1218 ARTHRITIS & RHEUMATISM Vol. 39, No. 7, July 1996. pp 1218-1221 0 1996. American College of Rheumatology

PEDIATRIC RHEUMATOLOGY IN ADULT RHEUMATOLOGY PRACTICES IN WASHINGTON STATE

DAVID D. SHERRY, CAROL A. WALLACE, and STUART J. KAHN

Objective. To determine both the extent to which adult rheumatologists treat children and their level of comfort in doing so.

Methods. A questionnaire was sent to all 77 physicians in the state of Washington who were listed as adult rheumatologists in the American College of Rheu- matology (ACR) directory.

Results. Sixty-six questionnaires (86%) were re- turned; 50 were identified as being from private- practicing adult rheumatologists and were the focus of this study. Sixty-two percent of the respondents re- ported that they care for children; predictors included increased exposure to pediatric rheumatology during fellowship (P = 0.003), increased distance from Seattle (P = 0.001), and listing oneself in the ACR directory as treating children (P = 0.03). Most respondents reported feeling discomfort in treating children younger than 6 years of age, treating Kawasaki disease, and treating polyarteritis nodosa, but most reported feeling comfort- able treating children with chronic arthritides. Impedi- ments to referring to a pediatric rheumatologist in- cluded distance (median distance 35 miles), convenience for the family, personal preference, and experience in caring for children. Twenty-nine percent reported diffi- culties referring to a pediatric rheumatologist outside of one’s managed care plan. Adult rheumatologists ex- pressed interest in continuing medical education deal- ing with pediatric rheumatology, preferably with a lec- ture format in their home communities.

Conclusion. A significant number of adult rheu- matologists care for children. Pediatric rheumatologists

Presented in part at the American College of Rheumatology 23rd Western Region Scientific Meeting, Seattle, WA. March 17-19, 1995.

David D. Sherry, MD, Carol A. Wallace, MD, Stuart J. Kahn, MD: University of Washington, Seattle.

Address reprint requests to David D. Sherry, MD, Director, Pediatric Rheumatology CH-73, Children’s Hospital and Medical Center, 4800 Sand Point Way NE, Seattle, WA 98105.

Submitted for publication July 12, 1995; accepted in revised form February 20, 1996.

should provide both educational and consultative sup- port for these adult rheumatologist colleagues.

Over the last 30 years, pediatric rheumatology has evolved from a small group of internists and pedia- tricians interested in childhood rheumatic diseases to a board-certified subspecialty. However, not every com- munity or medical school has access to a pediatric rheumatologist, and since many pediatric rheumatic diseases overlap with adult rheumatic diseases, many children are cared for by adult rheumatologists (1-5). This care may include consultation with staff at a re- gional pediatric rheumatology center. As managed care programs increase, adult rheumatologists may refer chil- dren less frequently to a pediatric rheumatologist (6).

There is little information on the amount of pediatric rheumatology performed by adult rheumatolo- gists. Four reports on outpatient adult rheumatology practices included information on treatment of children, with the youngest patient being 6 years old (1-4). A report detailing private-practice inpatient rheumatology consultations did not mention children (7).

We conducted the present study to determine the extent of care delivered by adult rheumatologists in our state to children, the factors that influence the adult rheumatologist to care for children, and the level of comfort the adult rheumatologist has when caring for children with various rheumatic conditions. Finally, we assessed the interest of adult rheumatologists in continu- ing medical education (CME) regarding pediatric rheu- matology .

METHODS

The 1994 American College of Rheumatology (ACR) membership directory (8) was used to identify physicians in the state of Washington who belonged to the ACR and listed themselves as an internist or adult rheumatologist. Question- naires were sent to each of these individuals, with a followup postcard if a reply was not received within 3-4 weeks. Ques- tions on the form addressed demographic data, pediatric

PEDIATRIC RHEUMATOLOGY IN ADULT PRACTICES 1219

Table 1. whose questionnaires were included in the study

Characteristics of the 50 practicing adult rheumatologists

Those who do Those who not care for care for

children children (n = 19) (n = 31)

Practice type Private-practice rheumatology Health maintenance organization

Private-practice internal medicine Military rheumatology Practice limited to the foot

rheumatology

Full-time practice Part-time practice

Listing in American College of Rheumatology directory

Internal medicine Adult rheumatology Adult and pediatric rheumatology

Male Female Not answered

Personal data

Mean age Mean years out of training Mean miles from Seattle

Pediatric rheumatology experience during fellowship

None Minimal Moderate Extensive

Ideal amount of pediatric rheumatology during fellowship

Minimal (introduction only) Moderate Extensive Not answered

13 27 3 2

2 0 I 1 0 1

15 24 3 7

1 1 17 18 1 12

1s 23 3 7 1 1

48 46 1s 14 21 101

0 3 12 12 3 19 I 0

7 5 10 24 0 2 1 0

rheumatology training, subsequent experience, interest in con- tinuing medical education (with responses on a 3-point or 4-point ranked scale) age groups of pediatric patients cared for (divided into 6 subsets) and individual pediatric diagnoses along with a response to indicate comfort level in treating this age or diagnosis, sources of referral (by checklist), and ranking of factors (if any) that limited referral to a pediatric rheuma- tologist. Questionnaires were coded to maintain anonymity.

All terms of degree on ranked responses (,i.e., minimal, moderate, or extensive) were defined by the individual respon- dent. Children were defined as individuals younger than 16 years old.

The results were tabulated, and statistical analyses were performed using chi-square analysis or Student’s t-test.

RESULTS A total of 77 physicians were identified; 66 (86%)

returned the questionnaires. We eliminated from this

analysis those who were not in a position to evaluate children, including 3 who returned blank questionnaires, 3 who were from the Veterans Administration Medical Center, 3 who were retired, and 7 who were university physicians (there is a longstanding pediatric rheumatol- ogy center associated with the university, and therefore, adult rheumatologists there do not accept children into their practices). Table 1 shows the characteristics of the remaining 50 physicians. Thirty-one (62%) reported that their patients included children. Twenty adult rheuma- tologists had an age policy stating that they would see patients of all ages; 16 reported that they only cared for adult patients.

Three predictors identified rheumatologists who took care of children: more experience in pediatric rheumatology during fellowship (P = 0.003 by chi- square analysis), practicing farther from a pediatric rheumatology center (mean -+ SD 101 -+ 110 miles, range 0-289 miles, versus mean -+ SD 21 2 51 miles, range 0-212 miles; P = 0.001 by Student’s t-test), and being listed in the ACR directory as seeing children ( P = 0.03 by chi-square analysis).

Table 2 lists the reasons reported as influencing the decision to not refer children to a pediatric rheuma- tologist: distance and convenience to the patient’s family were most commonly indicated; personal expertise in pediatric rheumatology and personal preference were cited by 46%. The mean distance for those who reported distance as a major impediment to referral was 110 miles; however, the median was only 35 miles. This marked difference in mean and median may be due to the geographic distribution of adult rheumatologists in our state.

Sources of referral of pediatric patients are shown in Table 3. Although family practice physicians were identified more frequently than pediatricians, this difference was not significant. Two-thirds of adult rheu- matologists indicated seeing at least 1 child who was a

Table 2. children to a pediatric rheumatologist

Reasons identified as influencing the decision to not refer

Factor %

Distance Convenience to family Personal expertise in pediatric rheumatology Personal preference Cost to family Patient not referred back Difficulty in referring out of the system Preference of referring doctor Takes too long to see pediatric rheumatologist Personal loss of income

66 60 46 46 37 33 29 23 19 1s

1220 SHERRY ET AL,

relative of an adult patient. Only rarely was another adult rheumatologist identified as the source of referral. The number of children referred by each source was not obtained.

Adult rheumatologists who see children were very comfortable treating children with chronic arthritis, but less comfortable with conditions typical of younger children (Kawasaki disease, Henoch-Schonlein purpura) and rarer systemic illnesses (polyarteritis nodosa, fever of unknown origin, Wegener’s granulomatosis) (Table 4). The mean age of children for which the physician felt comfortable was 6.3 years, whereas the mean age of the youngest child in the practice was 5.3 years (range 0-16 years).

The majority of adult rheumatologists (86%) indicated interest in obtaining CME focused on pediat- ric rheumatology. The most important issue for CME was the relevance of the topic; cost of the CME course and use of a nationally known speaker were not impor- tant issues. However, 66% preferred their CME to be close to home; 19% preferred CME during a regional meeting, whereas 15% preferred CME during a national meeting. A lecture format was preferred by 52%; “meet the expert” was preferred by 32%, and 16% preferred a workshop.

DISCUSSION

A significant number of private-practicing adult rheumatologists in the state of Washington (62%) care for children. Most see children younger than 10 years of age. The most significant factor predicting the inclusion of children in the practice was more exposure to pedi- atric rheumatology during adult rheumatology fellow- ship. However, 54% of the respondents listed their fellowship pediatric experience as none to minimal. Most (69%) indicated a lack of sufficient experience with pediatric rheumatology during their fellowship and sug- gested that adult fellowships should provide a moderate experience with the pediatric rheumatic diseases. This

Table 3. Referral sources of pediatric patients ~ ~ ~

Source %’

Family practice physicians Orthopedic surgeons Pediatricians Relatives of adult patients Relatives of staff/friends Self-referral Podiatrists Other adult rheumatologists

94 84 76 68 49 39 26 13

* Percent of adult rheumatologists reporting at least 1 patient from each source.

Table 4. able treating children, by diagnosis

Percent of addlt rheumatologists reporting feeling comfort-

Condition*

Kawasaki disease Polyarteritis nodosa Wegener’s granulomatosis Rheumatic fever Fever of unknown origin Psychogenic rheumatism Henoch-Schonlein purpura Sports injury Dermatomyositis Anterior knee syndrome Systemic lupus erythematosus Reflex neurovascular dystrophy Aches and pains Back pain Psoriatic arthritis Fibromyalgia Spondylarthropathy JRA, systemic onset JRA, pauciarticular onset JRA, polyarticular onset

% comfortable treating

36 44 52 56 57 61 63 65 69 74 77 78 82 83 83 83 85 85 89 89

* JRA = juvenile rheumatoid arthritis.

was also indicated by a majority (59%) of adult rheuma- tologists who subsequently did not care for children. We did not identify each rheumatologist’s training program or ask if a pediatric rheumatologist was part of the f acu 1 ty .

Adult rheumatologists report discomfort in car- ing for younger children, especially those below 6 years of age. More than half reported comfort in dealing with fever of unknown origin (57%) and systemic-onset juve- nile rheumatoid arthritis (85%) even though the differ- ential diagnosis in these children encompasses the entire scope of pediatric diseases including malignancies. How- ever, 5 respondents noted on their questionnaires that they care for children in conjunction with a pediatrician for certain conditions, such as fever of unknown origin, or when dealing with very young children.

The most common barrier to referral to a pedi- atric rheumatologist was distance (66%). Although many of these adult rheumatologists were 280 miles away from a pediatric rheumatologist, the median dis- tance for those reporting distance as a factor was only 35 miles, and some of these were within the city of Seattle. This discrepancy may have several explanations. Thirty- five miles may not appear to be a significant distance, but the Seattle metropolitan area has been reported as having the fourth worst traffic in the nation (9). Also, our pediatric rheumatology clinic in Seattle is not located on a direct bus route from the city center or from the large surrounding suburbs. Convenience to the family was listed as a barrier 60% of the time, which may be related

PEDIATRIC RHEUMATOLOGY IN ADULT PRACTICES 1221

to these travel difficulties. Our survey respondents were adult rheumatologists, not families of patients; there- fore, some of these responses may have been influenced by an underlying reluctance to refer.

Difficulty in referring outside of a health care plan was identified by 29% of the adult rheumatologists in our state. Rheumatologists in other areas of the country may have more or less difficulty referring to a pediatric rheumatologist depending on the local man- aged care environment. As managed care has grown in our community, we think more pressure has been placed upon adult rheumatologists to care for children. Further studies over time in a variety of locations are needed to address this.

Although our questionnaire was coded for confi- dentiality, respondents may not have felt that they had anonymity, since there are a relatively small number of rheumatologists and only 1 pediatric rheumatology cen- ter in the state. This may have influenced some self- reported answers. A randomized national survey may more accurately reflect geographic variations.

There is interest among private-practice adult rheumatologists in CME regarding pediatric rheumatol- ogy. Most prefer lectures in their home community. More effort by the regional pediatric centers to supply local CME is indicated. In our area, the focus of pediatric rheumatology CME is outreach toward pedia- tricians and family practitioners, not adult rheumatolo- gists. This is under review in light of the present data.

Pediatric rheumatologists need to support adult rheumatologists in both an educational and a consulta- tive role. This may present a problem since, in many instances, parents prefer the pediatric specialty setting to the adult setting. Factors that parents and patients have indicated as causing discomfort with the adult rheuma- tology clinic include waiting rooms filled with elderly patients, less time spent with the patient, lack of a full complement of pediatric specialists and allied health professionals who are experienced with children with rheumatic diseases, less educational support, lack of referral to parent support groups, and lack of exposure to other children with similar conditions. Adult rheuma- tologists might ease some of these concerns by seeing children at a separate time from adult patients.

Pediatric rheumatologists may argue that all chil- dren with rheumatic diseases should be seen by a pediatric rheumatologist. There are no data, however, regarding care and outcome differences. The ACR’s Council (now Committee) on Rheumatologic Care has stated that all children with systemic rheumatic disease should see a pediatric rheumatologist if one is accessible

(10). Accessibility is relative and multifactorial and includes both family and physician variables. However, adult rheumatologists, if uncomfortable, should not hes- itate to refer even if health care plans make this difficult and time consuming. It is heartening to know that, in our sample, neither physician income nor unavailability of pediatric rheumatology services was a significant issue.

It is of interest that 51% of those in our sample who listed themselves in the ACR directory as caring for only adult patients also took care of children. The directory more accurately identified those who listed themselves as seeing both adults and children. Factors determining how one listed oneself in the ACR directory were not explored.

In conclusion, a majority of adult rheumatologists in private-practice care for children. The comfort level of adult rheumatologists who care for children varies depending on fellowship experience or subsequent train- ing in pediatric rheumatology. Pediatric rheumatologists need to be an available resource to their adult rheuma- tologist colleagues in patient care and physician educa- tion. Adult rheumatologists should refer to a pediatric rheumatologist when they are uncomfortable with their ability to care for the child, regardless of health care plan impediments or other perceived difficulties.

ACKNOWLEDGMENT

The authors thank Grahame Beth Sherry for data entry.

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