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Thomas RL, Millett C, Sousa Soares RD, Hone T. More doctors, better health? A generalised synthetic control approach to estimating impacts of increasing doctors under Brazil's Mais Medicos programme. Soc Sci Med 2024; 358:117222. [PMID: 39181082 DOI: 10.1016/j.socscimed.2024.117222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/10/2024] [Accepted: 08/09/2024] [Indexed: 08/27/2024]
Abstract
Worldwide, there are an insufficient number of primary care physicians to provide accessible, high-quality primary care services. Better knowledge on the health impacts of policies aimed at improving access to primary care physicians is important for informing future policies. Using a generalised synthetic control estimator (GSC), we estimate the effect of the increase in primary care physicians from the Programa Mais Médicos in Brazil. The GSC allows us to estimates a continuous treatment effects which are heterogenous by region. We exploit the variation in physicians allocated to each Brazilian microregion to identify the impact of an increasing Mais Médicos primary care physicians. We explore hospitalisations and mortality rates (both total and from ambulatory care sensitive conditions) as outcomes. Our analysis differs from previous work by estimating the impact of the increase in physician numbers, as opposed to the overall impact of programme participation. We examine the impact on hospitalisations and mortality rates and employ a panel dataset with monthly observations of all Brazilian microregion over the period 2008-2017. We find limited effects of an increase in primary care physicians impacting health outcomes - with no significant impact of the Programa Mais Médicos on hospitalisations or mortality rates. Potential explanations include substitution of other health professionals, impacts materialising over the longer-term, and poor within-region allocation of Mais Médicos physicians.
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Affiliation(s)
- Rhys Llewellyn Thomas
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Christopher Millett
- Public Health Policy Evaluation Unit, Imperial College London, London, UK; NOVA National School of Public Health, Public Health Research Centre, Comprehensive Health Research Center, CHRC, NOVA University Lisbon, Lisbon, Portugal
| | | | - Thomas Hone
- Public Health Policy Evaluation Unit, Imperial College London, London, UK
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2
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Hoffer EP. Primary Care in the United States: Past, Present and Future. Am J Med 2024; 137:702-705. [PMID: 38499134 DOI: 10.1016/j.amjmed.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 03/11/2024] [Accepted: 03/12/2024] [Indexed: 03/20/2024]
Abstract
Even though a well-functioning primary care system is widely acknowledged as critical to population health, the number of primary care physicians (PCPs) practicing in the United States has steadily declined, and PCPs are in short supply. The reasons are multiple and include inadequate income relative to other specialties, excessive administrative demands on PCPs and the lack of respect given to primary care specialties during medical school and residency. Advanced practice nurses can augment the services of primary care physicians but cannot substitute for them. To change this situation, we need action on several fronts. Medical schools should give preference to students who are more likely to enter the primary care specialties. The income gap between primary care and other specialties should be narrowed. The administrative load placed on PCPs, including cumbersome electronic medical records, must be lessened. Insurers, including Medicare and Medicaid, must provide the resources to allow primary care physicians to act as leaders of multidisciplinary teams.
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O'Rourke P, Tackett S, Chacko K, Knaus SJ, Shalaby M, Fluker SA, Ma M, Overland M, Wright S. Factors Influencing Primary Care Career Choice: A Multi-Institutional Cross-sectional Survey of Internal Medicine Primary Care Residency Graduates. J Gen Intern Med 2024:10.1007/s11606-024-08846-z. [PMID: 38900381 DOI: 10.1007/s11606-024-08846-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Although primary care is associated with population health benefits, the supply of primary care physicians continues to decline. Internal medicine (IM) primary care residency programs have produced graduates that pursue primary care; however, it is uncertain what characteristics and training factors most affect primary care career choice. OBJECTIVE To assess factors that influenced IM primary care residents to pursue a career in primary care versus a non-primary care career. DESIGN Multi-institutional cross-sectional study. PARTICIPANTS IM primary care residency graduates from seven residency programs from 2014 to 2019. MAIN MEASURES Descriptive analyses of respondent characteristics, residency training experiences, and graduate outcomes were performed. Bivariate logistic regression analyses were used to assess associations between primary care career choice with both graduate characteristics and training experiences. KEY RESULTS There were 256/314 (82%) residents completing the survey. Sixty-six percent of respondents (n = 169) practiced primary care or primary care with a specialized focus such as geriatrics, HIV primary care, or women's health. Respondents who pursued a primary care career were more likely to report the following as positive influences on their career choice: resident continuity clinic experience, nature of the PCP-patient relationship, ability to care for a broad spectrum of patient pathology, breadth of knowledge and skills, relationship with primary care mentors during residency training, relationship with fellow primary care residents during training, and lifestyle/work hours (all p < 0.05). Respondents who did not pursue a primary care career were more likely to agree that the following factors detracted them from a primary care career: excessive administrative burden, demanding clinical work, and concern about burnout in a primary care career (all p < 0.05). CONCLUSIONS Efforts to optimize the outpatient continuity clinic experience for residents, cultivate a supportive learning community of primary care mentors and residents, and decrease administrative burden in primary care may promote primary care career choice.
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Affiliation(s)
- Paul O'Rourke
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - Sean Tackett
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Biostatistics, Epidemiology, and Data Management Core, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Karen Chacko
- Department of Medicine, University of Colorado, Denver, CO, USA
| | | | - Marc Shalaby
- Department of Medicine, Pennsylvania Hospital, Philadelphia, PA, USA
| | | | - Mina Ma
- Department of Medicine, UCLA, Los Angeles, CA, USA
| | - Maryann Overland
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Scott Wright
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Mahlknecht A, Engl A, Barbieri V, Bachler H, Obwegeser A, Piccoliori G, Wiedermann CJ. Attitudes towards career choice and general practice: a cross-sectional survey of medical students and residents in Tyrol, Austria. BMC MEDICAL EDUCATION 2024; 24:294. [PMID: 38491385 PMCID: PMC10943776 DOI: 10.1186/s12909-024-05205-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/21/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND The global primary healthcare workforce is declining, leading to a shortage of general practitioners. Although various educational models aim to increase interest in general practice, effective interventions are limited. The reasons for this low appeal among medical graduates remain unclear. METHODS This cross-sectional study surveyed medical students' and residents' attitudes towards general practice in Tyrol, Austria. The online questionnaire addressed professional values, general practice-related issues, personal professional intentions, and demographics. Data analysis employed chi-square tests and multivariate logistic regression to explore predictors of interest in general practice. RESULTS The study included 528 students and 103 residents. Key values identified were stable positions, assured income, and work-family reconciliation. General practice was recognised for long-term patient relationships and patient contact, with students attributing more positive work-environmental characteristics and higher reputation to it than residents. Few participants (students: 3.2%, residents: 11.7%) had opted for general practice; about half were considering it as career option. Reasons not to choose general practice were preferences for other specialties, intrinsic characteristics of general practice, workload, insufficient time for the patients, financial pressures, low reputation, and perceived mediocre training quality. Predictors of interest in general practice included perception of independent decision-making, importance of work-family balance (students), better practical experiences in general practice during medical school (students and residents), younger age, and perceiving general practice as offering a promising future (residents). Both groups felt underprepared by medical school and/or general practice training for general practice roles. The attractiveness of specialist medicine over general practice was related to clearer content boundaries, better career opportunities, and higher incomes. CONCLUSIONS According to these results, measures to improve attractiveness of general practice should focus on (i) high-quality undergraduate education including practical experiences, and (ii) on ensuring professional autonomy, work-family reconciliation, and job stability. Efforts to encourage more graduates to pursue this essential healthcare sector are crucial for strengthening primary healthcare and public health services. TRIAL REGISTRATION The study has not been registered as it did not include a direct medical intervention on human participants.
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Affiliation(s)
- Angelika Mahlknecht
- Institute of General Practice and Public Health, College of Health Care Professions, Lorenz-Boehler-street 13, Bolzano, 39100, Italy.
| | - Adolf Engl
- Institute of General Practice and Public Health, College of Health Care Professions, Lorenz-Boehler-street 13, Bolzano, 39100, Italy
| | - Verena Barbieri
- Institute of General Practice and Public Health, College of Health Care Professions, Lorenz-Boehler-street 13, Bolzano, 39100, Italy
| | - Herbert Bachler
- Institute of General Practice, Medical University Innsbruck, Christoph-Probst-square 1, Innsbruck, 6020, Austria
| | - Alois Obwegeser
- Department of Neurosurgery, University Hospital of Innsbruck, Anich-street 35, Innsbruck, 6020, Austria
| | - Giuliano Piccoliori
- Institute of General Practice and Public Health, College of Health Care Professions, Lorenz-Boehler-street 13, Bolzano, 39100, Italy
| | - Christian J Wiedermann
- Institute of General Practice and Public Health, College of Health Care Professions, Lorenz-Boehler-street 13, Bolzano, 39100, Italy.
- UMIT - Private University for Health Sciences, Medical Informatics and Technology - Tyrol, Eduard- Wallnöfer-center 1, Hall in Tirol, 6060, Austria.
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Hashtarkhani S, Schwartz DL, Shaban-Nejad A. Enhancing Health Care Accessibility and Equity Through a Geoprocessing Toolbox for Spatial Accessibility Analysis: Development and Case Study. JMIR Form Res 2024; 8:e51727. [PMID: 38381503 PMCID: PMC10918552 DOI: 10.2196/51727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/26/2023] [Accepted: 01/11/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Access to health care services is a critical determinant of population health and well-being. Measuring spatial accessibility to health services is essential for understanding health care distribution and addressing potential inequities. OBJECTIVE In this study, we developed a geoprocessing toolbox including Python script tools for the ArcGIS Pro environment to measure the spatial accessibility of health services using both classic and enhanced versions of the 2-step floating catchment area method. METHODS Each of our tools incorporated both distance buffers and travel time catchments to calculate accessibility scores based on users' choices. Additionally, we developed a separate tool to create travel time catchments that is compatible with both locally available network data sets and ArcGIS Online data sources. We conducted a case study focusing on the accessibility of hemodialysis services in the state of Tennessee using the 4 versions of the accessibility tools. Notably, the calculation of the target population considered age as a significant nonspatial factor influencing hemodialysis service accessibility. Weighted populations were calculated using end-stage renal disease incidence rates in different age groups. RESULTS The implemented tools are made accessible through ArcGIS Online for free use by the research community. The case study revealed disparities in the accessibility of hemodialysis services, with urban areas demonstrating higher scores compared to rural and suburban regions. CONCLUSIONS These geoprocessing tools can serve as valuable decision-support resources for health care providers, organizations, and policy makers to improve equitable access to health care services. This comprehensive approach to measuring spatial accessibility can empower health care stakeholders to address health care distribution challenges effectively.
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Affiliation(s)
- Soheil Hashtarkhani
- Center for Biomedical Informatics, Department of Pediatrics, College of Medicine, The University of Tennessee Health Science Center, Memphis, TN, United States
| | - David L Schwartz
- Department of Radiation Oncology, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Arash Shaban-Nejad
- Center for Biomedical Informatics, Department of Pediatrics, College of Medicine, The University of Tennessee Health Science Center, Memphis, TN, United States
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Gjessing S, Guldberg TL, Risør T, Skals RG, Kristensen JK. Would you like to be a general practitioner? Baseline findings of a longitudinal survey among Danish medical trainees. BMC MEDICAL EDUCATION 2024; 24:111. [PMID: 38317110 PMCID: PMC10845756 DOI: 10.1186/s12909-024-05074-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/19/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Recruiting and securing primary care physician workforce has been the center of international attention for decades. In Denmark, the number of general practitioners has decreased by 8.5% since 2013. However, a rising population age and increasing prevalence of chronic diseases and multimorbidity place an even greater future need for general practitioners in Denmark. The choice of general practice as specialty has been associated with a range of both intrinsic and extrinsic factors, however, few studies have examined the recruitment potential that lies within medical trainees' who are undecided about general practice specialization. The aim of this study was, therefore, to explore how medical trainees who are undecided about general practice specialization (GP-positive/undecided) differ from medical trainees who are either committed (GP-committed) or not committed to a general practice career (GP-non-committed) regarding factors related to future work life. METHODS The present study concerns baseline findings from a longitudinal survey study. An online questionnaire was e-mailed to a national cohort of medical trainees during their transition from under- to postgraduate education. The associations between orientations towards general practice specialization and work-related factors and potential influencing factors, respectively, were analyzed using uni- and multivariable modified Poisson regression models. RESULTS Of 1,188 invited participants, 461 filled out key study variables concerning specialty preferences and rejections, corresponding to a response rate of 38.8%. We found significant positive associations between GP-positive/undecided orientation and valuing a good work/life balance and the opportunity to organize own working hours when compared to GP-non-committed respondents. Compared to the GP-committed orientations, the GP-positive/undecided orientation was associated with a positive attitude towards technology, working shift hours, and an openness towards several career paths. Across all orientations, undergraduate exposure to the specialties was found to be highly influential on the specialty preferences. CONCLUSION GP-positive/undecided medical trainees value autonomy over their working hours more than the GP-non-committed, but less than the GP-committed. However, the GP-positive/undecided respondents present more openness to different career opportunities and the use of technology in daily work. We suggest using this knowledge in the planning of recruitment strategies aiming to increase interest in general practice specialization.
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Affiliation(s)
- Sofie Gjessing
- Center for General Practice, Aalborg University, Aalborg, Denmark.
| | - Trine Lignell Guldberg
- Department of Postgraduate Medical Education, Aalborg University Hospital, Aalborg, Denmark
| | - Torsten Risør
- Section for General Practice & Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Section for General Practice, Department of Community Medicine, UiT, The Arctic University of Norway, Tromsø, Norway
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Larrabee Sonderlund A, Williams NJ, Charifson M, Ortiz R, Sealy-Jefferson S, De Leon E, Schoenthaler A. Structural racism and health: Assessing the mediating role of community mental distress and health care access in the association between mass incarceration and adverse birth outcomes. SSM Popul Health 2023; 24:101529. [PMID: 37841218 PMCID: PMC10570581 DOI: 10.1016/j.ssmph.2023.101529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/01/2023] [Accepted: 10/03/2023] [Indexed: 10/17/2023] Open
Abstract
Research has linked spatial concentrations of incarceration with racial disparities in adverse birth outcomes. However, little is known about the specific mechanisms of this association. This represents an important knowledge gap in terms of intervention. We theorize two pathways that may account for the association between county-level prison rates and adverse birth outcomes: (1) community-level mental distress and (2) reduced health care access. Examining these mechanisms, we conducted a cross-sectional study of county-level prison rates, community-level mental distress, health insurance, availability of primary care physicians (PCP) and mental health providers (MHP), and adverse birth outcomes (preterm birth, low birth weight, infant mortality). Our data set included 475 counties and represented 2,677,840 live U.S. births in 2016. Main analyses involved between 170 and 326 counties. All data came from publicly available sources, including the U.S. Census and the Centers for Disease Control and Prevention. Descriptive and regression results confirmed the link between prison rates and adverse birth outcomes and highlighted Black-White inequities in this association. Further, bootstrap mediation analyses indicated that the impact of spatially concentrated prison rates on preterm birth was mediated by PCP, MHP, community-level mental distress, and health insurance in both crude and adjusted models. Community-level mental distress and health insurance (but not PCP or MHP) similarly mediated low birthweight in both models. Mediators were less stable in the effect on infant mortality with only MHP mediating consistently across models. We conclude that mass incarceration, health care access, and community mental distress represent actionable and urgent targets for structural-, community-, and individual-level interventions targeting population inequities in birth outcomes.
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Affiliation(s)
- Anders Larrabee Sonderlund
- Center for Healthful Behavior Change, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, USA
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Denmark
| | - Natasha J. Williams
- Center for Healthful Behavior Change, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, USA
| | - Mia Charifson
- Department of Population Health, NYU Grossman School of Medicine, USA
- Vilcek Institute of Graduate Biomedical Sciences, NYU Grossman School of Medicine, USA
| | - Robin Ortiz
- Center for Healthful Behavior Change, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, USA
- Department of Pediatrics, NYU Grossman School of Medicine, USA
| | | | - Elaine De Leon
- Department of Population Health, NYU Grossman School of Medicine, USA
| | - Antoinette Schoenthaler
- Center for Healthful Behavior Change, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, USA
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Wind K, Poland B, HakemZadeh F, Jackson S, Tomlinson G, Jadad A. Using self-reported health as a social determinants of health outcome: a scoping review of reviews. Health Promot Int 2023; 38:daad165. [PMID: 38041807 DOI: 10.1093/heapro/daad165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2023] Open
Abstract
Reducing disease prevalence rather than promoting health has long been the objective of significant population health initiatives, such as the social determinants of health (SDH) framework. However, empirical evidence suggests that people with diagnosed diseases often answer the self-reported health (SRH) question positively. In pursuit of a better proxy to understand, measure and improve health, this scoping review of reviews examines the potential of SRH to be used as an outcome of interest in population health policies. Following PRISMA-ScR guidelines, it synthesizes findings from 77 review papers (published until 11 May 2022) and reports a robust association between SDH and SRH. It also investigates inconsistencies within and between reviews to reveal how variation in population health can be explained by studying the impact of contextual factors, such as cultural, social, economic and political elements, on structural determinants such as socioeconomic situation, gender and ethnicity. These insights provide informed hypotheses for deeper explorations of the role of SDH in improving SRH. The review detects several gaps in the literature. Notably, more evidence syntheses are required, in general, on the pathway from contextual elements to population SRH and, in particular, on the social determinants of adolescents' SRH. This study reports a disease-oriented mindset in collecting, analysing and reporting SRH across the included reviews. Future studies should utilize the capability of SRH in interconnecting social, psychological and biological dimensions of health to actualize its full potential as a central public health measure.
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Affiliation(s)
- Keiwan Wind
- DeGroote School of Business, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4M4, Canada
| | - Blake Poland
- Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, Toronto, Ontario M5T 3M7, Canada
| | - Farimah HakemZadeh
- Faculty of Liberal Arts and Professional Studies, School of Human Resources Management, York University, 4700 Keele Street, Toronto, Ontario M3J 1P3, Canada
| | - Suzanne Jackson
- Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, Toronto, Ontario M5T 3M7, Canada
| | - George Tomlinson
- Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, Toronto, Ontario M5T 3M7, Canada
| | - Alejandro Jadad
- Centre for Digital Therapeutics, R. Fraser Elliott Building, 4th Floor, 190 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada
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Reinke CE, Slawson DC. Maintenance Matters and Compliance Conundrums-Optimization of Emergency General Surgery Outcomes in the Prehospital Phase of Care. JAMA Surg 2023; 158:1030-1031. [PMID: 37466989 DOI: 10.1001/jamasurg.2023.2748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Affiliation(s)
- Caroline E Reinke
- Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina
| | - David C Slawson
- Department of Family Medicine, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina
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Castle JT, Levy BE, Mangino AA, McDonald HG, McAtee E, Patel JA, Evers BM, Bhakta AS. Impact of the Affordable Care Act on Providing Equitable Healthcare Access for IBD in the Kentucky Appalachian Region. Dis Colon Rectum 2023; 66:1273-1281. [PMID: 37399124 PMCID: PMC10527721 DOI: 10.1097/dcr.0000000000002942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
BACKGROUND Medicaid expansion improved insurance coverage for patients with chronic conditions and low income. The effect of Medicaid expansion on patients with IBD from high-poverty communities is unknown. OBJECTIVE This study aimed to evaluate the impact of Medicaid expansion in Kentucky on care for patients with IBD from the Eastern Kentucky Appalachian community, a historically impoverished area. DESIGN This study was a retrospective, descriptive, and ecological study. SETTINGS This study was conducted in Kentucky using the Hospital Inpatient Discharge and Outpatient Services Database. PATIENTS All encounters for IBD care for 2009-2020 for patients from the Eastern Kentucky Appalachian region were included. MAIN OUTCOME MEASURES The primary outcomes measured were proportions of inpatient and emergency encounters, total hospital charge, and hospital length of stay. RESULTS Eight hundred twenty-five preexpansion and 5726 postexpansion encounters were identified. Postexpansion demonstrated decreases in the uninsured (9.2%-1.0%; p < 0.001), inpatient encounters (42.7%-8.1%; p < 0.001), emergency admissions (36.7%-12.3%; p < 0.001), admissions from the emergency department (8.0%-0.2%; p < 0.001), median total hospital charge ($7080-$3260; p < 0.001), and median total hospital length of stay (4-3 days; p < 0.001). Similarly, postexpansion demonstrated increases in Medicaid coverage (18.8%-27.7%; p < 0.001), outpatient encounters (57.3%-91.9%; p < 0.001), elective admissions (46.9%-76.2%; p < 0.001), admissions from the clinic (78.4%-90.2%; p < 0.001), and discharges to home (43.8%-88.2%; p < 0.001). LIMITATIONS This study is subject to the limitations inherent in being retrospective and using a partially de-identified database. CONCLUSION This study is the first to demonstrate the changes in trends in care after Medicaid expansion for patients with IBD in the Commonwealth of Kentucky, especially Appalachian Kentucky, showing significantly increased outpatient care utilization, reduced emergency department encounters, and decreased length of stays. IMPACTO DE LA LEY DEL CUIDADO DE SALUD A BAJO PRECIO EN LA PROVISIN DE ACCESO EQUITATIVO A LA ATENCIN MDICA PARA LA ENFERMEDAD INFLAMATORIA INTESTINAL EN LA REGIN DE LOS APALACHES DE KENTUCKY ANTECEDENTES: La expansión de Medicaid mejoró la cobertura de seguro para pacientes con enfermedades crónicas y bajos ingresos. Se desconoce el efecto de la expansión de Medicaid en pacientes con enfermedad inflamatoria intestinal de comunidades de alta pobreza.OBJETIVO: Este estudio tuvo como objetivo evaluar el impacto de la expansión de Medicaid en Kentucky en la atención de pacientes con enfermedad inflamatoria intestinal de la comunidad de los Apalaches del este de Kentucky, un área históricamente empobrecida.DISEÑO: Este estudio fue un estudio retrospectivo, descriptivo, ecológico.ESCENARIO: Este estudio se realizó en Kentucky utilizando la base de datos de servicios ambulatorios y de alta hospitalaria en pacientes hospitalizados.PACIENTES: Se incluyeron todos los encuentros para la atención de la enfermedad inflamatoria intestinal de 2009-2020 para pacientes de la región de los Apalaches del este de Kentucky.MEDIDAS DE RESULTADO PRINCIPALES: Los resultados primarios medidos fueron proporciones de encuentros de pacientes hospitalizados y de emergencia, cargo hospitalario total y duración de la estancia hospitalaria.RESULTADOS: Se identificaron 825 encuentros previos a la expansión y 5726 posteriores a la expansión. La posexpansión demostró disminuciones en los no asegurados (9.2% a 1.0%, p < 0.001), encuentros de pacientes hospitalizados (42.7% a 8.1%, p < 0.001), admisiones de emergencia (36.7% a 12.3%, p < 0,001), admisiones desde el servicio de urgencias (8.0% a 0.2%, p < 0.001), la mediana de los gastos hospitalarios totales ($7080 a $3260, p < 0.001) y la mediana de la estancia hospitalaria total (4 a 3 días, p < 0.001). De manera similar, la cobertura de Medicaid (18.8% a 27.7%, p < 0.001), consultas ambulatorias (57.3% a 91.9%, p < 0.001), admisiones electivas (46.9% a 76.2%, p < 0.001), admisiones desde la clínica (78.4% al 90.2%, p < 0.001), y las altas domiciliarias (43.8% al 88.2%, p < 0.001) aumentaron después de la expansión.LIMITACIONES: Este estudio está sujeto a las limitaciones inherentes de ser retrospectivo y utilizar una base de datos parcialmente desidentificada.CONCLUSIONES: Este estudio es el primero en demostrar los cambios en las tendencias en la atención después de la expansión de Medicaid para pacientes con enfermedad inflamatoria intestinal en el Estado de Kentucky, especialmente en los Apalaches de Kentucky, mostrando un aumento significativo en la utilización de la atención ambulatoria, visitas reducidas al departamento de emergencias y menor duración de la estancia hospitalaria. (Traducción-Dr. Jorge Silva Velazco ).
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Affiliation(s)
- Jennifer T. Castle
- Department of Surgery, University of Kentucky, Lexington, Kentucky
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Brittany E. Levy
- Department of Surgery, University of Kentucky, Lexington, Kentucky
| | - Anthony A. Mangino
- Department of Biostatistics, University of Kentucky, Lexington, Kentucky
| | - Hannah G. McDonald
- Department of Surgery, University of Kentucky, Lexington, Kentucky
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Erin McAtee
- Department of Surgery, University of Kentucky, Lexington, Kentucky
| | - Jitesh A. Patel
- Department of Surgery, University of Kentucky, Lexington, Kentucky
- Division of Colorectal Surgery, University of Kentucky, Lexington, Kentucky
| | - B. Mark Evers
- Department of Surgery, University of Kentucky, Lexington, Kentucky
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Avinash S. Bhakta
- Department of Surgery, University of Kentucky, Lexington, Kentucky
- Division of Colorectal Surgery, University of Kentucky, Lexington, Kentucky
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Harper PG, Van Riper K, Ramer T, Slattengren A, Adam P, Smithson A, Wicks C, Martin C, Wootten M, Carlson S, Miller E, Fallert C. Team-based care: an expanded medical assistant role - enhanced rooming and visit assistance. J Interprof Care 2023; 37:S95-S101. [PMID: 30388911 DOI: 10.1080/13561820.2018.1538107] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/16/2018] [Accepted: 10/08/2018] [Indexed: 01/17/2023]
Abstract
Primary care practices face significant challenges as they pursue the Quadruple Aim. Redistributing care across the interprofessional primary care team by expanding the role of the medical assistant (MA) is a potential strategy to address these challenges. Two sequential, linked processes to expand the role of the MA, called Enhanced Rooming and Visit Assistance, were implemented in four family medicine residency clinics in Minnesota. In Enhanced Rooming, MAs addressed preventive services, obtained a preliminary visit agenda, and completed a warm hand-off to the provider. In Visit Assistance, MAs stayed in the room the entire visit to assist with the visit workflow. Enhanced Rooming and Visit Assistance processes were successfully implemented and sustained for over one year. MAs and providers were satisfied with both processes, and patients accepted the expanded MA roles. Mammogram ordering rates increased from 10% to 25% (p < 0.0001). After Visit Summary (AVS) print rates increased by 12% (p < 0.0001). Visit Turn-Around-Time (TAT) decreased 3.1 minutes per visit (p = 0.0001). Expanding the MA role in a primary care interprofessional team is feasible and a potentially useful tool to address the Quadruple Aim.
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Affiliation(s)
- Peter G Harper
- Department of Family Medicine & Community Health, University of Minnesota, Minneapolis, MN, USA
| | | | - Timothy Ramer
- Department of Family Medicine & Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Andrew Slattengren
- Department of Family Medicine & Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Patricia Adam
- Department of Family Medicine & Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Angela Smithson
- Department of Family Medicine & Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Cherilyn Wicks
- Department of Family Medicine & Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Casey Martin
- Department of Family Medicine & Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Michael Wootten
- Department of Family Medicine & Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Samantha Carlson
- Department of Family Medicine & Community Health, University of Minnesota, Minneapolis, MN, USA
| | | | - Christopher Fallert
- Department of Family Medicine & Community Health, University of Minnesota, Minneapolis, MN, USA
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12
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Dasappa H, Agrawal T, Joy M, Ravindran GD. Knowledge, attitude, and practice of patients, visiting a private primary level health care facility towards family physicians. J Family Med Prim Care 2023; 12:1185-1189. [PMID: 37636188 PMCID: PMC10451603 DOI: 10.4103/jfmpc.jfmpc_2507_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/25/2023] [Accepted: 03/02/2023] [Indexed: 08/29/2023] Open
Abstract
Aim and Objective To study the knowledge, perception, attitude, and practice of patients visiting a private primary health centre towards family physicians. Methodology A cross-sectional questionnaire-based study was planned. Results A total of 272 patients visiting the health centre were included in the study. Knowledge Above 90% of the patients felt confident in the capabilities of family physicians in managing all kinds of health problems and the time/cost-effectiveness of this speciality. Timely referral and holistic care were other areas that boosted their confidence on family physicians. 96.7% knew that family physicians are trained specialists. Attitude Although only 50% of the study participants were already seeking the services of a family physician, 88% of them felt that a family physician would be their primary point of contact in their health care needs. Practice The positive attitude, knowledge, and perception towards family medicine were not reflected on their treatment seeking practice in areas of care, such as childcare (66.2%) and pregnancy (81.6%), where they preferred the services of a specialist. Also, for diabetes (52%) and chest pain (66%) related issues, the patients favoured a specialist's care over that of a family physician. Conclusion Patients visiting our primary health centre had good knowledge and positive perception about the family physicians. Preference for specialists over family physicians was seen for conditions such as chest pain, diabetes care, child care, and obstetrics issues.
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Affiliation(s)
- Hemavathi Dasappa
- Department of Family Medicine, St John’s Medical College, Bengaluru, Karnataka, India
| | - Twinkle Agrawal
- Department of Community Health, St John’s Medical College, Bengaluru, Karnataka, India
| | - Manuel Joy
- Department of Family Medicine, St John’s Medical College, Bengaluru, Karnataka, India
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13
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Everhart AR, Ferguson L, Wilson JP. Measuring Geographic Access to Transgender Hormone Therapy in Texas: A Three-step Floating Catchment Area Analysis. Spat Spatiotemporal Epidemiol 2023; 45:100585. [PMID: 37301600 DOI: 10.1016/j.sste.2023.100585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 12/31/2022] [Accepted: 04/07/2023] [Indexed: 06/12/2023]
Abstract
While the extant literature has established that transgender people face significant barriers to accessing healthcare, no studies to date have offered an explicitly spatial analysis of their access to trans-specific care. This study aims to fill that gap by providing a spatial analysis of access to gender-affirming hormone therapy (GAHT) using Texas as a case study. We used the three-step floating catchment area method, which relies on census tract-level population data and location data for healthcare facilities to quantify spatial access to healthcare within a specific drive-time window, in our case 120 min. For our tract-level population estimates we adapt estimates of the rates of transgender identification from a recent data source, the Household Pulse Survey, and use these in tandem with a spatial database of GAHT providers of the lead author's creation. We then compare results of the 3SFCA with data on urbanicity and rurality, as well as which areas are deemed medically underserved. Finally, we conduct a hot-spot analysis that identifies specific areas where health services could be planned in ways that could improve both access to GAHT for trans people and access to primary care for the general population. Ultimately, we conclude that our results illustrate that patterns of access to trans-specific medical care, like GAHT, do not neatly follow patterns of access to primary care for the general population and that therefore trans communities' access to healthcare warrants specific, further investigation.
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Affiliation(s)
- Avery R Everhart
- Center for Applied Transgender Studies, Chicago, IL, USA; School of Information, University of Michigan, Ann Arbor, MI, USA; Department of Health Behavior & Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA.
| | - Laura Ferguson
- Keck School of Medicine, Institute on Inequalities in Global Health, University of Southern California, Los Angeles, CA, USA
| | - John P Wilson
- Dana & David Dornsife College of Letters, Arts and Sciences, Spatial Sciences Institute, University of Southern California, Los Angeles, CA, USA
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14
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Watanabe S, Kataoka K, Sekine M, Aune D, Shikino K, Nishizaki Y. Characteristics of University Hospitals Implementing the Postgraduate Clinical Training "Tasukigake Method" and Their Correlation with Program Popularity: A Cross-Sectional Study. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2023; 14:323-332. [PMID: 37026061 PMCID: PMC10072141 DOI: 10.2147/amep.s402259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/13/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE In 2004, the postgraduate clinical training system in Japan was radically revised by introducing a super-rotation matching system. Although postgraduate clinical training became a mandatory 2 years of training, the program and operation were left to each facility's discretion, leading to training-program popularity differences. The Japanese Tasukigake method provides clinical training in which "hospitals where junior residents work" and "external hospitals/clinics that provide clinical training" conduct clinical training alternately on a 1-year basis. The study aimed to identify the characteristics of university hospitals that implement the Tasukigake method to help educators and medical institutions create more attractive and effective programs. METHODS All 81 university main hospitals were included in this cross-sectional study. The information regarding Tasukigake method implementation was collected from the facilities' websites. The training program's matching rate (popularity) was calculated from the Japan Residency Matching Program's interim report data (academic 2020). We used multiple linear regression analysis to evaluate the association between Tasukigake method implementation, program popularity, and university hospital characteristics. RESULTS The Tasukigake method was implemented by 55 (67.9%) university hospitals, significantly more by public university hospitals (44/55, 80%) than by private (11/55, 20%) (P < 0.01) and by hospitals without branches (38/55, 69.1%) than with branches (17/55, 30.9%) (P < 0.001). The maximum hiring capacity of junior residents (P = 0.015) and number of branches (P < 0.001) were negatively correlated, and the population of the hospital's city (P = 0.003) and salary/month (P = 0.011) were positively correlated with the Tasukigake method implementation. Multiple linear regression analysis results showed no significant association between the matching rate (popularity) and Tasukigake method implementation. CONCLUSION The results show no association between Tasukigake method and program popularity; also, highly specialized university hospitals in cities with fewer branch hospitals were more likely to implement the Tasukigake method.
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Affiliation(s)
- Sadatoshi Watanabe
- Clinical Translational Science, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Koshi Kataoka
- Division of Medical Education, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Miwa Sekine
- Division of Medical Education, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - David Aune
- Division of Medical Education, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Kiyoshi Shikino
- Department of Medical Education, Chiba University School of Medicine, Chiba, Japan
| | - Yuji Nishizaki
- Clinical Translational Science, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Division of Medical Education, Juntendo University Faculty of Medicine, Tokyo, Japan
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15
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Gao J, Moran E, Grimm R, Toporek A, Ruser C. The Effect of Primary Care Visits on Total Patient Care Cost: Evidence From the Veterans Health Administration. J Prim Care Community Health 2022; 13:21501319221141792. [PMID: 36564889 PMCID: PMC9793026 DOI: 10.1177/21501319221141792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Since the 1980s, primary care (PC) in the US has been recognized as the backbone of healthcare providing comprehensive care to complex patients, coordinating care among specialists, and rendering preventive services to contain costs and improve clinical outcomes. However, the effect of PC visits on total patient care cost has been difficult to quantify. OBJECTIVE To assess the effect of PC visits on total patient care cost. METHODS This is a retrospective study of over 5 million patients assigned to a PC provider in the Veterans Health Administration (VHA) in each of the 4 fiscal years (FY 2016-2019). The main outcome of interest is total annual patient care cost. We assessed the effect of primary care visits on total patient care cost first by descriptive statistics, and then by multivariate regressions adjusting for severity of illness and other confounders. We conducted in-depth sensitivity analyses to validate the findings. RESULTS On average, each additional in-person PC visit was associated with a total cost reduction of $721 (per patient per year). The first PC visit was associated with the largest savings, $3976 on average, and a steady diminishing return was observed. Further, the higher the patient risk (severity of illness), the larger the cost reduction: Among the top 10% of high-risk patients, the first PC in-person visit was associated with a reduction of $16 406 (19%). CONCLUSIONS These findings, substantiated by our exhaustive sensitivity analyses, suggest that expanding PC capacity can significantly reduce overall health care costs and improve patient care outcomes given the former is a strong proxy of the latter.
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Affiliation(s)
- Jian Gao
- Department of Veterans Affairs, Office
of Productivity, Efficiency and Staffing (OPES), Office of Analytics and Performance
Improvement,Jian Gao, Department of Veterans Affairs,
Office of Productivity, Efficiency and Staffing, Office of Analytics and
Performance Improvement, 67 Veterans Way, Albany, NY 12208, USA.
| | - Eileen Moran
- Department of Veterans Affairs, Office
of Productivity, Efficiency and Staffing (OPES), Office of Analytics and Performance
Improvement
| | | | - Andrew Toporek
- Department of Veterans Affairs, Office
of Productivity, Efficiency and Staffing (OPES), Office of Analytics and Performance
Improvement
| | - Christopher Ruser
- VACT Healthcare System, Yale University
School of Medicine, New Haven, CT, USA
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16
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Yamadori Y, Hirao T, Kanda K, Shirakami G. The number of physicians is related to the number of nighttime emergency surgeries in Japan: An ecological study. PLoS One 2022; 17:e0278517. [PMID: 36454998 PMCID: PMC9714914 DOI: 10.1371/journal.pone.0278517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/17/2022] [Indexed: 12/05/2022] Open
Abstract
PURPOSE Increasing the number of physicians per population may improve the quality of medical services, but there are few reports on this aspect in the field of surgery. This study aimed to examine whether the number of physicians is associated with the number of nighttime emergency surgeries, which may be one of the indicators of the quality of medical services in the field of surgery. METHODS This was a prefecture-based ecological study utilizing open data from Japanese government surveys conducted between 2015 and 2019. The relationship between the number of physicians and the number of nighttime emergency surgeries in 47 prefectures of Japan was evaluated by correlation analysis and panel data regression analysis. The correlation analysis was conducted between the number of physicians per 100,000 population and the number of nighttime emergency surgeries per 100,000 population per year in each prefecture in Japan. In the panel data regression analysis, panel data of the prefectures in Japan from 2015 to 2019 were created. We evaluated whether the number of physicians was related to the number of nighttime emergency surgeries, independent of the number of acute care beds per 100,000 population, population density, and the elderly population ratio. RESULTS From the correlation analysis, the correlation coefficient between the number of physicians per 100,000 population and the number of nighttime emergency surgeries per 100,000 population was 0.533 (P < 0.001). In the panel data regression analysis, there was a significant association between the number of physicians per 100,000 population and the number of nighttime emergency surgeries per 100,000 population (P < 0.001). The regression coefficient (95% confidence interval) for the number of physicians per 100,000 population was 0.246 (0.113-0.378). CONCLUSION The number of physicians is associated with the number of nighttime emergency surgeries.
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Affiliation(s)
- Yusuke Yamadori
- Department of Anesthesiology, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
- Department of Anesthesiology, Takamatsu Red Cross Hospital, Takamatsu, Kagawa, Japan
- Department of Public Health, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
- * E-mail:
| | - Tomohiro Hirao
- Department of Public Health, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Kanae Kanda
- Department of Public Health, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
| | - Gotaro Shirakami
- Department of Anesthesiology, Faculty of Medicine, Kagawa University, Miki-cho, Kagawa, Japan
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17
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Ford MM, Allard A, Goldberg J, Summers C. Federally Qualified Health Center Penetration Associated With Reduced Community COVID-19 Mortality in Four United States Cities. J Prim Care Community Health 2022; 13:21501319221138422. [PMID: 36448474 PMCID: PMC9716186 DOI: 10.1177/21501319221138422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has had significant impacts on health care access and delivery, with disparate effects across social and racial lines. Federally Qualified Health Centers (FQHCs) provide critical primary care services to the nation's most underserved populations, including many communities hardest hit by COVID-19. METHODS We conducted an ecological analysis that aimed to examine FQHC penetration, COVID-19 mortality, and socio-demographic factors in 4 major United States cities: New York, New York; Chicago, Illinois; Detroit, Michigan; and Seattle, Washington. RESULTS We found the distribution of COVID-19 cases and mortality varied spatially and in magnitude by city. COVID-19 mortality was significantly higher in communities with higher percentages of low-income residents and higher percentages of racial/ethnic minority residents. FQHC penetration was protective against increased COVID-19 mortality, after model adjustment. CONCLUSIONS Our study underpins the critical role of safety-net health care and policymakers must ensure investment in long-term sustainability of FQHCs, through strategic deployment of capital, workforce development, and reimbursement reform.
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Affiliation(s)
- Mary M. Ford
- Primary Care Development Corporation, New York, NY, USA,Mary M. Ford, Primary Care Development Corporation, 45 Broadway, New York, NY 10006, USA.
| | - Angela Allard
- Primary Care Development Corporation, New York, NY, USA,Angela Allard, Primary Care Development Corporation, 45 Broadway, New York, NY 10006, USA.
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18
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Dzampe AK, Takahashi S. Competition and quality of care under regulated fees: evidence from Ghana. HEALTH ECONOMICS REVIEW 2022; 12:57. [PMID: 36355234 PMCID: PMC9647994 DOI: 10.1186/s13561-022-00406-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 11/01/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND How competition affects the quality of care is still not well understood empirically because of limited and mixed results. This study examined whether competition leads to higher or lower quality health outcomes in Ghana. METHODS We used administrative claims data of hypertension patients for 2017 - 2019 (36 months), and an instrumental variable method to examine the effect of competition, measured as an increase in district doctor-to-population ratio on hospital-level ambulatory care sensitive condition hospitalization and in-hospital death rates. RESULTS Overall, we found that an increase in doctor density improves the quality of care for hypertension patients in Ghana. That is, when there are more doctors, fewer patients are hospitalized, and the risk of in-hospital deaths decreases. This result is robust to analyses at the individual and district population levels for ambulatory care sensitive hospitalizations rate. CONCLUSIONS Our findings suggest that in the presence of physician-induced demand, competition can lead to improvement in the quality of care, possibly through improved access to healthcare and increased physician time and contact per patient. Future health policies need to consider possible welfare benefits of induced medical services and training more doctors.
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Affiliation(s)
- Adolf Kwadzo Dzampe
- Japan Development Service (JDS) PhD Fellow, Graduate School for International Development and Cooperation, Hiroshima University, 1-5-1 Kagamiyama, Higashi-Hiroshima, Hiroshima, 739-8529 Japan
- Claims Processing Centre, National Health Insurance Authority, PMB Ministries, Accra, Ghana
| | - Shingo Takahashi
- Associate Professor, Graduate School for International Development and Cooperation, Hiroshima University, 1-5-1 Kagamiyama, Higashi-Hiroshima, Hiroshima, 739-8529 Japan
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19
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Association of Physician Densities and Gynecologic Cancer Outcomes in the United States. Obstet Gynecol 2022; 140:751-757. [DOI: 10.1097/aog.0000000000004955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 07/14/2022] [Indexed: 11/15/2022]
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20
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Wild EM, Winter V, Ress V, Golubinski V. What is the impact of introducing a non-clinical community health advice and navigation service on the demand for primary care in socially deprived areas? Evidence from an observational panel study with difference-in-differences design. BMJ Open 2022; 12:e061964. [PMID: 36270761 PMCID: PMC9594525 DOI: 10.1136/bmjopen-2022-061964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 10/02/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To examine the effect of introducing a non-clinical community health advice and navigation service on the demand for primary care in a socially deprived area. DESIGN Observational panel study with difference-in-differences design. We conducted fixed-effects negative binomial regressions to compare changes in the number of visits to general practitioners (GPs) in individuals who visited the health advice and navigation service and a matched control group of individuals who did not visit the service. In addition, we analysed the effects of visiting the service multiple times. SETTING AND PARTICIPANTS Our empirical setting is a socially deprived urban area in Germany with a multicultural population of about 110 000 people. Our analyses are based on patient data (N=1044) from a non-clinical community health advice and navigation service and from two statutory health insurers. OUTCOME MEASURES Patient demand for primary care measured as the number of visits to GPs before and after the first visit to the health advice and navigation service. RESULTS Visiting the service for the first time significantly decreased the number of GP visits compared with the control group (β=-0.113, p<0.1). Each additional visit to the service, however, significantly decreased the effect of the first visit (β=0.037, p<0.05). CONCLUSIONS Our findings suggest that non-clinical community health advice and navigation services can serve as a low-threshold first point of contact. As first point contact, such services might possibly reduce the burden of primary care physicians in socially deprived areas. At the same time, such services might function as a gateway to accessing the health system, reducing unmet care needs and stimulate demand. Ongoing counselling in the service can identify medical needs that require a physician visit. Our findings may be useful for policymakers and healthcare leaders seeking to reduce the demand on the primary care workforce and can stimulate further research in this area.
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Affiliation(s)
- Eva-Maria Wild
- Hamburg Center for Health Economics (HCHE), University of Hamburg, Hamburg, Germany
| | - Vera Winter
- Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
| | - Vanessa Ress
- Hamburg Center for Health Economics (HCHE), University of Hamburg, Hamburg, Germany
| | - Veronika Golubinski
- Hamburg Center for Health Economics (HCHE), University of Hamburg, Hamburg, Germany
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21
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Gao J, Moran E, Woolhandler S, Toporek A, Wilper AP, Himmelstein DU. Primary Care's Effects on Costs in the US Veterans Health Administration, 2016-2019: an Observational Cohort Study. J Gen Intern Med 2022; 37:3289-3294. [PMID: 34608563 PMCID: PMC9550907 DOI: 10.1007/s11606-021-07140-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 09/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Enhancing primary care is a promising strategy for improving the efficiency of health care. Previous studies of primary care's effects on health expenditures have mostly relied on ecological analyses comparing region-wide expenditures rather than spending for individual patients. OBJECTIVE To compare overall medical expenditures for individual patients enrolled vs. those not enrolled in primary care in the Veterans Health Administration (VHA). DESIGN Cohort study with stratification for clinical risk and multivariable linear regression models adjusted for clinical and demographic confounders of expenditures. PARTICIPANTS In total, 6,009,973 VHA patients in fiscal year (FY) 2019-5,410,034 enrolled with a primary care provider (PCP) and 599,939 without a PCP-and similar numbers in FYs 2016-2018. MAIN MEASURES Total annual cost per patient to the VHA (including VHA payments to non-VHA providers) stratified by a composite health risk score previously shown to predict VHA expenditures, and multivariate models additionally adjusted for VHA regional differences, patients' demographic characteristics, non-VHA insurance coverage, and driving time to the nearest VHA facility. Sensitivity analyses explored different modeling strategies and risk adjusters, as well as the inclusion of expenditures by the Medicare program that covers virtually all elderly VHA patients for care not paid for by the VHA. KEY RESULTS Within each health-risk decile, non-PCP patients had higher outpatient, inpatient, and total costs than those with a PCP. After adjustment for health risk and other factors, lack of a PCP was associated 27.4% higher VHA expenditures, $3274 per patient annually (p < .0001). Sensitivity analyses using different risk adjusters and including Medicare's spending for VHA patients yielded similar results. CONCLUSIONS In the VHA system, primary care is associated with substantial cost savings. Investments in primary care in other settings might also be cost-effective.
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Affiliation(s)
- Jian Gao
- Office of Productivity, Efficiency, and Staffing, Quality and Patient Safety, Office of Analytics and Performance Integration, Department of Veterans Affairs, Albany, NY, USA
| | - Eileen Moran
- Office of Productivity, Efficiency, and Staffing, Quality and Patient Safety, Office of Analytics and Performance Integration, Department of Veterans Affairs, Albany, NY, USA
| | - Steffie Woolhandler
- City University of New York at Hunter College, New York, NY, USA
- Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, MA, USA
| | - Andrew Toporek
- Office of Productivity, Efficiency, and Staffing, Quality and Patient Safety, Office of Analytics and Performance Integration, Department of Veterans Affairs, Albany, NY, USA
| | - Andrew P Wilper
- Boise Veterans Affairs Medical Center, Boise, ID, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - David U Himmelstein
- City University of New York at Hunter College, New York, NY, USA.
- Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, MA, USA.
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22
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Sullivan E, Zahnd WE, Zhu JM, Kenzie E, Patzel M, Davis M. Mapping Rural and Urban Veterans' Spatial Access to Primary Care Following the MISSION Act. J Gen Intern Med 2022; 37:2941-2947. [PMID: 34981345 PMCID: PMC9485404 DOI: 10.1007/s11606-021-07229-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/19/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The 2018 MISSION Act sought to improve Veterans' access to primary care by allowing Veterans living more than 30 min from VA care to utilize non-VA clinics. The impact of this legislation may vary for rural compared to urban Veterans. OBJECTIVE Assess the extent to which the 2018 MISSION Act facilitates spatial access to primary care for Veterans living in rural versus urban Oregon. DESIGN We identified locations of all VA and non-VA primary care clinics in Oregon then calculated 30-min drive-time catchment areas from census tract centroids to the nearest clinics. We compared measures of spatial access to primary care for Veterans in rural, micropolitan, and urban areas. PARTICIPANTS American Community Survey data representing Oregon adults. MAIN MEASURES Two measures of spatial access focusing on the number of clinics (supply), and an access index based on the two-step floating catchment area method (2SFCA) which accounts for number of clinics (supply) and population size (demand). KEY RESULTS Compared to only 13.0% of rural Veterans, 83.6% of urban Veterans lived within 30 min' drive time of VA primary care. Given the MISSION Act's eligibility criteria, 81.6% of rural Veterans and ~ 97% of urban and micropolitan Veterans had spatial access to primary care. When accounting for both supply and demand, rural areas had significantly higher access scores (p < 0.05) compared to urban areas. CONCLUSIONS Using MISSION Act guidelines for Veteran access to primary care, rural compared to urban Veterans had less spatial access based on clinic number (supply), but more access when considering clinic number and population size (supply and demand). Geographic Information System (GIS) spatial techniques may help to assess changes in access to care. However, these methods do not incorporate all dimensions of access and work is needed to understand whether utilization and quality of care is improved.
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Affiliation(s)
- Eliana Sullivan
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland, OR, USA.
| | - Whitney E Zahnd
- Arnold School of Public Health, Rural & Minority Health Research Center, University of South Carolina, Columbia, SC, USA
| | - Jane M Zhu
- Division of General Internal Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Erin Kenzie
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland, OR, USA
| | - Mary Patzel
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland, OR, USA
| | - Melinda Davis
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland, OR, USA
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR, USA
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Giannouchos TV, Ukert B, Andrews C. Association of Medicaid Expansion With Emergency Department Visits by Medical Urgency. JAMA Netw Open 2022; 5:e2216913. [PMID: 35699958 PMCID: PMC9198732 DOI: 10.1001/jamanetworkopen.2022.16913] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Relatively little is known about the association of the Medicaid eligibility expansion under the Patient Protection and Affordable Care Act with emergency department (ED) visits categorized by medical urgency. OBJECTIVE To estimate the association between state Medicaid expansions and ED visits by the urgency of presenting conditions. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used the Healthcare Cost and Utilization Project State Emergency Department Databases from January 2011 to December 2017 for 2 states that expanded Medicaid in 2014 (New York and Massachusetts) and 2 states that did not (Florida and Georgia). Difference-in-differences regression models were used to estimate the changes in ED visits overall and further stratified by the urgency of the conditions using an updated version of the New York University ED algorithm between the states that expanded Medicaid and those that did not, before and after the expansion. Data were analyzed between June 7 and December 12, 2021. EXPOSURE State-level Medicaid eligibility expansion. MAIN OUTCOMES AND MEASURES Emergency department visits per 1000 population overall and stratified by medical urgency of the conditions. RESULTS In total, 80.6 million ED visits by 26.0 million individuals were analyzed. Emergency department visits were concentrated among women (59.3%), non-Hispanic Black individuals (28.3%), non-Hispanic White individuals (47.8%), and those aged 18 to 34 years (47.5%) and 35 to 44 years (20.4%). The rates of ED visits increased by a mean of 2.4 visits in nonexpansion states and decreased by a mean of 2.2 visits in expansion states after 2014, resulting in a significant regression-adjusted decrease of 4.7 visits per 1000 population (95% CI, -7.7 to -1.5; P = .003) in expansion states. Most of this decrease was associated with decreases in ED visits by conditions classified as not emergent (-1.5 visits; 95% CI, -2.4 to -0.7; P < .001), primary care treatable (-1.1 visits; 95% CI, -1.6 to -0.5; P < .001), and potentially preventable (-0.3 visits; 95% CI, -0.5 to -0.1; P = .02). No significant changes were observed for ED visits related to injuries and conditions classified as not preventable (-1.4; 95% CI, -3.1 to 0.3; P = .10), as well as for substance use and mental health disorders (0.0; 95% CI, -0.2 to 0.2; P = .94). CONCLUSIONS AND RELEVANCE The findings of this study suggest that Medicaid expansion was associated with decreases in ED visits, for which decreases in ED visits for less medically emergent ED conditions may have been a factor.
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Affiliation(s)
- Theodoros V. Giannouchos
- Department of Health Services Policy & Management, Arnold School of Public Health, University of South Carolina, Columbia
| | - Benjamin Ukert
- Department of Health Policy & Management, School of Public Health, Texas A&M University, College Station
| | - Christina Andrews
- Department of Health Services Policy & Management, Arnold School of Public Health, University of South Carolina, Columbia
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Gaglioti AH, Rivers D, Ringel JB, Judd S, Safford MM. Individual and Neighborhood Influences on the Relationship Between Waist Circumference and Coronary Heart Disease in the REasons for Geographic and Racial Differences in Stroke Study. Prev Chronic Dis 2022; 19:E20. [PMID: 35446759 PMCID: PMC9044900 DOI: 10.5888/pcd19.210195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The objective of this study was to describe how the relationship between waist circumference and incident coronary heart disease (CHD) is influenced by individual and neighborhood factors in the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study. METHODS REGARDS is a cohort study of 30,239 US adults. The primary exposure was sex-specific quartiles of waist circumference. Individual covariates included sociodemographic characteristics, health status, health behavior, and usual source of care. Neighborhood (ie, zip code-level) covariates included access to primary care, poverty, rurality, and racial segregation. The main outcome was incident CHD from baseline (2003) through 2017. We used descriptive statistics, Kaplan-Meier curves, and Cox proportional hazard models to analyze the overall sample and race-sex subgroups. RESULTS During the study period, 23,042 study participants had 1,499 CHD events. We found a higher risk of incident CHD in the upper quartile of waist circumference compared with the first quartile in all 4 race-sex subgroups except African American men, among whom we found no relationship between waist circumference and incident CHD. Covariates did not attenuate these relationships. CONCLUSION In all groups except African American men, waist circumference in the highest quartile was associated with increased risk of incident CHD. Individual and neighborhood factors did not influence the relationship between waist circumference and development of CHD but differentially influenced incident CHD among race-sex subgroups.
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Affiliation(s)
- Anne H Gaglioti
- National Center for Primary Care, Department of Family Medicine, Morehouse School of Medicine, Atlanta, Georgia.,National Center for Primary Care, Department of Family Medicine, Morehouse School of Medicine, 720 Westview Dr SW; Atlanta, GA 30310.
| | - Desiree Rivers
- Department of Community Health and Preventive Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Joanna Bryan Ringel
- Department of Medicine, Division of General Internal Medicine, Weill Cornell School of Medicine, New York, New York
| | - Suzanne Judd
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Monika M Safford
- Department of Medicine, Division of General Internal Medicine, Weill Cornell School of Medicine, New York, New York
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Martin C, Sturmberg J. Universal Health (UHC) and Primary Health Care (PHC)-A complex dynamic endeavor. J Eval Clin Pract 2022; 28:332-334. [PMID: 35023270 DOI: 10.1111/jep.13654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 12/20/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Carmel Martin
- Medicine Monash Health, Faculty of Medicine, Nursing and Health Sciences, School of Clinical Sciences at Monash Health, Melbourne, Queensland, Australia
| | - Joachim Sturmberg
- Discipline of General Practice, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia.,Foundation President-International Society for Systems and Complexity Sciences for Health
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26
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Abzaliyeva A, Kausova G, Abdraimova E, Ismagilova A, Mamyrbekova S. Availability of General Practice Workforce and Basic Health Indicators in the Republic of Kazakhstan: 2015-2019. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.7880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Фон . Республика Казахстан уделяет особое внимание развитию кадров общей практики (ВОП) за последние три десятилетия. Это исследование было направлено на предоставление описательного распределения врачей общей практики между различными административными единицами Казахстана по основным показателям здоровья за период 2015-2019 гг. Методы . Это было ретроспективное перекрестное исследование, основанное на данных, полученных из реестра медицинских кадров. Данные о смертности от всех причин, смертности от сердечно-сосудистых заболеваний, материнской и младенческой смертности получены из ежегодных статистических отчетов, выпускного министерства здравоохранения. Полученные результаты .В настоящее время врачи общей практики составляют основную часть медицинского персонала в Казахстане. В Казахстане наблюдается стабильное снижение показателей сердечно-сосудистой, материнской и младенческой смертности в период 2015-2019 гг. Заключение . Врачи общей практики - передовые деятели казахстанской системы здравоохранения. Необходимо изучить другие факторы, способствующие улучшению основных показателей здоровья в Казахстане.
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Explaining the Role of Physicians in Urban Comprehensive Health Service Centers After Implementing Health Transformation Plan in Southeast of Iran: A Qualitative Study. HEALTH SCOPE 2022. [DOI: 10.5812/jhealthscope.121713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Health transformation plan (HTP) in Iran was established in 2014 to promote primary health care through expanding and strengthening the first level of services in urban and rural areas. The activities of physicians and their colleagues in comprehensive health service centers have increased access and improved community health. Conducting various studies on the urban physicians’ roles can help policymakers achieve the goals. Objectives: This study aimed to explain the role of physicians working in urban, comprehensive health service centers after implementing the HTP. Methods: Participants in this qualitative study consisted of physicians, healthcare providers, managers, and experts, working in urban health centers selected by a purposive sampling method. The data were collected by semi-structured interviews. After data saturation, they were analyzed by conventional content analysis. Results: After interviewing 35 people and several stages of review, coding, and using the experience of experts, the data were classified into six main categories, 11 subcategories, and 33 codes. Factors influencing the role of physicians were service delivery, electronic health records, resources, community culture, monitoring, supervision, and practical suggestion. The participants expressed the workload, referral system, integrated electronic health record, financial resources, human resources, equipment, and public participation as some aspects related to the role of physicians. Conclusions: Based on the current study, human and financial resources should be managed to retain the physicians in this plan. In addition, increasing the quality of services, improving electronic health records, and attention to public culture can be considered.
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Şahin B, İlgün G. Risk factors of deaths related to cardiovascular diseases in World Health Organization (WHO) member countries. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:73-80. [PMID: 32909378 DOI: 10.1111/hsc.13156] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 07/26/2020] [Accepted: 08/12/2020] [Indexed: 06/11/2023]
Abstract
This study aims to identify the risk factors affecting deaths related to cardiovascular diseases. The research population comprised of 194 World Health Organization (WHO) member countries, but the data analysis was conducted with the data from 152 countries as 42 of them do not have any data on study variables. Multivariable regression analysis was utilised for this study to analyse the effect of factors regarding metabolism, lifestyle, economic, socio-demographic and health system on the cardiovascular diseases related to deaths. As a result of regression analysis, the number of deaths related to cardiovascular diseases increases with the increase in blood pressure (p < .001), blood glucose (p = .032), obesity rate (p < .001), salt consumption (p < .001), GINI index (p = .002) and dependent age ratio (p < .001); the frequency of cardiovascular disease-related deaths is higher in the countries within low (p < .001) and high (p < .001) middle-income levels; yet, the number of deaths based on cardiovascular diseases diminishes with the increase in the number of doctors (p = .005) and health expenditures per capita (p = .044). The research findings are considered to guide the countries in the determination of their steps towards the prevention of deaths related to cardiovascular diseases.
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Affiliation(s)
- Bayram Şahin
- Department of Health Care Management, Faculty of Economics and Administrative Sciences, Hacettepe University, Ankara, Turkey
| | - Gülnur İlgün
- Aksaray University, Faculty of Health Sciences, Department of Health Care Management, Aksaray, Turkey
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Takayama A, Poudyal H. Incorporating Medical Supply and Demand into the Index of Physician Maldistribution Improves the Sensitivity to Healthcare Outcomes. J Clin Med 2021; 11:155. [PMID: 35011896 PMCID: PMC8745359 DOI: 10.3390/jcm11010155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Since the association between disparity in physician distribution and specific healthcare outcomes is poorly documented, we aimed to clarify the association between physician maldistribution and cerebrovascular disease (CeVD), a high-priority health outcome in Japan. METHODS In this cross-sectional study, we conducted multivariable regression analysis with the Physician Uneven Distribution Index (PUDI), a recently developed and adopted policy index in Japan that uniquely incorporates the gap between medical supply and demand, as the independent variable and CeVD death rate as the dependent variable. Population density, mean annual income, and prevalence of hypertension were used as covariates. RESULTS The coefficient of the PUDI for the CeVD death rate was -0.34 (95%CI: -0.49--0.19) before adjusting for covariates and was -0.19 (95%CI: -0.30--0.07) after adjusting. The adjusted R squared of the analysis for the PUDI was 0.71 in the final model. However, the same multivariable regression model showed that the number of physicians per 100,000 people (NPPP) was not associated with the CeVD death rates before or after adjusting for the covariates. CONCLUSION Incorporating the gap between the medical supply and demand in physician maldistribution indices could improve the responsiveness of the index for assessing the disparity in healthcare outcomes.
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Affiliation(s)
- Atsushi Takayama
- Center for Innovative Research for Communities and Clinical Excellence (CiRC2LE), Fukushima Medical University, Fukushima City 960-1295, Fukushima, Japan;
| | - Hemant Poudyal
- Population Health and Policy Research Unit, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Kyoto, Japan
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30
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Atmann O, Torge M, Schneider A. The "General practitioner learning stations"-development, implementation and optimization of an innovative format for sustainable teaching in general practice. BMC MEDICAL EDUCATION 2021; 21:622. [PMID: 34915875 PMCID: PMC8680029 DOI: 10.1186/s12909-021-03057-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/02/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Teaching general practice in a university setting is still challenging. In our department we have developed a teaching format with content from a previous lecture-style-teaching into an interactive small group format taught by frontline general practitioners (GPs). The "GP learning stations" introduce students to the skills and attributes of a GP working in primary care in a university setting. Our main objective was to understand whether the teaching format had proven itself sustainable in a university setting over eight years. Furthermore, we wanted to better understand the role of the GP as a medical educator. METHODS More than eight years of experience in organizational and staff expenses were collected and analyzed. In addition, the grade point average of the students' evaluation was calculated and their free text answers were categorized and evaluated descriptively. During two teach-the-teacher seminars attending GPs were asked why they teach and if they feel equipped to teach the format. RESULTS The initially high organizational and staff expenses were significantly reduced. The recruitment of GPs, their didactic contribution, and their joint creation of content went smoothly throughout the whole period. A total of 495 students participated in the regular evaluation. The analysis yielded a grade point average of 1.9, on a scale from 1 = very good to 6 = insufficient. In the free text answers students praised the educators, the format and the practical relevance. The interactive transfer of the content, the didactic competence of the educators and the spatial environment were viewed critically. Reasons for GPs to teach were the joy to pass on knowledge and experience, and to make the work of GPs more attractive to students. Most GPs felt prepared to teach through their experience as a physician although some felt unprepared to teach through their lack of didactic knowledge. CONCLUSION Despite reducing the costs of the format, a grade point average of 1.9 could be achieved in the long term. This supports the teaching concept of learning stations and its "mixture of discussion, scientific background and role play, combined with (…) experiences and exciting individual cases from (GPs) everyday life", hopefully making general practice more attractive to the students.
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Affiliation(s)
- Oxana Atmann
- Technical University of Munich, TUM School of Medicine, Institute of General Practice and Health Services Research, Orleansstrasse 47, 81667, Munich, Germany
| | - Marion Torge
- Technical University of Munich, TUM School of Medicine, Institute of General Practice and Health Services Research, Orleansstrasse 47, 81667, Munich, Germany.
| | - Antonius Schneider
- Technical University of Munich, TUM School of Medicine, Institute of General Practice and Health Services Research, Orleansstrasse 47, 81667, Munich, Germany
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Stigler FL, Zipp CR, Jeitler K, Semlitsch T, Siebenhofer A. Comprehensive catalogue of international measures aimed at preventing general practitioner shortages. Fam Pract 2021; 38:793-801. [PMID: 34160614 DOI: 10.1093/fampra/cmab045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Many countries are facing a shortage and misallocation of general practitioners (GPs). The development of a policy response may benefit from the knowledge of worldwide policies that have been adopted and recommended to counteract such a development. AIM To identify measures proposed or taken internationally to prevent GP shortages. DESIGN AND SETTING A literature review followed by an expert assessment focussed on sources from OECD countries. METHOD The literature search identified international policy documents and literature reviews in bibliographical databases, and examined institutional websites and references of included publications. The internet search engine Google was also used. The resulting measures were then assessed for completeness by three experts. RESULTS Ten policy documents and 32 literature reviews provided information on 102 distinct measures aimed at preventing GP shortages. The measures attempt to influence GPs at all stages of their careers. CONCLUSIONS This catalogue of measures to prevent GP shortages is significantly more comprehensive than any of the policy documents it is based on. It may serve as a blueprint for effective reforms aimed at preventing GP shortages internationally.
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Affiliation(s)
- Florian L Stigler
- Austrian health insurance fund, Health Center (ÖGK) - Styria, Graz, Austria
| | - Carolin R Zipp
- Medical University of Graz, Institute of General Practice and Evidence-Based Health Services Research, Graz, Austria
| | - Klaus Jeitler
- Medical University of Graz, Institute of General Practice and Evidence-Based Health Services Research, Graz, Austria.,Medical University of Graz, Institute for Medical Informatics, Statistics and Documentation, Graz, Austria
| | - Thomas Semlitsch
- Medical University of Graz, Institute of General Practice and Evidence-Based Health Services Research, Graz, Austria
| | - Andrea Siebenhofer
- Medical University of Graz, Institute of General Practice and Evidence-Based Health Services Research, Graz, Austria.,Goethe University Frankfurt, Institute of General Practice, Frankfurt am Main, Hessen, Germany
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Yan C, Liao H, Ma Y, Wang J. The Impact of Health Care Reform Since 2009 on the Efficiency of Primary Health Services: A Provincial Panel Data Study in China. Front Public Health 2021; 9:735654. [PMID: 34746081 PMCID: PMC8569255 DOI: 10.3389/fpubh.2021.735654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 09/23/2021] [Indexed: 12/19/2022] Open
Abstract
Background: Primary health care (PHC) is an important part of health systems in the world and in China. To improve the efficiency of PHC institutions (PHCIs), many countries have implemented reforms, including China's health care reform since 2009. This study aims to evaluate the impact of this reform on the efficiency of PHCIs from the perspective of the whole health system. Methods: Data were collected from China Health Statistical Yearbooks and China Statistical Yearbooks published from 2005 to 2019. By taking the number of beds, health technicians and PHCIs as inputs and the proportion of diagnosis, treatment and admission in PHCIs as outputs, Malmquist DEA was used to evaluate the efficiency change of PHCIs, and panel data regression was performed to analyze the impact of the reform and other factors on such efficiency. The interaction between reform and economic level was also estimated. Results: The MPI in Beijing, Tianjin, Shanghai, Hunan, and Guangdong improved after the reform. The efficiency improvement in Beijing, Tianjin and Shanghai is mainly reflected in the growth of TC, whereas the efficiency improvement in Guangdong and Hunan is mainly reflected in the growth of EC. Meanwhile, the EC and TC in Hebei, Heilongjiang, Shandong, and other provinces deteriorated. The deterioration of MPI in Shanxi, Inner Mongolia and Jilin was mainly attributed to EC. while the deterioration of MPI in Liaoning, Anhui, and Fujian provinces is mainly attributed to TC. Since 2009, the reform exerted a negative impact on MPI (β = -0.06; P < 0.01), TC (β = -0.048; P < 0.01) and EC (β = -0.03; P < 0.01). And such negative impact was weaker in economically developed areas (β = 0.076; P < 0.01). Conclusions: Attention should be paid to future reforms: China should continue investing in PHCIs, establish a structurally integrated and functionally complementary delivery system and promote the coordination of reform policies to avoid the adverse impacts of other reform policies on PHCIs.
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Affiliation(s)
- Chaoyang Yan
- Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hui Liao
- Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ying Ma
- Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Wang
- Department of Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,The Key Research Institute of Humanities and Social Science of Hubei Province, Huazhong University of Science and Technology, Wuhan, China.,Health Poverty Alleviation Center, Institute for Poverty Reduction and Development, Huazhong University of Science and Technology, Wuhan, China
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Sadanandan R, Sivaprasad S. Adding screening for "end organ damage" to the noncommunicable disease package in primary care. Indian J Ophthalmol 2021; 69:3064-3067. [PMID: 34708743 PMCID: PMC8725093 DOI: 10.4103/ijo.ijo_1496_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
There are several global and local initiatives aimed at screening for noncommunicable diseases (NCD). The fundamental health system strengthening to achieve this goal is by developing the primary care infrastructure. Most newly developed or improved primary care centers focus on maintaining an NCD register for onward reporting. However, the register is also the cornerstone for implementing systematic screening of all complications of NCDs. With epidemiologic transition, end organ damage due to NCDs is one of the most common causes of morbidity and mortality. Screening for end organ damage and early identification of treatable complications are far more impactful than waiting for self-reported symptomatic complications. Here, we show an example of how the Government of Kerala utilized the NCD register to implement a systematic diabetic retinopathy screening that allows for annual or biennial re-call in the primary care and refer treatable eye conditions to secondary care. The success of this program enabled the Government to initiate a holistic approach to screen for other complications of diabetes.
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Affiliation(s)
| | - Sobha Sivaprasad
- Medical Retina Department, NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital, London, UK
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Moss JL, Popalis M, Ramirez SI, Reedy-Cooper A, Ruffin MT. Disparities in Cancer Screening: The Role of County-Level Metropolitan Status and Racial Residential Segregation. J Community Health 2021; 47:168-178. [PMID: 34550504 DOI: 10.1007/s10900-021-01035-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2021] [Indexed: 12/21/2022]
Abstract
Mortality from cervical and colorectal cancers can be reduced through routine screening, which can often be accessed through primary care. However, uptake of screening in the US remains suboptimal, with disparities observed across geographic characteristics, such as metropolitan status or level of racial residential segregation. Little is known about the interaction of metropolitan status and segregation in their relationship with cancer screening. We conducted a quantitative survey of 474 women aged 45-65 in central Pennsylvania. The survey collected county-level characteristics and participant-level demographics, beliefs, cancer screening barriers, and cervical and colorectal cancer screening. We used bivariate and multivariable logistic regression to analyze relationships between metropolitan status and segregation with screening. For cervical cancer screening, 82.8% of participants were up-to-date, which did not differ by county type in the final analysis. Higher healthcare trust, higher cancer fatalism, and reporting cost as a barrier were associated with cervical cancer screening. For colorectal cancer screening, 55.4% of participants were up-to-date, which differed by county type. In metropolitan counties, segregation was not associated with colorectal cancer screening, but in non-metropolitan counties, segregation was associated with greater colorectal cancer screening. The relationship between metropolitan status and being up-to-date with colorectal, but not cervical, cancer screening varied by segregation. Other important beliefs and barriers to screening varied by county type. This research can guide future cancer screening interventions in primary care settings in underserved communities.
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Affiliation(s)
- Jennifer L Moss
- Penn State College of Medicine, The Pennsylvania State University, Hershey, PA, USA.
- Department of Family and Community Medicine, Department of Public Health Sciences, Penn State College of Medicine, The Pennsylvania State University, 134 Sipe Ave., #205, MC HS72, P.O. Box 850, Hershey, PA, 17033, USA.
| | - Madyson Popalis
- Penn State College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Sarah I Ramirez
- Penn State College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Alexis Reedy-Cooper
- Penn State College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Mack T Ruffin
- Penn State College of Medicine, The Pennsylvania State University, Hershey, PA, USA
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Andkhoie M, Szafron M. Geographic disparities in Saskatchewan prostate cancer incidence and its association with physician density: analysis using Bayesian models. BMC Cancer 2021; 21:948. [PMID: 34425772 PMCID: PMC8383452 DOI: 10.1186/s12885-021-08646-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 07/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Saskatchewan has one of the highest incidence of prostate cancer (PCa) in Canada. This study assesses if geographic factors in Saskatchewan, including location of where patients live and physician density are affecting the PCa incidence. First, the objective of this study is to estimate the PCa standardized incidence ratio (SIRs) in Saskatchewan stratified by PCa risk-level. Second, this study identifies clusters of higher than and lower than expected PCa SIRs in Saskatchewan. Lastly, this study identifies the association (if any) between family physician density and estimated PCa SIRs in Saskatchewan. METHODS First, using Global Moran's I, Local Moran's I, and the Kuldorff's Spatial Scan Statistic, the study identifies clusters of PCa stratified by risk-levels. Then this study estimates the SIRs of PCa and its association with family physician density in Saskatchewan using the Besag, York, and Mollie (BYM) Bayesian method. RESULTS Higher than expected clusters of crude estimated SIR for metastatic PCa were identified in north-east Saskatchewan and lower than expected clusters were identified in south-east Saskatchewan. Areas in north-west Saskatchewan have lower than expected crude estimated SIRs for both intermediate-risk and low-risk PCa. Family physician density was negatively associated with SIRs of metastatic PCa (IRR: 0.935 [CrI: 0.880 to 0.998]) and SIRs of high-risk PCa (IRR: 0.927 [CrI: 0.880 to 0.975]). CONCLUSIONS This study identifies the geographical disparities in risk-stratified PCa incidence in Saskatchewan. The study identifies areas with a lower family physician density have a higher-than-expected incidences of metastatic and high-risk PCa. Hence policies to increase the number of physicians should ensure an equitable geographic distribution of primary care physicians to support early detection of diseases, including PCa.
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Affiliation(s)
- Mustafa Andkhoie
- University of Saskatchewan, 104 Clinic Place, Saskatoon, SK S7N 2Z4 Canada
| | - Michael Szafron
- University of Saskatchewan, 104 Clinic Place, Saskatoon, SK S7N 2Z4 Canada
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Inequalities in the distribution of the general practice workforce in England: a practice-level longitudinal analysis. BJGP Open 2021; 5:BJGPO.2021.0066. [PMID: 34404634 PMCID: PMC8596307 DOI: 10.3399/bjgpo.2021.0066] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/25/2021] [Indexed: 11/29/2022] Open
Abstract
Background In England, demand for primary care services is increasing and GP shortages are widespread. Recently introduced primary care networks (PCNs) aim to expand the use of additional practice-based roles such as physician associates (PAs), pharmacists, paramedics, and others through financial incentives for recruitment of these roles. Inequalities in general practice, including additional roles, have not been examined in recent years, which is a meaningful gap in the literature. Previous research has found that workforce inequalities are associated with health outcome inequalities. Aim To examine recent trends in general practice workforce inequalities. Design & setting A longitudinal study using quarterly General Practice Workforce datasets from 2015–2020 in England. Method The slope indices of inequality (SIIs) for GPs, nurses, total direct patient care (DPC) staff, PAs, pharmacists, and paramedics per 10 000 patients were calculated quarterly, and plotted over time, with and without adjustment for patient need. Results Fewer GPs, total DPC staff, and paramedics per 10 000 patients were employed in more deprived areas. Conversely, more PAs and pharmacists per 10 000 patients were employed in more deprived areas. With the exception of total DPC staff, these observed inequalities widened over time. The unadjusted analysis showed more nurses per 10 000 patients employed in more deprived areas. These values were not significant after adjustment but approached a more equal or pro-poor distribution over time. Conclusion Significant workforce inequalities exist and are even increasing for several key general practice roles, with workforce shortages disproportionately affecting more deprived areas. Policy solutions are urgently needed to ensure an equitably distributed workforce and reduce health inequities.
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Duberstein PR, Halkitis PN. Ignoring Societal Structure in Public Health Approaches to Suicide Prevention. Am J Geriatr Psychiatry 2021; 29:745-747. [PMID: 33640266 DOI: 10.1016/j.jagp.2021.01.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 01/27/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Paul R Duberstein
- Rutgers School of Public Health, Rutgers Biomedical and Health Sciences, Piscataway, NJ.
| | - Perry N Halkitis
- Rutgers School of Public Health, Rutgers Biomedical and Health Sciences, Piscataway, NJ
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Basu S, Phillips RS, Berkowitz SA, Landon BE, Bitton A, Phillips RL. Estimated Effect on Life Expectancy of Alleviating Primary Care Shortages in the United States. Ann Intern Med 2021; 174:920-926. [PMID: 33750188 DOI: 10.7326/m20-7381] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Prior studies have reported that greater numbers of primary care physicians (PCPs) per population are associated with reduced population mortality, but the effect of increasing PCP density in areas of low density is poorly understood. OBJECTIVE To estimate how alleviating PCP shortages might change life expectancy and mortality. DESIGN Generalized additive models, mixed-effects models, and generalized estimating equations. SETTING 3104 U.S. counties from 2010 to 2017. PARTICIPANTS Children and adults. MEASUREMENTS Age-adjusted life expectancy; all-cause mortality; and mortality due to cardiovascular disease, cancer, infectious disease, respiratory disease, and substance use or injury. RESULTS Persons living in counties with less than 1 physician per 3500 persons in 2017 had a mean life expectancy that was 310.9 days shorter than for persons living in counties above that threshold. In the low-density counties (n = 1218), increasing the density of PCPs above the 1:3500 threshold would be expected to increase mean life expectancy by 22.4 days (median, 19.4 days [95% CI, 0.9 to 45.6 days]), and all such counties would require 17 651 more physicians, or about 14.5 more physicians per shortage county. If counties with less than 1 physician per 1500 persons (n = 2636) were to reach the 1:1500 threshold, life expectancy would be expected to increase by 56.3 days (median, 55.6 days [CI, 4.2 to 105.6 days]), and all such counties would require 95 754 more physicians, or about 36.3 more physicians per shortage county. LIMITATION Some projections are based on extrapolations of the actual data. CONCLUSION In counties with fewer PCPs per population, increases in PCP density would be expected to substantially improve life expectancy. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Sanjay Basu
- Harvard Medical School, Brigham and Women's Hospital, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Collective Health, San Francisco, California; and School of Public Health, Imperial College, London, United Kingdom (S.B.)
| | - Russell S Phillips
- Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.S.P., B.E.L.)
| | - Seth A Berkowitz
- Harvard Medical School, Boston, Massachusetts, and University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina (S.A.B.)
| | - Bruce E Landon
- Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.S.P., B.E.L.)
| | - Asaf Bitton
- Harvard Medical School, Brigham and Women's Hospital, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts (A.B.)
| | - Robert L Phillips
- Harvard Medical School, Boston, Massachusetts, and American Board of Family Medicine Center for Professionalism and Value in Health Care, Lexington, Kentucky (R.L.P.)
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Gaglioti AH, Li C, Douglas MD, Baltrus PT, Blount MA, Zahidi R, Caplan LS, Willock RJ, Fasuyi OB, Mack DH. Population-Level Disparities in COVID-19: Measuring the Independent Association of the Proportion of Black Population on COVID-19 Cases and Deaths in US Counties. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2021; 27:268-277. [PMID: 33762542 DOI: 10.1097/phh.0000000000001354] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
CONTEXT There is a need to understand population race and ethnicity disparities in the context of sociodemographic risk factors in the US experience of the COVID-19 pandemic. OBJECTIVE Determine the association between county-level proportion of non-Hispanic Black (NHB) on county COVID-19 case and death rates and observe how this association was influenced by county sociodemographic and health care infrastructure characteristics. DESIGN AND SETTING This was an ecologic analysis of US counties as of September 20, 2020, that employed stepwise construction of linear and negative binomial regression models. The primary independent variable was the proportion of NHB population in the county. Covariates included county demographic composition, proportion uninsured, proportion living in crowded households, proportion living in poverty, population density, state testing rate, Primary Care Health Professional Shortage Area status, and hospital beds per 1000 population. MAIN OUTCOME MEASURES Outcomes were exponentiated COVID-19 cases per 100 000 population and COVID-19 deaths per 100 000 population. We produced county-level maps of the measures of interest. RESULTS In total, 3044 of 3142 US counties were included. Bivariate relationships between the proportion of NHB in a county and county COVID-19 case (Exp β = 1.026; 95% confidence interval [CI], 1.024-1.028; P < .001) and death rates (rate ratio [RR] = 1.032; 95% CI, 1.029-1.035; P < .001) were not attenuated in fully adjusted models. The adjusted association between the proportion of NHB population in a county and county COVID-19 case was Exp β = 1.025 (95% CI, 1.023-1.027; P < .001) and the association with county death rates was RR = 1.034 (95% CI, 1.031-1.038; P < .001). CONCLUSIONS The proportion of NHB people in a county was positively associated with county COVID-19 case and death rates and did not change in models that accounted for other socioecologic and health care infrastructure characteristics that have been hypothesized to account for the disproportionate impact of COVID-19 on racial and ethnic minority populations. Results can inform efforts to mitigate the impact of structural racism of COVID-19.
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Affiliation(s)
- Anne H Gaglioti
- National Center for Primary Care (Dr Gaglioti, Douglas, Baltrus, and Mack, Mr Li, and Mss Blount and Zahidi), Department of Family Medicine (Drs Gaglioti, Fasuyi, and Mack), Department of Community Health and Preventive Medicine (Drs Douglas, Baltrus, Caplan, and Willock), Morehouse School of Medicine, Atlanta, Georgia
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Giannouchos TV, Kum HC, Gary JC, Morrisey MA, Ohsfeldt RL. The effect of expanded insurance coverage under the Affordable Care Act on emergency department utilization in New York. Am J Emerg Med 2021; 48:183-190. [PMID: 33964693 DOI: 10.1016/j.ajem.2021.04.076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/23/2021] [Accepted: 04/25/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND One of the proposed benefits of expanding insurance coverage under the Affordable Care Act (ACA) was a reduction in emergency department (ED) utilization for non-urgent visits related to lack of health insurance coverage and access to primary care providers. The objective of this study was to estimate the effect of the 2014 ACA implementation on ED use in New York. METHODS We used the Healthcare Cost and Utilization Project State Emergency Department and State Inpatient Databases for all outpatient and all inpatient visits for patients admitted through an ED from 2011 to 2016. We focused on in-state residents aged 18 to 64, who were covered under Medicaid, private insurance, or were uninsured prior to the 2014 expansion. We estimated the effect of the expanded insurance coverage on average monthly ED visits volumes and visits per 1000 residents (rates) using interrupted time-series regression analyses. RESULTS After ACA implementation, overall average monthly ED visits increased by around 3.0%, both in volume (9362; 95% Confidence Intervals [CI]: 1681-17,522) and in rates (0.80, 95% CI:0.12-1.49). Medicaid covered ED visits volume increased by 23,972 visits (95% CI: 16,240 -31,704) while ED visits by the uninsured declined by 13,297 (95% CI:-15,856 - -10,737), and by 1453 (95% CI:-4027-1121) for the privately insured. Medicaid ED visits rates per 1000 residents increased by 0.77 (95% CI:-1.96-3.51) and by 2.18 (95% CI:-0.55-4.92) for those remaining uninsured, while private insurance visits rates decreased by 0.48 (95% CI:-0.79 - -0.18). We observed increases in primary-care treatable ED visits and in visits related to mental health and alcohol disorders, substance use, diabetes, and hypertension. All estimated changes in monthly ED visits after the expansion were statistically significant, except for ED visit rates among Medicaid beneficiaries. CONCLUSION Net ED visits by adults 18 to 64 years of age increased in New York after the implementation of the ACA. Large increases in ED use by Medicaid beneficiaries were partially offset by reductions among the uninsured and those with private coverage. Our results suggest that efforts to expand health insurance coverage only will be unlikely to reverse the increase in ED use.
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Affiliation(s)
- Theodoros V Giannouchos
- Pharmacotherapy Outcomes Research Center, College of Pharmacy, University of Utah, Salt Lake City, UT, USA; Population Informatics Lab, Texas A&M University, College Station, TX, USA.
| | - Hye-Chung Kum
- Population Informatics Lab, Texas A&M University, College Station, TX, USA; Texas A&M University, School of Public Health, Department of Health Policy & Management, College Station, TX, USA
| | - Jodie C Gary
- Texas A&M University Health Science Center, College of Nursing, Bryan, TX, USA
| | - Michael A Morrisey
- Population Informatics Lab, Texas A&M University, College Station, TX, USA; Texas A&M University, School of Public Health, Department of Health Policy & Management, College Station, TX, USA
| | - Robert L Ohsfeldt
- Population Informatics Lab, Texas A&M University, College Station, TX, USA; Texas A&M University, School of Public Health, Department of Health Policy & Management, College Station, TX, USA
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Abrahams S, Kim EJ, Marrast L, Uwemedimo O, Conigliaro J, Martinez J. Examination of resident characteristics associated with interest in primary care and identification of barriers to cross-cultural care. BMC MEDICAL EDUCATION 2021; 21:218. [PMID: 33874946 PMCID: PMC8056670 DOI: 10.1186/s12909-021-02669-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 04/05/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND There is an increasing shortage of primary care physicians in the U.S. The difficult task of addressing patients' sociocultural needs is one reason residents do not pursue primary care. However, associations between residents' perceived barriers to cross-cultural care provision and career interest in primary care have not been investigated. OBJECTIVE We examined residents' career interest in primary care and associations with resident characteristics and their perceived barriers in providing cross-cultural care. METHODS We conducted a cross-sectional analysis of a resident survey from the 2018-2019 academic year. We first described residents' sociodemographic characteristics based on their career interest in primary care (Chi-square test). Our primary outcome was high career interest in primary care. We further examined associations between residents' characteristics and perceived barriers to cross-cultural care. RESULTS The study included 155 family medicine, pediatrics, and internal medicine residents (response rate 68.2%), with 17 expressing high career interest in primary care. There were significant differences in high career interest by race/ethnicity, as Non-White race was associated with high career interest in primary care (p < 0.01). Resident characteristics associated with identifying multiple barriers to cross-cultural care included disadvantaged background, multilingualism, and foreign-born parents (all p-values< 0.05). There were no significant associations between high career interest in primary care and barriers to cross-cultural care. CONCLUSION Residents from diverse racial/ethnic and socioeconomic backgrounds demonstrated higher career interest in primary care and perceived more barriers to cross-cultural care, underscoring the importance of increasing physician workforce diversity to address the primary care shortage and to improve cross-cultural care.
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Affiliation(s)
- Sara Abrahams
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra Blvd, Hempstead, NY, 11549, USA.
| | - Eun Ji Kim
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and Division of General Internal Medicine, Northwell Health, Hempstead, NY, USA
| | - Lyndonna Marrast
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and Division of General Internal Medicine, Northwell Health, Hempstead, NY, USA
| | - Omolara Uwemedimo
- Occupational Medicine, Epidemiology, and Prevention at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
| | - Joseph Conigliaro
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and Division of General Internal Medicine, Northwell Health, Hempstead, NY, USA
| | - Johanna Martinez
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and Division of General Internal Medicine, Northwell Health, Hempstead, NY, USA
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Baltrus PT, Douglas M, Li C, Caplan LS, Blount M, Mack D, Gaglioti AH. Percentage of Black Population and Primary Care Shortage Areas Associated with Higher COVID-19 Case and Death Rates in Georgia Counties. South Med J 2021; 114:57-62. [PMID: 33537783 PMCID: PMC7870015 DOI: 10.14423/smj.0000000000001212] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES We hypothesized that the proportion of Black individuals in a county would be associated with higher rates of coronavirus disease 2019 (COVID-19) cases and deaths, even after accounting for other high-risk socioecologic factors such as poverty, population density, and household crowding, and uninsured rates. We also expected that counties designated as primary care health professional shortage areas (PCHPSAs) would be associated with higher COVID-19 death rates, and the lack of primary care access would exacerbate racial disparities in death rates. We undertook this study to test these hypotheses and discern the independent effects of racial composition, socioecologic characteristics, and healthcare system factors on COVID-19 cases and deaths in Georgia counties. METHODS We used county-level COVID-19 cases and deaths on April 23, 2020 from the Johns Hopkins Coronavirus Resource Center and estimates of 2019 county-level populations from the US Census Bureau to calculate the cumulative event rates for the state of Georgia. We used multiple regression models to examine crude and adjusted associations of socioecologic and health system variables with county-level COVID-19 case and mortality rates. RESULTS After adjustment, a 1% increase in the proportion of Black people in the county resulted in a 2.3% increase in the county COVID-19 confirmed case rate and a 3.0% increase in the death rate (relative risk 1.03, 95% confidence interval 1.01-1.05, P < 0.001). Primary care shortage areas had a 74% higher death rate (relative risk 1.74, 95% confidence interval 1.00-3.00, P = 0.049). CONCLUSIONS These results highlight the impact of racial disparities on the spatial patterns of COVID-19 disease burden in Georgia, which can guide interventions to mitigate racial disparities. The results also support the need for robust primary care infrastructure throughout the state.
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Pompeii L, Benavides E, Pop O, Rojas Y, Emery R, Delclos G, Markham C, Oluyomi A, Vellani K, Levine N. Workplace Violence in Outpatient Physician Clinics: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E6587. [PMID: 32927880 PMCID: PMC7558610 DOI: 10.3390/ijerph17186587] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 11/30/2022]
Abstract
Workplace violence (WPV) has been extensively studied in hospitals, yet little is known about WPV in outpatient physician clinics. These settings and work tasks may present different risk factors for WPV compared to hospitals, including the handling/exchange of cash, and being remotely located without security presence. We conducted a systematic literature review to describe what is currently known about WPV in outpatient physician clinics. Six literature databases were searched and reference lists from included articles published from 2000-2019. Thirteen quantitative and five qualitative manuscripts were included which all focused on patient/family-perpetrated violence in outpatient physician clinics. No studies examined other violence types (e.g., worker-on-worker; burglary). The overall prevalence of Type II violence ranged from 9.5% to 74.6%, with the most common form being verbal abuse (42.1-94.3%), followed by threat of assault (14.0-57.4%), bullying (2.5-5.7%), physical assault, (0.5-15.9%) and sexual harassment/assault (0.2-9.3%). Worker consequences included reduced work performance, anger, and depression. Most workers did not receive training on how to manage a violent patient. More work is needed to examine the prevalence and risk factors of WPV in outpatient physician clinics for purposes of informing prevention efforts in these settings.
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Affiliation(s)
- Lisa Pompeii
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (E.B.); (A.O.)
| | - Elisa Benavides
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (E.B.); (A.O.)
| | - Oana Pop
- School of Public Health, University of Texas Health Science Center, Houston, TX 77030, USA; (O.P.); (R.E.); (G.D.); (C.M.)
| | - Yuliana Rojas
- Department of Population Health, The University of Texas at Austin, Austin, TX 78712, USA;
| | - Robert Emery
- School of Public Health, University of Texas Health Science Center, Houston, TX 77030, USA; (O.P.); (R.E.); (G.D.); (C.M.)
| | - George Delclos
- School of Public Health, University of Texas Health Science Center, Houston, TX 77030, USA; (O.P.); (R.E.); (G.D.); (C.M.)
| | - Christine Markham
- School of Public Health, University of Texas Health Science Center, Houston, TX 77030, USA; (O.P.); (R.E.); (G.D.); (C.M.)
| | - Abiodun Oluyomi
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (E.B.); (A.O.)
| | | | - Ned Levine
- Ned Levine & Associates, Houston, TX 77025, USA;
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Olm M, Donnachie E, Tauscher M, Gerlach R, Linde K, Maier W, Schwettmann L, Schneider A. Impact of the abolition of copayments on the GP-centred coordination of care in Bavaria, Germany: analysis of routinely collected claims data. BMJ Open 2020; 10:e035575. [PMID: 32878752 PMCID: PMC7470646 DOI: 10.1136/bmjopen-2019-035575] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES In 2012, Germany abolished copayment for consultations in ambulatory care. This study investigated the effect of the abolition on general practitioner (GP)-centred coordination of care. We assessed how the proportion of patients with coordinated specialist care changed over time when copayment to all specialist services were removed. Furthermore, we studied how the number of ambulatory emergency cases and apparent 'doctor shopping' changed after the abolition. DESIGN A retrospective routine data analysis of the Bavarian Association of Statutory Health Insurance Physicians, comparing the years 2011 and 2012 (with copayment), with the period from 2013 to 2016 (without copayment). Therefore, time series analyses covering 24 quarters were performed. SETTING Primary care in Bavaria, Germany. PARTICIPANTS All statutorily insured patients in Bavaria, aged ≥18 years, with at least one ambulatory specialist contact between 2011 and 2016. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome was the percentage of patients with GP-coordinated care (every regular specialist consultation within a quarter was preceded by a GP referral). Secondary outcomes were the number of ambulatory emergency cases and apparent 'doctor shopping'. RESULTS After the abolition, the proportion of coordinated patients decreased from 49.6% (2011) to 15.5% (2016). Overall, younger patients and those living in areas with lower levels of deprivation showed the lowest proportions of coordination, which further decreased after abolition. Additionally, there were concomitant increases in the number of ambulatory emergency contacts and to a lesser extent in the number of patients with apparent 'doctor shopping'. CONCLUSIONS The abolition of copayment in Germany was associated with a substantial decrease in GP coordination of specialist care. This suggests that the copayment was a partly effective tool to support coordinated care. Future studies are required to investigate how the gatekeeping function of GPs in Germany can best be strengthened while minimising the associated administrative overhead.
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Affiliation(s)
- Michaela Olm
- Institute of General Practice and Health Services Research, Technical University of Munich, TUM School of Medicine, Munich, Germany
| | - Ewan Donnachie
- Bavarian Association of Statutory Health Insurance Physicians, Munich, Germany
| | - Martin Tauscher
- Bavarian Association of Statutory Health Insurance Physicians, Munich, Germany
| | - Roman Gerlach
- Bavarian Association of Statutory Health Insurance Physicians, Munich, Germany
| | - Klaus Linde
- Institute of General Practice and Health Services Research, Technical University of Munich, TUM School of Medicine, Munich, Germany
| | - Werner Maier
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München - German Research Center for Environmental Health (GmbH), Neuherberg, Germany
| | - Lars Schwettmann
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München - German Research Center for Environmental Health (GmbH), Neuherberg, Germany
- Department of Economics, Martin Luther University Halle-Wittenberg, Halle an der Saale, Germany
| | - Antonius Schneider
- Institute of General Practice and Health Services Research, Technical University of Munich, TUM School of Medicine, Munich, Germany
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Olaisen RH, Schluchter MD, Flocke SA, Smyth KA, Koroukian SM, Stange KC. Assessing the Longitudinal Impact of Physician-Patient Relationship on Functional Health. Ann Fam Med 2020; 18:422-429. [PMID: 32928758 PMCID: PMC7489969 DOI: 10.1370/afm.2554] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 11/25/2019] [Accepted: 01/27/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Access to a usual source of care is associated with improved health outcomes, but research on how the physician-patient relationship affects a patient's health, particularly long-term, is limited. The aim of this study was to investigate the longitudinal effect of changes in the physician-patient relationship on functional health. METHODS We conducted a prospective cohort study using the Medical Expenditure Panel Survey (MEPS, 2015-2016). The outcome was 1-year change in functional health (12-Item Short-Form Survey). The predictors were quality of physician-patient relationship, and changes in this relationship, operationalized with the MEPS Primary Care (MEPS-PC) Relationship subscale, a composite measure with preliminary evidence of reliability and validity. Confounders included age, sex, race/ethnicity, educational attainment, insurance status, US region, and multimorbidity. We conducted analyses with survey-weighted, covariate-adjusted, predicted marginal means, used to calculate Cohen effect estimates. We tested differences in trajectories with multiple pairwise comparisons with Tukey contrasts. RESULTS Improved physician-patient relationships were associated with improved functional health, whereas worsened physician-patient relationships were associated with worsened functional health, with 1-year effect estimates ranging from 0.05 (95% CI, 0-0.10) to 0.08 (95% CI, 0.02-0.13) compared with -0.16 (95% CI, -0.35 to -0.03) to -0.33 (95% CI, -0.47 to -0.02), respectively. CONCLUSION The quality of the physician-patient relationship is positively associated with functional health. These findings could inform health care strategies and health policy aimed at improving patient-centered health outcomes.
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Affiliation(s)
- R Henry Olaisen
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio .,Center for Community Health Integration, Departments of Family Medicine & Community Health, Population and Quantitative Health Sciences, Sociology, and the Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Mark D Schluchter
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - Susan A Flocke
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Kathleen A Smyth
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - Kurt C Stange
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio.,Center for Community Health Integration, Departments of Family Medicine & Community Health, Population and Quantitative Health Sciences, Sociology, and the Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio
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Can Health Disparity Be Eliminated? The Role of Family Doctor Played in Shanghai, China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17155548. [PMID: 32751946 PMCID: PMC7432843 DOI: 10.3390/ijerph17155548] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/09/2020] [Accepted: 07/29/2020] [Indexed: 11/12/2022]
Abstract
Background: Globally, the elimination of health disparity is a significant policy target. Primary health care has been implemented as a strategy to achieve this target in China for almost 10 years. This study examined whether family doctor (FD) policy in Shanghai contributed to eliminating health disparity as expected. Methods: System dynamics modeling was performed to construct and simulate a system of health disparity formation (business-as-usual (BAU) scenario, without any interventions), a system with FD intervention (FD scenario), and three other systems with supporting policies (Policy 1/Policy 2/Policy hybrid scenario) from 2013 to 2050. Health disparities were simulated in different scenarios, making it possible to compare the BAU results with those of FD intervention and with other policy interventions. Findings: System dynamics models showed that the FD policy would play a positive role in reducing health disparities in the initial stage, and medical price control—rather than health management—was the dominant mechanism. However, in this model, the health gap was projected to expand again around 2039. The model examined the introduction of two intervention policies, with findings showing that the policy focused on socioeconomic status improvement would be more effective in reducing health disparities, suggesting that socioeconomic status is the fundamental cause of these disparities. Conclusions: The results indicate that health disparities could be optimized, but not eliminated, as long as differences in socioeconomic status persists.
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Hostetter J, Schwarz N, Klug M, Wynne J, Basson MD. Primary care visits increase utilization of evidence-based preventative health measures. BMC FAMILY PRACTICE 2020; 21:151. [PMID: 32718313 PMCID: PMC7385977 DOI: 10.1186/s12875-020-01216-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 07/09/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Primary care visits can serve many purposes and potentially influence health behaviors. Although previous studies suggest that increasing primary care provider numbers may be beneficial, the mechanism responsible for the association is unclear, and have not linked primary care access to specific preventative interventions. We investigated the association between the number of times patients accessed their primary care provider team and the likelihood they received selected preventative health interventions. METHODS Patients with complete data sets from Sanford Health were categorized based on the number of primary care visits they received in a specified time period and the preventative health interventions they received. Patient characteristics were used in a propensity analysis to control for variables. Relative risks and 95% confidence intervals were calculated to estimate the likelihood of obtaining preventative measures based on number of primary care visits compared with patients who had no primary care visits during the specified time period. RESULTS The likelihood of a patient receiving three specified preventative interventions was increased by 127% for vaccination, 122% for colonoscopy, and 75% for mammography if the patient had ≥ 1 primary care visit per year. More primary care visits correlated with increasing frequency of vaccinations, but increased primary care visits beyond one did not correlate with increasing frequency of mammography or colonoscopy. CONCLUSIONS One or more primary care visits per year is associated with increased likelihood of specific evidence-based preventative care interventions that improve longitudinal health outcomes and decrease healthcare costs. Increasing efforts to track and increase the number of primary care visits by clinics and health systems may improve patient compliance with select preventative measures.
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Affiliation(s)
- Jeffrey Hostetter
- Department of Family and Community Medicine, School of Medicine & Health Sciences, University of North Dakota, Grand Forks, USA
| | - Nolan Schwarz
- School of Medicine & Health Sciences, University of North Dakota, Grand Forks, USA
| | - Marilyn Klug
- Department of Population Health, School of Medicine & Health Sciences, University of North Dakota, Grand Forks, USA
| | - Joshua Wynne
- Department of Internal Medicine, School of Medicine & Health Sciences, University of North Dakota, Grand Forks, USA
| | - Marc D. Basson
- Department of Surgery, School of Medicine & Health Sciences, University of North Dakota, Grand Forks, USA
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Zhou M, Zhang L, Hu N, Kuang L. Association of primary care physician supply with maternal and child health in China: a national panel dataset, 2012-2017. BMC Public Health 2020; 20:1093. [PMID: 32652971 PMCID: PMC7353716 DOI: 10.1186/s12889-020-09220-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 07/06/2020] [Indexed: 12/04/2022] Open
Abstract
Background The Chinese government has been strengthening the primary care system since the launch of the New Healthcare System Reform in 2009. Among all endeavors, the most obvious and significant improvement lays in maternal and child health. This study was designed to explore the association of primary care physician supply with maternal and child health outcomes in China, and provide policy suggestions to the law makers. Methods Six-year panel dataset of 31 provinces in China from 2012 to 2017 was used to conduct the longitudinal ecological study. Linear fixed effects regression model was applied to explore the association of primary care physician supply with the metrics of maternal and child health outcomes while controlling for specialty care physician supply and socio-economic covariates. Stratified analysis was used to test whether this association varies across different regions in China. Results The number of primary care physicians per 10,000 population increased from 15.56 (95% CI: 13.66 to 17.47) to 16.08 (95% CI: 13.86 to 18.29) from 2012 to 2017. The increase of one primary care physician per 10,000 population was associated with 5.26 reduction in maternal mortality per 100,000 live births (95% CI: − 6.745 to − 3.774), 0.106% (95% CI: − 0.189 to − 0.023) decrease in low birth weight, and 0.419 decline (95% CI: − 0.564 to − 0.273) in perinatal mortality per 1000 live births while other variables were held constant. The association was particularly prominent in the less-developed western China compared to the developed eastern and central China. Conclusion The sufficient supply of primary care physician was associated with improved maternal and child health outcomes in China, especially in the less-developed western region. Policies on effective and proportional allocation of resources should be made and conducted to strengthen primary care system and eliminate geographical disparities.
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Affiliation(s)
- Mengping Zhou
- Department of Health Administration, School of Public Health, Sun Yat-sen University, No.74, Zhong Shan Er Road, Guangzhou, 510080, China
| | - Luwen Zhang
- Department of Health Management, School of Health Services Management, Southern Medical University, Guangzhou, 510515, China
| | - Nan Hu
- Department of Biostatistics, FIU Robert Stempel College of Public Health and Social Work, Miami, FL, 33199, USA.,Department of Family and Preventive Medicine, and Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, 84132, USA
| | - Li Kuang
- Department of Health Administration, School of Public Health, Sun Yat-sen University, No.74, Zhong Shan Er Road, Guangzhou, 510080, China.
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The impact of improved access to after-hours primary care on emergency department and primary care utilization: A systematic review. Health Policy 2020; 124:812-818. [PMID: 32513447 DOI: 10.1016/j.healthpol.2020.05.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 11/23/2022]
Abstract
Access to after-hours primary care is problematic in many developed countries, leading patients to instead visit the emergency department for non-urgent conditions. However, emergency department utilization for conditions treatable in primary care settings may contribute to emergency department overcrowding and increased health system costs. This systematic review examines the impact of various initiatives by developed countries to improve access to after-hours primary care on emergency department and primary care utilization. We performed a systematic review on the impact of improved access to after-hours primary and searched CINAHL, EMBASE, MEDLINE, and Scopus. We identified 20 studies that examined the impact of improved access to after-hours primary care on ED utilization and 6 studies that examined the impact on primary care utilization. Improved access to after-hours primary care was associated with increased primary care utilization, but had a mixed effect on emergency department utilization, with limited evidence of a reduction in non-urgent and semi-urgent emergency department visits. Although our review suggests that improved access to after-hours primary care may limit emergency department utilization by shifting patient care from the emergency department back to primary care, rigorous research in a given institutional context is required before introducing any initiative to improve access to after-hours primary care.
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Hill BC, Coster D, Black DR. National and Regional Variation in Local Primary Care Physician Density Relative to the Uninsured and the Affordable Care Act. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2020; 56:46958019873807. [PMID: 31526201 PMCID: PMC6749780 DOI: 10.1177/0046958019873807] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This study is the first to examine primary care physician (PCP) density relative to the uninsured at the local level prior to and after insurance expansion under the Affordable Care Act. Primary care physician density is associated with access to care, lower inpatient and emergency care, and primary care services. However, access to primary care among the uninsured may be limited due to inadequate availability of PCPs. Core-Based Statistical Area (CBSA) data from the Area Health Resource File were retrospectively examined before and after Medicaid expansion. Multiple logistic regressions were modeled for PCP density with predictor interaction effects for percentage uninsured, Medicaid expansion status, and US Census regions. Medicaid expansion CBSAs had significantly lower proportions of uninsured and higher PCP density compared with their nonexpansion counterparts. Nationally, increasing proportions of the uninsured were significantly associated with decreasing PCP density. Most notably, there is an expected 32% lower PCP density in Western Medicaid expansion areas with many uninsured (90th percentile) compared with those with few uninsured (10th percentile). Areas expanding Medicaid with greater proportions of people becoming insured postexpansion had significantly fewer PCPs. Areas with greater proportions of the uninsured may have reduced access to primary care due to the paucity of PCPs in these areas. Efforts to improve access should consider a lack of local PCPs as a limitation for ensuring accessible and timely care. Health care and policy leaders should focus on answers to improve the local availability of primary care clinicians in underserved communities.
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