The challenge of defining and counting generalist physicians: an analysis of Physician Masterfile data

The Supply and Distribution of the Preventive Medicine Physician Workforce

CONTEXT

Preventive medicine physicians work at the intersection of clinical medicine and public health. A previous report on the state of the preventive medicine workforce in 2000 revealed an ongoing decline in preventive medicine physicians and residents, but there have been few updates since.

OBJECTIVE

The purpose of this study was to describe trends in both the number of board-certified preventive medicine physicians and those physicians who self-designate preventive medicine as a primary or secondary specialty and examine the age, gender distribution, and geographic distribution of this workforce.

DESIGN

Analysis of the supply of preventive medicine physicians using data derived from board certification files of the American Board of Preventive Medicine and self-designation data from the American Medical Association Masterfile.

SETTING

The 50 US states and District of Columbia.

PARTICIPANTS

Board-certified and self-designated preventive medicine physicians in the United States.

MAIN OUTCOME MEASURES

Number, demographics, and location of preventive medicine physicians in United States.

RESULTS

From 1999 to 2018, the total number of physicians board certified in preventive medicine increased from 6091 to 9270; the number of self-identified preventive medicine physicians has generally decreased since 2000, with a leveling off in the past 4 years matching the trend of preventive medicine physicians per 100 000 population; there is a recent increase in women in the specialty; the practice locations of preventive medicine physicians do not match the US population in rural or micropolitan areas; and the average age of preventive medicine physicians is increasing.

CONCLUSIONS

The number of preventive medicine physicians is not likely to match population needs in the United States in the near term and beyond. Assessing the preventive medicine physician workforce in the United States is complicated by difficulties in defining the specialty and because less than half of self-designated preventive medicine physicians hold a board certification in the specialty.

Predictors of chemoradiotherapy versus single modality therapy and overall survival among patients with unresectable, stage III non-small cell lung cancer

Introduction

Concurrent chemoradiotherapy (cCRT) was the standard of care for patients with unresectable stage III non-small cell lung cancer (NSCLC) prior to the PACIFIC trial, however, patients also received single modality therapy. This study identified predictors of therapy and differences in overall survival (OS).

Methods

This retrospective study included stage III NSCLC patients aged ≥65 years, with ≥1 claim for systemic therapy (ST) or radiotherapy (RT) within 90 days of diagnosis, identified in SEER-Medicare data (2009–2014). Patients who had overlapping claims for chemotherapy and RT ≤90 days from start of therapy were classified as having received cCRT. Patients who received sequential CRT or surgical resection of tumor were excluded. Predictors of cCRT were analyzed using logistic regression. OS was compared between therapies using adjusted Cox proportional hazards models.

Results

Of 3,799 patients identified, 21.7% received ST; 26.3% received RT; and 52.0% received cCRT. cCRT patients tended to be younger (p <0.001), White (p = 0.002), and have a good predicted performance status (p<0.001). Patients who saw all three specialist types (medical oncologist, radiation oncologist, and surgeon) had increased odds of receiving cCRT (p<0.001). ST and RT patients had higher mortality risk versus cCRT patients (hazard ratio [95% CI]: ST: 1.38 [1.26–1.51]; RT: 1.75 [1.61, 1.91]); p<0.001).

Conclusions

Several factors contributed to treatment selection, including patient age and health status, and whether the patient received multidisciplinary care. Given the survival benefit of receiving cCRT over single-modality therapy, physicians should discuss treatment within a multidisciplinary team, and be encouraged to pursue cCRT for patients with unresectable stage III NSCLC.

Spatial accessibility to pediatric primary care in Philadelphia: an area-level cross sectional analysis

Background

Pediatric primary care visits are a foundational element in the health maintenance of children. Differential access may be a driver of racial inequities in health. We hypothesized that pediatric primary care accessibility would be lowest in neighborhoods with higher proportion of non-Hispanic Black residents.

Methods

Annual ratios (2008–2016) of providers to pediatric population were calculated by census tract in Philadelphia, Pennsylvania. Marginal logistic regression was used to estimate the independent association between neighborhood racial composition and access to pediatric primary care controlling for confounders.

Results

In general, low access to care was associated with greater neighborhood disadvantage (e.g., SES, % poverty, % public insurance). After controlling for neighborhood indicators of disadvantage, risk of being in the lowest quintile of access significantly increased as the percent of non-Hispanic Black residents increased.

Conclusion

A new measure of pediatric primary care accessibility demonstrates a persistent disparity in primary care access for predominantly non-Hispanic Black neighborhoods.

Does uneven geographic distribution of urologists effect bladder and prostate cancers mortality? National health insurance data in Korea from 2007-2011

The relationship between distribution of urologists and mortality of bladder and prostate cancers has not been clearly established. The aim of this study was to investigate the relationship between uneven distribution of urologists and urologic cancer specific mortality at country level. Data from the National Health Insurance Service and National Statistical Office in Korea from 2007 to 2011 were analyzed in this ecological study. Univariate and multivariable regression analyses were performed to determine risk factors for age standardized mortality rates (ASMR) of bladder and prostate cancers. Linear regression analysis showed a markedly (p < 0.001) uneven distribution of urologists between metropolitan and non-metropolitan areas. There was no significant difference in cancer specific ASMRs for either bladder cancer or prostate cancer. Univariate analysis after adjusting for time showed that country area, urologist density, and income were significant factors affecting bladder cancer incidence (p < 0.001, p = 0.013, and p < 0.001, respectively). It also showed that the number of training hospitals was a significant factor for prostate cancer incidence (p = 0.002). Although country area showed borderline significance (p = 0.056) for ASMR of bladder cancer, urologist density was not related to ASMR of bladder cancer or prostate cancer. Although there was a marked difference in urologist density between metropolitan and non-metropolitan areas for these years analyzed, mortality rates of bladder and prostate cancers were not significantly affected by country area or urologist density.

The geographic distribution of the otolaryngology workforce in the United States

OBJECTIVES

To describe the deployment of otolaryngologists and evaluate factors associated with the geographic distribution of otolaryngologists in the United States.

STUDY DESIGN

Cross-sectional study.

METHODS

The otolaryngology physician supply was defined as the number of otolaryngologists per 100,000 in the hospital referral region (HRR). The otolaryngology physician supply was derived from the American Medical Association Masterfile or from the Medicare Enrollment and Provider Utilization Files. Multiple linear regression tested the association of population, physician, and hospital factors on the supply of Medicare-enrolled otolaryngologists/HRR.

RESULTS

Two methods of measuring the otolaryngology workforce were moderately correlated across hospital referral regions (Pearson coefficient 0.513, P = .0001); regardless, the supply of otolaryngology providers varies greatly over different geographic regions. Otolaryngologists concentrate in regions with many other physicians, particularly specialist physicians. The otolaryngology supply also increases with regional population income and education levels. Using AMA-derived data, there was no association between the supply of otolaryngologists and staffed acute-care hospital beds and the presence of an otolaryngology residency-training program. In contrast, the supply of otolaryngology providers enrolled in Medicare independently increases for each HRR by 0.8 per 100,000 for each unit increase in supply of hospital beds (P < .0001) and by 0.49 per 100,000 in regions with an otolaryngology residency-training program (P = .006), accounting for all other factors.

CONCLUSION

Irrespective of methodology, the supply of otolaryngologists varies widely across geographic regions in the United States. For Medicare beneficiaries, regional hospital factors-including the presence of an otolaryngology residency program-may improve access to otolaryngology services.

LEVEL OF EVIDENCE

NA Laryngoscope, 127:95-101, 2017.

Association between Temporal Changes in Primary Care Workforce and Patient Outcomes

OBJECTIVE

To examine the association between 10-year temporal changes in the primary care workforce and Medicare beneficiaries' outcomes.

DATA SOURCES

2001 and 2011 American Medical Association Masterfiles and fee-for-service Medicare claims.

STUDY DESIGN/METHODS

We calculated two primary care workforce measures within Primary Care Service Areas: the number of primary care physicians per 10,000 population (per capita) and the number of Medicare primary care full-time equivalents (FTEs) per 10,000 Medicare beneficiaries. The three outcomes were mortality, ambulatory care-sensitive condition (ACSC) hospitalizations, and emergency department (ED) visits. We measured the marginal association between changes in primary care workforce and patient outcomes using Poisson regression models.

PRINCIPAL FINDINGS

An increase of one primary care physician per 10,000 population was associated with 15.1 fewer deaths per 100,000 and 39.7 fewer ACSC hospitalizations per 100,000 (both p < .05). An increase of one Medicare primary care FTE per 10,000 beneficiaries was associated with 82.8 fewer deaths per 100,000, 160.8 fewer ACSC hospitalizations per 100,000, and 712.3 fewer ED visits per 100,000 (all p < .05).

CONCLUSIONS

Medicare beneficiaries' outcomes improved as the number of primary care physicians and their clinical effort increased.

Geographic Distribution of Urologists in Korea, 2007 to 2012

The adequacy of the urologist work force in Korea has never been investigated. This study investigated the geographic distribution of urologists in Korea. County level data from the National Health Insurance Service and National Statistical Office was analyzed in this ecological study. Urologist density was defined by the number of urologists per 100,000 individuals. National patterns of urologist density were mapped graphically at the county level using GIS software. To control the time sequence, regression analysis with fitted line plot was conducted. The difference of distribution of urologist density was analyzed by ANCOVA. Urologists density showed an uneven distribution according to county characteristics (metropolitan cities vs. nonmetropolitan cities vs. rural areas; mean square=102.329, P<0.001) and also according to year (mean square=9.747, P=0.048). Regression analysis between metropolitan and non-metropolitan cities showed significant difference in the change of urologists per year (P=0.019). Metropolitan cities vs. rural areas and non-metropolitan cities vs. rural areas showed no differences. Among the factors, the presence of training hospitals was the affecting factor for the uneven distribution of urologist density (P<0.001). Uneven distribution of urologists in Korea likely originated from the relatively low urologist density in rural areas. However, considering the time sequencing data from 2007 to 2012, there was a difference between the increase of urologist density in metropolitan and non-metropolitan cities.

Toward graduate medical education (GME) accountability: measuring the outcomes of GME institutions

PURPOSE

Graduate medical education (GME) plays a key role in the U.S. health care workforce, defining its overall size and specialty distribution and influencing physician practice locations. Medicare provides nearly $10 billion annually to support GME and faces growing policy maker interest in creating accountability measures. The purpose of this study was to develop and test candidate GME outcome measures related to physician workforce.

METHOD

The authors performed a secondary analysis of data from the American Medical Association Physician Masterfile, National Provider Identifier file, Medicare claims, and National Health Service Corps, measuring the number and percentage of graduates from 2006 to 2008 practicing in high-need specialties and underserved areas aggregated by their U.S. GME program.

RESULTS

Average overall primary care production rate was 25.2% for the study period, although this is an overestimate because hospitalists could not be excluded. Of 759 sponsoring institutions, 158 produced no primary care graduates, and 184 produced more than 80%. An average of 37.9% of internal medicine residents were retained in primary care, including hospitalists. Mean general surgery retention was 38.4%. Overall, 4.8% of graduates practiced in rural areas; 198 institutions produced no rural physicians, and 283 institutions produced no Federally Qualified Health Center or Rural Health Clinic physicians.

CONCLUSIONS

GME outcomes are measurable for most institutions and training sites. Specialty and geographic locations vary significantly. These findings can inform educators and policy makers during a period of increased calls to align the GME system with national health needs.

Projecting surgeon supply using a dynamic model

OBJECTIVE

To develop a projection model to forecast the head count and full-time equivalent supply of surgeons by age, sex, and specialty in the United States from 2009 to 2028.

SUMMARY BACKGROUND DATA

The search for the optimal number and specialty mix of surgeons to care for the United States population has taken on increased urgency under health care reform. Expanded insurance coverage and an aging population will increase demand for surgical and other medical services. Accurate forecasts of surgical service capacity are crucial to inform the federal government, training institutions, professional associations, and others charged with improving access to health care.

METHODS

The study uses a dynamic stock and flow model that simulates future changes in numbers and specialty type by factoring in changes in surgeon demographics and policy factors.

RESULTS

: Forecasts show that overall surgeon supply will decrease 18% during the period form 2009 to 2028 with declines in all specialties except colorectal, pediatric, neurological surgery, and vascular surgery. Model simulations suggest that none of the proposed changes to increase graduate medical education currently under consideration will be sufficient to offset declines.

CONCLUSIONS

The length of time it takes to train surgeons, the anticipated decrease in hours worked by surgeons in younger generations, and the potential decreases in graduate medical education funding suggest that there may be an insufficient surgeon workforce to meet population needs. Existing maldistribution patterns are likely to be exacerbated, leading to delayed or lost access to time-sensitive surgical procedures, particularly in rural areas.

Multilevel analysis of the determinants of receipt of clinical preventive services among reproductive-age women

BACKGROUND

We investigated the impact of individual- and county-level contextual variables on women's receipt of a comprehensive panel of preventive services in a region that includes both urban and rural communities.

METHODS

Outcome variables were a screening and vaccination index (a count of Papanicolaou test, blood pressure check, lipid panel, sexually transmitted infections [STI] or HIV test, and influenza vaccination received in the past 2 years) and a preventivecounseling index (a count of topics discussed in the past 2 years: Smoking and tobacco, alcohol or drugs, violence and safety, pregnancy planning or contraception, diet/nutrition, and STIs). Contextual covariates from the Area Resource File (2004-2005) were appended to prospective survey data from the Central Pennsylvania Women's Health Study. Individual-level variables included predisposing, enabling, and need-based measures. Contextual variables included community characteristics and healthcare resources, including a measure of primary care physician (PCP) density specifically designed for this study of women's preventive care. Multilevel analyses were performed.

RESULTS

We found low overall use of preventive services. In multilevel models, individual-level factors predicted receipt of both screening and vaccinations and counseling services; significant predictors differed for each index. One contextual variable (PCP density) predicted receipt of screenings and vaccinations.

CONCLUSIONS

Women's receipt of preventive services was determined primarily by individual-level variables. Different variables predicted receipt of screening and vaccination versus counseling services. A contextual measure, PCP density, predicted receipt of preventive screenings and vaccinations. Individual variability in women's receipt of counseling services is largely explained by psychosocial factors and seeing an obstetrician-gynecologist.

Primary care physician workforce and Medicare beneficiaries' health outcomes

CONTEXT

Despite a widespread interest in increasing the numbers of primary care physicians to improve care and to moderate costs, the relationship of the primary care physician workforce to patient-level outcomes remains poorly understood.

OBJECTIVE

To measure the association between the adult primary care physician workforce and individual patient outcomes.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional analysis of the outcomes of a 2007 20% sample of fee-for-service Medicare beneficiaries aged 65 years or older (N = 5,132,936), which used 2 measures of adult primary care physicians (general internists and family physicians) across Primary Care Service Areas (N = 6542): (1) American Medical Association (AMA) Masterfile nonfederal, office-based physicians per total population and (2) office-based primary care clinical full-time equivalents (FTEs) per Medicare beneficiary derived from Medicare claims.

MAIN OUTCOME MEASURES

Annual individual-level outcomes (mortality, ambulatory care sensitive condition [ACSC] hospitalizations, and Medicare program spending), adjusted for individual patient characteristics and geographic area variables.

RESULTS

Marked variation was observed in the primary care physician workforce across areas, but low correlation was observed between the 2 primary care workforce measures (Spearman r = 0.056; P < .001). Compared with areas with the lowest quintile of primary care physician measure using AMA Masterfile counts, beneficiaries in the highest quintile had fewer ACSC hospitalizations (74.90 vs 79.61 per 1000 beneficiaries; relative rate [RR], 0.94; 95% confidence interval [CI], 0.93-0.95), lower mortality (5.38 vs 5.47 per 100 beneficiaries; RR, 0.98; 95% CI, 0.97-0.997), and no significant difference in total Medicare spending ($8722 vs $8765 per beneficiary; RR, 1.00; 95% CI, 0.99-1.00). Beneficiaries residing in areas with the highest quintile of primary care clinician FTEs compared with those in the lowest quintile had lower mortality (5.19 vs 5.49 per 100 beneficiaries; RR, 0.95; 95% CI, 0.93-0.96), fewer ACSC hospitalizations (72.53 vs 79.48 per 1000 beneficiaries; RR, 0.91; 95% CI, 0.90-0.92), and higher overall Medicare spending ($8857 vs $8769 per beneficiary; RR, 1.01; 95% CI, 1.004-1.02).

CONCLUSION

A higher level of primary care physician workforce, particularly with an FTE measure that may more accurately reflect ambulatory primary care, was generally associated with favorable patient outcomes.

The adoption and use of health information technology in rural areas: results of a national survey

CONTEXT

Health information technology (HIT) is a national policy priority. Knowledge about the special needs, if any, of rural health care providers should be taken into account as policy is put into action. Little is known, however, about rural-urban differences in HIT adoption at the national level.

PURPOSE

To conduct the first national assessment of HIT in rural primary care offices, with particular attention to electronic medical record (EMR) adoption, range of capabilities in use, and plans for adoption.

METHODS

A national mail survey of 5,200 primary care offices, stratified by rurality using Rural-Urban Commuting Area categories, was conducted in 2007-2008. Regression analyses were used to assess the relationship between office characteristics and EMR adoption, capabilities used, and future adoption plans.

RESULTS

A commercial EMR system was present in 31% of offices, with no significant differences by rurality. Of offices with EMRs, 12% reported using a full range of EMR capabilities, with 51% using a basic range and 37% using less than the basic range. Large Rural (adjusted OR = 3.71, P= .022) and Small Rural (aOR = 3.75, P= .049) offices were more likely than Urban offices to use a broader range of EMR capabilities. Among offices without EMRs, those in Isolated areas were less likely to have more immediate plans to adopt (aOR = 0.19, P= .02).

CONCLUSIONS

HIT adoption and use in rural primary care offices does not appear to be lower than in urban offices. The situation, however, is dynamic and warrants further monitoring.

Associations of physician supplies with colon cancer care in Ontario and California, 1996 to 2006

BACKGROUND

This study examined the differential effects of physician supplies on colon cancer care in Ontario and California. The associations of physician supplies with colon cancer stage at diagnosis, receipt of surgery and adjuvant chemotherapy, and 5-year survival were observed within each country and compared between-country.

METHODS

Random samples of Ontario and California cancer registries provided 2,461 and 2,200 colon cancer cases that were diagnosed between 1996 and 2000, and followed until 2006. Both registries included data on the stage of disease at the time of diagnosis, receipt of cancer-directed surgery, receipt of adjuvant chemotherapy, and survival. Census tract-level data on low-income prevalence were, respectively, taken from 2001 and 2000 Canadian and United States population censuses. County-level primary care physician and gastroenterologist densities were computed for the same years.

RESULTS

Significant income-adjusted, gastroenterologist density threshold effects (2.0 or more vs. less than 2.0 per 100,000 inhabitants) were observed for early diagnosis (OR = 1.57) and 5-year survival (OR = 1.63) in Ontario, but not in California. Significant incremental threshold effects of primary care physician densities on chemotherapy receipt (8.0 and 9.0 or more per 10,000 inhabitants, respective ORs of 1.79 and 2.37) were also only observed in Ontario.

CONCLUSIONS

These colon cancer care findings support the theory that while personal economic resources are more predictive in America, community-level resources such as physician supplies are more predictive of health care access and effectiveness in Canada.

The supply of physicians and care for breast cancer in Ontario and California, 1998 to 2006

INTRODUCTION

We examined the differential effects of the supply of physicians on care for breast cancer in Ontario and California. We then used criteria for optimum care for breast cancer to estimate the regional needs for the supply of physicians.

METHODS

Ontario and California registries provided 951 and 984 instances of breast cancer diagnosed between 1998 and 2000 and followed until 2006. These cohorts were joined with the supply of county-level primary care physicians (PCPs) and specialists in cancer care and compared on care for breast cancer.

RESULTS

Significant protective PCP thresholds (7.75 to = 8.25 PCPs per 10 000 inhabitants) were observed for breast cancer diagnosis (odds ratio [OR] 1.62), receipt of adjuvant radiotherapy (OR 1.64) and 5-year survival (OR 1.87) in Ontario, but not in California. The number of physicians seemed adequate to optimize care for breast cancer across diverse places in California and in most Ontario locations. However, there was an estimated need for 550 more PCPs and 200 more obstetrician-gynecologists in Ontario's rural and small urban areas. We estimated gross physician surpluses for Ontario's 2 largest cities.

CONCLUSION

Policies are needed to functionally redistribute primary care and specialist physicians. Merely increasing the supply of physicians is unlikely to positively affect the health of Ontarians.

Do international medical graduates (IMGs) "fill the gap" in rural primary care in the United States? A national study

CONTEXT

The contribution that international medical graduates (IMGs) make to reducing the rural-urban maldistribution of physicians in the United States is unclear. Quantifying the extent of such "gap filling" has significant implications for planning IMG workforce needs as well as other state and federal initiatives to increase the numbers of rural providers.

PURPOSE

To compare the practice location of IMGs and US medical graduates (USMGs) practicing in primary care specialties.

METHODS

We used the 2002 AMA physician file to determine the practice location of all 205,063 primary care physicians in the United States. Practice locations were linked to the Rural-Urban Commuting Areas, and aggregated into urban, large rural, small rural, and isolated small rural areas. We determined the difference between the percentage of IMGs and percentage of USMGs in each type of geographic area. This was repeated for each Census Division and state.

FINDINGS

One quarter (24.8% or 50,804) of primary care physicians in the United States are IMGs. IMGs are significantly more likely to be female (31.9% vs 29.9%, P < .0001), older (mean ages 49.7 and 47.1 year, P < .0001), and less likely to practice family medicine (19.0% vs 38%, P < .0001) than USMGs. We found only two Census Divisions in which IMGs were relatively more likely than USMGs to practice in rural areas (East South Central and West North Central). However, we found 18 states in which IMGs were more likely, and 16 in which they were less likely to practice in rural areas than USMGs.

CONCLUSIONS

IMGs fill gaps in the primary care workforce in many rural areas, but this varies widely between states. Policies aimed to redress the rural-urban physician maldistribution in the United States should take into account the vital role of IMGs.

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.

Sentinel physician networks as a technique for rapid immunization policy surveys

This study compared the use of mail and Internet surveys of sentinel networks of physicians with traditional random sample mail surveys for three national vaccine policy surveys. Three nationally representative sentinel networks of physicians were established (pediatricians, n = 427; general internists, n = 438; and family physicians, n = 433). Surveys of the sentinel networks were compared with simultaneous surveys conducted with random samples of the American Medical Association (AMA) Physician Masterfile. Response rates were 74% to 78% for sentinel surveys and 29% to 43% for traditional random sample surveys. Respondents to the two methods were generally comparable in demographic characteristics. While there were some differences in responses to survey topic questions, none of the differences were likely to affect policy decisions. Sentinel networks represent the opinions and experiences of physicians in a manner equivalent to traditional mail surveys and may provide a more efficient approach to conducting physician surveys.

The TennCare graduate medical education plan: ten years later

BACKGROUND

In 1994, Tennessee converted its Medicaid program to a managed care system--TennCare. Graduate medical education (GME) funding by TennCare was linked to several workforce goals that included increasing the number of residents training in primary care and increasing the number of primary care physicians practicing in underserved areas of Tennessee.

OBJECTIVES

To determine the effects of the TennCare GME plan on GME and the physician workforce of Tennessee.

DESIGN, SETTING, AND PARTICIPANTS

Bureau of TennCare GME data from 1996-2004 and American Medical Association Physician Masterfile data through 2003.

MEASUREMENTS

Changes in filled residency positions and number of stipend supplements awarded after implementation of the TennCare GME plan. Changes in physician workforce characteristics between a 5-year period before and after implementation of TennCare.

RESULTS

Filled primary care residency positions increased from 839 (45.2%) in 1996 to 906 (47.9%) in 2000, but declined to 862 (43.5%) by 2004. Eleven of 133 available primary care stipend supplements were awarded through 2004. The percentage of physicians remaining in Tennessee after completion of residency decreased from 46.2% before TennCare to 42.4% (P = .087) after implementation of TennCare. U.S. medical graduates remaining in state declined by 5.8% (P = .019).

CONCLUSIONS

The major goals of the TennCare GME plan have not been achieved. Overall, physician retention has decreased and the number of U.S. medical graduates remaining in state has declined. State policymakers should consider other methods to increase the number of residents training in primary care and ultimately practicing in underserved areas of Tennessee.

Changes in physician supply and scope of practice during a malpractice crisis: evidence from Pennsylvania

The extent to which liability costs cause physicians to restrict their scope of practice or cease practicing is controversial in policy debates over malpractice "crises." We used insurance department administrative data to analyze specialist physician scope-of-practice changes and exits in Pennsylvania in 1993-2002. In most specialties the proportions of high-risk specialists restricting their scope of practice did not increase during the crisis; however, the supply of obstetrician-gynecologists decreased by 8 percent in the three years following premium increases in 1999. We discuss methodological issues that could explain the disparate findings regarding physician supply effects in studies using administrative data sets and survey data.

Counting physicians: inconsistencies in a commonly used source for workforce analysis

PURPOSE

To assess the accuracy of the AMA Masterfile.

METHOD

In 2002, the authors compared the listing in the Masterfile for pediatric cardiologists with a roster of all such physicians documented by the American Board of Pediatrics (ABP) to have completed pediatric cardiology training. Physicians listed on the Masterfile but without ABP records of training completion received a mail survey. For main outcome measures, the differences in state-level distribution of pediatric cardiologists were used, depending on whether data were from the ABP or the AMA Masterfile. Survey items included nature and duration of medical training, the amount of time caring for pediatric or adult cardiology patients, and whether the respondent conducted echocardiograms and/or cardiac catheterizations on children and/or adults.

RESULTS

Of the 2,675 unique, individual physicians obtained from the queries of both lists, 58% (1,558) were listed by both the Masterfile and the ABP. Another 28% (738) were listed by the AMA Masterfile only, and 4% (108) were listed by the ABP only.Of those listed by the Masterfile only, 40% reported they provide no pediatric cardiology care. The amount of pediatric cardiology training was highly variable among the remainder of the respondents.

CONCLUSIONS

There are large differences in the number and distribution of physicians identified as pediatric cardiologists between these two datasets. Also, many are potentially providing care for which they have little or no training. Use of such data has the potential to lead to policy options at odds with the actual needs of our nation as a whole or of specific geographic areas.

Effects of physician supply on melanoma incidence and mortality in Florida

BACKGROUND

Increasing supplies of dermatologists and family physicians have been associated with earlier detection of malignant melanoma. We investigated whether physician supply was similarly related to incidence and mortality rates of malignant melanoma.

METHODS

Using the state tumor registry, we determined melanoma incidence and mortality rates for the years 1993 to 1995 for each Florida county. We measured physician supply for each Florida county using data from the 1994 American Medical Association Physician Masterfile. Multiple linear regression analysis was used to determine relationships between physician supply and melanoma incidence and mortality rates, controlling for other county-level characteristics.

RESULTS

Among male patients, an increasing supply of family physicians was associated with higher melanoma incidence and lower melanoma mortality. Increasing supplies of dermatologists were associated with lower overall melanoma mortality rates, and increasing supplies of general internists were associated with higher overall melanoma mortality.

CONCLUSION

We found that melanoma incidence and mortality rates varied substantially among Florida's 67 counties, and that differences in physician supply explained some of this variability. Further study is needed to confirm these findings and to elucidate possible mechanisms that would account for these associations.

Variation in predictors of primary care career choice by year and stage of training

CONTEXT

It is not known whether factors associated with primary care career choice affect trainees differently at different times or stages of medical education.

OBJECTIVE

To examine how role models, encouragement, and personal characteristics affect career choice at different stages (medical school vs residency) and periods (1994 vs 1997) of training.

DESIGN

A split-panel design with 2 cross-sectional telephone surveys and a panel survey in 1994 and 1997.

PARTICIPANTS

A national probability sample of fourth-year students (307 in 1994, 219 in 1997), 645 second-year residents in 1994, and 494 third-year residents in 1997. Of the fourth-year students interviewed in 1994, 241 (78.5%) were re-interviewed as third-year residents in 1997.

MAIN OUTCOME MEASURE

Primary care (general internal medicine, general pediatrics, or family medicine) career choice.

RESULTS

Having a primary care role model was a stronger predictor of primary care career choice for residents (odds ratio [OR], 18.0; 95% confidence interval [95% CI], 11.2 to 28.8 in 1994; OR, 43.7; 95% CI, 24.4 to 78.3 in 1997) than for students (OR, 6.5; 95% CI, 4.3 to 10.2; no variation by year). Likewise, peer encouragement was more predictive for residents (OR, 5.4; 95% CI, 3.3 to 8.9 in 1994; OR, 16.6; 95% CI; 9.7 to 28.4 in 1997) than for students (OR, 2.1; 95% CI, 1.3 to 3.2; no variation by year). Orientation to the emotional aspects of care was consistently associated with primary care career choice across stages and years of training.

CONCLUSIONS

The effect of peer encouragement and role models on career choice differed for students and residents and, in the case of residents, by year of training, suggesting that interventions to increase the primary care workforce should be tailored to stage of training.

Generalist and subspecialist care for children with chronic conditions

OBJECTIVE

To determine, among Medicaid-enrolled children with chronic conditions, associations of indicators of morbidity and expenditures with different patterns of generalist, subspecialist, and pediatric subspecialist use.

DESIGN AND SETTING

Cross-sectional analysis of Medicaid claims, enrollment, and provider data from 4 states (California, Georgia, Michigan, and Tennessee).

SAMPLE

All children enrolled in Supplemental Security Income (aged 0-21 years) and a sample of other Medicaid-enrolled children matched for age and gender. We included 11 chronic conditions, including both uncommon conditions (eg, spina bifida, hemophilia) and common ones (eg, asthma, attention deficit hyperactivity disorder).

MAIN OUTCOME MEASURES

We determined the number of visits per year to generalists and subspecialists (pediatric and other), using only subspecialists relevant to that condition. We categorized patterns of care as generalist only, predominantly generalist, or predominantly subspecialist, and examined patterns by condition and an indicator of morbidity. Among children seeing subspecialists, we also compared morbidity by pediatric and other subspecialists. We used linear regression to determine per-year total expenditures, controlling for demographic characteristics and morbidity.

RESULTS

Most children (60.7%) saw generalists only. Twenty-eight percent were in predominantly generalist arrangements, and 11% were in predominantly subspecialist arrangements. Children in predominantly generalist arrangements had higher morbidity than children in generalist-only or predominantly subspecialist arrangements. Among children seeing subspecialists, those seeing pediatric subspecialists had generally higher morbidity than those seeing other subspecialists. Mean yearly expenditures varied from 1306 dollars (attention deficit hyperactivity disorder) to 11,633 dollars (acquired immunodeficiency syndrome). Children who saw only generalists had significantly lower expenditures for 6 of the 11 conditions, after adjusting for morbidity.

CONCLUSIONS

Medicaid-enrolled children in predominantly generalist arrangements appear to have more complicated conditions than children in generalist-only or predominantly subspecialist arrangements, engendering also higher expenditures. Although children who saw generalists only had lower expenditures than those seeing subspecialists, this finding may reflect unmeasured variations in morbidity.

Who cares for medicaid-enrolled children with chronic conditions?

OBJECTIVE

To estimate generalist, pediatric subspecialist, and any subspecialist use by Medicaid-enrolled children with chronic conditions and to determine the correlates of use.

METHODS

We analyzed Medicaid claims data collected from 1989 to 1992 from 4 states for 57 328 children and adolescents with 11 chronic conditions. We calculated annual rates of generalist, subspecialist, and pediatric subspecialist use. We used logistic regression to determine the association of demographics, urban residence, and case-mix (Adjusted Clinical Groups) with the use of relevant pediatric and any subspecialist care.

RESULTS

Most children with chronic conditions had visits to generalists (range per condition: 78%-90% for children with Supplemental Security Income [SSI] and 85%-94% for children without SSI) during the year studied. Fewer children visited any relevant subspecialists (24%-59% for children with SSI and 13%-56% for children without SSI) or relevant pediatric subspecialists (10%-53% for children with SSI and 3%-37% for children without SSI). In general, children who were more likely to use pediatric subspecialists were younger, lived in urban areas, were white (only significant for non-SSI children), and had higher Adjusted Clinical Groups scores. Use of any subspecialists followed a similar pattern except that urban residence is statistically significant only for children with SSI and the youngest age group does not differ from the oldest age group for children without SSI.

CONCLUSIONS

Children who had chronic conditions and were enrolled in Medicaid received a majority of their care from generalist physicians. For most conditions, a majority of children did not receive any relevant subspecialty care during the year and many of these children did not receive care form providers with pediatric-specific training.

Management of hepatitis C patients by primary care physicians in the USA: results of a national survey

Hepatitis C is a major health problem worldwide, yet very little research has been performed to assess the knowledge base and practice patterns of primary care physicians (PCPs) regarding hepatitis C. The aim of this study is to determine the knowledge base and practice patterns of a nationwide cohort of PCPs. A survey was developed to assess the knowledge of PCPs regarding risk factors for hepatitis C, management of hepatitis C patients and attitude regarding testing for hepatitis C. The survey was mailed to 4000 PCPs in the USA. A total of 1412 (39%) PCPs completed the survey. The vast majority, > 90%, of PCPs correctly identified the most common risk factors for hepatitis C. However, only 59% indicated they ask all patients about hepatitis C risk factors, 70% reported they test all patients with hepatitis C risk factors and 78% test all patients with elevated liver enzymes for hepatitis C. Most (72%) PCPs would refer an HCV-positive patient with elevated aminotransferase but only 28% would refer an HCV-positive patient with normal aminotransferase to a specialist. One-fourth of the PCPs did not know what treatment to recommend for hepatitis C patients. Our data suggest that hepatitis C patients may be underdiagnosed and under-referred. Specific educational initiatives and practice guidelines for PCPs are needed to optimize the recognition of patients at risk for hepatitis C and to ensure appropriate testing and referral.

Confidence of primary care physicians in assessing the suicidality of geriatric patients

This study examined the confidence levels of physicians in assessing the risk of suicide among older adults in clinical settings. Of the 300 physicians who were selected from a population of 4980 family practice, internal medicine, and geriatric physicians in Illinois, 63% responded to the mail survey. Several categorical items inquired about specific assessment and treatment approaches, referral resources used, barriers to meeting the mental health needs of older patients, and sources of training in suicide risk assessment. All the training items (suicide assessment in medical school, residency, and CME courses; rating of medical school training; and insufficient training in geriatric mental health) were significantly (p < 0.01) associated with confidence in assessing suicidality. The overall model consisting of six variables explained 57% of the variation in confidence scores [F (6, 130) = 28.48, p < 0.001]. Three variables accounted for 50% of the explained variance: confidence in diagnosing depression, residency training in the assessment of suicide risk, and assessment of the intentional misuse of medication. Confidence in diagnosing depression (beta = 0.38, p < 0.001) was the strongest predictor. More effective mental health care will require specific preparation in treating geriatric patients through the full spectrum of medical training, including medical school, residency, and CME courses. Improved prevention of elderly suicide hinges on the enhancement of clinical skills in diagnosing and treating geriatric depression.

Marketplace reforms and primary care career decisions

A dramatic shift in the postgraduate career choices of medical school graduates toward primary care occurred during the mid-1990s. While some attributed this shift to changes in medical school curricula, perceptions stemming from marketplace reforms were probably responsible. For the most part, these perceptions were probably generated through informal communications among medical students and through the media. More recently, additional marketplace influences, such as the consumer backlash toward managed care and unrealized gains in primary care physicians' personal incomes, may have fostered contrasting perceptions among medical students, leading to career choices away from primary care, particularly family practice. The authors offer two recommendations for enhancing the knowledge of medical students concerning workforce supply and career opportunities: an educational seminar in the second or third year of medical school, and a public-private partnership between the Bureau of Health Professions and the Association of American Medical Colleges to create a national database about the shape of the primary care and specialty workforces, accessible through the Internet for educators, students, and policymakers. The authors conclude that appropriate career counseling through these efficient methods could avoid future abrupt swings in specialty choices of medical school graduates and may facilitate a more predictable physician workforce supply.

Hospitalization rates as indicators of access to primary care

Variations in hospitalization rates for selected conditions are being used as indicators of the effectiveness of primary care in small areas. Are these rates actually sensitive to problems in local primary care systems? This study examines the relationship between ambulatory care sensitive condition (ACSC) hospital admission rates and primary care resources and the economic conditions in primary care market areas in North Carolina in 1994. The data show a high degree of correlation between the rates and income but not primary care resources. The distribution of rates did agree with expert assessments of the location of places with poor access to health services. The data confirm that access to effective primary care reflected in lower rates of ACSC admissions is a function of more than the professional resources available in a market area. The solution to reducing disparities in health status may not lie within the health system.

Using the American Medical Association physician masterfile to measure physician supply in small towns

The goal of this study was to describe the magnitude, direction and sources of error of the American Medical Association's (AMA) masterfile (MF) in estimating physician supply in small towns. A random sample of nonmetropolitan towns in the United States was selected, and physicians with AMA MF (MFMDs) addresses in these towns were listed. Local pharmacists were asked to confirm or disconfirm the identities and locations of practice for the listed physicians and to add any unlisted physicians who were there. We took pharmacist confirmed or identified local source physicians (LSMDs) to be the "gold standard." The sample of 57 towns yielded 1,341 potential physician names. In these towns, there were 377 physician listings only from the MF, 188 only from local pharmacists, and 776 from both sources. About 80 percent of physicians identified by local informants were also listed on the MF; only 67 percent of physicians listed on the MF were identified by local informants as currently practicing in the town where they were listed. The error in these measures declined with increasing town size. The aggregate ratio of MFMDs to LSMDs was 1.20, ranging from 1.10 to 1.28 across size classes of towns. Given the persistence of local shortages of physicians, despite a national oversupply, accurate measurement of physician supply should be a priority of rural health care planners and advocates. Although the MF is the most comprehensive available national physician database, reliance on it alone to make local estimates of physician supply might lead one to believe that there are 20 percent more physicians in small rural communities than are actually there. Local pharmacists can be valuable informants about rural physician availability and their in- and out-migration.

How many rural doctors do we have?

The number of physicians practicing in the nonmetropolitan areas of the United States in relation to population has increased over the past two decades, but more slowly than the number of physicians in metropolitan counties. During the same period, there was a growing acceptance of the perception that the physician work force in the United States exceeded the number necessary to meet the requirements of an efficient health care system. This has caused policy-makers to consider reforming the incentives for training physicians and restricting the entry of physicians from other countries into the United States. The supply figures on which these assessments of oversupply were made are based on "head counts" of the number of licensed, active physicians. By using more detailed data describing the licensed practicing physicians in the states of North Carolina and Washington, and by using estimates of professional activity collected as part of the Socioeconomic Monitoring System of the American Medical Association, estimates of the number of full-time equivalent physicians actually in practice in the two states and the comparative productivity of those physicians were made. Based on the state-level data, the estimates of actively practicing physicians are approximately 14 percent lower than the head-count number in North Carolina and, by using a more conservative estimation method, are approaching a 10 percent lower number than the head-count number in Washington. Using national productivity data, the effective supply of nonmetropolitan physicians appears to have not grown significantly over the past 10 years, and for family physicians the supply has declined by 9 percent. These estimates of the effective physician supply support long-held claims that rural communities continue to experience a severe undersupply of practitioners. These results suggest that the way in which physicians are counted needs to be re-examined, especially in rural places where the ratios of providers to population are more sensitive to small changes in supply.

Trends in the rural-urban distribution of general pediatricians

OBJECTIVE

A major objective of national and state health policy has been to increase primary care physician supply in rural areas. It is not known whether this objective has been met for general pediatricians. This study examines trends in the rural-urban distribution of general pediatricians in the United States from 1981 to 1996.

DESIGN

Descriptive serial cross-sectional study.

PARTICIPANTS

At selected 5-year intervals, all clinically active general pediatricians in the United States listed in the American Medical Association Physician Masterfile.

MAIN OUTCOME MEASURES

The proportion of pediatricians practicing in rural counties and the ratio of pediatricians to the child population (per 100 000 children <18 years old) for US counties.

RESULTS

Between 1981 and 1996, the total number of general pediatricians increased from 19 739 to 34 100. However, rural pediatrician-to-child population ratios (PCPRs) remained well below urban ratios. Although rural counties of all population sizes experienced some gains over time, only those over 25 000 populations had a meaningful increase in their PCPR. Overall, the urban PCPR increased by 14.0 (or an additional pediatrician for every 7150 children) whereas the rural ratio only increased by 4.1 (an additional pediatrician for every 24 400 children). The percentage of recent residency graduates opting for rural practice declined by half (14.6% to 7.4%) over the 15-year study period. Women and international graduates were consistently less likely to practice in rural counties than were men and US graduates, respectively.

CONCLUSIONS

The near doubling in general pediatrician numbers from 1981 to 1996 yielded only a modest increase in pediatrician availability for rural children. The discrepancy between urban and rural pediatrician supply increased during this period and should continue growing based on the increasingly urban location of recent residency graduates and the continued growth of women in pediatrics. New policy strategies are needed to improve rural pediatrician availability, including focusing on larger rural counties and addressing barriers to rural practice for women. pediatrics/manpower, pediatrics/trends, rural health, physicians/supply and distribution, medically underserved area.

Increasing supplies of dermatologists and family physicians are associated with earlier stage of melanoma detection

BACKGROUND

Physicians are important in the early detection of melanoma. We investigated whether primary care physician supply and the supply of dermatologists were related to stage at diagnosis for malignant melanoma.

METHODS

From the state tumor registry in Florida in 1994, we identified incident cases of malignant melanoma for which stage at diagnosis was available (N = 1884). Data on physician supply was obtained from the 1994 American Medical Association Physician Masterfile. Logistic regression determined the effects of physician supply (at the ZIP code level) on the odds of early-stage diagnosis controlling for patients' age, gender, race/ethnicity, marital status, education level, income level, comorbidity, and type of health insurance.

RESULTS

Each additional dermatologist per 10,000 population was associated with a 39% increased odds of early diagnosis (odds ratio = 1.39, 95% confidence interval [CI] 1.09-1.70, P =.010). For each additional family physician per 10,000 population, the odds of early diagnosis increased 21% (odds ratio = 1.21, 95% CI 1.09-1.33, P <.001). Each additional general internist per 10,000 population was associated with a 10% decrease in the odds of early-stage diagnosis (odds ratio = 0.90, 95% CI 0.83-0.98, P =.009). The supplies of general practitioners, obstetrician/gynecologists, and other nonprimary care specialists were not associated with stage at diagnosis.

CONCLUSIONS

Increasing supplies of dermatologists and family physicians were associated with earlier detection of melanoma. In contrast, increasing supplies of general internists were associated with reduced odds of early detection. Our findings suggest that the composition of the physician work force may affect important health outcomes and needs further study.

Care and outcomes of elderly patients with acute myocardial infarction by physician specialty: the effects of comorbidity and functional limitations

PURPOSE

Whether patients with acute myocardial infarction who are treated by cardiologists have better outcomes than patients treated by generalist physicians is controversial. Because some of the survival benefit associated with cardiology care may be due to baseline differences in patient characteristics, we evaluated how differences in case-mix of comorbid illness and functional limitations may explain the association between specialty care and survival.

MATERIALS AND METHODS

We examined the records of 109,243 Medicare beneficiaries hospitalized for myocardial infarction from 1994 to 1995 from the national Cooperative Cardiovascular Project to evaluate the association of physician specialty with 30-day and 1-year mortality. We assessed the extent to which this relation was mediated by differences in the use of guideline-supported therapies (aspirin, beta-blockers, reperfusion, angiotensin-converting enzyme inhibitors) or differences in the clinical characteristics of the patients.

RESULTS

Patients who had board-certified cardiologists as attending physicians had the least number of comorbid conditions, whereas patients who had general practitioners or internal medicine subspecialists as attending physicians usually had the most comorbidities. Cardiologists had the greatest use of most guideline-supported therapies, and general practitioners had the lowest use. After adjustment for severity of myocardial infarction, clinical presentation, and hospital characteristics, patients treated by cardiologists were less likely to die within 1 year (relative risk [RR] = 0.92, 95%, confidence interval [CI]: 0.89 to 0. 95), and patients cared for by other general practitioners were more likely to die within 1 year (RR = 1.09, 95% CI: 1.03 to 1.14), than patients cared for by general internists. After adjusting for additional measures of comorbid illness and functional limitations, the 1-year survival benefit associated with cardiology care was attenuated relative to internists (RR = 0.97, 95% CI: 0.94 to 1.0), and the excess mortality associated with general practitioners decreased (RR = 1.05, 95% CI: 1.00 to 1.11). After further adjustment for the use of guideline-supported therapies, both differences in 1-year survival between patients treated by cardiologists or general practitioners were not significantly different from those of patients treated by internists.

CONCLUSION

Studies comparing outcomes by physician specialties that do not adjust adequately for differences in patient characteristics may attribute more benefit than is appropriate to specialists who treat patients who have fewer comorbid conditions. Some of the remaining benefit-at least among patients with myocardial infarction-may be attributable to greater use of recommended therapies.

Who is a generalist? An analysis of whether physicians trained as generalists practice as generalists

Accurate data on the number of generalist physicians are needed to monitor the physician workforce and to plan for future requirements in the changing health care system. This study assessed the relationship between two frequently used definitions of a generalist physician: completion of graduate medical education (GME) in only a generalist discipline and physician's self-report of practicing as a generalist. Data for 4,808 physician graduates from six Pennsylvania medical schools from 1986 to 1991 were analyzed using information from the GME tracking census of the Association of American Medical Colleges and the Physician Masterfile of the American Medical Association. Of 1,291 physicians trained in a generalist discipline, 1,205 (93%) reported practicing as generalists. Conversely, of the 3,517 not trained in a generalist discipline, 3,358 (95%) were not practicing as generalists. These results indicate GME training is a valid predictor of self-reported practice and provide baseline data to monitor future changes.

Preventing tuberculosis among HIV-infected persons: a survey of physicians' knowledge and practices

BACKGROUND

Guidelines exist for screening, diagnosing, and preventing tuberculosis (TB) among HIV-infected persons, but their application and utility are unknown.

METHODS

We conducted a survey of knowledge and practices among 1,300 physicians in the San Francisco Bay area to assess their practices towards TB among HIV-infected persons.

RESULTS

Of 630 respondents, 350 (56%) provided care for HIV-infected persons. Thirty-four percent of the respondents had seen the most recent guidelines for preventing tuberculosis among HIV-infected persons; 65% routinely provide information to HIV-infected patients about the risks of exposure to Mycobacterium tuberculosis; 39% provide annual tuberculin skin testing (TST) to HIV-infected patients without a history of a positive test; 86% knew that >/=5-mm induration is considered a positive TST result in HIV-infected persons; and 47% provide a 12-month regimen of chemoprophylaxis for HIV-infected persons who have a positive TST but not active tuberculosis. Physician specialty and experience with HIV-infected persons were not strongly correlated; experience was a better predictor of correct knowledge and practices.

CONCLUSIONS

Many physicians were not aware of the standards of care for preventing tuberculosis among HIV-infected patients, even in a geographic area with a high prevalence of M. tuberculosis and HIV.

Self-reported physician specialties and the primary care content of medical practice: a study of the AMA physician masterfile. American Medical Association

BACKGROUND

Many internal medicine physicians report both primary and secondary specialties in the American Medical Association (AMA) Physician Masterfile. Usually, those represent combinations of general internal medicine and medical subspecialty practice. Whether reported specialty combinations can be used to assess the contribution of specialists to primary care is unknown.

OBJECTIVES

To examine whether internists' primary and secondary specialties reported in the Masterfile reflect the amount of primary care that they provide, and whether changes over time in internists' reported specialties reflect changes in primary care provision.

DESIGN

The Masterfile was used to identify internists' reported specialties in 1992 and in 1996. A mail questionnaire was used to assess the primary care content of physicians' practices. The association between reported specialties and the amount of primary care provided was evaluated using analysis of variance.

SUBJECTS

A stratified random sample of internists in active clinical practice.

MEASURES

The percentage of visits which were for the general medical care of patients for whom the physicians maintained ongoing responsibility. In addition, how often the physicians initiated the provision of preventive care for their regular patients, provided general medical care to these patients, and organized and coordinated the care received by these patients from other providers.

RESULTS

There was a strong association between the internists' primary and secondary specialties reported in the Masterfile and measures of the primary care content of physicians' practices (P < 0.0001). In contrast, changes over time in internists' reported specialties were not associated with physicians' assessments of changes in the primary care content of their practices.

CONCLUSIONS

Aggregate estimates of the availability of primary care in the US could be adjusted by taking into account the primary and secondary specialties reported by internal medicine physicians in the AMA Physician Masterfile.

Do international medical graduates reduce rural physician shortages?

OBJECTIVES

The authors examined whether international medical graduates (IMGs) constitute a greater percentage of the US physician workforce in rural underserved areas than in rural non-underserved areas. Research findings could help policymakers determine whether the role of international medical graduates in compensating for local physician shortages counterbalances international medical graduates' potential for exacerbating a national oversupply.

METHODS

This research was based on data from the American Medical Association Physician Masterfile and the Bureau of Health Professions' Area Resource File. The authors calculated the percentage international medical graduates of all US primary care physicians in rural areas, stratified by the Health Professional Shortage Area (HPSA) designation of underservice.

RESULTS

The study showed that international medical graduates do constitute a greater percentage of US primary care physicians in rural areas with physician shortages than in rural areas without physician shortages. This finding held true at the national, Census region, and state scales of analysis, but to varying degrees. The finer the scale of analysis, the greater the variation in international medical graduates' practice in rural, underserved areas. There was substantial interstate variation in the extent to which international medical graduates practice in rural underserved areas.

CONCLUSIONS

International medical graduates do help reduce rural physician shortages, but interstate variation points to the role of state policies in influencing international medical graduates' distribution in rural, underserved areas. Such variation also can come about from many different causes, so there is a need for further research to determine why international medical graduates help compensate for physician shortages more so in some states than in others.

Influence of cardiac-surgery performance reports on referral practices and access to care. A survey of cardiovascular specialists

BACKGROUND

Reports on the comparative performance of physicians are becoming increasingly common. Little is known, however, about the credibility of these reports with target audiences or their influence on the delivery of medical services.

METHODS

Since 1992, Pennsylvania has published the Consumer Guide to Coronary Artery Bypass Graft Surgery, which lists annual risk-adjusted mortality rates for all hospitals and surgeons providing such surgery in the state. In 1995, we surveyed a randomly selected sample of 50 percent of Pennsylvania cardiologists and cardiac surgeons to find out whether they were aware of the guide and, if so, to determine their views on its usefulness, limitations, and influence on providers.

RESULTS

Eighty-two percent of the cardiologists and all the cardiac surgeons were aware of the guide. Only 10 percent of these respondents reported that its mortality rates were "very important" in assessing the performance of a cardiothoracic surgeon. Less than 10 percent reported discussing the guide with more than 10 percent of their patients who were candidates for a coronary-artery bypass graft (CABG). Eighty-seven percent of the cardiologists reported that the guide had a minimal influence or none on their referral recommendations. For both groups, the most important limitations of the guide were the absence of indicators of quality other than mortality (cited by 78 percent), inadequate risk adjustment (79 percent), and the unreliability of data provided by hospitals and surgeons (53 percent). Fifty-nine percent of the cardiologists reported increased difficulty in finding surgeons willing to perform CABG surgery in severely ill patients who required it, and 63 percent of the cardiac surgeons reported that they were less willing to operate on such patients.

CONCLUSIONS

The Consumer Guide to Coronary Artery Bypass Graft Surgery has limited credibility among cardiovascular specialists. It has little influence on referral recommendations and may introduce a barrier to care for severely ill patients. If publicly released performance reports are intended to guide the choice of providers without impeding access to medical care, a collaborative process involving physicians may enhance the credibility and usefulness of the reports.