Practice Characteristics of Board-certified Pediatric Anesthesiologists in the US: A Nationwide Survey

Introduction We conducted a survey to describe the practice characteristics of anesthesiologists who have passed the American Board of Anesthesiology (ABA) Pediatric Anesthesiology Certification Examination. Methods In July 2017, a list of anesthesiologists who had taken the ABA Pediatric Anesthesiology Certification Examination (hereafter referred to as "pediatric anesthesiologists") was obtained from the American Board of Anesthesiologists (theaba.org). Email contact information for these individuals was collected from departmental rosters, email distribution lists, hospital or anesthesia group profiles, manuscript author contact information, website source code, and other publicly available online sources. The survey was designed using Qualtrics (Qualtrics, Provo, Utah; Seattle, Washington), a web-based tool, to ascertain residency/fellowship training history and current practice characteristics that includes: years in practice, clinical work hours per week, primary hospital setting, practice type, supervision model, estimated percentage of cases by patient age group, and percentage of respondents who cared for any patient undergoing a fellowship-level index cases within the previous year. The invitation to complete the survey included a financial incentive - the chance to win one of twenty $50 Amazon gift cards. Results There were 3,492 anesthesiologists who had taken the Pediatric Anesthesiology Certification Examination since 2013. Surveys were sent to those whom an email address was identified (2,681) and 962 complete survey responses were received (35.9%, 962/2,681). Over 80% (785) of respondents completed a pediatric anesthesiology fellowship. Of these, 485 respondents (50.4%) work in academic practice, 212 (22.0%) in private practice, 233 (24.2%) in private practice and have academic affiliations, and 32 (3.3%) as locum tenens or in other practice settings. The majority of respondents (64.3%) in academic practice work in freestanding children’s hospitals. Pediatric anesthesiologists in academic practice and private practice with academic affiliations reported caring for a greater number of younger children and doing a wider variety of index cases than respondents in private practice. Conclusion The extent to which pediatric anesthesiologists care for pediatric patients - particularly young children and those undergoing complex cases - varies. The variability in practice characteristics is likely a result of differences in hospital type, anesthesia practice type, geographic location, and other factors.


Methods
In July 2017, a list of anesthesiologists who had taken the ABA Pediatric Anesthesiology Certification Examination (hereafter referred to as "pediatric anesthesiologists") was obtained from the American Board of Anesthesiologists (theaba.org). Email contact information for these individuals was collected from departmental rosters, email distribution lists, hospital or anesthesia group profiles, manuscript author contact information, website source code, and other publicly available online sources. The survey was designed using Qualtrics (Qualtrics, Provo, Utah; Seattle, Washington), a web-based tool, to ascertain residency/fellowship training history and current practice characteristics that includes: years in practice, clinical work hours per week, primary hospital setting, practice type, supervision model, estimated percentage of cases by patient age group, and percentage of respondents who cared for any patient undergoing a fellowship-level index cases within the previous year. The invitation to complete the survey included a financial incentive -the chance to win one of twenty $50 Amazon gift cards.

Results
There were 3,492 anesthesiologists who had taken the Pediatric Anesthesiology Certification Examination since 2013. Surveys were sent to those whom an email address was identified (2,681) and 962 complete survey responses were received (35.9%, 962/2,681). Over 80% (785) of respondents completed a pediatric anesthesiology fellowship. Of these, 485 respondents (50.4%) work in academic practice, 212 (22.0%) in private practice, 233 (24.2%) in private practice and have academic affiliations, and 32 (3.3%) as locum tenens or in other practice settings. The majority of respondents (64.3%) in academic practice work in freestanding children's hospitals. Pediatric anesthesiologists in academic practice and private practice with academic affiliations reported caring for a greater number of younger children and doing a wider variety of index cases than respondents in private practice.

Introduction
The field of pediatric anesthesiology has evolved and grown substantially since it became an American College for Graduate Medical Education (ACGME) approved fellowship in 1997 [1]. In 2011, the pediatric anesthesia fellowship entered the National Residency Matching Program (NRMP); the American Board of Anesthesiology (ABA) began offering the Pediatric Anesthesiology Certification Examination in 2013.
Until recently, no comprehensive list of pediatric anesthesiologists in the United States (US) existed. In 2015, our group created the first database of pediatric anesthesiologist demographic characteristics and geographic locations in the US [2]. Despite the improved understanding of pediatric anesthesiologist geographic location and demographics, the practice characteristics of pediatric anesthesiologists in the US remain largely unknown.
Understanding practice characteristics of pediatric anesthesiologists -the anesthesia practice types and hospital settings in which they work, categories of patients they care for, and for what types of procedures -are necessary for a better understanding of the spectrum of anesthesia care provided to pediatric patients in the US and is relevant for workforce planning, fellowship education, and outcome research. Therefore, we conducted a survey of the practice characteristics of anesthesiologists who passed the ABA Pediatric Anesthesiology Certification Examination.

Materials And Methods
In July 2017, a list of anesthesiologists who registered for the ABA Pediatric Anesthesiology Certification Examination was obtained at "theaba.org" using the "Advanced Search" function. From October to December 2017, email contact information for these individuals was collected from departmental rosters, email distribution lists, hospital or anesthesia group profiles, manuscript author contact information, website source code, and other publicly available online sources.
The Stanford University Administrative Panel on Human Subjects in Medical Research waived the requirement for written informed consent and approved the study.

Survey design
The survey instrument was designed and distributed using Qualtrics (Qualtrics, Provo, Utah; Seattle, Washington), a web-based tool for creating and conducting online surveys. Survey questions were designed to determine residency/fellowship training history and current practice characteristics including years in practice, clinical work hours per week, primary hospital setting, practice type, supervision model, estimated percentage of cases by patient age group, and percentage of respondents who cared for any patient undergoing a fellowship-level index cases within the previous year. Fellowship-level index cases are an indicator of complex pediatric anesthesia care and include airway surgery (excluding tonsillectomy and adenoidectomy), cardiac surgery with cardiopulmonary bypass, cardiac surgery without cardiopulmonary bypass, craniofacial surgery, intra-abdominal/intracavitary surgery, intracranial neurosurgery, intrathoracic non-cardiac surgery, major orthopaedic surgery, neonatal emergency surgery, and solid organ transplant [3].
Anesthesiologist sex was imported from an existing database. The years in practice was estimated based on the time of primary board certification in anesthesia until the survey date. Survey responses were retained for those who fully completed the demographics and practice characteristics sections of the survey. Respondents and non-respondents who registered for the ABA Pediatric Anesthesiology Certification Examination but did not subsequently pass were excluded from the analysis as to include only anesthesiologists with ABA Pediatric Anesthesiology Certification.
The survey was first distributed to 20 members of the authors' department and revised based on their suggestions for clarity and for improvement. In January 2018, the revised survey was emailed to all pediatric anesthesiologists whose email address had been identified (Supplement 1). The invitation to complete the survey included a financial incentive -the chance to win one of twenty $50 Amazon gift cards.
Two reminders were sent to survey non-respondents within the next 30 days. The survey was closed six weeks after the initial email.

Results
There were 3,492 anesthesiologists who had taken or were registered for the ABA Pediatric Anesthesiology Certification Examination in July, 2017. Surveys were sent to 2,681 individuals whose emails were identified; 962 (35.9% of those emailed) complete survey responses were received ( Figure 1).

FIGURE 1: Flow Diagram of Study Participants
Years in practice, sex, geographic location, and training characteristics are reported in Table 1. Over 80% (785) of respondents completed a pediatric anesthesiology fellowship. Sixty-nine respondents (7%) reported completing an advanced second-year fellowship, mostly in pediatric cardiac anesthesia.

Respondents
Non-Respondents  Pediatric anesthesiologists in academic practice reported working fewer clinical hours than those in private practice or in a private practice with an academic affiliation. The majority of pediatric anesthesiologists (64%) in academic practice work in a freestanding children's hospital at least 50% of the time, whereas only 17% of those in private practice, and 47% of those in private practice with an academic affiliation do the same. The majority of anesthesiologists in academic practice supervise residents (96.7%), fellows (80.8%), certified registered nurse anesthetists (CRNAs; 86.6%), and non-anesthesia trainees (58.6%) whereas the majority in private practice supervise CRNAs only ( Table 2). More than 20% of anesthesiologists in academic practice supervise certified anesthesiology assistants.  Pediatric anesthesiologists in academic practice indicated that the majority of their patients were five years old or younger (52.7%) versus 33.2% for those in private practice, and 45.3% for those in private practice with an academic affiliation. All practice characteristics, stratified by anesthesia practice type, are shown in Table 2.

Discussion
The results of this survey illustrate the practice characteristics of anesthesiologists who successfully completed the ABA Pediatric Anesthesia Certification. An understanding of their practice characteristics is important for workforce planning, fellowship education, outcome research, and optimizing the care of children.
The results of this survey suggest that, in general, respondents in academic practice or private practice with academic affiliations care for a higher percentage of younger patients as well for as patients undergoing a wider variety of fellow-level index cases, than those in private practice. Over 90% of all respondents, regardless of practice type, reported caring for patients undergoing at least one index-level case type in the past year. On the other hand, nearly one in 10 respondents in private practice (or one in 20 respondents in academic practice or academic practice with an academic affiliation) reported caring for no patients undergoing an index case within the preceding year.
This issue is particularly timely, given the potential effect of the American College of Surgeon's Children's Surgery Verification Quality Improvement Program on the distribution of pediatric surgery in the US. It is possible that with regionalization of pediatric surgical procedures, the number of pediatric cases per pediatric anesthesiologist at non-tertiary care children's hospitals will decrease. This raises questions about how anesthesiologists will maintain clinical competency given a potential reduction in the number of children undergoing care in the community hospital setting.
There are certain limitations that should be considered when interpreting the results of this survey. The survey describes the practice characteristics of anesthesiologists who passed the ABA Pediatric Anesthesiology Certification Examination; the respondents may be biased toward the academic end of the practice spectrum, where certification is often required. In addition, there are many anesthesiologists who did not take the ABA Pediatric Anesthesiology Certification Examination who nevertheless care for children routinely. Anesthesiologists who trained before the advent of time-limited anesthesiology subspecialty boards hold board certifications that include all subspecialties. The survey misses a large number of legitimately qualified practitioners who hold "board certified" status in the field of anesthesiologyinclusive of pediatric anesthesiology. In addition, the survey response rate was low (35.9%), thus raising the possibility of bias in the results. Although respondents and non-respondents appeared similar in terms of sex, years in practice, and geographic location, they may differ in unobservable ways, thus potentially limiting the generalizability of the results. Nevertheless, this survey gives us an improved understanding of the practice characteristics of those pediatric anesthesiologists with ABA Pediatric Anesthesiology Certification.

Conclusions
The practice characteristics of pediatric anesthesiologists are now better understood. The extent to which pediatric anesthesiologists care for pediatric patients -particularly young children and those undergoing complex cases -varies. The variability in practice characteristics is likely a result of differences in hospital type, anesthesia practice type, geographic location, and other factors.

Appendices
Practice Characteristics of Board-Certified Pediatric Anesthesiologists