Periodic Survey: Cross-survey Results and Findings

The American Academy of Pediatrics (AAP) presents cross-survey results and findings from the Periodic Survey.

Pediatrician Characteristics

Assessing Trends in Practice Demographics of Underrepresented Minority Pediatricians, 1993–2007

William T. Basco, Jr, William L. Cull, Karen G. O'Connor, Scott A. Shipman

Objective: To assess whether underrepresented minority (URM) pediatricians serve minority and/or publicly insured or uninsured children to a greater degree than non-URM pediatricians, and to evaluate trends in these relationships.

Participants and Methods: Respondents to American Academy of Pediatrics surveys in 1993, 2000, and 2007, provided their race/ethnicity, practice locations, and estimated race/ethnicity and insurance sources of their patient panels. We classified pediatricians by race/ethnicity as either URM (black, Hispanic, Hawaiian/Pacific Islander, or American Indian/Alaskan Native) or non-URM (white, non-Hispanic/Latino, Asian, or other). We compared the average percentages of minority individuals (excluding Asians) in the patient panels of URM and non-URM pediatricians, and compared the average percentages of publicly insured (includes TRICARE) or uninsured patients.

Results: Response rates were >50% for all surveys. There were 1003 (10.2% URM) postresidency respondents in 1993, 707 (11.8% URM) in 2000, and 900 (11.1% URM) in 2007. In all 3 surveys, the average percentage of minority children in URM pediatricians' patient panels was higher than for non-URM pediatricians by approximately 20 percentage points (all P < .001). The differences in the percentages of patients who were either publicly insured or uninsured widened over the study period, from 46% in URM pediatric practices versus 38.8% in non-URM practices in 1993 to 59.7% vs 40.7%, respectively, in 2007 (P < .001). In multivariable analyses, URM pediatricians' patient panels had a higher mean percentage of minorities (15.2 percentage points greater; 95% confidence interval [CI]: 12.1–18.4) and a higher mean percentage of publicly insured and uninsured patients (10.9 percentage points greater; 95% CI: 6.7–15.4) compared with non-URM pediatricians' patient panels.

Conclusions: Over the last 14 years, URM pediatricians were more likely than their non-URM peers to care for minority children and publicly insured or uninsured patients. This relationship has not appeared to attenuate over time, and these data support ongoing and enhanced efforts to recruit qualified URMs into pediatric careers to meet the growing needs of the expanding minority child population.

Minority Pediatricians More Likely to Care for Minorities, Uninsured

Minority pediatricians are more likely than other pediatricians to care for minority children. They also are more likely to care for children who are uninsured or on public insurance, according to AAP Periodic Surveys conducted in 1993, 2000 and 2007.

The results of this study were published in the March issue of Pediatrics.

Pediatricians who reported that their racial/ethnic background was black/ African-American, Hispanic/Latino, Hawaiian/ Pacific Islander or American Indian/Alaskan Native were classified as minority pediatricians. White, non-Hispanic Latino and Asian pediatricians were not included in the minority group.

The overall percentage of minority pediatricians observed was mostly flat across this 15-year period, with 10% minority pediatricians in 1993, 12% in 2000 and 11% in 2007. When pooled across survey years (see figure), African-American and Hispanic pediatricians were more likely to care for minority children than were white or Asian pediatricians.

In 2007, minority pediatricians reported that 57% of their patients were from minority groups whereas nonminority pediatricians reported 37%. Minority pediatricians also reported that 60% of their patients were uninsured or on public insurance in 2007 compared to 41% among nonminority pediatricians.

William T. Basco Jr., M.D., FAAP, and colleagues concluded that these results support ongoing and enhanced efforts to recruit qualified minority pediatricians into pediatric careers to meet the growing needs of the expanding minority child population.

Data for this study were collected via Periodic Surveys of Fellows conducted in 1993, 2000 and 2007. Surveys were mailed to random samples of roughly 1,600 AAP members, and analyses were limited to nonretired, post-trainee pediatricians. Across the three years, survey response rates were 71%, 52%, and 56%, respectively.

Part-time Work Among Pediatricians Expands

William L. Cull, Karen G. O'Connor, Lynn M. Olson

Objective: The objective of this study was to track trends in part-time employment among pediatricians from 2000 to 2006 and to examine differences within subgroups of pediatricians.

Methods: As part of the Periodic Survey of Fellows, national random samples of American Academy of Pediatrics members were surveyed in 2000, 2003, and 2006. These surveys shared questions concerning working part-time and other practice characteristics. Roughly 1600 pediatricians were included in each random sample. Totals of 812 (51%), 1020 (63%), and 1013 (62%) pediatricians completed the surveys in 2000, 2003, and 2006, respectively. Analyses were limited to nonretired, posttrainee pediatricians.

Results: The number of pediatricians who reported that they work part-time increased from 15% in 2000, to 20% in 2003, to 23% in 2006. The pattern of increased part-time work from 2000 to 2006 held for many subgroups, including men, women, pediatricians who were younger than 40 years, pediatricians who were aged ≥50 years, pediatricians who worked in an urban inner city, pediatricians who worked in suburban areas, general pediatricians, and subspecialist pediatricians. Those who were working part-time were more satisfied within their professional and personal activities. Part-time pediatricians worked on average 14.3 fewer hours per week in direct patient care.

Conclusions: Increases in part-time work are apparent throughout pediatrics. The possible continued growth of part-time is an important trend within the field of pediatrics that will need to be monitored.

Trends in Hours Worked Among US Primary Care Pediatricians 1993 to 2016: Age, Gender and Practice Type

Lynn Olson¹, Elizabeth A. Gottschlich¹, Blake Sisk¹, William L. Cull¹.

¹Research, American Academy of Pediatrics, Elk Grove Village, IL.

Presented at the 2017 Pediatric Academic Societies Annual Meeting.

Background: In pediatrics the interest in greater work-life balance and growth in part-time work has been documented, but less understood are the broader trends in hours worked.

Objective: Assess the trends in hours worked among US primary care pediatricians and variation by age, gender and type of practice.

Methods: Cross-sectional data were pooled from 71 Periodic Surveys of American Academy of Pediatrics US members conducted from 1993 to 2016 (response rates ranged from 39%-76%). The analysis excluded residents, fellowship trainees, and retired members, and was limited to respondents practicing > 60% time in primary care, n = 32,600. Hours worked was based on a survey item consistently used across years that asked pediatricians to self-report the hours they spend on all professional activities in a typical work week. Results were clustered in 3-year intervals. Linear regression was used to examine trends for the total sample and subgroups by age (30s, 40s, 50s, 60s & older), gender, and practice type (solo/two person, group practice, hospital/clinic).

Results: Overall, the average weekly work hours reported by pediatricians dropped from 49.9 to 43.0 between 1993-95 and 2014-16, a 13.8% decline. The decline in work hours occurred primarily before 2008 (Figure). Decreases were found for men [dropping from 54.2 to 47.6 hours, coefficient (B) = -.32, p<.001] and women [44.1 to 40.8 hours, B = -.15, p<.001]. By age group, the largest proportional decline in hours was among those in their 40s at the time of the survey (50.8 to 41.5 hours) and the smallest among those in their 60s (47.1 to 43.9 hours). However, the decline was significant across all ages [30s: B = -.34, p<.001; 40s: B = -.44, p<.001; 50s B = -.34, p<.001; > 60s B = -.16, p<.001] and for pediatricians in solo/2-person [53.4 to 48.3 hours, B = -.27, p<.001], group practice [49.5 to 41.9 hours, B = -.35, p<.001], or hospital/clinic settings [46.3 to 43.2 hours, B = -.16, p<.001].

Conclusion: From 1993-95 to 2014-16 the average hours worked among pediatricians in primary care declined significantly, averaging a reduction of 6.9 hours per week. The downward trend was found for men and women and across age groups and practice type. Since 2008, coincident with the economic downturn, the decline in hours worked attenuated. The trends in pediatrician work hours and the relationship to workforce issues and physician work-life balance will need ongoing monitoring.

Trends in Hours Worked in General Pediatrics 1993 to 2010: Age, Gender and Practice Type

Lynn Olson¹, Karen O'Connor¹, Alicia Merline¹ and William Cull¹

¹American Academy of Pediatrics, Elk Grove Village, United States.   

Presented at the April 2012 Pediatric Academic Societies Annual Meeting

Background: In general pediatrics, the growing interest in greater work-life balance and part-time work has been documented, but relatively little attention has been given to the broader trends in hours worked.

  Objective: Assess the trends in hours worked among general pediatricians and variation by age, gender and type of practice.  

Design/Methods: Cross-sectional data from 58 Periodic Surveys of AAP members conducted from 1993 to 2010 were pooled (response rates: 46%-76%). The analysis excluded residents and retired members, and was limited to respondents practicing > 60% time in primary care, n = 27,618. Hours worked was based on self-report of time in a typical week spent on all professional activities and clustered in 3-year intervals. Linear regression was used to examine trends for the total sample and subgroups by age (30s, 40s, 50s, 60s & older), gender, and practice type (solo/two person, group, hospital/clinic).  

Results: Overall, respondents' reported hours worked dropped from 49.6 to 43.3 hrs/week between 1993-96 and 2008-10. The largest proportional drop was among those in their 40s (50.5 to 42.4 hrs) and the smallest among those in their 60s (47.0 to 45.1 hrs). However, the decline was significant across all ages [30s: coefficient (B) = -.49, p<.001; 40s: B = -.54, p<.001; 50s B = -.39, p<.001; > 60 B = -.13, p<.05.] Decreases were found for men [54.0 to 48 hrs, B = -.38, p<.001] and women [43.7 to 40.1 hrs, B = -.24, p<.001], for pediatricians in solo/2-person [53.2 to 49.0 hrs, B = -.34, p<.001], group [49.3 to 42.0 hrs, B = -.46, p<.001], or hospital/clinic settings [46.8 to 43.5 hrs, B = -.22, p<.001], and those reporting they work full-time [56.6 to 46.5 hrs, B = -.66, p<.001].

Conclusions: Over 17 years the hours worked by the average general pediatrician declined 13%. While pediatricians still work many hours, there has been a clear shift toward more work-life balance across age, gender and practice types. This important trend and its relationship to workforce issues will need ongoing monitoring.

Trends in Practice Characteristics: Analyses of 19 Periodic Surveys (1987–1992) of Fellows of the American Academy of Pediatrics

Sarah E. Brotherton, Suk-fong S. Tang, Karen G. O'Connor

Objective: To examine 6 years of practice characteristics data of Fellows of the American Academy of Pediatrics (AAP), focusing on sex differences for specialty area, primary activity, practice setting, and practice location.

Methods: We analyzed data from 19 Periodic Surveys that were fielded between 1987 and 1992. The Periodic Survey is used to survey AAP members regularly about current issues in pediatric practice. There are no duplicate respondents in these analyses of the first 19 Periodic Surveys. We collapsed the 19 surveys into the years in which they were fielded, and analyzed sex differences for each of the 6 years. In addition, we ran logistic regressions on several questions, including all 16 868 respondents, to examine how the characteristics of the specialty have been affected by the increase in the number of female pediatricians, controlling for survey year, age of respondents, and specialty area practiced.

Results: The proportion of nonresident AAP members who are female has grown throughout the 6 years; in 1987, 26.9% were female, and in 1992, 36.4% were female. For 5 of the 6 years there were sex differences in specialty area, usually concerning pediatric subspecialties. Substantial sex differences occurred in primary activity, in which each year women were more likely than men to be salaried. Men were more often in group practices, whereas women were generally more likely to practice in hospitals or clinics. Logistic regression demonstrated that there are sex differences in practice characteristics across time, but there is also a substantial change in practice characteristics accountable to survey year, eg, a pediatrician of either sex was 75% more likely to be salaried in 1992 than in 1987.

Conclusions: Throughout the 6-year period, AAP members became increasingly more likely to practice general pediatrics, to be salaried, and to be younger—all effects independent of sex, all effects stronger for females. Rapid transformations in the health care system will likely reduce current sex differences in practice characteristics of the future.

Periodic Survey

AAP Periodic Survey Marks its Own Milestone: A 20th Anniversary

Alyson Sulaski Wyckoff

Pediatricians interested in what their colleagues think and do on an array of topics can turn to the storehouse of data compiled by the AAP Periodic Survey of Fellows, now marking its 20th anniversary.

Sixty-six surveys, on topics from circumcision to counseling about firearm safety, have been completed over the past two decades and helped illuminate opinions and experiences of U.S. pediatricians. The results document the issues of the day and provide information the Academy uses to evaluate and enhance programs as well as shape policy.

Two decades of data

Each Periodic Survey measures how a nationally representative sample of pediatricians renders treatment, how they operate their practices or what they think about current child health issues.

Respondents have expressed their views on issues from formula advertising to adolescent access to abortion. Some topics, such as immunization practices or experience with medical liability, are highlighted regularly and their results compared over time. The Academy tries not to replicate main topics within five years.

Survey results have been published on at least 20 occasions in peer-reviewed journals (including Pediatrics, Injury Prevention, Ambulatory Pediatrics and Health Services Research) and have formed the basis of more than 40 presentations at conferences and policy forums worldwide.

“The Academy's commitment to obtain continual feedback from members on emergent topics in practice helps provide an evidence-based approach to our decision-making and program planning, “said John S. Curran, M.D., FAAP, chair of AAP District X and the advisory committee to the AAP Board on Research. “And we are most grateful to our members for their time in completing these surveys.”

Some of the projects resulting from the surveys include:

Bright Futures Health Promotion/Prevention Education Center;
Pediatrics Collaborative Care (PedsCare) Program;
The Injury Prevention Program (TIPP); and
The National Center for Medical Home Initiatives for Children with Special Needs.

Ongoing programs that benefit from Periodic Surveys address immunization, obesity prevention and mental health.

With the Periodic Survey in existence for 20 years, pediatrics also has“ unique data to track trends in how the profession evolves,” Dr. Curran said. There has been substantial growth in part-time employment, for example, and an increase in the number of pediatricians who are salaried employees.

Survey data are used by AAP members, child health researchers and other pediatric leaders. In 1997, Susan S. Aronson, M.D., FAAP, a former AAP board member (1994-'00) and an authority on child care, used results from the Periodic Survey to show early childhood educators that 73% of pediatrician-respondents reported that they routinely used child care and preschool reports as a screening tool to help identify children with a developmental disability.

Genesis of a Periodic Survey

Potential topics for new surveys generally emanate from AAP committees or sections, which are required to submit a detailed form outlining the proposed topic, questions, how the data will be used, other collaborating groups within the Academy and additional background.

Once a survey topic is approved, state-of-the-art methods are used to ensure reliability and accuracy. Each self-administered questionnaire of eight pages or less goes out to a random sample of about 1,600 members. Up to five follow-up contacts are made, and response rates range from 55% to 64%, consistent within the industry.

The timeline for a typical survey is 12 to 13 months from approval to analysis. Each year, about three surveys are conducted, with up to two additional surveys supported by some outside funding (agencies have included the Centers for Disease Control and Prevention and the Maternal and Child Health Bureau, as well as university research groups).

Over the years, the layout of the surveys has changed slightly. Open-ended questions are kept to a minimum because many respondents don't complete them or, if they do, the writing often is not legible. Still, many of the questions include an “other—specify” question to allow for comments.

A logo debuted with Periodic Survey #41, and the Web page was added in recent years.

Results create attention

Occasionally, survey results can be surprising. A 1996 survey (#31) about opinions on legalization of drugs showed members were divided on legal status of marijuana, and 74% of respondents said legal prohibitions on possession or use of marijuana by adults should be less restrictive. When responses were analyzed by age and gender, pediatricians who were older (and male) tended to favor more decriminalization or legalization.

A survey on breastfeeding practices conducted in 1995 and published in 1999 (#30) revealed that while a majority of respondents recommended breastfeeding, a distinct proportion did not do so along AAP guidelines. Most pediatricians responding at that time said breastfeeding and formula-feeding were equally acceptable methods of feeding infants. Further, the reasons indicated for not recommending breastfeeding included medical conditions that generally do not preclude breastfeeding.

The survey found that the vast majority of respondents wanted more instructional opportunities; the results may have helped to confirm the need for a breastfeeding entity within the Academy. A work group on breastfeeding organized in 1996 was followed by a task force; a section was established in 2000.

Find results online

The Periodic Survey Web page (www.aap.org/research/periodicsurvey/psof.htm) is a repository of these survey topics and findings. Enter a key-word to search “bicycle helmets,” for example, and view all the results; or scroll to browse all surveys, with the most recent ones at the top.

Identified by the Periodic Survey (PS) number, each entry on the Web page provides title, years when the survey was conducted or “fielded,” executive summary and a link to publications (including AAP News). Topics also are cross-referenced for comparison.

Demographic data on personal and practice characteristics are updated annually and also can be found on the page (click on View Practice Characteristics).

Additional surveys in the works address attitudes and practices regarding patient communication and health literacy, pediatric subspecialty referral patterns, and oral health assessment.

Find on Gateway

Taking Stock: 20 Years of the Periodic Survey

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Response Rate and Response Bias

Effect of Monetary and Charity Incentives on Survey Response Rates Among Pediatricians

Karen G. O'Connor, Sanford Sharp, William L. Cull, Lynn M. Olson. Department of Research, American Academy of Pediatrics, Elk Grove Village, IL.

Presented at the 2008 Pediatric Academic Societies Annual Meeting.

Background: Physician response to mailed surveys has declined in recent years. Studies on the effectiveness of various methods to increase response have varying results. While use of a modest monetary incentive has proven effective in increasing response to mailed surveys of pediatricians, little is known about the effect of an offer of charity contribution.

Objective: To measure the effects of two methods of increasing response to surveys of pediatricians: use of an up-front monetary incentive and a promised contribution to a charity.

Design/Methods: A randomized, experimental design was incorporated into 3 AAP Periodic Surveys in 2007 (N=1605 each); 535 pediatricians in each survey were assigned to either the monetary incentive group, charity contribution group, or the control group. Incentives (either a 2-dollar bill in the survey packet, or an offer to donate $3.00 to a choice of AAP programs for every completed survey) were included only in the first of seven waves. The 3 surveys covered a range of topics: (1) Health Literacy/Subspecialty Referrals, (2) Sexual Violence Prevention, (3) Medical Liability Experiences.

Results: For all surveys, the response from the $2 incentive group was significantly higher than that of the charity contribution and the control group. The final response rates for the combined surveys were 60% for the $2 bill, 52% for the charity contribution and 55% for the control group (60% vs 52%, p<.001; 60% vs 55%, p<.01). The difference in response is primarily the result of the first wave (35% $2 vs 23% charity, p<.001; 35% $2 vs 24% control, p<.001); for each group, rates dropped steeply after the first wave. There was no significant difference in response (overall or by wave) between the charity contribution group and the control group. The benefit of the $2 bill was consistent across survey topics. For each survey, the $2 group had a higher response rate than the other groups combined, and was significantly higher for 2 of the 3 surveys (survey #1: 59% $2 vs 55% others, p=.07; #2: 59% vs 51%, p<.01; #3: 62% vs 55%, p<.01).

Conclusions: Irrespective of survey content, inclusion of a $2 bill as a token of appreciation in the first round mailing of surveys to pediatricians had a positive effect, while offering a charity incentive had no effect. Use of a modest monetary incentive can significantly increase survey response rates.

Response Rates and Response Bias for 50 Surveys of Pediatricians

Cull WL¹, O'Connor KG, Sharp S, Tang SF.

Research Objective: To track response rates across time for surveys of pediatricians, to explore whether response bias is present for these surveys, and to examine whether response bias increases with lower response rates.

Data Source/Study Setting: A total of 63,473 cases were gathered from 50 different surveys of pediatricians conducted by the American Academy of Pediatrics (AAP) since 1994. Thirty-one surveys targeted active U.S. members of the AAP, six targeted pediatric residents, and the remaining 13 targeted AAP-member and nonmember pediatric subspecialists. Information for the full target samples, including nonrespondents, was collected using administrative databases of the AAP and the American Board of Pediatrics.

Study Design: To assess bias for each survey, age, gender, location, and AAP membership type were compared for respondents and the full target sample. Correlational analyses were conducted to examine whether surveys with lower response rates had increasing levels of response bias.

Principal Findings: Response rates to the 50 surveys examined declined significantly across survey years (1994-2002). Response rates ranged from 52 to 81 percent with an average of 68 percent. Comparisons between respondents and the full target samples showed the respondent group to be younger, to have more females, and to have less specialty-fellow members. Response bias was not apparent for pediatricians' geographical location. The average response bias, however, was fairly small for all factors: age (0.45 years younger), gender (1.4 percentage points more females), and membership type (1.1 percentage points fewer specialty-fellow members). Gender response bias was found to be inversely associated with survey response rates (r=-0.38). Even for the surveys with the lowest response rates, amount of response bias never exceeded 5 percentage points for gender, 3 years for age, or 3 percent for membership type.

Conclusions: While response biases favoring women, young physicians, and nonspecialty-fellow members were found across the 52-81 percent response rates examined in this study, the amount of bias was minimal for these factors that could be tested. At least for surveys of pediatricians, more attention should be devoted by investigators to assessments of response bias rather than relying on response rates as a proxy of response bias.

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