How many rural doctors do we have?

Physician preferences for working in deprived areas: a systematic review of discrete choice experiment

Background: Physician shortages in rural areas is a universal concern, and most countries face this challenge. Many attributes influence the physician preferences about the choice of working location. The aim of this systematic review was to investigate which attributes were included in discrete choice experiment studies and which of them valued the most by physicians. Methods: The following databases were searched: PubMed, Embase, and Web of Science Core Collection. Further studies were retrieved from reference lists of included studies, and grey literature. Studies used discrete choice experiments methods to elicit preferences for working in the deprived area, focus on physicians or medical students, and published between 2000 and 2017 in the English language were included. Results: The literature search yielded 192 studies, of which 14 studies met inclusion criteria. The attributes and attribute levels were identified by literature review and qualitative research. The number of attributes varied from five to ten, and the most frequent number was six attributes. In most studies, maximum of sixteen different scenarios were given to the study samples. The "salary or income" attribute was the most important in fifty percent of the studies and the attributes related to "study and education" was at the next level. Conclusion: Financial attributes are not the only significant attributes considered by the physicians for deciding where to practice, but also the other non-financial attributes are important. It is suggested that based on the economic, social and cultural conditions of each country, a specific incentive package, including a set of financial and non-financial incentives, is developed to attract physicians to the deprived areas.

Climate Change and Healthcare Sustainability in the Agincourt Sub-District, Kruger to Canyons Biosphere Region, South Africa

As low-income communities are most vulnerable to climate-associated health concerns, access to healthcare will increase in importance as a key priority in South Africa. This study explores healthcare sustainability in the Agincourt sub-district, Kruger to Canyons Biosphere Region in Mpumalanga, South Africa. A rapid assessment and response methodology (RAR) was implemented, which includes the examination of previous studies conducted in the sub-district, the mapping of healthcare facilities in the area, and the implementation of a facility infrastructure and workforce capacity investigation by means of key informant (KI) interviews at eight healthcare facilities. Findings indicate that the greatest need across the facilities relate to access to medical doctors and pharmacists. None of the facilities factored climate associations with health into their clinical care strategies. The necessity to train healthcare facility staff on aspects related to climate change, health, and sustainability is highlighted. Environmental health practitioners should also be incorporated in grassroots community climate adaptation strategies. Outcomes further indicate the need for the advancement of integrated healthcare and climate adaptation strategies that focus on strengthening healthcare systems, which may include novel technological approaches such as telemedicine. Policy makers need to be proactive and pre-emptive in finding and improving processes and models to render healthcare services prepared for climate change.

Self-efficacy of Osteopathic Medical Students in a Rural-Urban Underserved Pathway Program

Context

Self-efficacy has been shown to play a role in medical students' choice of practice location. More physicians are needed in rural and urban underserved communities. Ohio University Heritage College of Osteopathic Medicine has a co-curricular training program in rural and urban underserved practice to address this shortage.

Objective

To assess whether participation in the co-curricular program in rural and urban underserved practice affects self-efficacy related to rural and underserved urban practice.

Methods

This cross-sectional study explored self-efficacy using Bandura's 5 sources of self-efficacy (vicarious learning, verbal persuasion, positive emotional arousal, negative emotional arousal, and performance accomplishments). A validated scale on self-efficacy for rural practice was expanded to include self-efficacy for urban underserved practice and e-mailed to all 707 medical students across 4 years of medical school. Composite rural and urban underserved self-efficacy scores were calculated. Scores from participants in the rural and urban underserved training program were compared with those who were not in the program.

Results

Data were obtained from 277 students. In the overall sample, students who indicated that they grew up in a rural community reported significantly higher rural self-efficacy scores than those who did not grow up in a rural community (F1,250=27.56, P<.001). Conversely, students who indicated that they grew up in a nonrural community reported significantly higher urban underserved self-efficacy scores than those who grew up in a rural community (F1,237=7.50, P=.007). The participants who stated primary care as their career interest (n=122) had higher rural self-efficacy scores than the participants who reported a preference for generalist specialties (general surgery, general psychiatry, and general obstetrics and gynecology) or other specialties (n=155) (F2,249=7.16, P=.001). Students who participated in the rural and urban underserved training program (n=49) reported higher rural self-efficacy scores (mean [SD], 21.06 [5.06]) than those who were not in the program (19.22 [4.22]) (t65=2.36; P=.022; equal variances not assumed). The weakest source of self-efficacy for rural practice in participants was vicarious experience. The weakest source of urban underserved self-efficacy was verbal persuasion.

Conclusion

Opportunities exist for strengthening weaker sources of self-efficacy for rural practice, including vicarious experience and verbal persuasion. The findings suggest a need for longitudinal research into self-efficacy and practice type interest in osteopathic medical students.

Placement, support, and retention of health professionals: national, cross-sectional findings from medical and dental community service officers in South Africa

BACKGROUND

In South Africa, community service following medical training serves as a mechanism for equitable distribution of health professionals and their professional development. Community service officers are required to contribute a year towards serving in a public health facility while receiving supervision and remuneration. Although the South African community service programme has been in effect since 1998, little is known about how placement and practical support occur, or how community service may impact future retention of health professionals.

METHODS

National, cross-sectional data were collected from community service officers who served during 2009 using a structured self-report questionnaire. A Supervision Satisfaction Scale (SSS) was created by summing scores of five questions rated on a three-point Likert scale (orientation, clinical advising, ongoing mentorship, accessibility of clinic leadership, and handling of community service officers' concerns). Research endpoints were guided by community service programmatic goals and analysed as dichotomous outcomes. Bivariate and multivariate logistical regressions were conducted using Stata 12.

RESULTS

The sample population comprised 685 doctors and dentists (response rate 44%). Rural placement was more likely among unmarried, male, and black practitioners. Rates of self-reported professional development were high (470 out of 539 responses; 87%). Participants with higher scores on the SSS were more likely to report professional development. Although few participants planned to continue work in rural, underserved communities (n = 171 out of 657 responses, 25%), those serving in a rural facility during the community service year had higher intentions of continuing rural work. Those reporting professional development during the community service year were twice as likely to report intentions to remain in rural, underserved communities.

CONCLUSIONS

Despite challenges in equitable distribution of practitioners, participant satisfaction with the compulsory community service programme appears to be high among those who responded to a 2009 questionnaire. These data offer a starting point for designing programmes and policies that better meet the health needs of the South African population through more appropriate human resource management. An emphasis on professional development and supervision is crucial if South Africa is to build practitioner skills, equitably distribute health professionals, and retain the medical workforce in rural, underserved areas.

Human resource inequalities at the base of India's public health care system

This paper examines the extent of inequalities in human resource provision at India's Heath Sub-Centres (HSC)--first level of service provision in the public health system. 'Within state' inequality explained about 71% and 'between state' inequality explained the remaining 29% of the overall inter-HSC inequality. The Northern states had a lower health worker share relative to the extent of their HSC provision. Contextual factors that contributed to 'between' and 'within' district inequalities were the percentages of villages connected with all-weather roads and having primary schools. Analysis demonstrates a policy and programming need to address 'within State' inequalities as a priority.

Redefining the role of the pharmacist: medication therapy management

PURPOSE

The purpose of this paper is to explore better use of pharmacists in rural communities as a partial solution to scarcity of physicians and other health care providers. It discusses expected reduction in public subsidies for rural health care and the changing market for pharmacists. The paper emphasizes the use of pharmacists as a backdrop for description of medication therapy management (MTM). A pilot study of MTM is also reported.

METHODS

This article explores rural health access, the market for pharmacists and MTM using the literature, and economic concepts to provide historical context for this new form of health care delivery. A small case study from a university-based clinic provided primary data to demonstrate viability.

FINDINGS

MTM can augment rural health by providing care for patients who receive increasing numbers of complex medications. It helps better integrate pharmacists into primary care and holds promise as a cost-effective, if not cost-saving alternative.

CONCLUSION

More constrained fiscal conditions are a virtual certainty going forward. The rural health community needs cost-effective health care alternatives that can prosper with lower levels of public financial support. MTM is one such option.

An International Health Track Is Associated With Care for Underserved US Populations in Subsequent Clinical Practice

BACKGROUND

Recent efforts to increase insurance coverage have revealed limits in primary care capacity, in part due to physician maldistribution. Of interest to policymakers and educators is the impact of nontraditional curricula, including global health education, on eventual physician location. We sought to measure the association between graduate medical education in global health and subsequent care of the underserved in the United States.

METHODS

In 2005, we surveyed 137 graduates of a family medicine program with one of the country's longest-running international health tracks (IHTs). We compared graduates of the IHT, those in the traditional residency track, and graduates prior to IHT implementation, assessing the anticipated and actual involvement in care of rural and other underserved populations, physician characteristics, and practice location and practice population.

RESULTS

IHT participants were more likely to practice abroad and care for the underserved in the United States in the first 5 years following residency than non-IHT peers. Their current practices were more likely to be in underserved settings and they had higher percentages of uninsured and non-English-speaking patients. Comparisons between pre-IHT and post-IHT inception showed that in the first 5 years following residency, post-IHT graduates were more likely to care for the underserved and practice in rural areas and were likely to offer volunteer community health care services but were not more likely to practice abroad or to be in an academic practice.

CONCLUSIONS

Presence of an IHT was associated with increased care of underserved populations. After the institution of an IHT track, this association was seen among IHT participants and nonparticipants and was not associated with increased long-term service abroad.

Interventions for increasing the proportion of health professionals practising in rural and other underserved areas

BACKGROUND

The inequitable distribution of health professionals, within and between countries, poses an important obstacle to the achievement of optimal attainable health for all.

OBJECTIVES

To assess the effectiveness of interventions aimed at increasing the proportion of health professionals working in rural and other underserved areas.

SEARCH STRATEGY

We searched the specialised register of the Cochrane Effective Practice and Organisation of Care Group (up to July 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effectiveness (up to July 2007), MEDLINE (1966 to July 2007), EMBASE (1988 to July 2007), CINAHL (1982 to July 2007) and LILACS (up to July 2007). We also searched reference lists of all papers and relevant reviews identified, and contacted authors of relevant papers regarding any further published or unpublished work.

SELECTION CRITERIA

Randomised controlled trials, controlled trials (not strictly randomised), controlled before-after studies and interrupted time series studies evaluating the effects of various interventions (e.g. educational, financial or regulatory strategies) on the recruitment and/or retention of health professionals in under-served areas.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened titles and abstracts obtained from the search in order to identify potentially relevant studies.

MAIN RESULTS

No studies met the inclusion criteria.

AUTHORS' CONCLUSIONS

There are no studies in which bias and confounding are minimised to support any of the interventions that have been implemented to address the inequitable distribution of health care professionals. Well-designed studies are needed to confirm or refute findings of various observational studies regarding educational, financial, regulatory and supportive interventions that may influence health care professionals' choice to practice in underserved areas. Governments and educators should ensure that where interventions are implemented this is done within the context of a well-planned study so that the true effects of these measures on recruitment and long term retention can be determined in various settings.

The accuracy of the Jamaican national physician register: a study of the status of physicians registered and their countries of training

BACKGROUND

The number of physicians per 10,000 population is a basic health indicator used to determine access to health care. Studies from the United States of America and Europe indicate that their physician registration databases may be flawed. Clinical research activities have suggested that the current records of physicians registered to practice in Jamaica may not be accurate. Our objective was to determine whether the Medical Council of Jamaica (MCJ) accurately records and reports the identities, number and specialty designation of physicians in Jamaica. An additional aim was to determine the countries in which these physicians were trained.

METHODS

Data regarding physicians practicing in Jamaica in 2005 were obtained from multiple sources including the MCJ and the telephone directory. Intense efforts at tracing were undertaken in a sub-sample of physicians, internists and paediatricians to further improve the accuracy of the data. Data were analysed using SPSS, version 11.5.

RESULTS

The MCJ listed 2667 registered physicians of which 118 (4.4%) were no longer practicing in Jamaica. Of the subset of 150 physicians who were more actively traced, an additional 11 were found to be no longer in practice. Thus at least 129 (4.8%) of the physicians on the MCJ list were not actively practising in Jamaica. Twenty-nine qualified physicians who were in practice, but not currently on the Jamaican register, were identified from other data sources. This yielded an estimate of 2567 physicians or 9.68 physicians per 10,000 persons. Seven hundred and twenty six specialists were identified, 118 from the MCJ list only, 452 from other sources, in particular medical associations, and 156 from both the MCJ list and other sources. Sixty-six percent of registered doctors completed medical school at the University of the West Indies (UWI).

CONCLUSION

These data suggest that the MCJ list includes some physicians no longer practicing in Jamaica while underestimating the number of specialists. Difficulty in accurately estimating the number of practicing physicians has been reported in studies done in other countries but the under-reporting of the number of specialists is uncommon. Additional consideration should be given to strategies to ensure compliance with the annual registration that is mandated by law and to changing the law to include registration of specialist qualifications.

Expanding the role of nurse practitioners: effects on rural access to care for injured workers

CONTEXT

A 3-year pilot program to expand the role of nurse practitioners (NPs) in the Washington State workers' compensation system was implemented in 2004 (SHB 1691), amid concern about disparities in access to health care for injured workers in rural areas. SHB 1691 authorized NPs to independently perform most functions of an attending physician.

PURPOSE

The aims of this study were to (1) describe the contribution by NPs to Washington's workers' compensation provider workforce, (2) evaluate change in provider availability attributable to SHB 1691, and (3) evaluate the effect of SHB 1691 on timely accident report filing.

METHODS

Administrative data were used to evaluate this natural experiment, using a pre-post design with primary care physicians (PCPs) as a nonequivalent comparison group.

FINDINGS

NPs served injured workers with characteristics similar to those served by PCPs, but 22.0% of NPs were rural, compared with 17.3% of PCPs. Of claimants with NPs as their attending provider, 53.3% were injured in a rural county, compared with 24.7% for those with PCP attending providers. The number of NPs participating in the workers' compensation system rose after SHB 1691 implementation, more so in rural areas. SHB 1691 implementation was associated with a 16 percentage point improvement in timely accident report filing by NPs in both rural and urban areas.

CONCLUSIONS

Authorizing NPs to function as attending providers for injured workers may improve provider availability (especially in rural areas) and timely accident report filing, which in turn may improve worker outcomes and system costs.

Mortality and physician supply: does region hold the key to the paradox?

OBJECTIVE

. To determine if the supply of physicians has a consistent relationship with mortality across regions.

DATA SOURCES

County-level data describing the supply of physicians, mortality, and socioeconomic conditions of the population as provided in the Area Resource File (BHPr, HRSA) and the Compressed Mortality File (NCHS, CDC).

STUDY DESIGN

Ordinary least squares and geographically weighted regression models with age-adjusted all-cause and disease-specific mortality as the dependent variables were specified using pooled data from 1996 to 2000 to test for the relationship with primary care and specialist physician-population ratios. The residuals from the OLS models were mapped and examined for potential clustering. A series of geographically weighted regression models were run for all 3,070 counties and the z-scores and significance of the models mapped.

PRINCIPAL FINDINGS

The association between primary care physician supply and mortality was not observed in contrast to other studies; mapping the residuals of those models suggested regional clustering. When weighted geographically, the relationship between primary care and specialist physician supply and mortality presents a mixed pattern. The results show strong regional patterns that may explain the lack of a consistent national association. Primary care physicians are associated with decreased mortality on the east coast and upper midwest, but that correlation disappears or is reversed in the west (with the exception of Washington State) and south central states.

CONCLUSIONS

We find evidence that there are regionally focused association between physician supply and mortality, holding constant population characteristics that reflect the influence of social and economic characteristics. However, these relationships are not consistent across the United States; there are regions where there are stronger and weaker associations between type of practitioner and mortality and other regions where no association is apparent. This suggests that the direction for further analysis lies in the understanding of the regional differences and whether there are policy alternatives to address these different patterns.

Beyond the horizon: the role of academic health centers in improving the health of rural communities

Academic health centers (AHCs) face increasing pressures from federal, state, and community stakeholders to fulfill their social missions to the communities they serve. Yet, in the 21st century, rural communities in the United States face an array of health care problems, including a shortage of physicians, health problems that disproportionately affect rural populations, a need to improve quality of care, and health disparities related to disproportionate levels of poverty and shifting demographics. AHCs have a key role to play in addressing these issues. AHCs can increase physician supply by targeting their admissions policies and educational programs. Specific health concerns of rural populations can be further addressed through increased use of telemedicine consultations. By partnering with providers in rural areas and through the use of innovative technologies, AHCs can help rural providers increase the quality of care. Partnerships with rural communities provide opportunities for participatory research to address health disparities. In addition, collaboration between AHCs, regional planning agencies, and rural communities can lead to mutually beneficial outcomes. At a time when many AHCs are operating in an environment with dwindling resources, it is even more critical for AHCs to build creative partnerships to help meet the needs of their regional communities.

Information and service needs of persons with Alzheimer's disease and their family caregivers living in rural communities

This study aimed to identify the information and service needs of persons with Alzheimer's disease (AD) and their family caregivers living in rural communities and to assess differences and similarities in each partner's perspective. In an outpatient clinic setting, a self-report survey was completed by 100 caregivers, while a similar survey was used to interview 100 persons with mild to moderate AD. The survey assessed respondents' interest in information or services related to 22 topics about AD and various aspects of coping with the disease. Although more caregivers than persons with AD reported interest in each topic, 8 of the top 10 topics endorsed by each group of respondents were the same. However, analysis of responses by dyads revealed substantial disagreement in terms of each partner's interest in information and services. Patient and family education, as well as referrals for services, must take into account each partner's unique perspective and needs.

Expected Annual Emergency Miles per Ambulance: An Indicator for Measuring Availability of Emergency Medical Services Resources

CONTEXT

To ensure equitable access to prehospital care, as recommended by the Rural and Frontier Emergency Medical Services (EMS) Agenda for the Future, policymakers will need a uniform measure of EMS infrastructure.

PURPOSE AND METHODS

This paper proposes a county-level indicator of EMS resource availability that takes into consideration existing EMS resources (ambulances), population health and demographics, and geographic factors. The indicator, the EXpected annual emergency miles per AMBulance (EXAMB), provides a basis for comparing ambulance availability across counties within states. A method for calculating the EXAMB indicator is demonstrated using data from 5 states.

FINDINGS

The EXAMB indicator was negatively correlated with ambulance availability per 100,000 population in 4 of the 5 states in the study. The indicator was positively correlated with rurality in 3 states. In Mississippi, South Carolina, and Wyoming, whole-county health professional shortage areas had median EXAMB values 45%-81% higher than those of the non-health professional shortage areas counties.

CONCLUSIONS

Future research should explore the relationship of the EXAMB to EMS outcomes, with the ultimate goal of developing a nationally recognized indicator of "adequate" EMS resource availability.

The geographic distribution of physicians revisited

CONTEXT

While there is debate over whether the U.S. is training too many physicians, many seem to agree that physicians are geographically maldistributed, with too few in rural areas.

OBJECTIVE

Official definitions of shortage areas assume the market for physician services is based on county boundaries. We wished to ascertain how the picture of a possible shortage changes using alternative measures of geographic access. We measure geographic access by the number of full-time equivalent physicians serving a community divided by the expected number of patients (possibly both from within the community and outside) receiving care from those physicians. Moreover, we wished to determine how the geographic distribution of physicians had changed since previous studies, in light of the large increase in physician numbers.

DESIGN

Cross-sectional data analyses of alternative measures of geographic access to physicians in 23 states with low physician-population ratios.

RESULTS

Between 1979 and 1999, the number of physicians doubled in the sample states. Although most specialties experienced greater diffusion everywhere, smaller specialties had not yet diffused to the smallest towns. Multiple measures of geographic access, including physician-to-population ratios, average distance traveled to the nearest physician, and projected average caseload per physician, confirm that residents of metropolitan areas have better geographic access to physicians. Physician-to-population ratios exhibit the largest degree of geographic disparity, but ratios in rural counties adjacent to metropolitan areas are smaller than in those not adjacent to metropolitan areas. Distance-traveled and caseload models that allow patients to cross county lines show less disparity and indicate that residents of isolated rural counties have less access than those living in counties adjacent to metropolitan areas.

CONCLUSION

Geographic access to physicians has continued to improve over the past two decades, although some smaller specialties have not diffused to the most rural areas. While substantial variation in the supply of physicians across communities remains, current measures of geographic access to physicians overstate the extent of maldistribution and yield an incorrect ranking of areas according to geographic accessibility of physicians.

The rural physician workforce in Florida: a survey of US- and foreign-born primary care physicians

CONTEXT

To meet the challenge of primary care needs in rural areas, continuing assessment of the demographics, training, and future work plans of practicing primary care physicians is needed.

PURPOSE

This study's goal was to assess key characteristics of primary care physicians practicing in rural, suburban, and urban communities in Florida.

METHODS

Surveys were mailed to all of Florida's rural primary care physicians (n = 399) and a 10% sampling (n = 1236) of urban and suburban primary care physicians.

FINDINGS

Responses from 1000 physicians (272 rural, 385 urban, 343 suburban) showed that rural physicians were more likely to have been raised in a rural area, foreign-born and trained, a National Health Service Corps member, or a J-1 visa waiver program participant. Rural physicians were more likely to have been exposed to rural medical practice or living in a rural environment during their medical school and residency training. Factors such as rural upbringing and medical school training did not predict future rural practice with foreign-born physicians. Overall, future plans for practice did not seem to differ between rural, urban, and suburban physicians.

CONCLUSIONS

Recruiting and retaining doctors in rural areas can be best supported through a mission-driven selection of medical students with subsequent training in medical school and residency in rural health issues. National programs such as the National Health Service Corps and the J-1 visa waiver program also play important roles in rural physician selection and should be taken into account when planning for future rural health care needs.

The contribution of nurse practitioners and physician assistants to generalist care in Washington State

OBJECTIVE

To quantify the total contribution to generalist care made by nurse practitioners (NPs) and physician assistants (PAs) in Washington State.

DATA SOURCES

State professional licensure renewal survey data from 1998-1999.

STUDY DESIGN

Cross-sectional. Data on medical specialty, place of practice, and outpatient visits performed were used to estimate productivity of generalist physicians, NPs, and PAs. Provider head counts were adjusted for missing specialty and productivity data and converted into family physician full-time equivalents (FTEs) to facilitate estimation of total contribution to generalist care made by each provider type.

PRINCIPAL FINDINGS

Nurse practitioners and physician assistants make up 23.4 percent of the generalist provider population and provide 21.0 percent of the generalist outpatient visits in Washington State. The NP/PA contribution to generalist care is higher in rural areas (24.7 percent of total visits compared to 20.1 percent in urban areas). The PAs and NPs provide 50.3 percent of generalist visits provided by women in rural areas, 36.5 percent in urban areas. When productivity data were converted into family physician FTEs, the productivity adjustments were large. A total of 4,189 generalist physicians produced only 2,760 family physician FTEs (1 FTE = 105 outpatient visits per week). The NP and PA productivity adjustments were also quite large.

CONCLUSIONS

Accurate estimates of available generalist care must take into account the contributions of NPs and PAs. Additionally, simple head counts of licensed providers are likely to result in substantial overestimates of available care. Actual productivity data or empirically derived adjustment factors must be used for accurate estimation of provider shortages.

Shortcomings in Medicare bonus payments for physicians in underserved areas

This study examines trends in Medicare spending for basic payments and bonus payments for physician services provided to beneficiaries residing in nonmetropolitan counties. For our analysis, we used Medicare Part B physician/supplier claims data for 1992, 1994, 1996, and 1998. Payments under the congressionally mandated bonus payment program acccounted for less than 1 percent of expenditures for physician services in nonmetropolitan, underserved counties. Physician payments increased from 1992 to 1998, while bonus payments increased through 1996 but then declined by 13 percent by 1998. The share of bonus payments to primary care physicians declined throughout the decade, but the share for primary care services increased.

Primary care service areas: a new tool for the evaluation of primary care services

OBJECTIVE

To develop and characterize utilization-based service areas for the United States which reflect the travel of Medicare beneficiaries to primary care clinicians.

DATA SOURCE/STUDY SETTING

The 1996-1997 Part B and 1996 Outpatient File primary care claims for fee-for-service Medicare beneficiaries aged 65 and older. The 1995 Medicaid claims from six states (1995) and commercial claims from Blue Cross Blue Shield of Michigan (1996).

STUDY DESIGN

A patient origin study was conducted to assign 1999 U.S. zip codes to Primary Care Service Areas on the basis of the plurality of beneficiaries' preference for primary care clinicians. Adjustments were made to establish geographic contiguity and minimum population and service localization. Generality of areas to younger populations was tested with Medicaid and commercial claims.

DATA COLLECTION/EXTRACTION METHODS

Part B primary care claims were selected on the basis of provider specialty, place of service, and CPT code. Selection of Outpatient File claims used provider number, type of facility/service, and revenue center codes.

PRINCIPAL FINDINGS

The study delineated 6,102 Primary Care Service Areas with a median population of 17,276 (range 1,005-1,253,240). Overall, 63 percent of the Medicare beneficiaries sought the plurality of their primary care from within area clinicians. Service localization compared to Medicaid (six states) and commercial primary care utilization (Michigan) was comparable but not identical.

CONCLUSIONS

Primary Care Service Areas are a new tool for the measurement of primary care resources, utilization, and associated outcomes. Policymakers at all jurisdictional levels as well as researchers will have a standardized system of geographical units through which to assess access to, supply, use, organization, and financing of primary care services.