identification. While different in approach, each strategy resulted in increased AKI identification and nephrology involvement. This study emphasizes the importance of local standardized approaches to AKI to improve AKI identification and nephrology involvement in the NICU.

Addressing Gender-Based Disparities in Earning Potential in Academic Medicine

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.

Seeking justice, equity, diversity and inclusion in pediatric nephrology

Inequity, racism, and health care disparities negatively impact the well-being of children with kidney disease. This review defines social determinants of health and describes how they impact pediatric nephrology care; outlines the specific impact of systemic biases and racism on chronic kidney disease care and transplant outcomes; characterizes and critiques the diversity of the current pediatric nephrology workforce; and aims to provide strategies to acknowledge and dismantle bias, address barriers to care, improve diversity in recruitment, and strengthen the pediatric nephrology community. By recognizing historical and current realities and limitations, we can move forward with strategies to address racism and bias in our field and clinical practices, thereby cultivating inclusive training and practice environments.