Role of Pediatric and Internist Rheumatologists in Treating Children With Rheumatic Diseases

Michelle L. Mayer; Christy I. Sandborg; Elizabeth D. Mellins

doi:10.1542/peds.113.3.e173

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Fig 1.
Percentage of internist rheumatologists who report being asked to see a pediatric patient by requesting source.

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TABLE 1.

Bivariate Comparison of Rheumatologists

	Pediatric Only (n = 20; % or Mean [SD])	Unadjusted P Pediatric vs All Internists	Internists Involved In Care of Children (n = 78; % or Mean [SD])	Internists Only (n = 134; % or Mean [SD])	Unadjusted P Value* Internists Who Treat Children vs Internists Only
Personal characteristics
Male	50.0	.04	67.6	75.2	NS
Age	49.3 (7.6)	NS	50.7 (9.2)	51.5 (11.3)	NS
Nonwhite	5.0	.05	21.3	25.8	NS
Years in practice	16.0 (8.7)	NS	17.2 (9.3)	17.9 (11.1)	NS
Training characteristics
Exposure to pediatrics during fellowship
None	5.3	N/A	17.8	24.6	NS
Minimal	5.3		48.0	40.2
Moderate	5.3		26.0	31.2
Extensive	84.2		8.2	4.1
Practice characteristics
Practice setting
Private practice	15.0	<.001	53.3	52.3	.076
Academic rheumatology	50.0		14.7	22.0
HMO	0.0		10.7	15.2
Multispecialty clinic	15.0		20.0	7.6
Other	20.0		1.3	3.0
Percentage of time in professional activities
Rheumatology care	58.3 (30.6)	.02	77.9 (25.4)	68.9 (30.9)	.07
Primary care	5.6 (21.3)	.08	5.1 (12.7)	9.2 (19.1)	NS
Research	14.9 (20.3)	<.001	7.2 (18.6)	9.2 (21.4)	NS
Teaching	12.7 (20.1)	<.001	3.8 (6.6)	3.7 (5.9)	NS
Other	8.4 (8.3)	.06	5.9 (10.8)	8.9 (16.5)	NS
Patients’ insurance status
Medicaid	37.5 (25.1)	<.001	8.2 (10.9)	11.5 (16.1)	NS
Private insurance	48.2 (22.5)	NS	49.8 (21.7)	44.9 (24.6)	NS
Medicare	7.3 (16.5)	<.001	34.0 (16.3)	34.4 (18.4)	NS
Self-pay/uninsured	5.2 (6.3)	NS	5.7 (8.7)	5.7 (10.8)	NS
Other	3.3 (11.5)	NS	4.9 (18.5)	9.7 (27.0)	NS
Hours worked per week	47.6 (19.8)	NS	48.6 (15.7)	49.2 (16.4)	NS
Total patients seen per week	34.5 (23.4)	<.001	76.6 (42.2)	67.1 (44.0)	NS
Patients <18 seen per week	27.5 (18.0)	<.001	3.1 (3.6)	1.7 (5.2)	<.001
Able to see more patients	35.0	NS	26.7	36.1	NS
Miles to nearest pediatric rheumatologist	N/A		30.2 (34.8)	15.3 (18.0)	<.001

SD indicates standard deviation; NS, not significant; HMO, health maintenance organization.
↵* For dichotomous variables, statistical tests were performed using χ² when all cell sizes were >5. When ≥1 cells were <5, a 2-sided Fisher exact test was used. For continuous variables, 2-sided t tests were performed without assuming equal variances. For nonnormally distributed variables (Shapiro-Wilks test P < .05), Wilcoxon rank sum tests were used.

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TABLE 2.

Logistic Regression Results; Likelihood That an Internist Rheumatologist Treats Children

Independent Variable	Odds Ratio	P	95% CI
Male	0.65	NS	0.32	1.32
Extensive experience in fellowship	2.07	NS	0.51	8.36
Practice location
Academic rheumatology	1.12	NS	0.34	3.71
HMO	0.92	NS	0.33	2.57
Multispecialty clinic	3.39	.022	1.19	9.67
Other	0.75	NS	0.07	8.21
Percentage of time in nonpatient care	0.40	NS	0.07	2.27
Has more time available to see patients	0.79	NS	0.37	1.70
Distance to pediatric rheumatologist
10–49 mi	2.06	.038	1.04	4.06
≥50 mi	6.84	.002	2.06	22.65

CI indicates confidence interval.

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TABLE 3.

Comparison of Pediatric and Internist Providers of Pediatric Rheumatology Care

	Pediatric Rheumatologists Only (n = 20)	Internists Involved in Care of Children (n = 78)	Unadjusted P Value* Pediatric vs Internists Who Treat Children
Age distribution
0–5 y	20.0	0.0	<.001
6–11 y	30.0	4.5	<.001
12–15 y	32.5 (9.84)	33.6 (22.59)	NS
16–17 y	16.4 (9.77)	52.4 (27.73)	<.001
Disease distribution among pediatric patients
JRA	41.5 (17.5)	44.1 (31.3)	NS
SLE	19.3 (13.6)	23.0 (25.7)	NS
Pain syndromes†	7.5	1.0	NS
Other rheumatic disease†	11.5	5.0	NS
Rheumatic compliant with no diagnosis†	5.0	0.0	NS
Comfortable treating
Dermatomyositis	95.0	56.2	.001
JRA, systemic onset	95.0	67.1	.01
JRA, pauciarticular	100.0	80.8	.04
JRA, polyarticular	100.0	80.8	.04
Fibromyalgia	100.0	64.4	.002
Kawasaki disease	100.0	24.7	<.001
Polyarteritis Nodosa	85.0	43.8	.001
Psoratic arthritis	90.0	80.8	NS
Reflex sympathethic dystropy	90.0	34.3	<.001
Rheumatic fever	100.0	49.3	<.001
Psychogenic rheumatism	90.0	30.1	<.001
Anterior knee syndrome	85.0	50.7	.005
SLE	95.0	72.6	<.001
Spondylarthropathy	100.0	79.5	.02
Wegener’s granulomatosis	85.0	42.5	.001
Henoch-Schonlein purpura	100.0	61.6	.001
Fever of unknown origin	100.0	28.8	<.001
Back pain	85.0	60.3	.06
Reason for treating
Personal expertise	N/A	78.4	N/A
Patient preference	N/A	73.6	N/A
Distance to nearest pediatric rheumatologist	N/A	65.8	N/A
Lack of available appointment	N/A	38.4	N/A
Inability to refer because of insurance	N/A	31.9	N/A
Practice income considerations	N/A	4.4	N/A
Other	N/A	42.1	N/A
Interested in obtaining advice from pediatric rheumatologist	N/A	71.4	N/A

SLE indicates systemic lupus erythematosus.
↵* For dichotomous variables, statistical tests were performed using χ² when all cell sizes were >5. When ≥1 cells were <5, a 2-sided Fisher exact test was used. For continuous variables, 2-sided t tests were performed without assuming equal variances. For nonnormally distributed variables (Shapiro-Wilks test < .05), Wilcoxon rank sum tests were used.
↵† Medians are presented for variables with highly skewed distributions for one or both groups.