A Cross-Sectional Study of Factors Associated With Pediatric Scope of Care in Family Medicine

Anuradha Jetty; Max J. Romano; Yalda Jabbarpour; Stephen Petterson; Andrew Bazemore

doi:10.3122/jabfm.2021.01.200300

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Figure 1.
Study flow diagram showing the analysis sample: American Board of Family Medicine (ABFM) Certification examination practice demographic questionnaire data (2017 to 2018). Lack of exact match between the National Provider Identifier (NPI) and physician’s identification number from the American Medical Association (AMA) because some physicians do not have an NPI or may have changed last name (n = 1477).
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Figure 2.
A, Factors associated with family physicians’ provision of care to children (≤ 18 years): ABFM certification examination demographic questionnaire data (2017 to 2018) (n = 11,674). B, Factors associated with family physicians’ provision of care to children (< 5 years and 5 to 18 years): ABFM certification examination demographic questionnaire data (2017 to 2018) (n = 11,674). Adjusted odds ratios from multivariate logistic regression examining association between demographic and practice characteristics of family physicians and likelihood of providing care to children under 18 years of age (A), under 5 years of age and 5 to 18 years of age (B). ABFM, American Board of Family Medicine; HMO, health maintenance organization; IMG, international medical graduate; USMG, United States medical graduate; MD, doctor of medicine; NH, non-Hispanic; ER/OP, emergency room or outpatient facility; FPL, federal poverty level.
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Figure 3.
Percentage of family physicians registering for the ABFM certification examination who report caring for children under the age of 18 years, 2017 to 2018.

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Table 1.

Demographic Characteristics of Family Physicians Providing Care to Children (n = 11,674): American Board of Family Medicine Certification Examination Practice Demographic Questionnaire Data (2017 to 2018)

Characteristics	Demographics		Care of Children
	Demographics		≤ 18 Years		P-Value	< 5 Years		P-Value	5 to 18 Years		P-Value
	n	%	n	%	P-Value	n	%	P-Value	n	%	P-Value
Gender
Female	5094	43.6	4183	82.1	< .001	3341	65.6	< .001	4174	81.9	< .001
Male	6580	56.4	5561	84.5		4527	68.8		5553	84.4
Age in years
< 39	1419	12.1	1233	86.9	< .001	1056	74.4	< .001	1232	86.8	< .001
40 to 49	4314	37.0	3632	84.2		2939	68.1		3624	84.0
50 to 59	3936	33.7	3260	82.8		2606	66.2		3255	82.7
60+	2005	17.2	1619	80.7		1267	63.2		1616	80.6
Location of medical school
International medical graduate	1200	10.3	936	78.0	< .001	694	59.0	< .001	934	77.8	< .001
United States medical graduate	10,474	89.7	8808	84.1		7174	69.2		8793	84.0
Type of medical degree
Osteopath	1146	9.8	997	87.0	< .001	813	70.9	.006	996	86.9	< .001
MD	10,528	90.2	8747	83.1		7055	67.0		8731	82.9
Race/ethnicity
Non-Hispanic, White	8296	71.1	7102	85.6	< .001	5944	71.6	< .001	7093	85.5	< .001
Non-Hispanic, Black	547	4.7	439	80.3		310	56.7		437	79.9
Asian	1605	13.7	1250	77.9		881	54.9		1246	77.6
Non-Hispanic, Other	532	4.6	431	81.0		332	62.4		430	80.8
Hispanic	694	5.9	522	75.2		401	57.8		521	75.1

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Table 2.

Characteristics of Practice and Geographic Areas Served by Family Physicians Providing Care to Children (n=11,674): American Board of Family Medicine Certification Examination Practice Demographic Questionnaire Data (2017-2018)

Characteristics	Practice & Geographic Characteristics		Care of Children
	Practice & Geographic Characteristics		≤ 18 Years			Under 5 Years			5 to 18 years
	n	%	n	%	P-Value	n	%	P-Value	n	%	P-Value
Census region
South	3799	32.5	3052	80.3	< .001	2202	58.0	< .001	3047	80.2	< .001
Northeast	1699	14.6	1400	82.4		1140	67.1		1400	82.4
West	3089	26.5	2547	82.5		2032	65.8		2540	82.2
Midwest	3087	26.5	2745	88.9		2494	80.8		2740	88.8
Practice size
Solo	1421	12.2	1154	81.2	< .001	790	55.6	< .001	1152	81.1	< .001
Small	3962	33.9	3374	85.2		2708	68.3		3370	85.1
Medium	3647	31.2	3131	85.9		2691	73.8		3125	85.7
Large	2644	22.7	2085	78.9		1679	63.5		2080	78.7
Practice organization*
Independently owned	3910	33.5	3473	88.8	< .001	2710	69.3	< .001	3471	88.8	< .001
Safety-net	1175	10.1	999	85.0		879	74.8		997	84.9
Health Maintenance Organization	678	5.8	484	71.4		328	48.4		483	71.2
Academic	701	6.0	607	86.6		536	76.5		604	86.2
Hospital-owned	4137	35.4	3698	89.4		3097	74.9		3691	89.2
Other	1073	9.2	483	45.0		318	29.6		481	44.8
Rurality of location
Rural	1963	16.8	1779	90.6	< .001	1612	82.1	< .001	1777	90.5	< .001
Urban	9711	83.2	7965	82.0		6256	64.4		7950	81.9
Language of care delivery
English	8012	68.6	6676	83.3	.534	5449	68.0	.038	6668	83.2	.672
Other Language	3662	31.4	3068	83.8		2419	66.1		3059	83.5
Poverty status
Percent population earning < 200% of federal poverty Level (top quintile)	2252	19.3	1886	83.7	.690	1523	67.6	.795	1881	83.5	.773
Percent census tract population < 18 years
Tertile I (0.01-22.3)	3871	19.4		80.8	< .001		62.5	< .001		80.6	< .001
Tertile II (22.3-25.1)	3890	23.7		84.5			70.2			84.4
Tertile III (25.1-42.0)	3913	27.8		85.0			69.7			84.9
Pediatricians per 3000 children
Quintile IA (0)	1298			82.2	< .001		77.3	< .001		82.1	< .001
Quintile IB (0.09-0.73)	1467			74.6			64.3			74.4
Quintile II (0.73-1.38)	2767			73.4			60.2			73.3
Quintile III (1.38-2.07)	2763			70.7			56.3			70.6
Quintile IV (2.07-3.32)	2767			70.6			54.1			70.4
Quintile V (3.33 to 59.8)	2763			65.5			48.1			65.3
Year of recertification
2017	6220	53.3	5243	53.8	.010	4249	54	.024	5237	53.8	.007
2018	5454	46.7	4501	46.2		3619	46		4490	46.2

↵* Practice organizations were collapsed into 6 categories from 11 responses on the survey. The “independently owned” category included respondents selecting “independently owned medical practice.” The “safety-net” category included federally qualified health centers or look-alikes; rural health clinics (federally qualified); Indian Health Service; and governmental non-federal clinics such as the state, county, city, maternal and child health and public health centers. The “managed care/HMO, health maintenance organization” category included managed care or HMO-owned clinics. The “academic” category included academic medical centers and faculty practices. The “hospital ER/OP, emergency room or outpatient facility” included all hospital or health system-owned medical practices, which excludes managed care or HMOs. The “other” category included federal (military, Veterans Administration/Department of Defense), workplace clinics, and other practice types not listed.

Appendix Table 1: Factors Associated with Family Physicians Provision of Care to Children

Characteristics	Care of Children
Characteristics	< 5 Years, OR (95% CI)	5 to 18 Years, OR (95% CI)	≤ 18 Years, OR (95% CI)
Gender
Male
Female	0.92* (0.84-1.00)	0.95 (0.85-1.06)	0.95 (0.85-1.06)
Age (years)
< 39
40 to 49	0.80^‡ (0.69-0.92)	0.84* (0.70-1.02)	0.85 (0.71-1.03)
50 to 59	0.66^‡ (0.57-0.77)	0.73^‡ (0.60-0.88)	0.73^‡ (0.60-0.89)
60 or over	0.52^‡ (0.44-0.62)	0.56^‡ (0.45-0.70)	0.58^‡ (0.46-0.70)
Location of medical school
USMG
IMG	0.73^‡ (0.63-0.83)	0.74^‡ (0.63- 0.88)	0.74^‡ (0.63-0.87)
Type of medical degree
MD
Osteopath	0.97 (0.83-1.12)	1.16 (0.95-1.41)	1.16 (0.95-1.41)
Race/ethnicity
Non-Hispanic, White
Non-Hispanic, Black	0.74^‡ (0.61-0.90)	0.97 (0.76-1.24)	0.99 (0.77-1.26)
Asian	0.53^‡ (0.47-0.61)	0.64^‡ (0.55-0.75)	0.65^‡ (0.55-0.76)
Non-Hispanic, other	0.69^‡ (0.569-0.849)	0.75^† (0.58-0.96)	0.75^† (0.58-0.96)
Hispanic	0.60^‡ (0.50-0.73)	0.51^‡ (0.41-0.63)	0.50^‡ (0.40-0.62)
Census region
South
Northeast	1.57^‡ (1.37-1.80)	1.09 (0.92-1.29)	1.08 (0.91-1.28)
West	1.65^‡ (1.47-1.85)	1.37^‡ (1.18-1.58)	1.38^‡ (1.19-1.60)
Midwest	2.52^‡ (2.23-2.85)	1.52^‡ (1.31-1.78)	1.54^‡ (1.32-1.80)

Practice size
Solo
Small (2 to 5 providers)	1.67^‡ (1.45-1.93)	1.48^‡ (1.23-1.77)	1.47^‡ (1.22-1.77)
Medium (6 to 20 providers)	2.36^‡ (2.02-2.75)	1.81^‡ (1.49-2.20)	1.81^‡ (1.49-2.20)
Large (> 20 providers)	1.72^‡ (1.46-2.02)	1.28^† (1.04-1.56)	1.27^† (1.04-1.56)
Rural
Urban	1.60^‡ (1.38-1.85)	1.39^‡ (1.15-1.67)	1.38^‡ (1.15-1.67)
Speaks second language
No, speaks English
Yes, Spanish/other	1.33^‡ (1.20-1.48)	1.43^‡ (1.25-1.63)	1.45^‡ (1.27-1.65)
Practice organization
Independently owned
Safety-net	0.80^‡ (0.68-0.95)	0.47^‡ (0.38-0.58)	0.48^‡ (0.39-0.59)
HMO	0.38^‡ (0.31-0.46)	0.30^‡ (0.24-0.38)	0.30^‡ (0.24-0.38)
Academic	1.320^‡ (1.07-1.62)	0.81 (0.62-1.04)	0.83 (0.64-1.08)
Hospital owned	0.91 (0.82-1.02)	0.82^† (0.70-0.96)	0.83^† (0.71-0.97)
Other	0.16^‡ (0.14-0.19)	0.096^‡ (0.08-0.11)	0.096^‡ (0.081-0.11)
Poverty status of the PCSA of practice location
Percent population < 200% FPL (top quintile)	0.96 (0.86-1.08)	0.94 (0.82-1.09)	0.95 (0.83-1.10)
Percent population < 18 years
Tertile I
Tertile II	1.31^‡ (1.18-1.4)	1.087 (0.951-1.241)	1.082 (0.947-1.237)
Tertile III	1.36^‡ (1.21-1.52)	1.14* (0.99-1.32)	1.14* (0.99-1.31)
Pediatrician density per 3000 children
Quintile IA
Quintile IB	0.53^‡ (0.42-0.68)	0.57^‡ (0.41-0.79)	0.57^‡ (0.41-0.79)
Quintile II	0.42^‡ (0.34-0.53)	0.51^‡ (0.38-0.69)	0.512^‡ (0.38-0.69)
Quintile III	0.36^‡ (0.29-0.45)	0.45^‡ (0.34-0.605)	0.44^‡ (0.33-0.60)
Quintile IV	0.34^‡ (0.27-0.42)	0.42^‡ (0.31-0.57)	0.42^‡ (0.31-0.56)
Quintile V	0.26^‡ (0.21-0.32)	0.29^‡ (0.21-0.39)	0.29^‡ (0.21-0.39)

2017
2018	0.92* (0.85-1.01)	0.88^† (0.79-0.98)	0.89^† (0.80-0.99)

Constant	3.62^‡ (2.70-4.84)	15.80^‡ (10.78-23.15)	15.73^‡ (10.72-23.11)
Observations	11,674	11,674	11,674

OR, Odds Ratio; CI, Confidence Interval; MD; Doctor of Medicine; IMG, International Medical Graduate; USMG, United States Medical Graduate; HMO, Health Maintenance Organization; PCSA, Primary Care Service Area; FPL, Federal Poverty Level.
Source: 2017 and 2018 American Board of Family Physician Recertification Examination Application Survey.
↵* P < .1.
↵† P < .05.
↵‡ P < .01.