Primary Care Shortage in Medically Underserved and Health Provider Shortage Areas: Lessons from Delaware, USA

Health care Utilization and Expenditures in Health Professional Shortage Areas

Healthcare provider shortages are associated with adverse health outcomes, presumably stemming from the lack of access to primary care. This study examines the impact of Health Professional Shortage Areas (HPSAs) on healthcare utilization and spending across different types of care. Using the Medical Expenditure Panel Survey from 2002 to 2019, this study estimates the difference in healthcare utilization in HPSAs compared with non-HPSAs using a generalized random forest, which allows for more complex modeling of the outcome and a principled examination of heterogenous treatment effects. The results indicate HPSAs are associated with a 5% reduction in medical office visits, but no reduction in hospital-based care. These effects are concentrated in older persons living in urban areas, Black persons, and Medicaid beneficiaries. No statistically significant effects on annual spending were observed. These results offer insight into potential areas for further policy efforts aimed at reducing provider shortages.

Overcoming Challenges for Non-US International Medical Graduates in Pediatric Infectious Diseases

International medical graduates (IMGs) in pediatric infectious diseases face unique and complex challenges related to their immigration status. This Perspective provides a review of challenges impacting non-US IMG trainees and early-career faculty, and how the infectious diseases community can respond.

Impact of a Remote Primary Care Telehealth Staffing Model on Primary Care Access in the Veterans Health Administration

BACKGROUND

The Veterans Health Administration (VHA) implemented the Clinical Resource Hub (CRH) program to fill staffing gaps in primary care (PC) clinics via telemedicine and maintain veterans' healthcare access.

OBJECTIVE

To evaluate PC wait times before and after CRH implementation.

DESIGN

Comparative interrupted time series analysis among a retrospective observational cohort of PC clinics who did and did not use CRH during pre-implementation (October 2018-September 2019) and post-implementation (October 2019-February 2020) periods.

PARTICIPANTS

Clinics completing ≥10 CRH visits per month for 2 consecutive months and propensity matched control clinics.

MAIN MEASURES

Two measures of patient access (i.e., established, and new patient wait times) and one measure of clinic capacity (i.e., third next available appointment) were assessed. Clinics using CRH were 1:1 propensity score matched across clinical and demographic characteristics. Comparative interrupted time series models used linear mixed effects regression with random clinic-level intercepts and triple interaction (i.e., CRH use, pre- vs. post-implementation, and time) for trend and point estimations.

KEY RESULTS

PC clinics using CRH (N = 79) were matched to clinics not using CRH (N = 79). In the 12-month pre-implementation, third next available time increased in CRH clinics (0.16 days/month; 95% CI = [0.07, 0.25]), and decreased in the 5 months post-implementation (-0.58 days/month; 95% CI = [-0.90, -0.27]). Post-implementation third next available time also decreased in control clinics (-0.48 days/month; 95% CI = [-0.81, -0.17]). Comparative differences remained non-significant. There were no statistical differences in established or new patient wait times by CRH user status, CRH implementation, or over time.

CONCLUSIONS

In a national VHA telemedicine program developed to provide gap coverage for PC clinics, no wait time differences were observed between clinics using and not using CRH services. This hub-and-spoke telemedicine service is an effective model to provide gap coverage while maintaining access. Further investigation of quality and long-term access remains necessary.

Associations of clinical personnel characteristics and telemedicine practices

CONTEXT

The use of telemedicine strategies has been increasing in the United States for more than a decade, with physicians taking advantage of this new tool to reach more patients. Determining the specific demographics of physicians utilizing telemedicine most in their practice can inform recommendations for expanded telemedicine use among all physicians and aid in mitigating the need for local physicians in urban and rural populations.

OBJECTIVES

This study aims to assess the use of telemedicine by physicians in 2021, based on four demographics utilizing the National Electronic Health Record Survey (NEHRS): physician age, sex, specialty, and training.

METHODS

We performed a cross-sectional study of the 2021 NEHRS to determine the relationship between physician characteristics and telemedicine practices. Differences between groups were measured through design-based chi-square tests.

RESULTS

Compared to male physicians, female physicians were more likely to utilize telemedicine services (X 2=8.0; p=0.005). Compared to younger physicians, those over the age of 50 were less likely to utilize telemedicine services (X 2=4.1; p=0.04). Compared to primary care physicians, medical and surgical specialty physicians were less likely to utilize telemedicine services, with surgical specialty physicians being the least likely overall (X 2=11.5; p<0.001). We found no significant differences in telemedicine use based on degree (Osteopathic and Allopathic).

CONCLUSIONS

Our results showed a statistically significant difference between physician's age, sex, and specialty on telemedicine use in practice during 2021. Efforts to increase telemedicine use among physicians may be needed to provide more accessible care to patients. Thus, by increasing physician education on the importance of telemedicine for modern patients, more physicians may decide to utilize telemedicine services in practice.

Building Interest in the Primary Care Specialty Through Enhanced Global Health Experience

Background An overwhelming majority of matriculating medical students in the USA are keen to deliver quality health care to all people, including the socioeconomically disadvantaged populations in remote, resource-scarce regions nationally and worldwide. Here, we describe a protocol developed to evaluate the interest of our medical students in global health activities. We also examined the relationship between students' interest in global health and readiness to pursue a future career in the primary care specialty. Materials and methods We designed a survey in Qualtrics online software and reached all first-year and third-year medical students between 2019 and 2022 enrolled at the Alabama College of Osteopathic Medicine (ACOM). The survey utilized ordinal scale items to explore the medical students' interest in primary care residency programs, their interest in global health and international travel, and their perceptions of how a range of factors might motivate their desire to participate in global health activities. The study was approved by ACOM's Institutional Review Board (IRB). In order to compare findings from this study with data from other medical schools, we developed constructs using the national aggregate data, in percentages, from matriculants and graduates of Doctor of Osteopathic Medicine (DO) degree-granting medical schools according to gender, published by the American Association of Colleges of Osteopathic Medicine (AACOM). Statistical analysis of national aggregate data was performed using the unpaired t-test. Results Both female and male participants had lived or traveled abroad before starting medical school. Female (98%, n=249) and male (95%, n=140) participants in the first-year cohorts considered helping the underserved population as important or very important as it is related to a career in medicine. Females in the third-year cohorts (97%, n=71) also ranked this statement as important or very important compared to male cohorts (89%, n=31). A higher proportion of females (43%, n=108) compared to males (35%, n=52) in first-year cohorts agreed or strongly agreed that they would likely pursue a residency in primary care. More females (59%, n=43) than males (46%, n=16) in the third-year cohorts agreed or strongly agreed with the same statement. Analysis of the aggregate national data (2009-2022) revealed that the percentage (actual count not available) of female students who planned to practice in underserved/shortage area was higher both at the time of matriculation (M=51%, SD=4%) and before graduation (M=40%, SD=4%) compared to males (matriculation: M=40%, SD=5%; graduation: M=33%, SD=4%) presenting a significant difference (matriculation t(24)=6.7, p<0.0001; graduation t(24)=5.4, p<0.0001). Furthermore, a higher percentage of females at the time of matriculation (M=25%, SD=5%) and graduation (M=40%, SD=6%) planned to practice in the primary care specialties compared to males (matriculation: M=17%, SD=4%; graduation: M=29%, SD=6%) presenting a significant difference (matriculation: t(24)=4.6, p = 0.0001; graduation: t(24)=4.8, p<0.0001). Conclusions Interest in global health activities may be associated with interest in pursuing a future career in the primary care specialty. In this study, more female medical students expressed interest in participating in global health experiences, serving the underserved population domestically and abroad, and expressing interest in primary care than males.

Expanding Pharmacists' Role in the Management of Non-Alcoholic Fatty Liver Disease

Non-alcoholic fatty liver disease (NAFLD) stands as an increasingly pressing global health challenge, underscoring the need for timely identification to facilitate effective treatment and prevent the progression of chronic liver disorders. Given the projected scarcity of specialized healthcare professionals, particularly hepatologists and gastroenterologists, the role of pharmacists emerges as pivotal in NAFLD management. This article sheds light on the potential of pharmacists within community pharmacy settings, not as diagnostic entities, but as facilitators in recognizing and screening individuals at elevated NAFLD risk using validated non-invasive tools like portable devices and calculators. By prioritizing patient education, referrals, and continuous monitoring, pharmacists can refine NAFLD management, ultimately advancing patient outcomes. Enhancing pharmacists' impact in early NAFLD detection and management can be facilitated through collaborations with healthcare institutions and the incorporation of patient self-assessment tools. This collaborative approach holds promise for further promoting improved liver health within the community.

Perceptions and Proficiencies of Primary Care Physicians Treating Metabolic Syndrome: A Descriptive Survey-Based Study

INTRODUCTION

Metabolic syndrome (MetS) is a chronic condition that has been implicated in adverse public health outcomes worldwide, including in the United States. It has been linked to diseases such as type 2 diabetes and heart disease. Little is known about the perceptions and practices of primary care physicians (PCPs) regarding MetS. The only studies examining this research topic were conducted outside the United States. The aim of this study was to evaluate the MetS knowledge, proficiency, training, and practices of American PCPs, for the purpose of informing future physician education initiatives directed at MetS.

METHODS

This was a descriptive correlational design using a Likert-scale questionnaire. The survey was distributed to more than 4000 PCPs. The first 100 completed surveys were evaluated using descriptive statistical analyses.

RESULTS

Cumulative survey results revealed that most PCPs perceived themselves as knowledgeable on MetS, but only a minority demonstrated an understanding of leading-edge MetS protocols. Ninety-seven percent agreed that MetS is a condition of concern, but only 22% reported possessing sufficient time and resources to fully address MetS. Only half indicated that they had received training in MetS.

DISCUSSION

Overall results suggested that a lack of time, training, and resources may pose the greatest obstacles to optimal MetS care. Future studies should aim to identify the specific reasons why these barriers exist.

Challenges for International Medical Graduates in the US Graduate Medical Education and Health Care System Environment: A Narrative Review

International medical graduates (IMGs) have become a vital part of the US graduate medical education (GME) and health care system (HCS) workforce; they contribute to essential diversity that relieves cultural and linguistic barriers to health care. The number of IMGs looking for medical training in the United States. has constantly been increasing in the last decades. The challenges they meet begin long before residency application, continue during their transition to residency programs, through early medical training, and eventually subside in senior years. IMGs' hurdles permeate the themes of navigating the US GME and HCS, adaptation to the US culture, communication skills, racial discrimination, emotional distress, and finances. This article aims to comprehensively review available information concerning the challenges encountered by IMGs in their transition to the US GME and HCS environments.

Foreign Body in the Urinary Bladder: Another Outpatient Presentation

Primary care physicians manage a variety of medical conditions in their practice; to do this successfully, they require proper preparation and a wealth of experience, which they garner over years of practice. This case describes a 41-year-old male who presented to an outpatient clinic with a foreign body in the urinary bladder. This case report captures the level of preparedness required in primary care, the challenges that come with the broad spectrum of disease presentations, inter-specialty collaboration, and consultation or referral as appropriate with regards to having a foreign body in the urinary bladder. This report also shows how misinformation from patients can play a part in delayed diagnosis of simple presentations such as a self-inserted foreign body.

Assessment of Chronic Disease Management Strategies Among Health Care Practices in Medically Underserved South Carolina Counties

Diabetes and heart disease are among the leading causes of death and disability in the United States, and these conditions are especially prevalent in the South. South Carolina's persistent racial and socioeconomic disparities in chronic disease outcomes are well-documented, yet little is known about how health care practices in medically underserved areas are addressing these challenges. Data were collected through a cross-sectional survey as part of two complementary 5-year cooperative agreements between the Centers for Disease Control and Prevention and the Division of Diabetes and Heart Disease Management (the Division) at the South Carolina Department of Health and Environmental Control. The Division fielded a survey to (a) assist in determining which Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) were best poised to implement specific strategies as part of these cooperative agreements and (b) provide data to establish the baseline for performance measures. FQHCs and RHCs in the top 25% of counties with the highest diabetes and heart disease burden were surveyed about eight domains: staffing/services, electronic health records, team-based care policies, lifestyle change programs, medication therapy management, telehealth, quality improvement collaboratives, and patient demographics. Data representing 71 practices revealed contrasts between RHCs and FQHCs and opportunities for improvement. For example, while most practices reported they were not implementing evidence-based lifestyle change programs (e.g., the National Diabetes Prevention Program), most RHCs and FQHCs expressed interest in starting such programs. Findings are being used to guide efforts to improve diabetes and heart disease prevention and management in South Carolina.

Medically underserved areas and International Medical Graduates (IMGs) in the United States: challenges during the COVID-19 era

Background: Given that nearly a quarter of the US physician workforce are international medical graduates (IMGs), many of whom remain on temporary work visas for prolonged periods due to processing delays, the pandemic has posed unique challenges to these frontline workers and has arbitrarily limited our physician workforce. Methods: This is cross-sectional survey data obtained from IMGs on temporary work visas pertaining to their role in healthcare, impact of visa-related restrictions on their professional and personal lives was sent to the participants. Results: A total of 2630 IMGs responded to the survey. Most of the respondents (1493, 56.8%) were physicians in active practice, with Internal Medicine (1684, 65.7%) being the predominant specialty encountered. 64.1% were practicing in Medically Underserved Areas (MUA) or Health Professional Shortage Areas (HPSA), with 45.6% practicing in a rural area. Nearly 89% of respondents had been involved with direct care of COVID-19 patients, with 63.7% assuming administrative responsibilities for COVID-19 preparedness. 261 physicians (11.5%) were subject to quarantine, while 28 (1.2%) reported a confirmed COVID-19 infection. 93% physicians expressed inability to serve in COVID-19 surge areas due to visa-related restrictions, while 57% had been approached by recruiters due to staffing shortages. 72% physicians reported that their families would be at risk for deportation in case of their disability or death. Most respondents (98.8%) felt that permanent resident status would help alleviate the above concerns. Conclusion: A significant proportion of the US physician workforce is adversely impacted by work-based visa restrictions and processing backlog. Mitigating these restrictions could significantly bolster the current physician workforce and prove beneficial in our response to the COVID-19 pandemic.