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Frogner BK, Stubbs BA, Skillman SM Emerging Roles and Occupations in the Health Workforce Center for Health Workforce Studies, University of Washington 08-01-2018
Policy Brief
Full Report
Emerging Roles in Allied Health Occupations

Systematically quantifying and tracking the evolution of the health workforce is a challenge, yet is important for identifying emerging demands for different skills and competencies. Real Time Labor Market Information (RT-LMI), a source of data that is increasingly used to monitor workforce demand, extracts information from online job ads to track demand for general labor market skills, including for the health workforce. The purpose of this study is to identify how five domains of emerging roles in healthcare have been incorporated into the job titles and descriptions of healthcare occupations by using RT-LMI data from LinkUp, a job search engine company. The key findings from this study are:

  • “Care coordination” was the most common emerging role appearing in healthcare job ads, either in the job title or job description, in both 2014 and 2015, and “disease management” and “patient education” were more frequently mentioned in 2015 compared to 2014.
  • Physical therapists, social workers, nursing assistants and medical assistants were among the allied health occupations mentioned in job ads in which emerging roles appeared.
  • Care coordination was a dominant emerging role for occupations across all education requirement categories in the job ads examined, and disease management became a more frequently requested emerging role between 2014 and 2015.
  • Jobs requiring a high school degree or below rarely referenced an emerging role (2.0% in 2014 and 3.5% in 2015) despite the relatively high frequency of job ads for healthcare jobs at this education level.
  • Often, where an emerging role was identified in the job title, no other specific healthcare occupation was identified within either the job title or job description, suggesting that these occupations may be becoming stand-alone healthcare occupations.

In this study we found that RT-LMI can provide valuable information on the emergence of new skills and roles in the health workforce, including for many allied health occupations. Findings from this study contribute to the development of methods for monitoring and tracking changing healthcare workforce demands using large electronic databases of job ads. This important information on how employers associate skills with posted job titles can help educational institutions, training programs, accrediting bodies and health workforce planners better prepare workers with the competencies to meet market demand.

care continuum navigator care coordinating care coordination care coordination navigator care coordinator care management care navigation care navigator case manager consumer education coordination of care coordination of patient care disease management disease manager health coach health coaching health educating health education health educator health service navigator health services navigator management of patient care managing disease managing risk navigate care navigate patient care navigation of care nurse navigator patient care coordination patient care management patient navigation patient navigator peer advisor peer advocate peer coach peer counselor peer education peer educator peer liaison peer mentor peer navigator peer partner peer recovery coach peer recovery specialist peer specialist peer support peer support specialist population health risk management
Stubbs BA, Skillman SM 2018 Washington State data snapshot: registered nurses (RNs) Center for Health Workforce Studies, University of Washington 05-01-2018
Snapshot
2018 Registered Nurses in Washington: Snapshot of Demographics and Employment Characteristics
Stubbs BA, Skillman SM 2018 Washington State data snapshot: licensed practical nurses (LPNs) Center for Health Workforce Studies, University of Washington 05-01-2018
Snapshot
2018 Licensed Practical Nurses in Washington: Snapshot of Demographics and Employment Characteristics
Skillman SM, Stubbs BA 2018 Washington State data snapshot: advanced registered nurse practitioners (ARNPs) Center for Health Workforce Studies, University of Washington 05-01-2018
Snapshot
2018 Washington State Data Snapshot: Advanced Registered Nurse Practitioners
Skillman SM, Stubbs BA, Dahal A Maine’s physician, nurse practitioner, and physician assistant workforce in 2018 Seattle, WA: Center for Health Workforce Studies, University of Washington 07-30-2018
Full Report
N/A

Compared with 2014, Maine had slightly fewer licensed physicians, and more  NPs and PAs in Maine for every 100,000 state residents in 2018.

Mean ages of physicians were the same, but NPs’ and PAs’ mean ages each decreased by one year from 2014 to 2018.

Maine’s practicing physician supply, on a per capita basis, was somewhat larger than national averages, both overall and for primary care.

The number of primary care physicians per capita varied greatly by county, with more than twice as many in counties with the highest physician density compared with counties having the lowest density.

Half or more of the physicians in many of Maine’s most rural counties were age 55 or older.

Nearly a quarter of Maine’s total 2018 practicing physician supply graduated from medical school at one of the three colleges affiliated with Maine Medical Center.

About 27% of all of Maine’s physicians in 2018 – 42% of primary care physicians, and more than half in family medicine specialties – completed a residency in Maine, which is an overall increase from 2014.

Comparisons of county-level physician, NP and PA workforce supply with indicators of population health show some areas of the state where the availability of providers may be affecting access to healthcare, suggesting areas for further examination.

AMA demographics Maine NP Nurse Practitioner PA Physician physician assistant residency supply
Frogner BK, Harwood K, Andrilla CHA, Schwartz M, Pines JM Physical Therapy as the First Point of Care to Treat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Costs Health Services Research doi: 10.1111/1475-6773.12984 05-23-2018 URL Direct Access to Physical Therapists health care costs imaging insurance claims opioid Physical therapy
Frogner, BK Update on the Stock and Supply of Health Services Researchers in the United States Health Services Research Special Issue: Global Health Services Research Workforce. doi.org/10.1111/1475-6773.12988 06-04-2018 URL N/A diversity education health care Health services research workforce
Snyder CR, Dahal A, Frogner BK Occupational Mobility among Individuals in Entry‐level Healthcare Jobs in the United States Journal of Advanced Nursing 03-31-2018 URL Career Paths of Allied Health Professionals

To explore career transitions among individuals in select entry-level healthcare occupations.

allied health career pathways health workforce job mobility nursing panel data
Snyder CR, Frogner BK, Skillman SM Facilitating Racial and Ethnic Diversity in the Health Workforce Journal of Allied Health Volume 47, Number 1, Spring 2018, pp. 58-69(12) 03-01-2018 URL Facilitating Racial and Ethnic Diversity in the Health Workforce

Racial and ethnic diversity in the health workforce can facilitate access to healthcare for underserved populations and meet the health needs of an increasingly diverse population. In this study, we explored 1) changes in the racial and ethnic diversity of the health workforce in the United States over the last decade, and 2) evidence on the effectiveness of programs designed to promote racial and ethnic diversity in the U. S. health workforce. Findings suggest that although the health workforce overall is becoming more diverse, people of color are most often represented among the entry-level, lower-skilled health occupations. Promising practices to help facilitate diversity in the health professions were identified in the literature, namely comprehensive programs that integrated multiple interventions and strategies. While some efforts have been found to be promising in increasing the interest, application, and enrollment of racial and ethnic minorities into health profession schools, there is still a missing link in understanding persistence, graduation, and careers.

Gattman NE, McCarty RL, Balassa A, Skillman SM Washington State Behavioral Health Workforce Assessment Washington Workforce Training and Education Coordinating Board 12-01-2017
Full Report
Washington State Behavioral Health Workforce Assessment
McCarty RL, Skillman SM Washington State's Behavioral Health Workforce (profiles) Center for Health Workforce Studies, University of Washington 12-01-2017
Chemical Dependency Counselors
Community Health Workers
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Washington State Behavioral Health Workforce Assessment
Patterson DG, Andrilla CHA, Schwartz MR, Hager LJ, Skillman SM Assessing the Impact of Washington State’s Oral Health Workforce on Patient Access to Care Seattle, WA: Center for Health Workforce Studies, University of Washington 11-09-2017
Final Report
Policy Brief
The Status of the Oral Health Workforce in Washington State dentist licensure
Skillman SM, Dahal A Alaska's physician workforce in 2016 Center for Health Workforce Studies, University of Washington 07-28-2017
Full Report
Alaska’s Physician Workforce
Skillman SM, Dahal A Wyoming’s physician workforce in 2016 Center for Health Workforce Studies, University of Washington 04-01-2017
Full Report
Wyoming’s Physician Workforce
Stubbs BA, Frogner BK, Skillman SM The value of real time labor market information for monitoring health workforce demand: a case study examining employer demand for health information technology skills Center for Health Workforce Studies, University of Washington 03-01-2017
Full Report
Policy Brief
Emerging Health IT Roles and Skillsets
Skillman SM, Dahal A Montana’s physician workforce in 2016 Center for Health Workforce Studies, University of Washington 03-01-2017
Full Report
Montana Physician Workforce
Skillman SM, Dahal A Idaho’s physician workforce in 2016 Center for Health Workforce Studies, University of Washington 02-01-2017
Full Report
Idaho’s Physician Workforce
Boat TF, Land ML, Leslie LK, Haogwood KE, Hawkins-Walsh E, McCabe MA, Fraser MW, deSaxe Zerden L, Lombardi BM, Fritz GK, Frogner BK, Hawkins JD, Sweeney M Workforce development to enhance the cognitive, affective, and behavioral health of children and youth: opportunities and barriers in child health care training Perspectives: Expert Voices in Heath & Health Care, National Academy of Medicine. 29p 11-29-2016 URL N/A
Frogner BK, Wu X, Ku L, Pittman P, Masselink LE Do years of experience with electronic health records matter for productivity in community health centers? Journal of Ambulatory Care Management 40(1):36-47 01-01-2017 URL N/A

This study investigated how years of experience with an electronic health record (EHR) related to productivity in community health centers (CHCs). Using data from the 2012 Uniform Data System, we regressed average annual medical visits, weighted for service intensity, as a function of full-time equivalent medical staff controlling for CHC size and location. Physician productivity significantly improved. Although the productivity of all other staff types was not significantly different by years of EHR experience, the trends showed lower productivity among nurses and other medical staff in CHCs with fewer years of EHR experience versus more years of experience.

community health center electronic health records health IT productivity safety net providers workforce
Frogner BK, Wu X, Park J, Pittman P The association of electronic health record adoption with staffing mix in community health centers Health Services Research 52(S1)407-421 DOI: 10.1111/1475-6773.12648 01-27-2017 URL N/A

Objective
To assess how medical staffing mix changed over time in association with the adoption of electronic health records (EHRs) in community health centers (CHCs).

Study Setting
Community health centers within the 50 states and Washington, DC.

Study Design
Estimated how the change in the share of total medical staff full-time equivalents (FTE) by provider category between 2007 and 2013 was associated with EHR adoption using fractional multinomial logit.

Data Collection
2007–2013 Uniform Data System, an administrative data set of Section 330 federal grant recipients; and Readiness for Meaningful Use and HIT and Patient Centered Medical Home Recognition Survey responses collected from Section 330 recipients between December 2010 and February 2011.

Principal Findings
Having an EHR system did significantly shift the share of workers over time between physicians and each of the other categories of health care workers. While an EHR system significantly shifted the share of physician and other medical staff, this effect did not significantly vary over time. CHCs with EHRs by the end of the study period had a relatively greater proportion of other medical staff compared to the proportion of physicians.

Conclusions
Electronic health records appeared to influence staffing allocation in CHCs such that other medical staff may be used to support adoption of EHRs as well as be leveraged as an important care provider.

administrative data uses Econometrics health workforce: distribution/incomes/training information technology in health uninsured/safety net providers
Frogner BK The health care job engine: where do they come from and what do they say about our future? Medical Care Research and Review 75 issue: 2, page(s): 219-231 01-19-2017 URL N/A

Health care has been cited as a job engine for the U.S. economy. This study used the Current Population Survey to examine the sector and occupation shifts that underlie this growth trend. Health care has had a cyclical relationship with retail trade, leisure and hospitality, education, and professional services. The entering workforce has been increasingly taking on low-skilled occupations. The exiting workforce has not been necessarily retiring or going back to school, but appeared to be leaving without a job, with potentially more child care duties, and with high rates of disability and poverty levels. This study also found that the number of workers staying in health care has been slowly declining over time. As the United States moves toward team-based care, more attention should be paid to the needs of the lower skilled workers to reduce turnover and ensure delivery of quality care.

health care industry health care workforce job growth job mobility turnover
Skillman SM, Dahal A Washington State’s physician workforce in 2016 Center for Health Workforce Studies, University of Washington 02-01-2017
Full Report
Washington State’s Physician Workforce
Patterson DG, Snyder CR, Frogner BK Immigrants in healthcare occupations Center for Health Workforce Studies, University of Washington 01-01-2017
Full Report
Policy Brief
Immigrants in Allied Health Professions
Skillman SM, Dahal A, Frogner BK, Stubbs BA Leveraging data to monitor the allied health workforce: national supply estimates using different data sources: data snapshot - diagnostic related technologists and technicians Center for Health Workforce Studies, University of Washington 01-05-2017
Data Snapshot
Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability
Skillman SM, Dahal A, Frogner BK, Stubbs BA Leveraging data to monitor the allied health workforce: national supply estimates using different data sources: data snapshot - medical assistants Center for Health Workforce Studies, University of Washington 01-05-2017
Data Snapshot
Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability
Skillman SM, Dahal A, Frogner BK, Stubbs BA Leveraging data to monitor the allied health workforce: national supply estimates using different data sources: data snapshot - occupational therapists Center for Health Workforce Studies, University of Washington 01-05-2017
Data Snapshot
Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability
Skillman SM, Dahal A, Frogner BK, Stubbs BA Leveraging data to monitor the allied health workforce: national supply estimates using different data sources: data snapshot - physical therapists Center for Health Workforce Studies, University of Washington 01-05-2017
Data Snapshot
Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability
Skillman SM, Dahal A, Frogner BK, Stubbs BA Leveraging data to monitor the allied health workforce: national supply estimates using different data sources: data snapshot - social workers Center for Health Workforce Studies, University of Washington 01-05-2017
Data Snapshot
Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability
Skillman SM, Dahal A, Frogner BK, Stubbs BA Leveraging data to monitor the allied health workforce: national supply estimates using different data sources: data snapshot - speech-language pathologists Center for Health Workforce Studies, University of Washington 01-05-2017
Data Snapshot
Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability
Skillman SM, Dahal A, Frogner BK, Stubbs BA Leveraging data to monitor the allied health workforce: national supply estimates using different data sources: data snapshot - clinical laboratory technologists and technicians Center for Health Workforce Studies, University of Washington 01-05-2017
Data Snapshot
Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability
Skillman SM, Dahal A, Frogner BK, Stubbs BA Leveraging data to monitor the allied health workforce: national supply estimates using different data sources: data snapshot - dental hygienists Center for Health Workforce Studies, University of Washington 01-05-2017
Data Snapshot
Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability
Skillman SM, Dahal A, Frogner BK, Stubbs BA Leveraging data to monitor the allied health workforce: national supply estimates using different data sources: data snapshot - respiratory therapists Center for Health Workforce Studies, University of Washington 01-05-2017
Data Snapshot
Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability
Skillman SM, Dahal A, Frogner BK, Stubbs BA Leveraging data to monitor the allied health workforce: national supply estimates using different data sources Center for Health Workforce Studies, University of Washington 12-01-2016
Policy Brief
Full Report
Leveraging Data to Monitor the Allied Health Workforce: Building a Database for Studies of Workforce Size, Distribution and Availability
Frogner BK, Skillman SM, Patterson DG, Snyder CR Comparing the socioeconomic well-being of workers across healthcare occupations Center for Health Workforce Studies, University of Washington 12-01-2016
Full Report
Policy Brief
Impacts of Greater Use of Low Skilled, Low-wage Workers in Health Care Delivery
Frogner BK, Skillman SM Pathways to middle-skill allied health care occupations Issues in Science & Technology Fall, 33(1):52-57 11-30-2016 URL N/A

Better information about the skills required in health occupations and the paths to career advancement could provide opportunities for workers as well as improved health care.

Health care has been a “job engine” for the US economy, given the sector’s historically strong job growth, an aging population, and increasing demand for health care due to the Patient Protection and Affordable Care Act of 2010 (ACA). Health care professions dominate the list of the 20 fastest growing occupations, with growth rates between 25% and 50%, according to data compiled by the federal Bureau of Labor Statistics. With a good demand outlook and the relatively low entry requirements for several of these jobs, health care occupations appear to be a good career path.

Many of the growing health care professions are “middle-skill,” a term with considerable overlap with the term “allied health,” a category that encompasses a diverse and not precisely defined set of careers. The Association of Schools of Allied Health Professions has identified 66 such occupations; the Health Professions Network, a collaborative group representing the leading allied health professions, has identified over 45; and the Commission on Accreditation of Allied Health Education Programs provided accreditation in 2010 to 28 occupations. These jobs may or may not involve direct patient care, and some do not require specialized skill at entry. Many require less than a baccalaureate degree for entry.

The pathway to an allied health career can be unclear, especially in relatively new and emerging positions. Clear career pathways and ladders that lead to socioeconomic success need to be clarified in order to direct investments for attracting and retaining a competent workforce. Our task here, then, is to describe what is known about the career pathways into middle-skill allied health careers and the challenges that exist for individuals seeking such careers.

allied healthcare apprenticeship career pathways education health occupations training workforce
Gattman N, Reule R, Balassa A, Skillman SM, McCarty RL, Schwartz MR Washington's behavioral health workforce assessment: project phase I Washington State Workforce Training and Education Coordinating Board Fall 11-01-2016
Final Report
Washington State Behavioral Health Workforce Assessment
McCarty RL, Schwartz MR, Skillman SM Washington’s behavioral health workforce assessment: input from key informants Center for Health Workforce Studies, University of Washington 11-18-2016
Full Report
Policy Brief
Washington State Behavioral Health Workforce Assessment
Roberts FA, DiMarco AC, Skillman SM, Mouradian WE Growing the dental workforce for rural communities: University of Washington’s RIDE program Generations: Journal of the American Society on Aging 40(3):79-84 11-17-2016 URL N/A

Oral health is an integral part of overall health and an important part of healthy (U.S. Department of Health and Human Services, 2000). The oral cavity is the gateway to the body and its first line of defense. Infections in the teeth and gums can contribute to health consequences elsewhere in the body and, conversely, health conditions and their treatment can affect the mouth. Healthy, pain-free dentition is essential for good nutrition, and plays a role in an individual’s expression and self-esteem across the life span.

Older adults are at special risk for oral health problems, and those living in rural areas face additional challenges accessing dental care. Gum tissue shrinks with age, leaving the roots of teeth more vulnerable to caries (decay), while chronic illnesses such as diabetes can trigger gum infection and inflammation. Another factor contributing to dental decay is dry mouth (xerostomia), which is a side effect of many medications taken by older adults—medications such as those used for pain (narcotics), high blood pressure (diuretics), seasonal allergies (antihistamines), and depression (numerous antidepressants).

Smoking tobacco and using smokeless tobacco—practices prevalent in many rural-area populations—also increase the risk of periodontal (gum) disease, dental caries, and oropharyngeal cancer. If unchecked, periodontal disease can lead to tooth loss. Significantly, adults who have lost their teeth are still at risk for cancerous lesions and should have regular oral examinations and evaluations of their dentures.

Older adults with poor dentition and chewing capacity can experience malnutrition or over-consumption of soft foods that are calorie-dense (but nutrient-poor) and are potentially cariogenic (cavity-causing). Concurrent with an increase in their oral health needs, older adults frequently experience diminished neuromotor or cognitive abilities, which, along with other medical problems, may hinder their capacity to maintain oral hygiene and to access dental care.

These challenges are increasing as the U.S. population ages. Timely access to dental healthcare can ameliorate many of these problems, but this access is an ongoing challenge in rural areas of the United States. While those older than age 65 represent about 15 percent of the U.S. population, in rural areas about 20 percent of the population is older than age 65 (U.S. Census Bureau, 2016). As baby boomers age, many move to less populous or geographically isolated areas, and their numbers in these communities are expected to grow disproportionately.

aging in community dental education Generations health and wellness healthcare and aging oral health rural workforce
Frogner BK, Skillman SM, Snyder CR Characteristics of veterans in allied healthcare occupations Center for Health Workforce Studies, University of Washington 11-11-2016
Full Report
Policy Brief
Characteristics of Veterans in Allied Health Care Jobs
Miller SC, Frogner BK, Saganic LM, Cole AM, Rosenblatt RA Affordable Care Act impact on community health center staffing and enrollment: a cross-sectional study Journal of Ambulatory Care Management 39(4):299-307 10-01-2016 URL N/A

Over 500 000 Washingtonians gained health insurance under the Affordable Care Act (ACA). As more patients gain insurance, community health centers (CHCs) expect to see an increase in demand for their services. This article studies the CHCs in Washington State to examine how the increase in patients has been impacting their workload and staffing. We found a reported mean increase of 11.7% and 5.4% in new Medicaid and Exchange patients, respectively. Half of the CHCs experienced large or dramatic workload impact from the ACA. Our findings suggest that CHCs need further workforce support to meet the expanding patient demand.

Affordable Care Act community health centers
Pittman P, Masselink L, Bade L, Frogner BK, Ku L Factors determining medical staff configurations in community health centers: CEO perspectives Journal of Healthcare Management 61(5):364-377 09-01-2016 URL N/A

While financial incentives to adopt team-based care are mounting, little is known about how leaders of primary care organizations make decisions regarding medical staff configurations. This study explores perceptions of CEOs of community health centers (CHCs) that have a variety of staff configurations. We used the 2012 Uniform Data System to identify a maximum variety sample of CHCs with unusually high proportions of advanced practice providers, nurses, medical assistants, case managers, or community health workers. We conducted semistructured interviews with CEOs at 19 selected CHCs about factors that influenced their medical staff configuration decisions. We found that CEOs considered two major dimensions in their decisions: choice and balance of providers (physicians versus nurse practitioners [NPs] and physician assistants [PAs]) and configuration of clinical support staff. Across these decision domains, CEOs consider contextual issues (e.g., local labor supply, wage gaps between professions, scope of practice regulations, local payment policies, and institutional history), as well as their own perceptions of individual attributes, the quality of specific professions, and the likelihood of retention. Strong preferences emerged for a balance among physicians and NPs/PAs and the inclusion of nurses with “stackable” degrees. This study provides a preliminary framework for understanding how CEOs at CHCs weigh staffing options in a variety of contexts. This framework can serve to inform research on the comparative effectiveness of different staffing configurations and improve national and state workforce projection models.

advanced practice providers case managers CEOs CHCs community health workers medical assistants NP nurse practitioners nurses PA primary care staff configuration
Lutfiyya MN, Tomai L, Frogner BK, Cerra F, Zismer D, Parente S Does primary care diabetes management provided to Medicare patients differ between primary care physicians and nurse practitioners? Journal of Advanced Nursing Volume73, Issue1 January 2017 Pages 240-252 01-01-2017 URL N/A
Skillman SM, Andrilla CHA, Patterson DG, Fenton SH, Ostergard SJ Health information technology workforce needs of rural primary care practices J Rural Health. Winter 2015, 31(1):58-66 12-01-2015 N/A
Kaplan L, Klein TA, Skillman SM, Andrilla CHA Faculty supervision of NP program practicums: a comparison of rural and urban site differences The Nurse Practitioner 41(7):36-42 07-01-2016 N/A
Andrilla CHA, Skillman SM Washington State data snapshot: licensed practical nurses (LPNs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 06-01-2016
Snapshot
2018 Licensed Practical Nurses in Washington: Snapshot of Demographics and Employment Characteristics
Andrilla CHA, Skillman SM Washington State data snapshot: advanced registered nurse practitioners (ARNPs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 06-01-2016
Snapshot
2018 Washington State Data Snapshot: Advanced Registered Nurse Practitioners
Andrilla CHA, Skillman SM Washington State data snapshot: registered nurses (RNs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 06-01-2016
Snapshot
2018 Registered Nurses in Washington: Snapshot of Demographics and Employment Characteristics
Snyder CR, Wick KH, Skillman SM, Frogner BK Pathways for military veterans to enter healthcare careers Center for Health Workforce Studies, University of Washington 05-01-2016
Full Report
Policy Brief
Pathways for Military Veterans to Enter Allied Health Careers
Skillman SM, Snyder CR, Frogner BK, Patterson DG The behavioral health workforce needed for integration with primary care: information for health workforce planning Center for Health Workforce Studies, University of Washington 04-20-2016
Full Report
Policy Brief
The Workforce Needed to Integrate Behavioral/Mental Health Workforce with Primary Care
Frogner BK, Harwood K, Pines J, Andrilla CHA, Schwartz M Does unrestricted direct access to physical therapy reduce utilization and health spending? Health Care Cost Institute and National Academy for State Health Policy State Health Policy Grant Program. Washington, DC: Health Care Cost Institute. 01-01-2016 Direct Access to Physical Therapists
National Academies of Sciences Engineering and Medicine A framework for educating health professionals to address the social determinants of health Washington, DC: The National Academies Press 130p 01-01-2016 URL Educating Health Professionals to Address the Social Determinants of Health
Forte G, Graham K, Frogner BK Commentaries on health services research Journal of the American Academy of Physician Assistants Vol. 29(1) DOI: 10.1097/01.JAA.0000475475.25004.86 01-01-2016 URL N/A

A cornerstone of patient-centered medical homes (PCMHs) is team-based care; however, little information exists on the composition of providers delivering direct primary care in PCMHs. This study examined the number and distribution of primary care physicians, NPs, and PAs in New York state practices (n=7,431). Designated PCMHs had more NPs and PAs per primary care physician relative to non-PCMHs. The ratios of NPs to primary care physicians were almost twice as high in PCMHs compared with non-PCMHs (0.20 and 0.11), and ratios were similarly different for PAs to primary care physicians (0.16 and 0.09, respectively). The multivariate analyses also support that higher NP and PA staffing was associated with PCMH designation—that is, for every 25 primary care physicians, PCMHs had one additional NP and/or PA. The growth of PCMHs may require more NPs and PAs to meet the anticipated growth in demand for healthcare. Policy- and practice-level changes are necessary to use them in the most effective ways.

NP PA patient-centered medical homes PCHM PCP primary care physicians primary care provider team-based care
Frogner BK, Pauley GC Do skill mix and high tech matter for hospitals’ competency in adopting electronic health records? Health Economics Outcomes Research (Open Access) Vol. 1(1): 1-10 01-01-2015 URL N/A

Health workforce plays an important role in the adoption of electronic health records (EHRs). Hospitals have cited barriers around hiring a competent workforce to adopt EHRs. The literature does not adequately relate organizational and health workforce competency with EHR adoption, which makes it difficult to monitor and evaluate any programs targeting trying to improve this problem. In this study, we develop an index measuring hospitals’ competency in adopting electronic health records (EHRs) using Item Response Theory. We test to what extent hospitals’ skill mix and high tech capacity influence their competency. We use health IT data from Health Information and Management Systems Society
(HIMSS) Analytics Database and workforce and high tech data from the Centers of Medicare and Medicaid Services (CMS) Provider of Services file. We found that hospitals with a larger share of registered nurses (RNs) had higher EHR competency, but environments with more high tech potentially compete for their attention and results in lower EHR competency. Technicians, therapists, and lower skilled nurses that interact with high tech apparently transfer their knowledge and skills into higher EHR competency. Future EHR adoption incentives should target lower competency hospitals with insufficient workforce and less technological capacity

Capital-skill complementarity EHR health IT health workforce Item response theory Organizational competency
Frogner BK, Parente ST, Frech HE Comparing efficiency of health systems across industrialized countries: a panel analysis BMC Health Services Research Vol. 15 (1):415-426 01-01-2015 URL N/A

BACKGROUND:

Rankings from the World Health Organization (WHO) place the US health care system as one of the least efficient among Organization for Economic Cooperation and Development (OECD) countries. Researchers have questioned this, noting simplistic or inappropriate methodologies, poor measurement choice, and poor control variables. Our objective is to re-visit this question by using newer modeling techniques and a large panel of OECD data.

METHODS:

We primarily use the OECD Health Data for 25 OECD countries. We compare results from stochastic frontier analysis (SFA) and fixed effects models. We estimate total life expectancy as well as life expectancy at age 60. We explore a combination of control variables reflecting health care resources, health behaviors, and economic and environmental factors.

RESULTS:

The US never ranks higher than fifth out of all 36 models, but is also never the very last ranked country though it was close in several models. The SFA estimation approach produces the most consistent lead country, but the remaining countries did not maintain a steady rank.

DISCUSSION:

Our study sheds light on the fragility of health system rankings by using a large panel and applying the latest efficiencymodeling techniques. The rankings are not robust to different statistical approaches, nor to variable inclusion decisions.

CONCLUSIONS:

Future international comparisons should employ a range of methodologies to generate a more nuanced portrait of healthcare system efficiency.

Efficiency Health systems International comparison Life expectancy Stochastic frontier analysis
Frogner BK, Spetz J, Oberlin S, Parente ST The Demand for Healthcare Workers Post-ACA International Journal of Health Economics and Management Vol. 15(1): 139-151 01-01-2015 URL N/A

Concern abounds about whether the health care workforce is sufficient to meet changing demands spurred by the Affordable Care Act (ACA). We project that by 2022 the health care industry needs three to four million additional workers, forty percent of which is related to demand growth under the ACA. We project faster job growth in the ambulatory care sector, especially in home health care. Given the current profile, we expect that the future health care workforce will be increasingly female, young, racially/ethnically diverse, not US-born, at or below the poverty level and at a low level of educational attainment.

health reform health workforce microsimulation projections
Ku L, Frogner BK, Steinmetz E, Pittman P Many paths to primary care: flexible staffing and productivity in community health centers Health Affairs Vol. 34(1): 95-103 01-01-2015 URL Impact of Electronic Health Records on Community Health Center Staffing

Community health centers are at the forefront of ambulatory care practices in their use of nonphysician clinicians and team-based primary care. We examined medical staffing patterns, the contributions of different types of staff to productivity, and the factors associated with staffing at community health centers across the United States. We identified four different staffing patterns: typical, high advanced-practice staff, high nursing staff, and high other medical staff. Overall, productivity per staff person was similar across the four staffing patterns. We found that physicians make the greatest contributions to productivity, but advanced-practice staff, nurses, and other medical staff also contribute. Patterns of community health center staffing are driven by numerous factors, including the concentration of clinicians in communities, nurse practitioner scope-of-practice laws, and patient characteristics such as insurance status. Our findings suggest that other group medical practices could incorporate more nonphysician staff without sacrificing productivity and thus profitability. However, the new staffing patterns that evolve may be affected by characteristics of the practice location or the types of patients served.

community health centers confidence intervals medicaid patients medical practice nurses nursing patient care physicians primary care uninsured
Skillman SM, Hager LJ, Frogner BK Incentives for Nurse Practitioners and Registered Nurses to Work in Rural and Safety Net Settings Seattle, WA: UW Center for Health Workforce Research Studies UW Health Workforce Research Center Rapid Turnaround prepared for Health Resources and Services Administration 01-01-2015
Rapid Turnaround Brief
N/A
Skillman SM, Palazzo L, Hart LG, Keepnews D The characteristics of registered nurses whose licenses expire: why they leave nursing and implications for retention and re-entry Nurs Econ 28(3):181-189. 05-01-2010 URL RNs with Expired Licenses in Washington

Little is known about RNs who drop their licenses and their potential re-entry into the nursing workforce. The results of this study provide insight into reasons nurses leave their careers and the barriers to re-entry, all important indicators of the current professional climate for nursing. While representing only one state, these findings suggest that RNs who allow their licenses to expire do so because they have reached retirement age or, among those who do not cite age as a factor, because many are unable or unwilling to work in the field. Inactive nurses who might otherwise appear to be likely candidates for re-entry into the profession may not be easily encouraged to practice nursing again without significant changes in their personal circumstances or the health care work environment. Effective ways to address current and pending RN workforce shortages include expanding RN education capacity to produce more RNs who can contribute to the workforce across the coming decades, and promote work environments in which RNs want to, and are able to, practice across a long nursing career.

education license RN workforce
Skillman SM, Stover B Idaho's physician workforce in 2014 Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 09-01-2014
Full Report
Idaho’s Physician Workforce
Skillman SM, Stover B Alaska’s physician workforce in 2014 Seattle, WA:WWAMI Center for Health Workforce Studies, University of Washington 12-29-2015
Full Report
Alaska’s Physician Workforce
Frogner BK, Westerman B, DiPietro L The value of athletic trainers in ambulatory settings Journal of Allied Health Vol. 44(3): 160-167 01-01-2015 Value of Athletic Trainers in Ambulatory Care Settings
Westerman B, Frogner BK, DiPietro L Hiring patterns of athletic trainers in ambulatory settings International Journal of Athletic Therapy and Training Vol. 20(5): 39-42 01-01-2015 Value of Athletic Trainers in Ambulatory Care Settings
Frogner BK, Spetz J Exit and entry of workers in long-term care San Francisco, CA: UCSF Health Workforce Research Center on Long-Term Care 2015 01-01-2015 URL Entry and Exit of Workers in Long-Term Care
Skillman SM, Stover B Wyoming's physician workforce in 2014 Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 10-11-2014
Full report
Wyoming’s Physician Workforce
Patterson DG, Skillman SM, Andrilla CHA Data snapshots: Wyoming health care providers, 2009 Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 10-31-2009
Physicians
Physician Assistants
Advanced Practice Nurses
Pharmacists
Dentists
Psychologists
Licensed Professional Counselors
Licensed Clinical Social Workers
Licensed Marriage & Family Therapists
Licensed Addiction Therapists
Wyoming Health Care Workforce Distribution and Policy Analyses
Patterson DG, Skillman SM, Doescher MP, Andrilla CHA Obstacles to providing high-quality patient care: findings from a survey of Wyoming's medical care providers Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Final Report #131 08-31-2009
Full report Policy brief
Wyoming Health Care Workforce Distribution and Policy Analyses
Patterson DG, Skillman SM, Andrilla CHA, Doescher MP Workforce challenges in delivering health care to elderly and low-income populations in Wyoming: medical providers' acceptance of Medicaid and Medicare patients Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Final Report #128 09-30-2009
Full report Policy brief
Wyoming Health Care Workforce Distribution and Policy Analyses
Skillman SM, Andrilla CHA, Doescher MP, Robinson BJ Wyoming primary care gaps and policy options Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Final Report #122 12-01-2008
Full report
Wyoming Health Care Workforce Distribution and Policy Analyses
WWAMI Center for Health Workforce Studies, University of Washington Data snapshot: current osteopathic physician workforce in the WWAMI states Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 10-01-2007
Snapshot
Physician Workforce in WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho): 2005
Chen FM, Fordyce MA, Hart LG WWAMI Physician Workforce 2005 Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #98 01-01-2005
Full report
Physician Workforce in WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho): 2005
Patterson DG, Skillman SM, Hart LG Washington State's radiographer workforce through 2020: influential factors and available data Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #89 01-01-2004
Full report Policy brief
Washington State’s Radiographer Workforce Through 2020: Influential Factors and Available Data
Patterson DG, Skillman SM, Hart LG Washington State's pharmacist workforce through 2020: influential factors and available data Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #90 01-01-2004
Full report Policy brief
Washington State’s Pharmacist Workforce through 2020: Influential Factors and Available Data
Patterson DG, Skillman SM, Hart LG Washington State's pharmacist workforce through 2020: influential factors and available data Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #90 01-01-2004
Full report Policy brief
Washington State’s Dental Hygienist Workforce through 2020: Influential Factors and Available Data
Skillman SM, Andrilla CHA, Alves-Dunkerson JA, Mouradian WE, Comenduley M, Yi J, Doescher MP Washington State's oral health workforce Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Final Report #130 08-31-2009
Full report
Assessment of the Oral Health Workforce in Washington State
Andrilla CHA, Hart LG Practice patterns and characteristics of dental hygienists in Washington State Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Final Report #114 08-01-2007
Full report
Washington’s Dental Hygienists: 2004 Survey Findings
Patterson DG, Skillman SM, Hart LG Washington State's dental hygienist workforce through 2020: influential factors and available data Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #92 01-01-2004
Full report Policy brief
Washington State’s Dental Hygienist Workforce through 2020: Influential Factors and Available Data
Skillman SM, Andrilla CHA, Tieman L, Doescher MP Demographic, education, and practice characteristics of registered nurses in Washington State: results of a 2007 survey Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Final Report #120 06-01-2008
Full report Policy brief
Demographic, Education, and Practice Characteristics of Registered Nurses in Washington State: Results of a 2007 Survey
Skillman SM, Andrilla CHA, Tieman L, McCook AU Washington State registered nurse supply and demand projections: 2011-2031 Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Final Report #134 12-31-2011
Full report Policy brief
Projections of Washington State RN Supply and Demand through 2031
Skillman SM, Andrilla CHA, Hart LG Washington State registered nurse supply and demand projections: 2006-2025 Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Final Report #112 06-01-2007
Full report Policy brief
Projections of Washington State RN Supply and Demand through 2025
Skillman SM, Andrilla CHA, Ostergard SJ Washington State registered nurses - analysis of RNs who did not renew their licenses: 2008-2014 Seattle, WA:WWAMI Center for Health Workforce Studies, University of Washington 09-30-2014
Full report
Washington State Registered Nurses – Analysis of RNs who did not renew their licenses: 2008-2014
Skillman SM, Stover B Washington State's physician workforce in 2014 Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 08-14-2014
Full report
Washington State’s Physician Workforce
Dresden GM, Baldwin LM, Andrilla CHA, Skillman SM, Benedetti TJ Influence of obstetric practice on workload and practice patterns of family physicians and obstetrician-gynecologists Ann Fam Med 6(Suppl 1):S5-S11 01-01-2008 URL Professional Liability Issues and Practice Patterns of Obstetrical Providers in Washington State

PURPOSE:

Obstetric practice among family physicians has declined in recent years. This study compared the practice patterns of familyphysicians and obstetrician-gynecologists with and without obstetric practices to provide objective information on one potential reason for this decline–the impact of obstetrics on physician lifestyle.

METHODS:

In 2004, we surveyed all obstetrician-gynecologists, all rural family physicians, and a random sample of urban family physiciansidentified from professional association lists (N =2,564) about demographics, practice characteristics, and obstetric practices.

RESULTS:

A total of 1,197 physicians (46.7%) overall responded to the survey (41.5% of urban family physicians, 54.7% of rural familyphysicians, and 55.0% of obstetrician-gynecologists). After exclusions, 991 were included in the final data set. Twenty-seven percent of urban family physicians, 46% of rural family physicians, and 79% of obstetrician-gynecologists practiced obstetrics. The mean number of total professional hours worked per week was greater with obstetric practice than without for rural family physicians (55.4 vs 50.2, P=.005) and for obstetrician-gynecologists (58.3 vs 43.5, P = .000), but not for urban family physicians (47.8 vs 49.5, P = .27). For all 3 groups, physicianspracticing obstetrics were more likely to provide inpatient care and take call than physicians not practicing obstetrics. Large proportions of family physicians, but not obstetrician-gynecologists, took their own call for obstetrics. Concerns about the litigation environment and personal issues were the most frequent reasons for stopping obstetric practice.

CONCLUSIONS:

Practicing obstetrics is associated with an increased workload for family physicians. Organizing practices to decrease the impact on lifestyle may support family physicians in practicing obstetrics.

Family medicine lifestyle obstetrics practice patterns rural health care workload
Benedetti TJ, Baldwin LM, Skillman SM, Andrilla CHA, Bowditch E, Carr KC, Myers SJ Professional liability issues and practice patterns of obstetrical providers in Washington State Obstet Gynecol 107(6):1238-1246 06-01-2006 URL Professional Liability Issues and Practice Patterns of Obstetrical Providers in Washington State

OBJECTIVE:

To describe recent changes in obstetric practice patterns and liability insurance premium costs and their consequences to Washington State obstetric providers (obstetrician-gynecologists, family physicians, certified nurse midwives, licensed midwives).

METHODS:

All obstetrician-gynecologists, rural family physicians, certified nurse midwives, licensed midwives, and a simple random sample of urban family physicians were surveyed about demographic and practice characteristics, liability insurance characteristics, practice changes and limitations due to liability insurance issues, obstetric practices, and obstetric practice environment changes.

RESULTS:

Fewer family physicians provide obstetric services than obstetrician-gynecologists, certified nurse midwives, and licensed midwives. Mean liability insurance premiums for obstetric providers increased by 61% for obstetrician-gynecologists, 75% for family physicians, 84% for certified nurse midwives, and 34% for licensed midwives from 2002 to 2004. Providers‘ most common monetary responses to liability insurance issues were to reduce compensation and to raise cash through loans and liquidating assets. In the 2 years of markedly increased premiums, obstetrician-gynecologists reported increasing their cesarean rates, their obstetric consultation rates, and the number of deliveries. They reported decreasing high-risk obstetric procedures during that same period.

CONCLUSION:

Liability insurance premiums rose dramatically from 2002 to 2004 for Washington‘s obstetric providers, leading many to make difficult financial decisions. Many obstetric providers reported a variety of practice changes during that interval. Although this study’s results do not document an impending exodus of providers from obstetric practice, rural areas are most vulnerable because family physicians provide the majority of rural obstetric care and are less likely to practice obstetrics.

LEVEL OF EVIDENCE:

III.

Comment in

certified nurse midwives family physicians gynecologists liability premiums licensed midwives maternity care midwifery obstetricians obstetrician–gynecologists practice patterns Professional liability registered nurses
Benedetti TJ, Baldwin LM, Andrilla CHA, Hart LG The productivity of Washington State's obstetrician-gynecologist workforce: does gender make a difference? Obstet Gynecol 103(3):499-505 01-01-2004 URL Obstetrics and Gynecology Specialty Services: Supply, Distribution, and the Effect of Changing Demography in Washington State

OBJECTIVE:

To compare the practice productivity of female and male obstetrician-gynecologists in Washington State.

METHODS:

The primary data collection tool was a practice survey that accompanied each licensed practitioner’s license renewal in 1998-1999. Washington State birth certificate data were linked with the licensure data to obtain objective information regarding obstetric births.

RESULTS:

Of the 541 obstetrician-gynecologists identified, two thirds were men and one third were women. Women were significantly younger than men (mean age 43.3 years versus 51.7 years). Ten practice variables were evaluated: total weeks worked per year, total professional hours per week, direct patient care hours per week, nondirect patient care hours per week, outpatient visits per week, inpatient visits per week, percent practicing obstetrics, number of obstetrical deliveries per year, percentage working less than 32 hours per week, and percentage working 60 or more hours per week. Of these, only 2 variables showed significant differences: inpatient visits per week (women 10.1 per week, men 12.8 per week, P < or =.01) and working 60 or more hours per week (women 22.1% versus men 31.5%, P < or =.05). After controlling for age, analysis of covariance and multiple logistic regression confirmed these findings and in addition showed that women worked 4.1 fewer hours per week than men (P <.01). When examining the ratio of female-to-male practice productivity in 10-year age increments from the 30-39 through the 50-59 age groups, a pattern emerged suggesting lower productivity in many variables in the women in the 40-49 age group.

CONCLUSION:

Only small differences in practice productivity between men and women were demonstrated in a survey of nearly all obstetrician-gynecologists in Washington State. Changing demographics and behaviors of the obstetrician-gynecologist workforce will require ongoing longitudinal studies to confirm these findings and determine whether they are generalizable to the rest of the United States.

LEVEL OF EVIDENCE:

II-3

obstetrician–gynecologists practice productivity
Benedetti TJ, Baldwin LM, Andrilla CHA, Hart LG The productivity of Washington State's obstetrician-gynecologist workforce: does gender make a difference? Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #82 10-01-2003
Full report
Obstetrics and Gynecology Specialty Services: Supply, Distribution, and the Effect of Changing Demography in Washington State
Andrilla CHA, Skillman SM, Tieman L Demographic, education, and practice characteristics of licensed practical nurses in Washington State: results of a 2007 survey Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Final Report #123 01-01-2009
Full report Policy brief
Demographic, Education, and Practice Characteristics of Licensed Practical Nurses in Washington State: Results of a 2007 Survey
Skillman SM, Andrilla CHA, Patterson DG, Tieman L, Doescher MP The licensed practical nurse workforce in the United States: one state's experience Cah Sociol Demogr Med 50(2):179-212 06-01-2010 URL Projections of Washington State LPN Supply and Demand through 2025

BACKGROUND:

Licensed practical nurses (LPNs) are employed in multiple health care settings in the United States, with the largest portion providing nursing care in long-term care, skilled nursing, and nursing home facilities, which largely provide custodial care and rehabilitative services to elderly residents. Rapid growth in the size of the elderly population in the U.S., combined with retirements from an aging LPN workforce, are expected to increase the demand for LPNs in the coming decades. This paper describes the characteristics of LPNs in one state, Washington, and makes projections of LPN supply and demand in the state through 2026.

METHODS:

The study uses data from a 2007 survey of LPNs with Washington State licenses to describe the demographic, education, and practice characteristics of the workforce. The projections of LPN supply and demand were built from the baseline survey data and changes over time were estimated using available data and literature from a variety of sources.

RESULTS:

Of the 14,446 LPNs with Washington licenses in 2007, 72% practiced in the state. The work setting in which the largest percentage worked was long-term care (37%). Of the average 37 hours worked per week by LPNs, 25 hours were spent in direct patient care. The average age of practicing LPNs was 46 and 12% of LPNs were male. The racial/ethnic distribution of Washington’s LPNs resembled that of the overall state population, with 17% non-White and 4% Hispanic. Nearly three quarters obtained their LPN education within Washington. If the 2007 number of completions from LPN schools in Washington is sustained, the projected supply of practicing LPNs in 2026 will be more than 3,500 (24%) below estimated demand. If the current education completion number increased by 200 LPNs (nearly 20%) in 2011, and this number was maintained through 2026, the projected supply of practicing LPNs would increase but would still be 2,052 LPNs below estimated demand in 2026. Neither projection scenario produces enough LPNs to maintain the 2007 LPN-to-population ratio through 2026. CONCLUSIONS/POLICY IMPLICATIONS: It is not known precisely whether or how LPN workforce roles will change in the future, but the projected LPN shortages in Washington State mirror similar findings from other parts of the U.S., with major growth in projected LPN demand due to increases in, and aging of the state’s population. The number of LPNs completing education programs in the state is unlikely to keep pace with the decline in supply from retirements unless a significant expansion of education programs takes place. The LPN profession is an important entry point into the nursing profession, and increasing the number of LPNs educated in-state could expand the pipeline leading to registered nurse (RN) careers, another nursing profession for which major shortages are predicted. Carefully articulated LPN-to-RN education programs could improve the attractiveness of the profession and increase the supply of LPNs.

licensed practical nurses LPN workforce
Skillman SM, Andrilla CHA, Patterson DG, Thomas A, Tieman L Washington State licensed practical nurse supply and demand projections: 2007-2026 Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Final Report #129 08-27-2009
Full report Policy brief.
Projections of Washington State LPN Supply and Demand through 2025
Skillman SM, Hutson T, Andrilla CHA, Berkowitz B, Hart LG How are Washington's hospitals affected by the nursing shortage? Results of a 2001 survey Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #68 05-01-2002
Washington’s Hospital Staffing Surveys – 2001, 2002, 2003-4, 2005
Skillman SM, Andrilla CHA, Phippen E, Hutson T, Bowditch E, Praseuth T Washington State hospitals: results of 2005 workforce survey Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #104 10-01-2005
Full report Policy brief
Washington’s Hospital Staffing Surveys – 2001, 2002, 2003-4, 2005
Skillman SM, Andrilla CHA, Hutson T, Deacon H, Praseuth T Washington State hospitals: results of 2003/04 workforce survey Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #93 10-01-2004
Full report Policy brief
Washington’s Hospital Staffing Surveys – 2001, 2002, 2003-4, 2005
Skillman SM, Hutson T, Andrilla CHA Washington State hospitals: results of 2002 workforce survey Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #79 08-01-2003
Full report Policy brief
Washington’s Hospital Staffing Surveys – 2001, 2002, 2003-4, 2005
Skillman SM, Andrilla CHA, Kaplan L, Brown MA Demographic, education, and practice characteristics of advanced registered nurse practitioners in Washington State: results of a 2008 survey Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Final Report #124 04-01-2009
Full report Policy brief
Demographic, Education, and Practice Characteristics of Advanced Registered Nurse Practitioners in Washington State: Results of a 2008 Survey
Skillman SM, Sadow-Hasenberg J, Hart LG, Henderson T The effects of the Workforce Investment Act of 1998 on health workforce development in the states Washington, DC: Bureau of Health Professions, Health Resources and Services Administration, National Center for Health Workforce Analysis 11-01-2004
Full report
The Workforce Investment Act of 1998: Are States Targeting the Health Workforce?
Rosenblatt RA, Rosenblatt FS The role and function of small isolated public health departments: a case study in three western states Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #65 06-01-2001
Policy brief
Rural-Urban Differences in the Public Health Workforce: Findings from Local Health Departments in Three Rural Western States (Alaska, Montana and Wyoming)
Rosenblatt RA, Casey S, Richardson M Rural-urban differences in the public health workforce: findings from local health departments in three rural western states Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #61 12-01-2000
Policy brief
Rural-Urban Differences in the Public Health Workforce: Findings from Local Health Departments in Three Rural Western States (Alaska, Montana and Wyoming)
Richardson M, Casey S, Rosenblatt RA Local health districts and the public health workforce: a case study of Wyoming and Idaho Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #56 11-01-1999
Policy brief
Rural-Urban Differences in the Public Health Workforce: Findings from Local Health Departments in Three Rural Western States (Alaska, Montana and Wyoming)
Richardson M, Casey S, Rosenblatt RA Local health districts and the public health workforce: a case study of Wyoming and Idaho J Public Health Manag Pract 7(1):37-48 01-01-2001 URL Rural-Urban Differences in the Public Health Workforce: Findings from Local Health Departments in Three Rural Western States (Alaska, Montana and Wyoming)

This study of personnel in local health departments (LHDs) focused on two predominantly rural states: Idaho and Wyoming. Although in the same region of the country, the structure of local public health is different in each state. Idaho’s regionalized LHDs are relatively autonomous, whereas Wyoming’s are county based, with many public health functions retained at the state level. The majority of professionals are nurses followed by environmental health workers and sanitarians, similar to data reported nationally. With increased emphasis on core public health functions of policy, assurance, and assessment, rural LHDs will be challenged to redirect the functions of their workforce.

health workers local health districts (LHD) nurses sanitarians workforce
Rosenblatt RA, Casey S, Richardson M Rural-urban differences in the public health workforce: findings from local health departments in three rural western states Am J Public Health 92(7):1102-1105 01-01-2002 URL Rural-Urban Differences in the Public Health Workforce: Findings from Local Health Departments in Three Rural Western States (Alaska, Montana and Wyoming)

Most local health departments or districts are small and rural; two thirds of the nation’s 2832 local health departments serve populations smaller than 50000 people.1 Rural local health departments have small staffs and slender budgets, yet they are expected to provide a wide array of services2 during a period when the health care system of which they are a part is undergoing change.3

This study provided quantitative, population based data on the supply and composition of the rural public health workforce in 3 extremely rural states: Alaska, Montana, and Wyoming. The study focused on the relative supply of personnel in the principal public health occupational categories, differences across states in staffing levels, and difficulties experienced in recruiting and retaining personnel.

local health departments public health professionals rural vs urban workforce
Skillman SM, Fordyce MA, Yen W, Mounts T Washington State primary care provider survey, 2011-2012: summary of findings Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 08-31-2012
Full report
Washington State Survey of Primary Care Physicians, Nurse Practitioners, and Physician Assistants–Technical Assistance
Matthews B, Mounts T Washington State primary care workforce: summary of physician focus group findings Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 08-31-2012
Policy brief
Washington State Survey of Primary Care Physicians, Nurse Practitioners, and Physician Assistants–Technical Assistance
Patterson DG, Baldwin LM, Olsen P Supports and obstacles in the medical school application process for American Indians and Alaska Natives J Health Care Poor Underserved 20(2):308-329 05-01-2009 URL An Analysis of Factors that Affect the Acceptance of American Indians and Alaska Natives (AI/ANs) into Medical School Training Programs

Purpose. This study examines how a wide range of supports and obstacles are associated with the medical school admissions process of American Indians and Alaska Natives (AI/ANs), an under-studied population.

Method. All AI/AN applicants to the University of Washington School of Medicine during the 2002–2004 admissions cycles were sent a mail-in survey with numerical and open-ended items. We analyzed admissions data for all 107 applicants and data on supports and obstacles for 34 survey respondents.

Results. Compared with respondents accepted by at least one medical school, rejected respondents were older, more often were parents, submitted fewer applications, and reported receiving less support for the medical school application process. Obstacles included difficulty with the Medical College Admission Test, insufficient finances, and poor information about the process.

Conclusion. A conceptual framework that considers both supports and obstacles in the medical school application process will improve our understanding of the needs of AI/AN applicants.

Alaska Natives American Indians career choice education Indians medical North American students
Andrilla CHA, Skillman SM, Morrison CC, Reeves MA Washington State data snapshot: registered nurses (RNs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 04-01-2014
Snapshot
2018 Registered Nurses in Washington: Snapshot of Demographics and Employment Characteristics
Skillman SM, Andrilla CHA Washington State data snapshot: registered nurses (RNs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 04-30-2013
Snapshot
2018 Registered Nurses in Washington: Snapshot of Demographics and Employment Characteristics
Skillman SM, Andrilla CHA Washington State data snapshot: registered nurses (RNs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 03-01-2011
Snapshot
2018 Registered Nurses in Washington: Snapshot of Demographics and Employment Characteristics
WWAMI Center for Health Workforce Studies and Washington Center for Nursing Washington State data snapshot: registered nurses (RNs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 09-01-2008
Snapshot
2018 Registered Nurses in Washington: Snapshot of Demographics and Employment Characteristics
WWAMI Center for Health Workforce Studies and Washington Center for Nursing Washington State data snapshot: registered nurses (RNs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 10-01-2007
Snapshot
2018 Registered Nurses in Washington: Snapshot of Demographics and Employment Characteristics
WWAMI Center for Health Workforce Studies and Washington Center for Nursing Washington State data snapshot: registered nurses (RNs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 08-01-2006
Snapshot
2018 Registered Nurses in Washington: Snapshot of Demographics and Employment Characteristics
WWAMI Center for Health Workforce Studies, University of Washington Data snapshot: registered nurses (RNs) in Washington: demographics and employment characteristics Seattle, WA : WWAMI Center for Health Workforce Studies, University of Washington 12-01-2001
Snapshot
2018 Registered Nurses in Washington: Snapshot of Demographics and Employment Characteristics
WWAMI Center for Health Workforce Studies, University of Washington Data snapshot: pharmacists in Washington: demographics and employment characteristics Seattle, WA : WWAMI Center for Health Workforce Studies, University of Washington 12-01-2001
Snapshot
Pharmacists in Washington: Snapshot of Demographics and Employment Characteristics in 1999
Andrilla CHA, Skillman SM, Morrison CC, Reeves MA Washington State data snapshot: licensed practical nurses (LPNs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 04-01-2014
Snapshot
2018 Licensed Practical Nurses in Washington: Snapshot of Demographics and Employment Characteristics
Skillman SM, Andrilla CHA Washington State data snapshot: licensed practical nurses (LPNs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 04-30-2013
Snapshot
2018 Licensed Practical Nurses in Washington: Snapshot of Demographics and Employment Characteristics
Skillman SM, Andrilla CHA Washington State data snapshot: licensed practical nurses (LPNs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 03-01-2011
Snapshot
2018 Licensed Practical Nurses in Washington: Snapshot of Demographics and Employment Characteristics
WWAMI Center for Health Workforce Studies and Washington Center for Nursing Washington State data snapshot: licensed practical nurses (LPNs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 09-01-2008
Snapshot.
2018 Licensed Practical Nurses in Washington: Snapshot of Demographics and Employment Characteristics
WWAMI Center for Health Workforce Studies and Washington Center for Nursing Washington State data snapshot: licensed practical nurses (LPNs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 10-31-2007
Snapshot
2018 Licensed Practical Nurses in Washington: Snapshot of Demographics and Employment Characteristics
WWAMI Center for Health Workforce Studies and Washington Center for Nursing Washington State data snapshot: licensed practical nurses (LPNs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 09-01-2006
Snapshot
2018 Licensed Practical Nurses in Washington: Snapshot of Demographics and Employment Characteristics
WWAMI Center for Health Workforce Studies, University of Washington Data snapshot: licensed practical nurses (LPNs) in Washington: demographics and employment characteristics Seattle, WA : WWAMI Center for Health Workforce Studies, University of Washington 12-01-2001
Snapshot
2018 Licensed Practical Nurses in Washington: Snapshot of Demographics and Employment Characteristics
Andrilla CHA, Skillman SM, Morrison CC, Reeves MA Washington State data snapshot: advanced registered nurse practitioners (ARNPs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 04-01-2014
Snapshot
2018 Washington State Data Snapshot: Advanced Registered Nurse Practitioners
Skillman SM, Andrilla CHA Washington State data snapshot: advanced registered nurse practitioners (ARNPs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 04-30-2013
Snapshot
2018 Washington State Data Snapshot: Advanced Registered Nurse Practitioners
Skillman SM, Andrilla CHA Washington State data snapshot: advanced registered nurse practitioners (ARNPs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 03-01-2011
Snapshot
2018 Washington State Data Snapshot: Advanced Registered Nurse Practitioners
WWAMI Center for Health Workforce Studies and Washington Center for Nursing Washington State data snapshot: advanced registered nurse practitioners (ARNPs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 09-01-2008
Snapshot
2018 Washington State Data Snapshot: Advanced Registered Nurse Practitioners
WWAMI Center for Health Workforce Studies and Washington Center for Nursing Washington State data snapshot: advanced registered nurse practitioners (ARNPs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 10-01-2007
Snapshot
2018 Washington State Data Snapshot: Advanced Registered Nurse Practitioners
WWAMI Center for Health Workforce Studies and Washington Center for Nursing Washington State data snapshot: advanced registered nurse practitioners (ARNPs) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 08-01-2006
Snapshot
2018 Washington State Data Snapshot: Advanced Registered Nurse Practitioners
Skillman SM, Palazzo L, Keepnews D, Hart LG Characteristics of registered nurses in rural vs. urban areas: implications for strategies to alleviate nursing shortages in the United States Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #91 01-01-2004
Full report Policy brief
Characteristics of Rural RNs in the U.S.: Analysis of the 2000 National Sample Survey of RNs
Skillman SM, Palazzo L, Keepnews D, Hart LG Characteristics of registered nurses in rural vs. urban areas: implications for strategies to alleviate nursing shortages in the United States. J Rural Health 22(2):151-157 01-01-2006 URL Characteristics of Rural RNs in the U.S.: Analysis of the 2000 National Sample Survey of RNs

Methods: This study compares characteristics of rural and urban registered nurses (RNs) in the United States using data from the 2000 National Sample Survey of Registered Nurses. RNs in 3 types of rural areas are examined using the rural-urban commuting area taxonomy. Findings: Rural and urban RNs are similar in age and sex; nonwhites and Hispanics are underrepresented in both groups. Rural RNs have less nursing education, are less likely to work in hospitals, and are more likely to work full time and in public/community health than urban RNs. The more rural an RN’s residence, the more likely he/she commutes to another area for work and the lower salary he/she receives.Conclusions: Strategies to reduce nurse shortages should consider differences in education, work patterns, and commuting behavior among rural and urban RNs. Solutions for rural areas require understanding of the impact of the workplace on these behaviors.

commuting behavior education registered nurses RN rural vs urban shortages work patterns
Skillman SM, Hart LG, Bowditch E, Kirlin BA Retail pharmacies in Washington State: results of 2003 workforce survey Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #100 12-01-2004
Full report Policy brief
Retail Pharmacies in Washington: Results of a 2003 Workforce Demand Survey
Hollow WB, Patterson DG, Olsen P, Baldwin LM American Indians and Alaska Natives: how do they find their path to medical school? Acad Med 81(10 Suppl):S65-S69 10-01-2006 URL Factors that Promote the Recruitment of American Indians and Alaska Natives into (AI/ANs) Medicine

BACKGROUND:

American Indians and Alaska Natives (AI/ANs) remain underrepresented in the medical profession. This study sought to understand the supports and barriers that AI/AN students encountered on their path to successful medical school entry.

METHOD:

The research team analyzed qualitative semistructured, one-on-one, confidential interviews with 10 AI/AN medical students to identify salient support and barrier themes.

RESULTS:

Supports and barriers clustered in eight categories: educational experiences, competing career options and priorities, health care experiences, financial factors, cultural connections, family and friends, spirituality, and discrimination. Some of the most notable findings of this study include the following: (1) students reported financial barriers severe enough to constrain participation in the medical schoolapplication process, and (2) spirituality played an important role as students pursued a medical career.

CONCLUSION:

Promoting AI/AN participation in medical careers can be facilitated with strategies appropriate to the academic, financial, and cultural needs of AI/AN students.

Alska Native American Indian cultural cultural needs financial medical profession medical students spirituality
Hollow WB, Buckley A, Patterson DG, Olsen P, Dorscher J, Medora R, Morin L, Padilla RS, Tahsequah J, Baldwin LM Clearing the path to medical school for American Indians and Alaska Natives: new strategies Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #101 01-01-2006
Full report Policy brief
Factors that Promote the Recruitment of American Indians and Alaska Natives into (AI/ANs) Medicine
Hollow WB, Patterson DG, Olsen P, Baldwin LM American Indians and Alaska Natives: how do they find their path to medical school? Seattle, WA:WWAMI Center for Health Workforce Studies, University of Washington Working Paper #86 01-01-2004 Factors that Promote the Recruitment of American Indians and Alaska Natives into (AI/ANs) Medicine
Larson E, Hart LG Growth and change in the physician assistant workforce in the United States, 1967-2000 J Allied Health 36(3):121-130 09-01-2007 URL Historical Trends in Physician Assistant Education and their Contribution to Primary Health Care for Rural and Underserved Populations in the U.S.

The physician assistant (PA) profession grew rapidly in the 1970s and 1990s. As acceptance of PAs in the health care system increased, roles for PAs in specialty care took shape and the scope of PA practice became more clearly defined. This report describes key elements of change in the demography and distribution of the PA population between 1967 and 2000, as well as the spread of PA training programs. Individual-level data from the American Academy of Physician Assistants, supplemented with county-level aggregate data from the Area Resource File, were used to describe the emergence of the PA profession between 1967 and 2000. Data on 49,641 PAs who had completed training by 2000 were analyzed. More than half (52.4%) of PAs active in 2000 were women. PA participation in the rural workforce remains high, with more than 18% of PAs practicing in rural settings, compared with about 20% in 1980. Primary care participation appears to have stabilized at about 47% among active PAs for whom specialty is known. By 2000, 51.5% of practicing PAs had been trained in the stateswhere they worked. The profession has grown rapidly; 56% of all PAs were trained between 1991 and 2000. In 2000, more than 42% of accredited PA programs offered a master’s degree, compared to master’s degree programs in 1986. Although many critical issues of scope of practice and patient and physician acceptance of PAs have been resolved, the PA profession remains young and continues to evolve. Whether the historical contribution of PAs to primary care for rural and underserved populations can be sustained in the face of increasing specialization and higher-level academic credentialing is not clear.

PA training programs physician assistant primary care rural workforce underserved populatioon
Larson E, Hart LG Geographic and demographic dimensions of the adoption of a health workforce innovation: physician assistants in the U.S., 1967-2000 Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #105 02-01-2006
Full report Policy brief
Historical Trends in Physician Assistant Education and their Contribution to Primary Health Care for Rural and Underserved Populations in the U.S.
Larson E, Hart LG, Ballweg R National estimates of physician assistant productivity Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #57 01-01-2000
Policy brief
National Estimates of Physician Assistant Productivity
Palazzo L, Hart LG, Skillman SM The impact of the changing scope of practice of physician assistants, nurse practitioners, and certified nurse-midwives on the supply of practitioners and access to care: Oregon case study Seattle, WA:WWAMI Center for Health Workforce Studies, University of Washington Working Paper #70 01-01-2002
Full report
The Impact of the Changing Scope of Practice of Physician Assistants, Nurse Practitioners, and Certified Nurse-Midwives on the Supply of Practitioners and Access to Care: Oregon Case Study
Larson E, Palazzo L, Berkowitz B, Pirani MJ, Hart LG The contribution of nurse practitioners and physician assistants to generalist care in underserved areas of Washington State Health Serv Res 38(4):1003-1050 01-01-2003 URL The Contribution of Generalist Nurse Practitioners and Physician Assistants to Primary Care in Rural Washington State

OBJECTIVE:

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

DATA SOURCES:

State professional licensure renewal survey data from 1998-1999.

STUDY DESIGN:

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

PRINCIPAL FINDINGS:

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

CONCLUSIONS:

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

generalist care nurse practitioners physician assistants provider shortage
Larson E, Palazzo L, Berkowitz B, Pirani MJ, Hart LG The contribution of nurse practitioners and physician assistants to generalist care in underserved areas of Washington State Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #64 06-01-2001
Full report Policy brief
The Contribution of Generalist Nurse Practitioners and Physician Assistants to Primary Care in Rural Washington State
Grumbach K, Hart LG, Mertz E, Coffman J, Palazzo L Who is caring for the underserved? A comparison of primary care physicians and nonphysician clinicians Ann Fam Med 1(2):97-104 01-01-2003 URL The Contribution of Generalist Nurse Practitioners and Physician Assistants to Primary Care in Rural Washington State

PURPOSE: Little is known about whether different types of physician and nonphysician primary care clinicians vary in their propensity to care for underserved populations. The objective of this study was to compare the geographic distribution and patient populations of physician and nonphysician primary care clinicians.

METHODS: This study was a cross-sectional analysis of 1998 administrative and survey data on primary care clinicians (family physicians, general internists, general pediatricians, nurse practitioners, physician assistants, and certified nurse-midwives) in California and Washington. For geographic analysis, main outcome measures were practice in a rural area, a vulnerable population area (communities with high proportions of minorities or low-income residents), or a health professions shortage area (HPSA). For patient population analysis, outcomes were the proportions of Medicaid, uninsured, and minority patients in the practice.

RESULTS: Physician assistants ranked first or second in each state in the proportion of their members practicing in rural areas and HPSAs, and in California physician assistants also had the greatest proportion of their members working in vulnerable populations areas (P < .001). Compared with primary care physicians overall, nurse practitioners and certified nurse-midwives also tended to have a greater proportion of their members in rural areas and HPSAs (P < .001). Family physicians were much more likely than other primary care physicians to work in rural areas and HPSAs (P < .001). Compared with physicians, nonphysician clinicians in California had a substantially greater proportion of Medicaid, uninsured, and minority patients (P < .001).

CONCLUSIONS: Nonphysician primary care clinicians and family physicians have a greater propensity to care for underserved populations than do primary care physicians in other specialties. Achieving a more equitable pattern of service to needy populations will require ongoing, active commitment by policy makers, educational institutions, and the professions to a mission of public service and to incentives that support and promote care to the underserved.

family physicians Health Personnel Medically Underserved Areas nurse practitioners physician assistants Primary Health Care/manpower
Larson E, Hart LG, Ballweg R National estimates of physician assistant productivity J Allied Health 30(3):146-152 01-01-2001 URL The Contribution of Generalist Nurse Practitioners and Physician Assistants to Primary Care in Rural Washington State

Analysis of productivity data from a nationally representative sample of physician assistants (PAs) showed that PAs performed 61.4 outpatient visits per week compared with 74.2 visits performed by physicians, for an overall physician full-time equivalent (FTE) estimate of 0.83. However, productivity of PAs varies strongly across practice specialty and location, with generalist PAs performing more visits than their specialist counterparts. Rural PA productivity is higher than urban productivity because of the concentration of generalist PAs in rural settings. A generalist PA physician FTE estimate of 0.75 appears to be more accurate than the 0.5 currently under consideration in proposed modifications to Health Personnel Shortage Area designation regulations.

generalist health personnel shortage area (HPSA) HPSA non-physician clinician (NPC) physician assistants (PAs) specialist
Thompson M, Skillman SM, Schneeweiss R, Hart LG, Johnson K The University of Washington Pacific Islands Continuing Education Program (PICCEP): Guam conference on structure and content of continuing clinical education programs in the U.S.-associated jurisdictions Pac Health Dialog 9(1):119-122 03-01-2002 URL Pacific Islands Continuing Clinical Education Program (PICCEP)

On July 20 and 21, 2000 a meeting was convened of individuals from the U.S.-associated jurisdictions of the Pacific region who play key roles related to clinical training institutions, provider professional organizations, and representatives of physicians and  health  policy  leadership. The meeting, held in Guam was organized by the Pacific Islands Continuing Medical Education Program (PICCEP) based at the Center for Health Workforce Studies at the University of Washington in Seattle and funded by the  Health Resources and Services Administration’s (HRSA’s) Bureau of Health Professions and Bureau of Primary Health Care. The overall goal of the meeting was to explore ways  of developing a sustainable program of continuing clinical education (CCE) for physicians and other health professionals in the Pacific region. Specific objectives of the meeting included a review of previous CCE efforts in the region, assessment of current CCE needs,  and  discussion of PICCEP’s proposed CCE program. The meeting was also designed to foster further collaborative relationships  among the various clinical education  programs  active  in the  region.

continuing clinical education (CCE) health professionals physicians Piccep training
Johnson K, Skillman SM, Ellsbury K, Thompson M, Hart LG Updating hospital reference resources in the U.S.-associated Pacific basin: efforts of the Pacific Islands Continuing Clinical Education Program (PICCEP) Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #81 09-01-2003 Pacific Islands Continuing Clinical Education Program (PICCEP)
Thompson M, Schneeweiss R, Johnson K, Skillman SM, Ellsbury K, Hart LG Assessing physician's continuing medical education (CME) needs in the U.S.-associated Pacific Basin jurisdictions Pac Health Dialog 9(1):11-16 01-01-2002 URL Pacific Islands Continuing Clinical Education Program (PICCEP)

OBJECTIVE:

To assess the self-perceived continuing medical education (CME) needs of physicians in American Samoa, Commonwealth of the Northern Mariana Islands, Guam, Federated States of Micronesia, Republic of the Marshall Islands, and the Republic of Palau.

METHODS:

Questionnaire-based survey of all physicians.

RESULTS:

Responses obtained from a total of 143 physicians in the region provided information on training backgrounds, previous experiences with CME, local access to regular CME sessions, perceived priority educational needs and preferred methods of CME delivery.

CONCLUSIONS:

Overall 64% of respondents had attended a formal CME event in 1999 or 2000, and 71% had access to local weekly or biweekly CME. However the perceived usefulness of these events varied by region. Priority learning needs were identified by physicians including non-communicable diseases such as diabetes, hypertension, cardiac disease; communicable diseases such as tuberculosis, HIV/AIDS and tropical diseases; as well as skills such as EKG and X-ray interpretation, trauma management and cardiac life support. Information on the most pressing educational needs and desired methods of delivery will be crucial in planning CME in this region.

communicable diseases continuing medical education diabetes mellitus electrocardiography heart diseases hypertensive disease jurisdiction life support tuberculosis
Thompson M, Skillman SM, Johnson K, Schneeweiss R, Hart LG The University of Washington Pacific Islands Continuing Clinical Education Program (PICCEP): Guam Conference on structure and content of continuing clinical education programs in the U.S.-associated jurisdictions Pac Health Dialog 9(1):119-122 01-01-2002 URL Pacific Islands Continuing Clinical Education Program (PICCEP)

On July 20 and 21, 2000 a meeting was convened of individuals from the U.S.-associated jurisdictions of the Pacific region who play key roles related to clinical training institutions, provider professional organizations, and rep­ resentatives of physicians and  health  policy  leadership. The meeting, held in Guam was organized by the Pacific Islands Continuing Medical Education Program (PICCEP) based at the Center for Health Workforce Studies at the University of Washington in Seattle and funded by the  Health Resources and Services Administration’s (HRSA’s) Bureau of Health Professions and Bureau of Primary Health Care. The overall goal of the meeting was to explore ways  of developing a sustainable program of continuing clinical education (CCE) for physicians and other health profes­ sionals in the Pacific region. Specific objectives of the meeting included a review of previous CCE efforts in the region, assessment of current CCE needs,  and  discussion of PICCEP’s proposed CCE program. The meeting was also designed to foster further collaborative relationships  among the various clinical education  programs  active  in the  region.

continuing clinical education (CCE) physicians training
Porter A, Skillman SM, Johnson K, Schneeweiss R, Hart LG Pacific Islands Continuing Clinical Education Program (PICCEP) final report Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 01-01-2003
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Pacific Islands Continuing Clinical Education Program (PICCEP)
Johnson K, Skillman SM, Ellsbury K, Thompson M, Hart LG Updating hospital reference resources in the U.S.-associated Pacific Basin: efforts of the Pacific Islands Continuing Clinical Education Program (PICCEP) J Med Libr Assoc 92(4):495-497 01-01-2004 URL Pacific Islands Continuing Clinical Education Program (PICCEP)

This article describes a project by the Pacific Islands Continuing Clinical Education Program (PICCEP) at the University of Washington (UW) to supplement hospital reference materials in six jurisdictions in the US-associated Pacific Islands. It outlines a model for cooperatively developing a suite of clinical reference materials suitable to low-resource settings.

The US-associated Pacific Islands encompass the US flag territories of American Samoa, the Commonwealth of the Northern Mariana Islands (CNMI), and Guam, as well as the independent countries, “freely associated with the United States,” of the Federated States of Micronesia (FSM), the Republic of the Marshall Islands (RMI), and the Republic of Palau. The region contains 104 inhabited islands that cover an area of the Pacific that is larger than the continental United States. Nearly 500,000 total residents live in the jurisdictions. Gross domestic product per capita in 2000 varied from $1,600 in RMI to $21,000 in Guam. English is an official language throughout the region, although many people speak one or more other languages [1]. The United States serves as the region’s primary funder of social and health services. Each jurisdiction has one or more secondary hospitals, with bed sizes ranging from under 50 to over 200. Only a few of them offer advanced specialty services.

In 1998, the federal Institute of Medicine (IOM) found numerous health care challenges in the region: deteriorating health infrastructure, high health care costs, serious health problems on some islands such as high rates of substance abuse and infant mortality, and particularly “shortages of adequately trained health care personnel” [2]. The IOM recommended an emphasis on health workforce improvement, in large part through continuing medical education (CME). The federal government responded, in part, by funding PICCEP, a four-year effort implemented by the UW Center for Health Workforce Studies.

PICCEP conducted a needs assessment and concluded that, among other problems, the region’s health care providers lacked current clinical reference materials [3]. Most hospitals did not have libraries or librarians. They all had at least a small collection of reference materials, but most physicians felt these materials were too limited to help solve specific clinical problems or maintain skills. Personal computers were few in number and not readily available for most clinicians. In addition, limited, slow, and expensive Internet access made computerized references impractical in all but the most developed jurisdictions, such as Guam and the Republic of Palau.

American Samoa clinical reference materials Commonwealth of the Northern Mariana Islands continuing clinical education Federated States of Micronesia Guam hospital reference resources library resources Piccep Republic of Palau
Andrilla CHA, Hart LG, Kaplan L, Brown MA Practice patterns and characteristics of nurse practitioners in Washington State Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #109 03-01-2007
Full report Policy brief
Demographics, Education, and Practice Characteristics of Nurse Practitioners in Washington
Kaplan L, Brown MA, Andrilla CHA, Hart LG The Washington State nurse anesthetist workforce: a case study AANA J 75(1):37-42 02-01-2007 URL Demographics, Education, and Practice Characteristics of Nurse Practitioners in Washington

The purposes of this study were to describe the Washington State Certified Registered Nurse Anesthetist (CRNA) workforce and analyze selected dimensions of their clinical practice. We developed the 31-item CRNA Practice Questionnaire. After receiving institutional review board approval, the questionnaire was mailed in 2003 to CRNAs licensed in Washington with an address in Washington, Oregon, and Idaho. Statistical analysis included descriptive statistics for all variables and was performed by University of Washington Center for Health WorkforceStudies staff. Results indicate that the typical Washington State CRNA is 50.7 years old, white, and equally likely to be a man or woman. More than half of the Washington State CRNAs are master’s educated and have an average of 19 years of CRNA experience. Most work at least 40 hours a week, take call, and earn more than 100,000 dollars per year. Almost all have hospital privileges, but only 30% believe they are equal colleagues with physicians. A chi2 analysis comparing urban and rural respondents yielded few differences except that rural CRNAs reported seeking significantly less consultation and were more likely to take call. Workforce data may assist CRNAs when negotiating with employers and institutions and in resolving interprofessional conflicts and can have implications for scope of practice, policy, and legislative issues.

Certified Registered Nurse Anesthetist (CRNA) CRNA Idaho Oregon Washington workforce
Kaplan L, Brown MA, Andrilla CHA, Hart LG Barriers to autonomous practice Nurse Pract 31(1):57-63 01-01-2006 URL Demographics, Education, and Practice Characteristics of Nurse Practitioners in Washington

This article describes a Washington State law enacted in 2000 that mandated indirect physician involvement and a study on whether or not this eliminated barriers to nurse practitioner (NP) practice. The study also investigated the impact this had on Schedule II-IV prescriptive authority for NPs. Using the research from this article in testimony, NPs were able to eliminate the indirect physician involvement requirement in 2005.

autonomous practice controlled substances legend drugs nurse practitioners prescribing authority Schedule II-IV
Chapman SA, Lindler V, Kaiser JA, Nielsen CS, Bates T, Hailer-O'Keefe L, Skillman SM, Patterson DG, Dawson D, Wijetunge G EMS workforce for the 21st century: a national assessment Washington, DC: National Highway Traffic and Safety Administration; Jun 2008 06-01-2008
Full report
EMS Workforce for the 21st Century: A National Assessment
Skillman SM, Stover B Montana's physician workforce in 2014 Seattle, WA:WWAMI Center for Health Workforce Studies, University of Washington 11-07-2014
Full report
Montana Physician Workforce
Frogner BK, Skillman SM Pathways to middle skilled allied health occupations Committee on the Supply Chain for Middle-skill Jobs: Education, Training and Certification Pathways of the National Academies of Sciences/Engineering/Medicine. Washington, DC 09-01-2015
Full report
Pathways to Middle Skilled Allied Health Care Occupations
Baldwin LM, Patanian MM, Larson E, Lishner DM, Mauksch LB, Katon WJ, Walker E, Hart LG Modeling the mental health workforce in Washington State: using state licensing data to examine provider supply in rural and urban areas J Rural Health 22(1):50-58 01-01-2006 URL Modeling the Mental Health Workforce in Washington State: Using Licensing Data to Examine Provider Supply

CONTEXT:

Ensuring an adequate mental health provider supply in rural and urban areas requires accessible methods of identifying providertypes, practice locations, and practice productivity.

PURPOSE:

To identify mental health shortage areas using existing licensing and survey data.

METHODS:

The 1998-1999 Washington State Department of Health files on credentialed health professionals linked with results of a licensure renewal survey, 1990 US Census data, and the results of the 1990-1992 National Comorbidity Survey were used to calculate supply and requirements for mental health services in 2 types of geographic units in Washington state-61 rural and urban core health service areas and 13 larger mental health regions. Both the number of 9 types of mental health professionals and their full-time equivalents (FTEs) per 100,000 population measured supply in the health service areas and mental health regions.

FINDINGS:

Notable shortages of mental health providers existed throughout the state, especially in rural areasUrban areas had 3 times the psychiatrist FTEs per 100,000 and more than 1.5 times the nonpsychiatrist mental health provider FTEs per 100,000 as rural areas. More than 80% of rural health service areas had at least 10% fewer psychiatrist FTEs and nonpsychiatrist mental health provider FTEs than the state ratio (10.4 FTEs per 100,000 and 306.5 FTEs per 100,000, respectively). Ten of the 13 mental health regions were more than 10% below the state ratio of psychiatrist FTEs per 100,000.

CONCLUSIONS:

States gathering a minimum database at licensure renewal can identify area-specific mental health care shortages for use in program planning.

mental health provider rural services urban
Baldwin LM, Fay M, Larson E, Lishner DM, Mauksch LB, Katon WJ, Walker E, Hart LG Modeling the mental health workforce in Washington State: using state licensing data to examine provider supply in rural and urban areas Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #80 10-01-2003
Full report Policy brief
Modeling the Mental Health Workforce in Washington State: Using Licensing Data to Examine Provider Supply
Rosenblatt RA, Andrilla CHA The impact of U.S. medical students' debt on their choice of primary care careers: an analysis of data from the 2002 medical school graduation questionnaire Acad Med 80(9):815-819 09-01-2005 URL Student Debt and the Decline in Primary Care: Can Medical School Graduates Still Afford to Become Primary Care Doctors?

PURPOSE:

To examine the hypothesis that medical students’ rising total educational debt is one of the factors that explains the recent decline in students’ interest in family medicine and primary care.

METHOD:

The authors used results from questions on the Association of American Medical Colleges’ 2002 Medical School GraduationQuestionnaire that focused on students’ debt and career choices. Logistic regression was used to determine the independent association of students’ debt with career choices, while controlling for students’ demographic characteristics.

RESULTS:

In 2002, 83.5% of graduating students were in debt, and the average student owed US $86,870. Minority students had higher levels of debt. Students reported that higher levels of debt influenced their future career choices, and there was an inverse relationship between the level of total educational debt and the intention to enter primary care, with the most marked effect noted for students owing more than $150,000 at graduation. Total debt was associated with a lower likelihood of choosing a primary care career, but factors such as gender and race appeared to have more explanatory power. Female students were much more interested in primary care-and especially pediatrics-than were male students; African American students were more interested in inner-city practice than was any other identified racial or ethnic group.

CONCLUSION:

In 2002, students’ debt levels were high and increasing. Although students with higher debt levels were less likely than were their counterparts to pursue a career in primary care, the effect was modest when demographic characteristics were taken into consideration.

career choice debt load ethnicity medical education medical students primary care race rural student debt
Patterson DG, Andrilla CHA, Skillman SM, Hanscom J The impact of Medicaid primary care payment increases in Washington state Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 12-01-2014
Full report
The Impact of Medicaid Primary Care Payment Increases in Washington State
Skillman SM, Stover B Maine's physician, nurse practitioner and physician assistant workforce in 2014 Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 09-05-2014
Full report
Maine’s Physician, Nurse Practitioner and Physician Assistant Workforce in 2014
House PJ The direct-care paraprofessional workforce providing long-term care services in the United States: Wyoming case study Seattle, WA:WWAMI Center for Health Workforce Studies, University of Washington Working Paper #71 03-01-2002
Full report
The Direct-Care Paraprofessinal Workforce Providing Long-Term Care Services in the U.S.: Wyoming Case Study
Johnson K, Hagopian A, Veninga C, Fordyce MA, Hart LG The changing geography of Americans graduating from foreign medical schools Seattle, WA: WWAMI Center for Health Workforce Studies Working Paper #96 01-01-2005
Full report
The Sources and Distribution of International Medical Graduates (IMGs)
Hagopian A, Ofosu A, Fatusi A, Biritwum R, Essel A, Hart LG, Watts C The flight of physicians from West Africa: views of African physicians and implications for policy Soc Sci Med 61:1750-1760 01-01-2005 URL The Sources and Distribution of International Medical Graduates (IMGs)

West African-trained physicians have been migrating from the sub-continent to rich countries, primarily the US and the UK, since medical education began in Nigeria and Ghana in the 1960s. In 2003, we visited six medical schools in West Africa to investigate the magnitude, causes and consequences of the migration. We conducted interviews and focus groups with faculty, administrators (deans and provosts), students and post-graduate residents in six medical schools in Ghana and Nigeria. In addition to the migration push and pull factors documented in previous literature, we learned that there is now a well-developed culture of medical migration. This culture is firmly rooted, and does not simply fail to discourage medical migration but actually encourages it. Medical school faculty are role models for the benefits of migration (and subsequent return), and they are proud of their students who successfully emigrate.

Africa Ghana Health policy medical education Nigeria Physician migration
Johnson K, Hagopian A, Veninga C, Hart LG The changing geography of Americans graduating from foreign medical schools Acad Med 81(2):179-184 01-01-2006 URL The Sources and Distribution of International Medical Graduates (IMGs)

Purpose To study U.S.-born international medical graduates in order to analyze changes in their numbers and countries of training from the 1960s and before until the early 2000s.

Method This study was conducted from 2003–2004 at the Center for Health Workforce Studies, University of Washington. The analysis was based on data from March 2002 from the American Medical Association (AMA) for active physicians. AMA data were supplemented with data from several other sources. Descriptive statistics were produced on country of birth, country of medical school training, and year of training for all foreign-trained, patient-care physicians whose birth country was known.

Results At least 17,000 of the foreign-trained physicians practicing in the United States are known to have been born in the United States. American physicians have graduated from foreign medical schools in increasing numbers since the 1960s. The number of U.S.-born physicians who graduated from a foreign medical school peaked in the early 1980s, but the phenomenon endures today. However, the countries in which these physicians chose to attend medical schools have changed significantly from the 1950s to the early 2000s.

Conclusions Over time, U.S.-born physicians have become much less likely to train in Europe and much more likely to train in certain Caribbean countries. U.S.-born physicians who graduate from medical schools abroad tend to train in just a handful of countries and attend a limited number of medical schools.

international medical graduates physicians US-born IMGs
Hagopian A, Thompson M, Kaltenbach E, Hart LG The role of international medical graduates in America's small rural critical access hospitals J Rural Health 20(1):52-58 01-01-2004 URL The Sources and Distribution of International Medical Graduates (IMGs)

Context: Critical access hospitals (CAHs) are a federal Medicare category for isolated rural facilities with 15 or fewer acute care beds that receive cost-based reimbursement from Medicare. Purpose: This study examines the role of foreign-born international medical graduates (IMGs) in the staffing of CAHs. Methods: Chief executive officers (CEOs) of CAH facilities answered a telephone survey on their use of IMGs and the characteristics of those IMGs in winter 2002 (388 responded, for a 96% response rate). This descriptive report presents roles and characteristics of IMGs in CAH facilities and the opinions of the CEOs about these practitioners. Findings: Overall, 1 (24%) in 4 admitting physicians in CAHs are graduates of non-US medical schools (compared with 23% of physicians nationally), although the rates are higher for CAHs in persistent poverty counties, CAHs that report recruitment problems, and CAHs with smaller medical staffs. Hospitals east of the Mississippi River are more heavily reliant on IMGs than hospitals in the west. Most IMGs are internists (59%) and most (61%) come from India, the Philippines, or Pakistan. Hospital administrators rate the clinical skills of their IMGs highly and their interpersonal skills only slightly lower. Almost half of CAH administrators said their communities recruited their first IMGs during or after 1994, the year of pro-IMG legislative changes. Conclusion: IMG physicians play a significant and possibly growing role in staffing CAHs.

critical access hospitals IMGs international medical graduates physicians rural
Hagopian A, Thompson M, Fordyce MA, Johnson K, Hart LG The migration of physicians from sub-Saharan Africa to the United States of America Hum Resour Health 2(1):17 01-01-2004 URL The Sources and Distribution of International Medical Graduates (IMGs)

Background

The objective of this paper is to describe the numbers, characteristics, and trends in the migration to the United States of physicians trained in sub-Saharan Africa.

Methods

We used the American Medical Association 2002 Masterfile to identify and describe physicians who received their medical training in sub-Saharan Africa and are currently practicing in the USA.

Results

More than 23% of America’s 771 491 physicians received their medical training outside the USA, the majority (64%) in low-income or lower middle-income countries. A total of 5334 physicians from sub-Saharan Africa are in that group, a number that represents more than 6% of the physicians practicing in sub-Saharan Africa now. Nearly 86% of these Africans practicing in the USA originate from only three countries: Nigeria, South Africa and Ghana. Furthermore, 79% were trained at only 10 medical schools.

Conclusions

Physician migration from poor countries to rich ones contributes to worldwide health workforce imbalances that may be detrimental to the health systems of source countries. The migration of over 5000 doctors from sub-Saharan Africa to the USA has had a significantly negative effect on the doctor-to-population ratio of Africa. The finding that the bulk of migration occurs from only a few countries and medical schools suggests policy interventions in only a few locations could be effective in stemming the brain drain.

Africa brain drain health workforce IMGs international medical graduates migration physicians
Hagopian A, Thompson M, Johnson K, Lishner DM International medical graduates in the United States: a review of the literature 1995 to 2003 Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #83 01-01-2003
Full report
The Sources and Distribution of International Medical Graduates (IMGs)
Hagopian A, Thompson M, Kaltenbach E, Hart LG Health departments' use of international medical graduates in physician shortage areas Health Aff 22(5):241-249 01-01-2003 URL The Sources and Distribution of International Medical Graduates (IMGs)

The Conrad “State 20” Program places international medical graduates (IMGs) on J-1 visas in health professional shortage areas (HPSAs). The authors surveyed program administrators from health departments in forty-two participating states. Problems reported include unfair working conditions and compensation for physicians. Federal immigration agencies were reported to be unresponsive and difficult. Employers seem to be more satisfied than physicians with the program. After the exit of the U.S. Department of Agriculture as a sponsor for physician J-1 visa waivers, Congress expanded the Conrad Program, signaling a continued reliance on IMGs to serve in shortage areas.

Conrad Program health professional shortage areas HPSAs IMGs international medical graduates J-1 visa visa waivers working conditions
Johnson K, Kaltenbach E, Hoogstra K, Thompson M, Hagopian A, Hart LG How international medical graduates enter U.S. graduate medical education or employment Seattle, WA: WWAMI Center for Health Workforce Studies University of Washington Working Paper #76 01-01-2003
Full report
The Sources and Distribution of International Medical Graduates (IMGs)
Hart LG, Skillman SM, Fordyce MA, Thompson M, Hagopian A, Konrad TR International medical graduate physicians in the United States: changes since 1981 Health Aff 26(4):1159-1169 04-19-2007 URL International Medical Graduates: Changes in Characteristics Over Time

Nearly a quarter of all active U.S. physicians are international medical graduates (IMGs)–physicians trained outside the United States and Canada. We describe changes in characteristics of IMGs from 1981 to 2001 and compare them with their U.S. medical graduate (USMG) counterparts. Since 1981, the leading source countries for IMGs have included India, the Philippines, and Mexico. IMGs were more likely to be generalists and to practice in designated underserved areas than USMGs but slightly less likely to practice in isolated small rural areas and persistent-poverty counties. IMGs are an important source of primary care physicians in rural and underserved areas.

family practice HPSA counties international medical graduates persistent-poverty counties rural
Hart LG, Skillman SM, Hagopian A, Fordyce MA, Thompson M, Konrad TR International medical graduate (IMG) physicians in the U.S.: changes since 1981 National health workforce assessment of the past and agenda for the future: proceedings of an international symposium Paris: Centre de Sociologie et de Demographie Medicales 12-31-2006 URL International Medical Graduates: Changes in Characteristics Over Time

Nearly a quarter of all active U.S. physicians are international medical graduates (IMGs)—physicians trained outside the United States and Canada. We describe changes in characteristics of IMGs from 1981 to 2001 and compare them with their U.S. medical graduate (USMG) counterparts. Since 1981, the leading source countries for IMGs have included India, the Philippines, and Mexico. IMGs were more likely to be generalists and to practice in designated underserved areas than USMGs but slightly less likely to practice in isolated small rural areas and persistent-poverty counties. IMGs are an important
source of primary care physicians in rural and underserved areas.

international medical graduates (IMGs) physicians primary care physicians underserved
Hart LG, Skillman SM, Hagopian A, Fordyce MA, Thompson M, Konrad TR International medical graduate (IMG) physicians in the U.S.: changes since 1981 Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #102 01-01-2005 International Medical Graduates: Changes in Characteristics Over Time
Andrilla CHA, Hart LG Evaluation of alternative Health Professional Shortage Area (HPSA) definitions in Washington State Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 08-21-2006
Full report
Health Professional Shortage Area (HPSA) Criteria Evaluation Project in Washington State
Skillman SM, Basye A Policy brief: Home care aides in Washington State: current supply and future demand Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington 01-31-2011
Policy Brief
Home Care Aides in Washington State: Estimating Current Supply and Future Demand
Fenton SH, Joost E, Gongora J, Patterson DG, Andrilla CHA, Skillman SM Health Information Technology Employer Needs Survey: an assessment instrument for workforce planning Educ Perspect Health Inform Inf Manage Winter:1-36 12-16-2013 URL Health Information Technology (HIT) Workforce Demand in the State of Texas

The widespread implementation of electronic health records (EHRs) has resulted in an increased need for a well-trained health information technology (HIT) workforce. The Texas HIT Workforce Development Project was initiated with an assessment of HIT employer needs as one of the major goals. The researchers were required to develop a new survey because no existing tool could be found. From the results of HIT employer focus groups, the team determined that quantitative outcome measures for the survey should include HIT skills categorized as basic, intermediate, or advanced. Other data collected included employer-perceived barriers related to the HIT workforce, as well as a determination of the number of employees needed presently and in the future. The development process for the resulting survey instrument is described here. The survey tool was utilized for the planned assessment and is now made available for others to use.

electronic health records health information technology informatics workforce workforce development
Texas HIT Workforce Development Team Texas health information technology: employer needs assessment report San Marcos, TX: Texas State University 02-03-2012 URL Health Information Technology (HIT) Workforce Demand in the State of Texas
Patterson DG, Skillman SM Health professions education in Washington State: 1996-2004 program completion statistics Seattle, WA:WWAMI Center for Health Workforce Studies, University of Washington Working Paper #94 11-01-2004
Full report
Health Professions Education in Washington State: 1996-2004 Program Completion Statistics
Patterson DG, Skillman SM Health professions education in Washington State: 1996-2000 program completion statistics Seattle, WA: WWAMI Center for Health Workforce Studies Working Paper #73 10-01-2002
Full report Policy brief
Health Professions Education in Washington State: 1996-2004 Program Completion Statistics
Thompson M, Hagopian A, Fordyce MA, Hart LG Do international medical graduates (IMGs) "fill the gap" in rural primary care in the United States? A national study J Rural Health 25(2):124-134 04-01-2009 URL Do International Medical Graduates Fill Rural Gaps

CONTEXT:

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

PURPOSE:

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

METHODS:

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

FINDINGS:

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

CONCLUSIONS:

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

international medical graduates primary care rural-urban US medical graduates workforce
Thompson M, Hagopian A, Fordyce MA, Hart LG Do international medical graduates "fill the gap" in rural primary care in the United States? A national study Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #106 01-31-2006
Full report
Do International Medical Graduates Fill Rural Gaps
WWAMI Center for Health Workforce Studies, University of Washington Data snapshot: race and ethnicity of Washington State health professionals compared with state population Seattle, WA: WAMI Center for Health Workforce Studies, University of Washington 12-01-2000
Snapshot
Race and Ethnicity of Washington’s Health Professionals Compared with the State’s Population
Snyder CR, Stover B, Skillman SM, Frogner BK Facilitating racial and ethnic diversity in the health workforce Seattle, WA:WWAMI Center for Health Workforce Studies, University of Washington 07-02-2015
Full report
Facilitating Racial and Ethnic Diversity in the Health Workforce
Andrilla CHA, Hart LG Montana dental workforce technical report Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #51 05-01-2001 State-Level Requirements Model of the General Dental Workforce in Montana
Wright GE, Paschane DM, Baldwin LM, Domoto P, Cantrell D, Hart LG Distribution of the dental workforce in Washington State: patterns and consequences Seattle, WA:WWAMI Center for Health Workforce Studies, University of Washington Working Paper #60 03-01-2001
Policy brief
The Distribution of the Dental Workforce and Its Relationship to Unmet Needs in Washington State
Palazzo L, Skillman SM, Basye A, Morrison CC Health workforce demand in Washington State: employers' current and expected needs for home care aides, medical assistants, nursing assistants certified, licensed practical nurses, associate's degree registered nurses Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Final Report #145 07-31-2013
Full report
Current and Future Demand for Home Care Aides, Nursing Assistants Certified, Medical Assistants, Licensed Practical Nurses, and Associate’s Degree Registered Nurses in Washington State
Skillman SM, Palazzo L, Hart LG, Keepnews D What happens to registered nurses whose licenses expire? An exploratory study in Washington State Seattle, WA: WWAMI Center for Health Workforce Studies, University of Washington Working Paper #110 11-16-2006
Full report Policy brief
RNs with Expired Licenses in Washington
Andrilla CHA, Moore TE, Patterson DG, Larson EH Geographic Distribution of Providers With a DEA Waiver to Prescribe Buprenorphine for the Treatment of Opioid Use Disorder: A 5-Year Update Journal of Rural Health 06-20-2018 URL N/A

PURPOSE:
Opioid use disorder (OUD) is a substantial public health problem. Buprenorphine is an effective medication-assisted treatment (MAT) for OUD, but access is difficult for patients, especially in rural locations. To improve access, the Comprehensive Addiction and Recovery Act of 2016 extended the ability to get a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine to treat OUD to nurse practitioners (NPs) and physician assistants (PAs). This study summarizes the geographic distribution of waivered physicians, NPs, and PAs at the end of 2017 and compares it to the distribution of waivered physicians 5 years earlier.

METHODS:
Using the DEA list of providers with a waiver to prescribe buprenorphine to treat OUD and the Area Health Resources File, we assigned waivered providers to counties in 1 of 4 geographic categories. We calculated the number of counties in each category that did not have a waivered provider and county provider to population ratios and then compared our results to the waivered workforce in 2012.

FINDINGS:
The availability of a physician with a DEA waiver to provide office-based MAT has increased across all geographic categories since 2012. More than half of all rural counties (56.3%) still lack a provider, down from 67.1% in 2012. Almost one-third (29.8%) of rural Americans compared to 2.2% of urban Americans live in a county without a buprenorphine provider. NPs and PAs add otherwise lacking treatment availability in 56 counties (43 rural).

CONCLUSIONS:
Overall, MAT access has improved, but rural communities still experience treatment disparities.

buprenorphine medication-assisted treatment opioid treatment programs opioid use disorder rural health
Mroz TM, Andrilla CHA, Garberson LA, Skillman SM, Patterson DG, Larson EH Service provision and quality outcomes in home health for rural Medicare beneficiaries at high risk for unplanned care Home Health Care Services Quarterly 37(3):141-157 06-25-2018 URL N/A

Abstract
Multiple barriers exist to providing home health care in rural areas. This study examined relationships between service provision and quality outcomes among rural, fee-for-service Medicare beneficiaries who received home health care between 2011 and 2013 for conditions associated with high-risk for unplanned care. More skilled nursing visits, visits by more types of providers, more timely care, and shorter lengths of stay were associated with significantly higher odds of hospital readmission and emergency department use and significantly lower odds of community discharge. Results may indicate unmeasured clinical severity and care needs among this population. Additional research regarding the accuracy of current severity measures and adequacy of case-mix adjustment for quality metrics is warranted, especially given the continued focus on value-based payment policies.

Health Services home health care Medicare/Medicaid quality of care/evaluation of services rural issues
Andrilla CHA, Coulthard C, Larson EH, Patterson DG, Moore TE Projected Contributions of Nurse Practitioners and Physicians Assistants to Buprenorphine Treatment Services for Opioid Use Disorder in Rural Areas Medical Care Research and Review 08-09-2018 URL Increasing the Supply of Providers with a Drug Enforcement Agency Waiver to Treat Opioid Addiction in Rural America – Possible Effects of Permitting Physician Assistants and Nurse Practitioners to Prescribe Buprenorphine

The United States is experiencing an opioid use disorder epidemic. The Comprehensive Addiction and Recovery Act allows nurse practitioners (NPs) and physician assistants (PAs) to obtain a Drug Enforcement Administration waiver to prescribe medication-assisted treatment (MAT) for opioid use disorder. This study projected the potential increase in MAT availability provided by NPs and PAs for rural patients. Using workforce and survey data, and state scope of practice regulations, the number of treatment slots that could be provided by NPs and PAs was estimated for rural areas. NPs and PAs are projected to increase the number of rural patients treated with buprenorphine by 10,777 (15.2%). Census Divisions varied substantially in the number of projected new treatment slots per 10,000 population (0.8-10.6). The New England and East South Central Census Divisions are projected to have the largest population-adjusted increase. NPs and PAs have considerable potential to reduce substantial MAT access disparities.

buprenorphine CARA 2016 medication-assisted treatment opioid treatment opioid use disorder rural health
Mroz TM, Andrilla CHA, Garberson LA, Skillman SM, Patterson DG, Wong JL, Larson EH Different Populations Served by the Medicare Home Health Benefit: Comparison of Post-acute versus Community-entry Home Health in Rural Areas Seattle, WA: WWAMI Rural Health Research Center, University of Washington Policy Brief #165 07-31-2018
Policy Brief 165
Diverging Populations Served by the Medicare Home Health Benefit: Comparison of Post-acute vs. Community-entry Home Health in Rural Areas

Rural, fee-for-service Medicare beneficiaries who are admitted to home health from the community (community-entry) are significantly different from those who are admitted to home health following an inpatient stay (post-acute). Higher rates of community-entry were seen among beneficiaries who were older, female, non-white, living alone, and dually eligible for Medicare and Medicaid, and who had lower clinical severity, lower functional status, more cognitive impairment, and higher need for caregiver assistance for supervision and safety.

Wide variation by state exists in rates of community-entry home health episodes for rural beneficiaries, even after controlling for beneficiary characteristics. Maryland had the lowest percentage of community-entry home health episodes as a percentage of all home health episodes (17.6%), while Texas had the highest (38.8%).

County-level community characteristics—including rurality, persistent poverty, population loss, number of acute hospital beds, number of skilled nursing facility beds, number of home health agencies, and state-level Medicaid expenditures on home- and community-based services—also have significant but relatively small associations with rates of community-entry compared with state and beneficiary characteristics.

Health Services Home health Medicare Post-acute Care
Larson EH, Coulthard C, Andrilla CHA What Makes Physician Assistant Training Programs Successful at Training Rural PAs? Seattle WA: WWAMI Rural Health Research Center, University of Washington Policy Brief #164 06-01-2018
Policy Brief #164
What Makes Physician Assistant Programs Successful at Training Rural PAs?

Key Findings

  • A survey of United States physician assistant (PA) training programs showed that 57.1% of the responding programs considered training rural PAs to be an important program goal.
  • Of those rurally oriented programs, just over half actively recruited rural students. Fewer than half used rural background as an admission criterion or required clinical training in a rural location.
  • PA training programs that are successful at training PAs who choose rural practice are likely to combine a rural mission, targeted recruitment of rural students, and specific rural clinical training experiences.
PA physician assistants primary care shortage rural
Andrilla CHA, Coulthard C, Patterson DG Prescribing Practices of Rural Physicians Waivered to Prescribe Buprenorphine American Journal of Preventive Medicine Volume 54, Issue 6, Supplement 3, Pages S208–S214 06-01-2018 URL Who Treats Opioid Addiction in Rural America? Quantifying the Availability of Buprenorphine Services in Rural Areas

Opioid use disorder is a serious public health burden, especially throughout rural America. Although efforts have been made to increase the availability of buprenorphine (an office-based medication-assisted treatment), more than 60% of rural counties in the U.S. lack a physician with a Drug Enforcement Administration waiver to prescribe it.

This study surveyed all rural physicians with a Drug Enforcement Administration waiver in 2016 to prescribe buprenorphine for opioid use disorder in the U.S. and asked about physician’s demographics, prescribing practices, and barriers to prescribing buprenorphine for treatment of opioid use disorder.

Andrilla CHA, Coulthard C, Larson EH, Patterson DG, Garberson LA Geographic Variation in the Supply of Selected Behavioral Health Providers American Journal of Preventive Medicine Volume 54, Issue 6, Supplement 3, Pages S199–S207 06-01-2018 URL Supply and Distribution of the Behavioral Health Workforce in Rural America

Introduction
In 2015, an estimated 43.4 million Americans aged 18 and older suffered from a behavioral health issue. Accurate estimates of the number of psychiatrists, psychologists, and psychiatric nurse practitioners are needed as demand for behavioral health care grows.

Methods
The National Plan and Provider Enumeration System National Provider Identifier data (October 2015) was used to examine the supply of psychiatrists, psychologists, and psychiatric nurse practitioners. Providers were classified into three geographic categories based on their practicing county (metropolitan, micropolitan, and non-core). Claritas 2014 U.S. population data were used to calculate provider-to-population ratios for each provider type. Analysis was completed in 2016.

Results
Substantial variation exists across Census Divisions in the per capita supply of psychiatrists, psychologists, and psychiatric nurse practitioners. The New England Census Division had the highest per capita supply and the West South Central Census Division had among the lowest supply of all three provider types. Nationally, the per capita supply of these providers was substantially lower in non-metropolitan counties than in metropolitan counties, but Census Division disparities persisted across geographic categories. There was a more than tenfold difference in the percentage of counties lacking a psychiatrist between the New England Census Division (6%) and the West North Central Census Division (69%). Higher percentages of non-metropolitan counties lacked a psychiatrist.

Conclusions
Psychiatrists, psychologists, and psychiatric nurse practitioners are unequally distributed throughout the U.S. Disparities exist across Census Divisions and geographic categories. Understanding this unequal distribution is necessary for developing approaches to improving access to behavioral health services for underserved populations.

Supplement information
This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

Patterson DG The contributions of international medical graduates to healthcare for rural and underserved populations: a reference list, 2000-2010 Seattle, WA: WWAMI Rural Health Research Center, University of Washington Reference List 01-01-2010
Reference List
International Medical Graduates on J-1 and H-1B Visas: Understanding Trends in their Contributions to Health Care Delivery for Rural Underserved Populations
Andrilla CHA, Coulthard C, Larson EH Barriers rural physicians face prescribing buprenorphine for opioid use disorder Ann Fam Med 15(4):359-62 07-10-2017 URL Who Treats Opioid Addiction in Rural America? Quantifying the Availability of Buprenorphine Services in Rural Areas

Opioid use disorder is a serious public health problem. Management with buprenorphine is an effective, office-based, medication-assisted treatment, but 60.1% of rural counties in the United States lack a physician with a Drug Enforcement Agency waiver to prescribe buprenorphine. This national study surveyed all rural physicians who have received a waiver in the United States and found that those who were not actively prescribing buprenorphine reported significantly more barriers than those who were, regardless of whether they were treating the maximum number of patients their waiver allowed. These findings suggest the need for tailored strategies to address barriers to providing buprenorphine for opioid use disorder and to support physicians who are adding or maintaining this service.

buprenorphine medication-assisted treatment mental health care opiate addiction opiate substitution treatment opioid treatment programs rural health
Andrilla CHA, Garberson LA, Patterson DG, Larson EH The supply and distribution of the behavioral health workforce in America: a state-level analysis Seattle, WA: WWAMI Rural Health Research Center, University of Washington 07-10-2017
Full Report
Alabama
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...
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Supply and Distribution of the Behavioral Health Workforce in Rural America
Andrilla CHA, Coulthard C, Larson EH Changes in the supply of physicians with a DEA DATA Waiver to prescribe buprenorphine for opioid use disorder Seattle, WA: WWAMI Rural Health Research Center, University of Washington Data Brief #162 05-01-2017
Data Brief
Who Treats Opioid Addiction in Rural America? Quantifying the Availability of Buprenorphine Services in Rural Areas
Doescher MP, Lee C, Berke EM, Adachi-Mejia AM, Lee CK, Stewart O, Patterson DG, Hurvitz PM, Carlos HA, Duncan GE, Moudon AV The built environment and utilitarian walking in small U.S. towns Prev Med 69:80-6 12-01-2014 URL Small Town Walkability: Measuring the Effect of the Built Environment

Objectives

The role of the built environment on walking in rural United States (U.S.) locations is not well characterized. We examined self-reported and measured built environment correlates of walking for utilitarian purposes among adult residents of small rural towns.

Methods

In 2011–12, we collected telephone survey and geographic data from 2152 adults in 9 small towns from three U.S. regions. We performed mixed-effects logistic regression modeling to examine relationships between built environment measures and utilitarian walking (“any” versus “none”; “high” [≥ 150 min per week] versus “low” [< 150 min per week]) to retail, employment and public transit destinations.

Results

Walking levels were lower than those reported for populations living in larger metropolitan areas. Environmental factors significantly (p < 0.05) associated with higher odds of utilitarian walking in both models included self-reported presence of crosswalks and pedestrian signals and availability of park/natural recreational areas in the neighborhood, and also objectively measured manufacturing land use.

Conclusions

Environmental factors associated with utilitarian walking in cities and suburbs were important in small rural towns. Moreover, manufacturing land use was associated with utilitarian walking. Modifying the built environment of small towns could lead to increased walking in a sizeable segment of the U.S. population.

Exercise/physical activity Health promotion Physical environment Prevention rural health Social environment Walking
Doescher M, Lee C, Saelens BE, Lee C, Berke EM, Adachi-Mejia AM, Patterson DG, Moudon AV Utilitarian and recreational walking among Spanish- and English-speaking Latino adults in micropolitan U.S. towns Journal of Immigrant and Minority Health doi:10.1007/s10903-016-0383-5 04-01-2016 URL Small Town Walkability: Measuring the Effect of the Built Environment
Evans D, Patterson DG, Andrilla CHA, Schmitz D, Longenecker R Do residencies that aim to produce rural family physicians offer relevant training? Family Medicine 48:596-602 12-01-2016 URL A Novel Master File of Rural Family Medicine Residency Training: Program Models and Graduate Outcomes

BACKGROUND AND OBJECTIVES:

Rural family physicians are in short supply. Rural training can promote rural practice, but the number of family medicine residencies with a rural focus, geographic distribution of training, and training content are poorly understood. This study identified rural-centric family medicine residencies, their training locations, and rurally relevant skills training provided.

METHODS:

The authors identified family medicine residencies offering rural tracks or in rural locations using FREIDA Online®, the American Osteopathic Association “Opportunities,” and the American College of Osteopathic Family Physicians Residency Finder online databases. Program personnel completed a survey in 2013 about training locations and content.

RESULTS:

Of 583, 171 (29%) family medicine residencies met inclusion criteria. A total of 131 returned surveys (77%). Fifty-eight programs (44% of respondents) required at least 8 weeks of rural training; results describe these rural-centric programs. Programs reported a mean of 43.6 weeks (SD 49.7) of required rural block rotations. Mean hours per week in required rural continuity clinic sessions were 14.3 (SD 12.2). Thirty-nine percent of block rotation sites, 31% of clinic sites, and 21% of full-time training sites reported as rural were urban according to Rural-Urban Commuting Area codes. Over 90% of programs provided training in orthopedic care and emergency skills. Fewer than 60% provided endoscopy and operative obstetrics training.

CONCLUSIONS:

Though numerous family medicine residencies seek to produce rural physicians, most programs required fewer than 8 weeks of rural training. Programs varied substantially in rurally located training and rurally relevant content. Students seeking rural training should examine program curricula carefully.

Curriculum Education Emergency Medical Services Family Practice/education Family/supply & distribution Graduate Humans Internship and Residency/methods Medical Orthopedics/education Osteopathic Physicians Physicians Professional Practice Location Rural Health Services/organization & administration rural track Surveys and Questionnaires
Patterson DG, Coulthard C, Garberson LA, Wingrove G, Larson EH What Is the potential of community paramedicine to fill rural health care gaps? J Health Care Poor Underserved 27(4):144-158 11-01-2016 URL What Is the Potential of Community Paramedicine to Fill Rural Healthcare Gaps?
Mroz TM, Andrilla CHA, Skillman SM, Garberson LA, Patterson DG Community factors and outcomes of home health care for high-risk rural medicare beneficiaries Seattle, WA: WWAMI Rural Health Center, University of Washington Policy Brief #161 10-31-2016
Policy Brief
Use of Home Health Services among High Risk Rural Medicare Patients: Patient, Service, and Community Factors Associated with Outcomes of Care
Larson EH, Patterson DG, Garberson LA, Andrilla CHA Supply and distribution of the behavioral health workforce in rural America Seattle, WA: WWAMI Rural Health Center, University of Washington Data Brief #160 09-29-2016
Data Brief #160
N/A
Patterson DG, Andrilla CHA, Larson EH Graduates of rural-centric family medicine residencies: determinants of rural and urban practice Seattle, WA: WWAMI Rural Health Center, University of Washington Policy Brief #159 07-01-2016
Policy Brief
Family Medicine Rural Training Track Graduates: Determinants of Rural and Urban Practice
Patterson DG, Keppel G, Skillman SM Conrad 30 waivers for physicians on J-1 visas: state policies, practices, and perspectives Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #157 03-10-2016
Final Report
The Influence of State Policies and Practices on J-1 Visa Waiver Physicians’ Service in Rural Areas
Patterson DG, Andrilla CHA, Schmitz D, Longenecker R, Evans DV Outcomes of rural-centric residency training to prepare family medicine physicians for rural practice Seattle. WA: WWAMI Rural Health Center, University of Washington Policy Brief #158 03-01-2016
Policy Brief 158
A Novel Master File of Rural Family Medicine Residency Training: Program Models and Graduate Outcomes
Larson EH, Andrilla CHA, Coulthard C, Spetz J How could nurse practitioners and physician assistants be deployed to provide rural primary care? Seattle, WA: WWAMI Rural Health Research Center, University of Washington Policy Brief #155 03-01-2016
Policy Brief
What Are the Possible Impacts of Nurse Practitioners and Physician Assistants on Future Provision of Primary Care in Rural Areas?
Baldwin LM, Andrilla CHA, Porter MP, Rosenblatt RA, Patel S, Doescher MP Treatment of early-stage prostate cancer among rural and urban patients Cancer 119(16):3067-3075 08-15-2013 URL Do Rural Patients with Early Stage Prostate Cancer Gain Access to All Treatment Choices?

BACKGROUND:

Geographic barriers and limited availability of cancer specialists may influence early prostate cancer treatment options for rural men. This study compares receipt of different early prostate cancer treatments between rural and urban patients.

METHODS:

Using 2004-2006 SEER Limited-Use Data, 51,982 early prostate cancer patients were identified (T1c, T2a, T2b, T2c, T2NOS; no metastases) who were most likely to benefit from definitive treatment (< 75 years old, Gleason score < 8, PSA ≤ 20). Definitive treatmentincluded radical prostatectomy, daily external beam radiation for 5 to 8 weeks, brachytherapy, or combination external beam radiation/brachytherapy. Adjusted definitive treatment rates were calculated by ruralurban residence overall, and for different sociodemographic and cancer characteristics, and different states based on logistic regression analyses, using general estimating equation methods to account for clustering by county.

RESULTS:

Adjusted definitive treatment rates were lower for rural (83.7%) than urban (87.1%) patients with early-stage prostate cancer (P ≤ .01). Rural men were more likely than urban men to receive non-definitive surgical treatment and no initial treatment. The lowest definitive treatment rates were among rural subgroups: 70 to 74 years (73.9%), African Americans (75.6%), American Indians/Alaska Natives (77.8%), single/separated/divorced (76.8%), living in New Mexico (69.3%), and living in counties with persistent poverty (79.6%).

CONCLUSIONS:

Between 2004 and 2006, this adjusted analysis found that men who were living in rural areas were less likely to receive definitive treatment for their early-stage prostate cancer than those living in urban areas. Certain rural patient groups with prostate cancer need particular attention to ensure their access to appropriate treatmentRural providers, rural health care systems, and cancer advocacy and support organizations should ensure resources are in place so that the most vulnerable rural groups (men between 60 and 74 years of age; African American men; men who are single, separated, or divorced; and men living in rural New Mexico) can make informed prostate cancer treatment choices based on their preferences.

access and evaluation health care quality prostatic neoplasms rural population SEER Program
Baldwin LM, Andrilla CHA, Porter MP, Rosenblatt RA, Patel S, Doescher MP Do rural patients with early-stage prostate cancer gain access to all treatment choices? Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #144 02-01-2014
Full Report Policy Brief
Do Rural Patients with Early Stage Prostate Cancer Gain Access to All Treatment Choices?
Skillman SM, Patterson DG, Coulthard C, Mroz TM Access to rural home health services: views from the field Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #152 02-01-2016
Final Report
Access to Home Care Services in the Rural United States
Patterson DG, Schmitz D, Longenecker R, Andrilla CHA Family medicine rural training track residencies: 2008-2015 graduate outcomes Seattle, WA: WWAMI Rural Health Research Center, University of Washington 02-01-2016
Policy Brief
Distributed Expertise: Sustaining Rural Training Tracks as a Strategy in Rural Medical Education
Larson EH, Andrilla CHA, Morrison C, Ostergard SJ, Glicken A Which physician assistant training programs produce rural PAs? A national study Seattle, WA: WWAMI Rural Health Research Center, University of Washington Policy Brief #154 02-01-2016
Policy Brief #154
Which Physician Assistant Training Programs Produce Rural Physician Assistants? A National Study
Skillman SM, Keppel GA, Patterson DG, Doescher MP The contributions of community colleges to the education of allied health professionals in rural areas of the United States Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #136 10-31-2012
Full report
Community Colleges’ Contributions to the Education of Allied Health Professionals in Rural Areas of the United States
Institute of Medicine Community colleges and the education of allied health professionals in rural areas (summary of presentation by SM Skillman) Institute of Medicine Allied health workforce and services: workshop summary. Washington, DC: The National Academies Press; 42-44 02-10-2012 Community Colleges’ Contributions to the Education of Allied Health Professionals in Rural Areas of the United States
Spetz J, Skillman SM, Andrilla CHA Nurse practitioner autonomy and satisfaction in rural settings Med Care Res Rev pii: 1077558716629584 01-29-2016 URL Practice Characteristics of Rural Nurse Practitioners in the United States

Rural primary care shortages may be alleviated if more nurse practitioners (NPs) practiced there. This study compares urban and rural primary care NPs (classified by practice location in urban, large rural, small rural, or isolated small rural areas) using descriptive analysis of the 2012 National Sample Survey of NPs. A higher share of rural NPs worked in states without physician oversight requirements, had a DEA (drug enforcement administration) number, hospital admitting privileges, and billed using their own provider identifier. Rural NPs more often reported they were fully using their NP skills, practicing to the fullest extent of the legal scope of practice, satisfied with their work, and planning to stay in their jobs. We found lower per capita NP supply in rural areas, but the proportion in primary care increased with rurality. To meet rural primary care needs, states should support rural NP practice, in concert with support for rural physician practice.

nurse practitioners nurses primary care rural health care scope of practice
Patterson DG, Keppel GA, Skillman SM, Berry C, Daniel C, Doescher MP Recruitment of non-U.S. citizen physicians to rural and underserved areas through Conrad State 30 J-1 visa waiver programs Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #148 04-01-2015
Final Report
The Influence of State Policies and Practices on J-1 Visa Waiver Physicians’ Service in Rural Areas
Skillman SM, Patterson DG, Andrilla CHA, Fenton S, Morrison C Access to health information technology training programs at the community college level Seattle. WA: WWAMI Rural Health Center, University of Washington Policy Brief #151 11-01-2015
Policy Brief
HIT Workforce Development in Rural-Serving Community Colleges
Doescher MP, Keppel GA Dentist supply, dental care utilization, and oral health among rural and urban U.S. residents Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #135 06-01-2015
Full Report
Dentist Supply, Access to Dental Care, and Oral Health Among Rural and Urban Residents: A National Study
Allen SM, Ballweg RA, Cosgrove EM, Engle KA, Robinson LR, Rosenblatt RA, Skillman SM, Wenrich MD Challenges and opportunities in building a sustainable rural primary care workforce in alignment with the Affordable Care Act: the WWAMI Program as a case study Acad Med 88(12):1862-1869 11-27-2013 URL WWAMI Physician Workforce Education

The authors examine the potential impact of the Patient Protection and Affordable Care Act (ACA) on a large medical education program in the Northwest United States that builds the primary care workforce for its largely rural region. The 42-year-old Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) program, hosted by the University of Washington School of Medicine, is one of the nation’s most successful models for rural health training. The program has expanded training and retention of primary care health professionals for the region through medical school education, graduate medical education, a physician assistant training program, and support for practicing health professionals.

The ACA and resulting accountable care organizations (ACOs) present potential challenges for rural settings and health training programs like WWAMI that focus on building the health workforce for rural and underserved populations. As more Americans acquire health coverage, more health professionals will be needed, especially in primary care. Rural locations may face increased competition for these professionals. Medical schools are expanding their positions to meet the need, but limits on graduate medical education expansion may result in a bottleneck, with insufficient residency positions for graduating students. The development of ACOs may further challenge building a rural workforce by limiting training opportunities for health professionals because of competing demands and concerns about cost, efficiency, and safety associated with training. Medical education programs like WWAMI will need to increase efforts to train primary care physicians and increase their advocacy for student programs and additional graduate medical education for rural constituents.

ACA accountable care organizations ACO graduate medical education health professionals medical education primary care physicians primary care workforce rural
Jackson JE, Doescher MP, Saver BG, Hart LG Trends in professional advice to lose weight among obese adults, 1994-2000 J Gen Intern Med 20(9):814-818 01-01-2005 URL Unhealthy Lifestyle Behaviors Among Minority Group Members: A National Rural and Urban Study of Obesity

CONTEXT:

Obesity is a fast-growing threat to public health in the U.S., but information on trends in professional advice to lose weight is limited.

OBJECTIVE:

We studied whether rising obesity prevalence in the U.S. was accompanied by an increasing trend in professional advice to lose weight among obese adults.

DESIGN AND PARTICIPANTS:

We used the Behavioral Risk Factor Surveillance System, a cross-sectional prevalence study, from 1994 (n = 10,705), 1996 (n = 13,800), 1998 (n = 18,816), and 2000 (n = 26,454) to examine changes in advice reported by obese adults seen for primary care.

MEASUREMENTS:

Self-reported advice from a health care professional to lose weight.

RESULTS:

From 1994 to 2000, the proportion of obese persons receiving advice to lose weight fell from 44.0% to 40.0%. Among obese persons not graduating from high school, advice declined from 41.4% to 31.8%; and for those with annual household incomes below 25,000 dollars, advice dropped from 44.3% to 38.1%. In contrast, the prevalence of advice among obese persons with a college degree or in the highest income group remained relatively stable and high (> 45%) over the study period.

CONCLUSIONS:

Disparities in professional advice to lose weight associated with income and educational attainment increased from 1994 to 2000. There is a need for mechanisms that allow health care professionals to devote sufficient attention to weight control and to link with evidence-based weight loss interventions, especially those that target groups most at risk for obesity.

obesity primary care professional advice weight loss
Jackson JE, Doescher MP, Jerant AF, Hart LG A national study of obesity prevalence and trends by type of rural county J Rural Health 21(2):140-148 01-01-2005 URL Unhealthy Lifestyle Behaviors Among Minority Group Members: A National Rural and Urban Study of Obesity

CONTEXT:

Obesity is epidemic in the United States, but information on this trend by type of rural locale is limited.

PURPOSE:

To estimate the prevalence of and recent trends in obesity among US adults residing in rural locations.

METHODS:

Analysis of data from the Behavioral Risk Factor Surveillance System (BRFSS) for the years 1994-1996 (n = 342,055) and 2000-2001 (n = 385,384). The main outcome measure was obesity (body mass index [BMI] > or = 30), as determined by calculating BMI from respondents’ self-reported height and weight.

RESULTS:

In 2000-2001, the prevalence of obesity was 23.0% (95% confidence interval [CI] 22.6%-23.4%) for rural adults and 20.5% (95% CI 20.2%-20.7%) for their urban counterparts, representing increases of 4.8% (95% CI 4.2%-5.3%) and 5.5% (95% CI 5.1%-5.9%), respectively, since 1994-1996. The highest obesity prevalence occurred in rural counties in Louisiana, Mississippi, and Texas; obesityprevalence increased for rural residents in all states but Florida over the study period. African Americans had the highest obesity prevalenceof any group, up to 31.4% (95% CI 29.1%-33.6) in rural counties adjacent to urban counties. The largest difference in obesity prevalencebetween those with a college education compared with those without a high school diploma occurred in urban areas (18.4% [95% CI 17.9%-18.9%] vs 23.5% [95% CI 22.5%-24.5%], respectively); the smallest difference occurred in small, remote rural counties (20.3% [95% CI 18.7%-21.9%] versus 22.3% [95% CI 20.7%-24.0%], respectively).

CONCLUSIONS:

The prevalence of obesity is higher in rural counties than in urban counties; obesity affects some residents of rural counties disproportionately.

obesity rural urban
Jackson JE, Doescher MP, Jerant AF, Hart LG Obesity prevalence in rural counties: a national study Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #87 01-01-2004
Full report Policy brief
Unhealthy Lifestyle Behaviors Among Minority Group Members: A National Rural and Urban Study of Obesity
Doescher MP, Jackson JE, Jerant A, Hart LG Prevalence and trends in smoking: a national rural study J Rural Health 22(2):112-118 03-01-2006 URL Unhealthy Lifestyle Behaviors Among Minority Group Members: A National Rural and Urban Study of Cigarette Smoking

CONTEXT:

Cigarette smoking is the leading preventable cause of death in the United States.

PURPOSE:

To estimate the prevalence of and recent trends in smoking among adults by type of rural location and by state.

METHODS:

Random-digit telephone survey of adults aged 18 years or older who participated in the Behavioral Risk Factor Surveillance System in 1994-1996 (n = 342,055) and 2000-2001 (n = 385,384). The main outcome measure was current cigarette smoking, defined as persons who smoke every day or some days, while nonsmokers were those who smoke not at all or reported never having smoked as many as 100 cigarettes.

FINDINGS:

The prevalence of smoking changed little from the mid-1990s; in 2000-2001, it was 22.0% in urban areas, 24.9% in rural adjacent areas, 24.0% in large rural nonadjacent areas, and 24.9% in small rural nonadjacent areas. For rural locations combined, smokingprevalence was not below the 12% goal of Healthy People 2010 for any state, although the 12.5% prevalence in rural Utah approached this target. Prevalence was > or = 28% for rural residents of Kentucky, Ohio, and Indiana. Since the mid-1990s, the prevalence of smoking for rural respondents decreased by more than 2 percentage points in 6 states: California, Connecticut, Maryland, North Carolina, Tennessee, and Utah. However, it increased by 2 percentage points or more in 10 states: Alabama, Delaware, Georgia, Massachusetts, Michigan, Mississippi, New Hampshire, Oklahoma, South Carolina, and Texas.

CONCLUSIONS:

Smoking remains a refractory public health problem. Better ways to curb smoking in rural America are needed.

BRFSS prevalence public health rural Smoking
Jackson JE, Doescher MP, Jerant AF, Hart LG Prevalence and trends in smoking: a national rural study Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #85 12-31-2003
Full report Policy brief
Unhealthy Lifestyle Behaviors Among Minority Group Members: A National Rural and Urban Study of Cigarette Smoking
Jackson JE, Doescher MP, Hart LG Problem drinking: rural and urban trends in America, 1995/1997 to 2003 Prev Med 43(2):122-124 08-01-2006 URL Unhealthy Lifestyle Behaviors Among Minority Group Members: A National Rural and Urban Study of Alcohol Use

Objective.

Studies examining trends in problem alcohol use for U.S. adults residing in rural locations are lacking. This study examines recent trends in heavy and binge drinking in urban counties and three types of rural counties.

Methods.

Random-digit telephone survey of adults aged 18 years or older residing in states participating in the Behavioral Risk Factor Surveillance System, in the years 1995/1997 (n = 247,255), 1999/2001 (n = 362,077) and 2003 (n = 257,659). Analyses were performed in 2006.

Results.

Metropolitan counties experienced higher prevalence of heavy and binge drinking than rural counties in all years, and all geographic areas showed upward trends in both drinking behaviors. Trends in heavy drinking were sharper in rural counties (3.8% to 5.4% compared with 4.9% to 6.0% in metro counties). Metropolitan and rural counties overall saw similar increases in binge drinking, however, the greatest increase occurred in remote micropolitan counties (12.7% to 15.7%).

Conclusion.

Heavy and binge drinking are problems that continue to increase in rural areas nationwide. Because of the difficulties inherent in accessing and administering substance abuse treatment in rural areas, special attention should be given to tailoring alcohol abuse interventions to the needs of rural residents.

Alcohol abuse Binge drinking Heavy drinking rural health trends
Jackson JE, Doescher MP, Hart LG Heavy and binge drinking in rural America: a comparison of rural and urban counties from 1995/1997 through 1999/2001 Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #95 02-01-2005
Full report
Unhealthy Lifestyle Behaviors Among Minority Group Members: A National Rural and Urban Study of Alcohol Use
Baldwin LM, Grossman DC, Murowchick E, Larson EH, Hollow WB, Sugarman JR, Freeman WL, Hart LG National trends in the perinatal and infant health of rural American Indians (AIs) and Alaska Natives (ANs): have the disparities between AI/ANs and whites narrowed? Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #111 06-30-2008
Full report Policy brief
National Trends in the Perinatal and Infant Health Care of Rural and Urban American Indians (AIs) and Alaska Natives (ANs)
Baldwin LM, Grossman DC, Murowchick E, Larson EH, Hollow WB, Sugarman JR, Freeman WL, Hart LG Trends in perinatal and infant health disparities between rural American Indians and Alaska Natives and rural whites Am J Public Health 99(4):638-646 04-01-2009 URL National Trends in the Perinatal and Infant Health Care of Rural and Urban American Indians (AIs) and Alaska Natives (ANs)

Objectives. We examined disparities in perinatal care, birth outcomes, and infant health between rural American Indian and Alaska Native (AIAN) persons and rural Whites over time.

Methods. We compared perinatal and infant health measures for 217 064 rural AIAN births and 5 032 533 rural non-Hispanic White births.

Results. Among American Indians and Alaska Natives, unadjusted rates of inadequate prenatal care (1985–1987, 36.3%; 1995–1997, 26.3%) and postneonatal death (1985–1987, 7.1 per 1000; 1995–1997, 4.8 per 1000) improved significantly. However, disparities between American Indians and Alaska Natives and Whites in adjusted odds ratios (AORs) of postneonatal death (1985–1987, AOR = 1.55; 95% confidence interval [CI] = 1.41, 1.71; 1995–1997, AOR = 1.46; 95% CI = 1.31, 1.64) and adjusted risk ratios (ARRs) of inadequate prenatal care (1985–1987, ARR = 1.67; 95% CI = 1.65, 1.69; 1995–1997, ARR = 1.84; 95% CI = 1.81, 1.87) persisted.

Conclusions. Despite significant decreases in inadequate prenatal care and postneonatal death among American Indians and Alaska Natives, additional measures are needed to close persistent health gaps for this group.

Previous studies and reports published by the Indian Health Service have demonstrated dramatic improvements in perinatal and infant health among American Indian and Alaska Native (AIAN) populations over the past 50 years. Infant mortality rates declined substantially from 62.7 per 1000 live births in 1955 to 9.3 per 1000 live births in the years 1994 to 1996.1 Yet disparities between American Indians and Alaska Natives and Whites have persisted. In 1989–1991, American Indians and Alaska Natives overall had 2.4 times the rate of postneonatal death compared with the White population1; rural American Indians and Alaska Natives had a postneonatal death rate 2.6 times that of Whites.2

Since the mid-1980s, considerable attention has been paid to improving access to health care services, changing risk behaviors among pregnant women, and modifying provider practices, with the intention of improving birth outcomes and lowering infant mortality rates.35 Among the general population, some of these efforts have been associated with higher rates of early and adequate prenatal care, as well as declining postneonatal mortality rates, especially from sudden infant death syndrome (SIDS).68 However, it is not known how these efforts have influenced the perinatal health status of American Indians and Alaska Natives specifically, especially among rural American Indians and Alaska Natives, many of whom live in remote settings that may be more distant from health services.

Our goal was to determine whether the disparities in perinatal care, birth outcomes, and infant health among rural American Indians and Alaska Natives and rural Whites diminished, remained stable, or increased during a period of policy, funding, and practice changes in maternal and child health care from the mid-1980s through the 1990s. We addressed these questions by examining trends in prenatal care receipt, low-birthweight rates, neonatal and postneonatal death rates, and causes of death among rural American Indians and Alaska Natives and Whites between 1985 and 1997.

Alaska Native American Indian birth outcomes infant health perinatal care postneonatal death rural rural health care sudden infant death syndrome (SIDS)
Larson EH, Murowchick E, Hart LG Poor birth outcome in the rural United States: 1985-1987 to 1995-1997 Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #119 02-29-2008
Full report Policy brief
Changes in U.S. Rural Perinatal Care During the Last Decade
Andrilla CHA, Lishner DM, Hart LG Rural dental practice: a tale of four states Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #107 03-01-2006
Full report Policy brief
Rural Dentistry: Availability, Practice, and Access
Rosenblatt RA, Bovbjerg RR, Whelan A, Baldwin LM, Hart LG, Long C Tort reform and the obstetric access crisis. The case of the WAMI states West J Med 154(6):693-699 06-01-1991 URL Tort Reform and the Obstetrical Access Crisis

The states of Washington, Alaska, Montana, and Idaho (WAMI) have all had declines in the proportion of physicians offering obstetricservices during the past few years, a decline precipitated by rising medical malpractice premiums. One response to the problem of rising liability premiums has been the passage of extensive tort reform legislation. We present the results of recent studies of physicians’ obstetricpractices in the WAMI states and summarize the major changes in tort legislation and regulation that have occurred in these states. Most general and family physicians in the WAMI region no longer provide obstetric care; by contrast, more than 80% of the obstetrician-gynecologists in the WAMI states are still practicing obstetrics. Despite the fact that only a minority of family physicians are still active in obstetrics, most rural family physicians in all four states still deliver babies. Most physicians in all four states limit the amount of care they provide to those covered by Medicaid, which suggests that significant barriers to care exist for medically indigent persons. All four states have adopted significant tort reforms. Despite these changes in the legal environment, the cost of malpractice premiums and concerns over the likelihood of being sued continue to limit the number of physicians willing to provide obstetric care. Although it cannot be inferred from these data that tort reform has decreased the rate at which physicians give up obstetric practice, the evidence is compatible with such a conclusion.

Comment in

family physicians liability insurance Medicaid obstetric services Physicians tort reform
Rosenblatt RA, Whelan A, Hart LG, Long C, Baldwin LM, Bovbjerg RR Tort reform and the obstetric access crisis: the case of the WAMI states Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #8 06-01-1990 Tort Reform and the Obstetrical Access Crisis
Skillman SM, Patterson DG, Lishner DM, Doescher MP, Andrilla CHA The rural health workforce: data and issues for policymakers in Washington, Wyoming, Alaska, Montana, Idaho. Issue #5: health workforce assessment: tools for policymakers and planners Seattle, WA: WWAMI Rural Health Research Center, University of Washington Policy Brief #146.5 07-27-2013
Policy brief
The Rural Health Workforce: Data and Issues for Policymakers in Washington, Wyoming, Alaska, Montana, Idaho
Skillman SM, Patterson DG, Lishner DM, Doescher MP, Fordyce MA The rural health workforce: data and issues for policymakers in Washington, Wyoming, Alaska, Montana, Idaho. Issue #4: what is rural in the WWAMI States? Why definitions matter Seattle, WA: WWAMI Rural Health Research Center, University of Washington Policy Brief #146.4 07-28-2013
Policy brief
The Rural Health Workforce: Data and Issues for Policymakers in Washington, Wyoming, Alaska, Montana, Idaho
Patterson DG, Lishner DM, Skillman SM, Doescher MP The rural health workforce: data and issues for policymakers in Washington, Wyoming, Alaska, Montana, Idaho. Issue #3: building and maintaining the rural health workforce: resources and strategies Seattle, WA: WWAMI Rural Health Research Center, University of Washington Policy Brief #146.3 07-29-2013
Policy brief
The Rural Health Workforce: Data and Issues for Policymakers in Washington, Wyoming, Alaska, Montana, Idaho
Patterson DG, Skillman SM, Andrilla CHA, Lishner DM, Doescher MP The rural health workforce: data and issues for policymakers in Washington, Wyoming, Alaska, Montana, Idaho. Issue #2: the rural health workforce in the WWAMI states: by the numbers Seattle, WA: WWAMI Rural Health Research Center, University of Washington Policy Brief #146.2 07-30-2013
Policy brief
The Rural Health Workforce: Data and Issues for Policymakers in Washington, Wyoming, Alaska, Montana, Idaho
Skillman SM, Patterson DG, Lishner DM, Doescher MP The rural health workforce: data and issues for policymakers in Washington, Wyoming, Alaska, Montana, Idaho. Issue #1: the rural health workforce: challenges and opportunities Seattle, WA: WWAMI Rural Health Research Center, University of Washington Policy Brief #146.1 07-31-2013
Policy brief
The Rural Health Workforce: Data and Issues for Policymakers in Washington, Wyoming, Alaska, Montana, Idaho
Doescher MP, Jackson JE, Fordyce MA, Lynge DC Variability in general surgical procedures in rural and urban U.S. hospital inpatient settings Seattle: WA, WWAMI Rural Health Research Center, University of Washington Policy Brief #142 02-01-2015
Full report
General and Specialist Surgeon Supply and Inpatient Procedural Content: A National Rural-Urban Study
Welch HG, Larson EH, Hart LG, Rosenblatt RA Readmission after surgery in Washington State rural hospitals Am J Public Health 82(3):407-411 03-01-1992 URL Surgical Outcomes of Rural and Urban Hospitals

BACKGROUND. Because of concern about the quality of care in rural hospitals, we examined readmission following four surgical procedures commonly performed in Washington State rural hospitals: appendectomy, cesarean section, cholecystectomy, and transurethral prostatectomy. METHODS. In a retrospective cohort study, we identified all patients discharged after receiving one of the foregoing procedures using the statewide hospital discharge database. Readmissions to any hospital in the state within 7 or 30 days of discharge were also identified. RESULTS. During the 2-year period examined, there were no significant differences in readmission rates for surgeries performed in rural and urban hospitals, although the readmission rates for all four procedures were nominally lower in rural hospitals. Logistic regression analyses that controlled for factors that influence readmission did not change these results. CONCLUSIONS. Investigating readmission rates following common surgeries, we found no evidence of low-quality surgical care in Washington State rural hospitals. Early readmission is an imperfect marker for poor surgical outcome, however, and other proxies for quality remain to be examined.

appendectomy cesarean section cholecystectomy rural hospitals rural vs urban surgery transurethral prostatectomy
Welch HG, Larson EH Patients requiring at least five admissions in 1 year. Data from Washington State Med Care 29(6):578-582 06-01-1991 URL Surgical Outcomes of Rural and Urban Hospitals

Concern about rising health expenditures has fostered interest in patients who are frequent users of medical care, who were labeled “high utilizers” as early as 1959.  Because of the high cost of inpatient services, subsequent research has generally focused on patients with frequent hospital admissions.  Recent investigations have examined multiple admission in selected patient populations, including newborns, psychiatric patients, and Medicare beneficiaries.  However, the characteristics of patients with multiple admissions have not been described among unselected populations.  In this investigation, we report on multiple admissions among the general population of Washington state and focus on those patients requiring at least five admissions in 1 year.

hospital admissions hospitals multiple admissions
Welch HG, Larson EH, Hart LG, Rosenblatt RA Readmission following surgery in Washington State rural hospitals Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #10 01-01-1991 Surgical Outcomes of Rural and Urban Hospitals
Lynge DC, Larson EH, Thompson MJ, Rosenblatt RA, Hart LG A longitudinal analysis of the general surgery workforce in the United States, 1981-2005 Arch Surg 143(4):345-350 04-01-2008 URL Distribution and Retention of General Surgeons in Rural Areas of the U.S.

Hypothesis  The overall supply of general surgeons per 100 000 population has declined in the past 2 decades, and small and isolated rural areas of the United States continue to have relatively fewer general surgeons per 100 000 population than urban areas.

Design  Retrospective longitudinal analysis.

Setting  Clinically active general surgeons in the United States.

Participants  The American Medical Association’s Physician Masterfiles from 1981, 1991, 2001, and 2005 were used to identify all clinically active general surgeons in the United States.

Main Outcome Measures  Number of general surgeons per 100 000 population and the age, sex, and locale of these surgeons.

Results  General surgeon to population ratios declined steadily across the study period, from 7.68 per 100 000 in 1981 to 5.69 per 100 000 in 2005. The overall urban ratio dropped from 8.04 to 5.85 (−27.24%) across the study period, and the overall rural ratio dropped from 6.36 to 5.02 (−21.07%). The average age of rural surgeons increased compared with their urban counterparts, and women were disproportionately concentrated in urban areas.

Conclusions  The overall number of general surgeons per 100 000 population has declined by 25.91% during the past 25 years. The decline has been most marked in urban areas. However, more remote rural areas continue to have significantly fewer general surgeons per 100 000 population. These findings have implications for training, recruiting, and retaining general surgeons.

General surgeons play a pivotal role in the health care systems of the United States, particularly its rural areas.1 They provide surgical backup to rural primary care physicians, ensure the success of rural trauma systems, and contribute to the financial viability of small rural hospitals.2– 6 Urban general surgeons also provide important surgical services, including emergency and trauma care that some surgical subspecialists may not offer.7There is some question as to whether there will be an adequate number of general surgeons to care for an increasingly elderly population, with its attendant increased demand for surgical care.8

Recent studies9– 11 have indicated that the overall number of general surgeons has remained static since 1994, despite an increase in population of 1% per annum during this period. This fact, coupled with the rise in surgical specialization, the decreased interest of medical students in general surgical careers, and the changes in demographics of medical students and surgery residents, has generated concern that there will soon be a shortage of general surgeons.12– 16 Recent publications by the Institute of Medicine and the American College of Surgeons attest to staffing and availability problems of general, and other, surgeons for emergency services.17,18 Our study group11 found that the general surgeon to population ratio in the more remote rural areas of the United States was almost half that of urban areas. The present study builds on this previous work by adding a longitudinal dimension and describing the trends in the number, distribution, and characteristics of general surgeons in the United States during the 25 years from 1981 to 2005, with particular emphasis on surgeons in small and isolated rural areas. Examination of such trends is crucial to predicting and addressing future workforce problems.

General surgeons rural rural primary care physicians
Thompson MJ, Lynge DC, Larson EH, Tachawachira P, Hart LG Characterizing the general surgery workforce in rural America Arch Surg 140(1):74-79 01-01-2005 URL Distribution and Retention of General Surgeons in Rural Areas of the U.S.

BACKGROUND:

General surgeons form a crucial component of the medical workforce in rural areas of the United States. Any decline in their numbers could have profound effects on access to adequate health care in such areas.

HYPOTHESIS:

We hypothesize that the rural areas of the United States are relatively undersupplied with general surgeons.

DESIGN AND SETTING:

The American Medical Association’s Physician Masterfile was used to identify all clinically active general surgeons as well as their locations and characteristics. Their geographic distribution was examined using the ZIP code version of the Rural-Urban Commuting Areas. Surgeons were classified as practicing in urban areas, large rural areas, or small/isolated rural areas.

RESULTS:

There are currently 17 243 general surgeons practicing in the United States. Nationally, the number of general surgeons per population of 100 000 varies from 6.53 in urban areas to 7.71 in large rural areas and 4.67 in small/isolated rural areas. Only 10.6% of the nation’s general surgeons are female. Wide variations in numbers of general surgeons were found between and within individual states. General surgeons in the smallest rural areas are more likely than those in urban areas to be male (92.7% vs 88.3%, P<.001), 50 years of age or older (51.6% vs 42.1%, P<.001), or international medical graduates (25.2% vs 20.1%, P<.001).

CONCLUSIONS:

The overall size of the rural general surgical workforce has remained static over the last decade, but its demographic characteristics suggest that numbers will decline. Many rural residents have limited access to surgical services. Steps to reverse this trend are needed to preserve the viability of health care in many parts of rural America.

General surgeons medical workforce rural urban
Thompson MJ, Lynge DC, Larson EH, Tachawachira P, Hart LG Characterizing the general surgery workforce in rural America Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #77 05-01-2004
Full report
Distribution and Retention of General Surgeons in Rural Areas of the U.S.
Larson EH, Johnson KE, Norris TE, Lishner DM, Rosenblatt RA, Hart LG State of the health workforce in rural America: profiles and comparisons Seattle, WA: WWAMI Rural Health Research Center, University of Washington 01-01-2003
Cover.
Contents.
Chapter 1.
Chapter 2.
Chapter 3.
Chapter 4.
Chapter 5.
Chapter 6.
References.
State Rural Health Workforce Monograph
Williamson HA, Rosenblatt RA, Hart LG Physician staffing of small rural hospital emergency departments: rapid change and escalating cost J Rural Health 8(3):171-177 06-01-1992 URL Physician Staffing of Small Rural Hospital Emergency Departments

We surveyed all 37 rural Washington state hospitals with fewer than 100 beds to determine how rural emergency departments are staffed by physicians and to estimate rural hospital payments for emergency department physician services. Only five hospital emergency departments (14%) were still covered by the traditional rotation of local practitioners and billed on a fee-for-service basis. Ten hospitals (27%) paid local private practitioners to provide emergency department coverage. Twelve other hospitals (32%) hired visiting emergency department physicians to cover only weekends or evenings. The remaining 10 rural emergency departments (27%) were staffed entirely by external contract physicians. Thus, 86 percent of rural hospitals contracted for emergency department coverage, and 59 percent obtained some or all of this service from nonlocal physicians. Most of the 32 hospitals with some form of contracted services have changed to this emergency department coverage in the last few years. The cost of these services is high, particularly for the smallest hospitals that have fewer than eight emergency department visits per day and pay physician wages of nearly $100 per patient visit. Emergency staffing responsibility has shifted from local practitioners to the hospital administrators because of rural physician scarcity and a desire to improve quality and convenience. The cost of these changes may further undermine the economic viability of the smaller rural hospitals.

emergency Physicians rural rural hospitals
Williamson H, Rosenblatt RA, Hart LG Physician staffing of small rural hospital emergency departments: rapid change and escalating cost Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #15 09-01-1991 Physician Staffing of Small Rural Hospital Emergency Departments
Baldwin LM, Hollow WB, Casey S, Hart LG, Larson EH, Moore K, Lewis E, Andrilla CHA, Grossman DC Access to specialty health care for rural American Indians in two states J Rural Health 24(3):269-278 06-21-2008 URL Availability of Specialty Health Care for Rural American Indians (AIs) and Alaska Natives (ANs)

CONTEXT:

The Indian Health Service (IHS), whose per capita expenditure for American Indian and Alaska Native (AI/AN) health services is about half that of the US civilian population, is the only source of health care funding for many rural AI/ANs. Specialty services, largely funded through contracts with outside practitioners, may be limited by low IHS funding levels.

PURPOSE:

To examine specialty service access among rural Indian populations in two states.

METHODS:

A 31-item mail survey addressing perceived access to specialty physicians, barriers to access, and access to non-physician clinical services was sent to 106 primary care providers in rural Indian health clinics in Montana and New Mexico (overall response rate 60.4%) and 95 primary care providers in rural non-Indian clinics within 25 miles of the Indian clinics (overall response rate 57.9%).

FINDINGS:

Substantial proportions of rural Indian clinic providers in both states reported fair or poor non-emergent specialty service accessfor their patients. Montana’s rural Indian clinic providers reported poorer patient access to specialty care than rural non-Indian clinic providers, while New Mexico’s rural Indian and non-Indian providers reported comparable access. Indian clinic providers in both states most frequently cited financial barriers to specialty care. Indian clinic providers reported better access to most non-physician services than non-Indian clinic providers.

CONCLUSIONS:

Reported limitations in specialty care access for rural Indian clinic patients appear to be influenced by financial constraints. Health care systems factors may play a role in perceived differences in specialty access between rural Indian and non-Indian clinic patients.

American Indian Indian Health Service (IHS) Montana New mexico rural specialty service
Baldwin LM, Hollow WB, Casey S Access to specialty health care for rural American Indians: provider perceptions in two states Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #78 10-01-2004
Full report Policy brief
Availability of Specialty Health Care for Rural American Indians (AIs) and Alaska Natives (ANs)
Larson EH, Hart LG, Rosenblatt RA Rural residence and poor birth outcome in Washington State J Rural Health 8(3):162-170 06-01-1992 URL Quality of Obstetrical Care Provided to Rural Versus Urban Residents

It is often assumed that poor birth outcomes are more common among rural women than urban women, but there is little substantive evidence to that effect. While the effectiveness of rural providers and hospitals has been evaluated in previous studies, this study focuses on poor birth outcomes in a population of rural residents, including those who leave rural areas for obstetrical care. Rural and urban differences in rates of inadequate prenatal care, neonatal death, and low birth weight were examined in the general population and in subpopulations stratified by risk and race using data from five years (1984-88) of birth and infant death certificates from Washington state. Also examined were care and outcome differences between rural women delivering in rural hospitals and those delivering in urban facilities. Bivariate analyses were confirmed with logistic regression. Results indicate that rural residents in the general population and in various subpopulations had similar or lower rates of poor outcome than did urban residents but experienced higher rates of inadequate prenatal care than did urban residents. Rural residents delivering in urban hospitals had higher rates of poor outcomes than those delivering in rural hospitals. We conclude that rural residence is not associated with greater risk of poor birth outcome. White and nonwhite differences appear to exceed any rural and urban resident differences in rates of poor birth outcome.

birth outcomes hospitals rural rural vs urban
Larson EH, Hart LG, Rosenblatt RA Is rural residence associated with poor birth outcome? Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #14 06-01-1991 Quality of Obstetrical Care Provided to Rural Versus Urban Residents
Baldwin LM, Rosenblatt RA, Lishner DM, Hart LG, Schneeweiss R Rural and urban physicians: does the content of their practices differ? Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #48 05-01-1998 Who Are the Generalists in Rural and Urban Areas?
Baldwin LM, Rosenblatt RA, Schneeweiss R, Lishner DM, Hart LG Rural and urban physicians: does the content of their Medicare practices differ? J Rural Health 15(2):240-251 04-01-1999 URL Who Are the Generalists in Rural and Urban Areas?

Rural and urban areas have significant differences in the availability of medical technology, medical practice structures and patient populations. This study uses 1994 Medicare claims data to examine whether these differences are associated with variation in the content of practice between physicians practicing in rural and urban areas. This study compared the number of patients, outpatient visits, and inpatient visits per physician in the different specialties, diagnosis clusters, patient age and sex, and procedure frequency and type for board-certified rural and urban physicians in 12 ambulatory medical specialties. Overall, 14.4 percent of physicians in the 12 specialties practiced exclusively in rural Washington, with great variation by specialty. Rural physicians were older and less likely to be female than urban physicians. Rural physicians saw larger numbers of elderly patients and had higher volumes of outpatient visits than their urban counterparts. For all specialty groups except general surgeons and obstetrician-gynecologists, the diagnostic scope of practice was specialty-specific and similar for rural and urban physicians. Rural general surgeons had more visits for gastrointestinal disorders, while rural obstetrician-gynecologists had more visits out of their specialty domain (e.g., hypertension, diabetes) than their urban counterparts. The scope of procedures for rural and urban physicians in most specialties showed more similarities than differences. While the fund of knowledge and outpatient procedural training needed by most rural and urban practitioners to care for the elderly is similar, rural general surgeons and obstetrician-gynecologists need training outside their traditional specialty areas to optimally care for their patients.

geographic location medical technology Medicare Physicians practice characteristics practices rural urban
Baldwin LM, Fordyce MA, Andrilla CHA, Doescher MP Inadequate prenatal care among racial and ethnic groups in the rural United States, 2005 Seattle, WA: WWAMI Rural Health Research Center, University of Washington Policy Brief #141 10-12-2013
Policy brief
Perinatal Health in the Rural United States, 2005
Baldwin LM, Fordyce MA, Andrilla CHA, Doescher MP Inadequate prenatal care in the rural United States, 2005 Seattle, WA: WWAMI Rural Health Research Center, University of Washington Policy Brief #140 10-13-2013
Policy brief
Perinatal Health in the Rural United States, 2005
Baldwin LM, Fordyce MA, Andrilla CHA, Doescher MP Low birth weight rates among racial and ethnic groups in the rural United States, 2005 Seattle, WA: WWAMI Rural Health Research Center, University of Washington Policy Brief #139 10-14-2013
Policy brief
Perinatal Health in the Rural United States, 2005
Baldwin LM, Fordyce MA, Andrilla CHA, Doescher MP Low birth weight rates in the rural United States, 2005 Seattle, WA: WWAMI Rural Health Research Center, University of Washington Policy Brief #138 10-15-2013
Policy brief
Perinatal Health in the Rural United States, 2005
Skillman SM, Palazzo L, Doescher MP, Butterfield P Characteristics of rural RNs who live and work in different communities Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #133 09-28-2012
Full report Policy brief
Factors Associated with Rural-Residing Registered Nurses’ Choices to work in Urban Locations and Larger Rural Cities
Rosenblatt RA, Andrilla CHA, Catlin M, Larson EH Geographic and specialty distribution of US physicians trained to treat opioid use disorder Ann Fam Med 13(1):23-6 01-01-2015 URL The Supply of Physicians Waivered to Treat Opioid Addiction in Rural America: Policy Options to Remedy Critical Shortages

PURPOSE The United States is experiencing an epidemic of opioid-related deaths driven by excessive prescribing of opioids, misuse of prescription drugs, and increased use of heroin. Buprenorphine-naloxone is an effective treatment for opioid use disorder and can be provided in office-based settings, but this treatment is unavailable to many patients who could benefit. We sought to describe the geographic distribution and specialties of physicians obtaining waivers from the Drug Enforcement Administration (DEA) to prescribe buprenorphine-naloxone to treat opioid use disorder and to identify potential shortages of physicians.

METHODS We linked physicians authorized to prescribe buprenorphine on the July 2012 DEA Drug Addiction Treatment Act (DATA) Waived Physician List to the American Medical Association Physician Masterfile to determine their age, specialty, rural-urban status, and location. We then mapped the location of these physicians and determined their supply for all US counties.

RESULTS Sixteen percent of psychiatrists had received a DEA DATA waiver (41.6% of all physicians with waivers) but practiced primarily in urban areas. Only 3.0% of primary care physicians, the largest group of physicians in rural America, had received waivers. Most US counties therefore had no physicians who had obtained waivers to prescribe buprenorphine-naloxone, resulting in more than 30 million persons who were living in counties without access to buprenorphine treatment.

CONCLUSIONS In the United States opioid use and related unintentional lethal overdoses continue to rise, particularly in rural areas. Increasing access to office-based treatment of opioid use disorder—particularly in rural America—is a promising strategy to address rising rates of opioid use disorder and unintentional lethal overdoses.

buprenorphine opiate addiction opiate substitution treatment opioid treatment programs primary health care rural health
Larson EH, Hart LG, Muus K, Geller J Content of physician assistant practice: results from a national survey Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #55 05-01-1999
Full report
National Rural Physician Assistant Content of Care Study
Melzer SM, Grossman DC, Hart LG, Rosenblatt RA Hospital services for rural children in Washington State Pediatrics 99(2):196-203 02-01-1997 URL Pediatric Inpatient Care in Rural Hospitals

Objective. To examine the current delivery of inpatient hospital services to a statewide population of rural children, define the types of pediatric conditions currently treated in rural hospitals or transferred to urban centers, and explore the role of rural pediatricians and family practitioners in the care of children in rural hospitals.

Design. Retrospective review of statewide hospital discharge data.

Subjects. All patients younger than 18 years of age with nonsurgical diagnoses discharged from both urban and rural civilian hospitals in Washington State during 1989 and 1990.

Results. Of 69 690 pediatric hospital discharges during the study period, 16% were rural residents and 10% were from rural hospitals. Rural hospitals cared for 59% of hospitalized rural children. Marked differences were found between urban and rural hospitals in the diagnoses treated; more than two-thirds of all discharges for chemotherapy, psychiatric disorders, and neonates with multiple major problems were from urban hospitals; but the majority of the discharges for gastrointestinal diagnoses, respiratory conditions, or minor problems in the neonatal period were from rural hospitals. Rural hospitals with staff pediatricians had higher annual pediatric discharges, total charges, lengths of stay, and case mix with a higher proportion of neonates with complications, compared to hospitals without pediatricians. However, there was no evidence that these hospitals served as local referral centers for rural pediatric inpatients; the proportion of patients from outside the local hospital catchment areas was similar for rural hospitals with staff pediatricians and for those without. In rural hospitals, pediatricians and family practitioners were listed as the attending physician for 37% and 49% of discharges, respectively. The average rural pediatrician cared for five times as many inpatients as a rural family practitioner. Pediatricians cared for significantly more neonates with birth weights of less than 2500 grams, but otherwise had a similar case mix among inpatient discharges as rural family practitioners.

Conclusions. Most rural children in Washington who require hospitalization for common problems receive their care in local rural hospitals staffed with pediatricians and family practitioners, although those with illnesses requiring a high level of specialty care are predominantly cared for in urban centers. Rural pediatricians make a substantial contribution to the care of rural children, especially in the area of neonatal care, although their presence in rural hospitals does not in itself create local referral centers. Inpatient volumes are higher for pediatricians, but their case mix is similar to that of rural family practitioners, except in the area of neonatology. These data support the recommendations that family practitioners contemplating rural practice receive training in general inpatient pediatrics (regardless of whether they are going to a site with pediatricians) and that pediatricians in rural practice be trained for a high volume of inpatient cases, including problems of low birth weight infants. Because systems of hospital care for rural children depend on regionalized programs, clinical and educational linkages between urban centers and rural providers should be developed and supported.

children hospital services hospitalization neonatal pediatricians pediatrics physician practice patterns referral patterns rural rural health
Melzer S, Grossman DC, Hart LG, Larson EH, Sodenberg R, Rosenblatt RA Rural inpatient pediatrics: pediatricians and family physicians Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #35 10-01-1995 Pediatric Inpatient Care in Rural Hospitals
Skillman SM, Doescher MP, Mouradian WE, Brunson DK The challenge to delivering oral health services in rural America J Public Health Dent 70(S1):S49-S57 06-01-2010 URL Oral Health Services in Rural America

Objectives: This review identifies the challenges to oral health in rural America and describes areas of innovation in prevention, delivery of dental services, and workforce development that may improve oral health for rural populations.

Methods: This descriptive article is based on literature reviews and personal communications.

Results: Rural populations have lower dental care utilization, higher rates of dental caries, lower rates of insurance, higher rates of poverty, less water fluoridation, fewer dentists per population, and greater distances to travel to access care than urban populations. Improving the oral health of rural populations requires practical and flexible approaches to expand and better distribute the rural oral health workforce, including approaches tailored to remote areas. Solutions that involve mass prevention/public health interventions include increasing water fluoridation, providing timely oral health education, caries risk assessment and referral, preventive services, and offering behavioral interventions such as smoking and tobacco cessation programs. Solutions that train more providers prepared to work in rural areas include recruiting students from rural areas, training students in rural locations, and providing loan repayment and scholarships. Increasing the flexibility and capacity of the oral health workforce for rural areas could be achieved by creating new roles for and new types of providers. Solutions that overcome distance barriers include mobile clinics and telehealth technology.

Conclusions: Rural areas need flexibility and resources to develop innovative solutions that meet their specific needs. Prevention needs to be at the front line of rural oral health care, with systematic approaches that cross health professions and health sectors.

dental Education oral health Prevention rural solutions urban workforce
Rosenblatt RA, Dawson AJ, Larson EH, Tressler CJ, Jones A, Hart LG, Nesbitt TS A comparison of the investment in hospital-based obstetrical ultrasound in Wales and Washington State Int J Technol Assess Health Care 11(3):571-584 01-01-1995 URL N/A

The purpose of this study was to examine differences in the way Britain and the United States invest in and deploy a new medical technology. We used structured interviews to obtain information on the technical sophistication and approximate replacement value of all hospital-based obstetrical ultrasound machines in every maternity hospital in Washington state and Wales. The supply of hospital-based ultrasound machines–approximately two machines per 1,000 births–was similar in both countries. Wales had fewer advanced ultrasound machines than Washington state, and they were based exclusively in high-volume district general hospitals; there were no obstetric ultrasound machines in the private sector. In Washington state, the majority of advanced machines were in small and medium-sized hospitals, and many private offices had ultrasound machines. The approximate replacement value of hospital-based machines was three times as high per birth in Washington state as in Wales. In the case of obstetrical ultrasound, centralization of facilities, a relatively small private sector, and global budgeting lead to lower expenditures per patient within the National Health Service without compromising access to care.

Britain hospitals medical technology obstetrical ultrasound private pubnlic USA Wales Washington State
Hart LG, Taylor P The emergence of federal rural health policy in the United States. In: Geyman JP, Norris TE, Hart LG, eds Textbook of rural medicine New York: McGraw-Hill 01-01-2001 FORHP Rural Health Research Center Book and Rural Medicine Textbook
Larson EH, Hart LG The rural physician. In: Geyman JP, Norris TE, Hart LG, eds Textbook of rural medicine New York: McGraw-Hill 01-01-2001 FORHP Rural Health Research Center Book and Rural Medicine Textbook
Rosenblatt RA The health of rural people and the communities and environments in which they work. In: Geyman JP, Norris TE, Hart LG, eds Textbook of rural medicine New York: McGraw-Hill 01-01-2001 FORHP Rural Health Research Center Book and Rural Medicine Textbook
Wright GE The economics of rural practice. In: Geyman JP, Norris TE, Hart LG, eds Textbook of rural medicine New York: McGraw-Hill 01-01-2001 FORHP Rural Health Research Center Book and Rural Medicine Textbook
Norris TE Telemedicine and telehealth service. In: Geyman JP, Norris TE, Hart LG, eds Textbook of rural medicine New York: McGraw-Hill 01-01-2001 FORHP Rural Health Research Center Book and Rural Medicine Textbook
Geyman JP Graduate education for rural practice. In: Geyman JP, Norris TE, Hart LG, eds Textbook of rural medicine New York: McGraw-Hill 01-01-2001 FORHP Rural Health Research Center Book and Rural Medicine Textbook
Coombs JB Quality of care in rural settings: bringing the "new quality" to rural practice. In: Geyman JP, Norris TE, Hart LG, eds Textbook of rural medicine New York: McGraw-Hill 01-01-2001 FORHP Rural Health Research Center Book and Rural Medicine Textbook
Williams R, House P Community oriented primary care and rural services development. In: Geyman JP, Norris TE, Hart LG, eds Textbook of rural medicine New York: McGraw-Hill 01-01-2001 FORHP Rural Health Research Center Book and Rural Medicine Textbook
Rosenblatt RA, Hart LG Chapter 3: physicians and rural America. In: Ricketts TC, ed Rural health in the United States New York: Oxford University Press 01-01-1999 FORHP Rural Health Research Center Book and Rural Medicine Textbook
Lishner DM, Larson EH, Rosenblatt RA, Clark SJ Chapter 12: rural maternal and perinatal health. In: Ricketts TC, ed Rural health in the United States New York: Oxford University Press 01-01-1999 FORHP Rural Health Research Center Book and Rural Medicine Textbook
Williamson HA Jr, Hart LG, Pirani MJ, Rosenblatt RA Market shares for rural inpatient surgical services: where does the buck stop? J Rural Health 10(2):70-79 04-01-1994 URL Surgical Capacity of Rural Washington State Hospitals

Utilization of surgical services by rural citizens is poorly understood, and few data are available about rural hospitals’surgical market shares and their financial implications. Understanding these issues is particularly important in an era of financially stressed rural hospitals.

In this study information about rural surgical providers and services was obtained through telephone interviews with administrators at Washington state’s 42 rural hospitals. The Washington State Department of Health’s Commission Hospital Abstract Recording System (CHARS) data were used to measure market shares and billed charges for rural surgical services. ZIP codes were used to assign rural residents to a hospital service area (HSA) of the nearest hospital, providing the geographic basis for market share calculations. “Total hospital expenses” from the American Hospital Association Guide were used as a proxy for hospital budget, and the surgical financial contribution was expressed as a ratio of billed surgical charges to total hospital expense.

For rural hospitals as a whole, 21 percent of admissions and 43 percent of billed inpatient charges resulted from surgical services. In 1989, 27,202 rural Washington residents were hospitalized for surgery. Overall, 42 percent went to the closest rural hospital, 14 percent went to other rural hospitals, and 44 percent went to urban hospitals. The presence of surgical providers markedly increased local market shares, but a substantial proportion of basic surgical procedures bypassed available local services in favor of urban hospitals. For example, about one-third of patients needing cholecystectomies, a basic general surgery of low complexity, bypassed local hospitals with staff surgeons.

Thirty-eight percent of hospitals had no general surgeon (classified as “minimal service” hospitals), 41 percent had at least one (“basic service” hospitals), and 21 percent had a comprehensive surgical staff consisting of general surgeons plus at least one anesthesiologist, gynecologist, orthopedist, and urologist (“comprehensive service” hospitals). Minimal service hospitals billed a mean of $90,000 annually for surgery; basic service hospitals, $1.5 million; and comprehensive service hospitals, $7.1 million. Billed surgical charges were 4 percent of total expenses at minimal service hospitals, 31 percent for basic service hospitals, and 41 percent for comprehensive service hospitals. There was a moderate amount of surgical activity at larger rural hospitals that represented rural-to-rural movement of surgical care, and this amounted to $14 million. More importantly, 60 percent of surgical charges billed on behalf of rural citizens ($116 million) went to urban hospitals.

These data demonstrate the considerable potential financial advantage to hospitals that have surgical services. This financial advantage can in turn be used to support other important but less lucrative rural hospital services. If supporting some or all rural hospitals as they struggle financially is an important rural health goal, then public policy should be directed toward supporting appropriate surgical services at rural hospitals and encouraging the proper training and recruitment of rural surgeons.

anesthesiologist General surgeons gynecologist orthopedist rural rural hospitals surgical services urologist
Williamson HA Jr, Hart LG, Pirani MJ, Rosenblatt RA Rural hospital inpatient surgical volume: cutting-edge service or operating on the margin? J Rural Health 10(1):16-25 11-01-1994 URL Surgical Capacity of Rural Washington State Hospitals

Surgical services are an important part of modern health care, but providing them to isolated rural citizens is especially difficult. Public policy initiatives could influence the supply, training, and distribution of surgeons, much as they have for rural primary care providers. However, so little is known about the proper distribution of surgeons, their contribution to rural health care, and the safety of rural surgery that policy cannot be shaped with confidence. This study examined the volume and complexity of inpatient surgery in rural Washington state as a first step toward a better understanding of the current status of rural surgical services. Information about rural surgical providers was obtained through telephone interviews with administrators at Washington’s 42 rural hospitals. The Washington State Department of Health’s Commission Hospital Abstract Recording System (CHARS) data provided a count of the annual surgical admissions at rural hospitals. Diagnosis-related group (DRG) weights were used to measure complexity of rural surgical cases. Surgical volume varied greatly among hospitals, even among those with a similar mix of surgical providers. Many hospitals provided a limited set of basic surgical services, while some performed more complex procedures. None of these rural hospitals could be considered high volume when compared to volumes at Seattle hospitals or to research reference criteria that have assessed volume-outcome relationships for surgical procedures. Several hospitals had very low volumes for some complex procedures, raising a question about the safety of performing them. The leaders of small rural hospitals must recognize not only the fiscal and service benefits of surgical services–and these are considerable–but also the potentially adverse effect of low surgical volume on patient outcomes. Policies that encourage the proper training and distribution of surgeons, the retention of basic rural surgical services, and the rational regionalization of complex surgery are likely to enhance the convenience and safety of surgery for rural citizens.

rural rural hospitals surgeons surgical services
Williamson H, Hart LG, Pirani MJ, Rosenblatt RA Market shares for rural surgical services: where does the buck stop? Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #21 04-01-1993 Surgical Capacity of Rural Washington State Hospitals
Williamson H, Hart LG, Pirani MJ, Rosenblatt RA Rural hospital surgical volume: cutting edge service or operating on the margin? Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #19 01-01-1993 Surgical Capacity of Rural Washington State Hospitals
Amundson BA, Hagopian A, Robertson DG Implementing a community-based approach to strengthening rural health services: the Community Health Services Development Model (parts I and II) Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #11 02-01-1991 Transferability of the Rural Hospital Project
Hoare G, Katz A, Porter A, Dannenbaum A, Baldwin H Rural hospital care linkages in the Northwest Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #12 04-01-1991 Rural Hospital Linkages in the WAMI Region
Dyck SM, Hagopian A, House PJ, Hart LG Northwest rural hospital governing boards Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #43 11-01-1997 Characteristics of Rural Hospital Governing Boards. Part C: Which Activities of Small Rural Hospital Boards Are Associated with Success?
Dyck SM, Hagopian A, House PJ, Hart LG Northwest rural hospital governing boards Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #43 11-01-1997 Characteristics of Rural Hospital Governing Boards. Part B: An Assessment of the Knowledge of Governing Board Members in Rural Hospitals
Dyck SM, Hagopian A, House PJ, Hart LG Northwest rural hospital governing boards Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #43 11-01-1997 Characteristics of Rural Hospital Governing Boards. Part A: Who Governs Rural Hospitals?
Lishner DM, Robertson DG, Rosenblatt RA, Hart LG Educational and geographic career pathways of rural vs. urban hospital administrators Hosp Health Serv Adm 39(3):359-367 09-01-1994 URL Administrator Turnover in Rural Hospitals

Information on academic and geographic career patterns was obtained through a survey of 93 urban and rural hospital administrators in the State of Washington in 1990 (90 percent response rate). A greater proportion of urban than rural administrators had advanced degrees (93 versus 74 percent). While the most common career pathways were “always urban” (39 percent) and “always rural” (20 percent), there was little support for the presumption that hospital administrators use rural positions as stepping stones into urban careers.

degrees hospital administrators rural rural vs urban urban
Hart LG, Robertson DG, Lishner DM, Rosenblatt RA CEO turnover in rural northwest hospitals Hosp Health Serv Adm 38(3):353-374 09-01-1993 URL Administrator Turnover in Rural Hospitals

This study examines rates of and reasons for turnover among administrators from 148 rural hospitals in four northwestern states. Data were obtained from a survey of CEOs who left their positions between 1987 and 1990 and from a survey of board members from those same hospitals. During the study period, 85 CEO turnovers occurred at 78 hospitals. High-turnover hospitals were generally smaller than those facilities with fewer turnovers. The annual rate of CEO turnover was 15 percent in 1988 and 16 percent in 1989. The reasons for turnover most often cited by those in their positions for less than four years were due to: seeking a better position elsewhere, an unstable health care system, conflict with hospital board members or with medical staff, and inadequate salary. High levels of self-reported job satisfaction and job performance by turnover CEOs contrasted to the much lower performance evaluations reported by hospital board members. Nearly three out of four board members indicated they would not rehire their departed CEOs. CEOs perceived their professional weaknesses to center on deficiencies in leadership and financial skills as well as problems with physician, hospital board, and community relations.

CEOs rural hospitals turnovers
Hart LG, Robertson DG, Lishner DM, Rosenblatt RA CEO turnover in rural WAMI hospitals Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #18 08-01-1992 Administrator Turnover in Rural Hospitals
Baldwin LM, Chan L, Andrilla CHA, Huff E, Hart LG Quality of care for acute myocardial infarction: are the gaps between rural and urban hospitals closing? Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #118 03-01-2010
Full report Policy brief
Improvement in the Quality of Care for Acute Myocardial Infarction: Have Rural Hospitals Followed National Trends?
Baldwin LM, Chan L, Andrilla CHA, Huff ED, Hart LG Quality of care for myocardial infarction in rural and urban hospitals J Rural Health 26(1):51-57 02-01-2010 URL Improvement in the Quality of Care for Acute Myocardial Infarction: Have Rural Hospitals Followed National Trends?

Background: In the mid-1990s, significant gaps existed in the quality of acute myocardial infarction (AMI) care between rural and urban hospitals. Since then, overall AMI care quality has improved. This study uses more recent data to determine whether rural-urban AMI quality gaps have persisted.

Methods: Using inpatient records data for 34,776 Medicare beneficiaries with AMI from 2000-2001, unadjusted and logistic regression analysis compared receipt of 5 recommended treatments between admissions to urban, large rural, small rural, and isolated small rural hospitals as defined by Rural Urban Commuting Area codes.

Results: Substantial proportions of hospital admissions in all areas did not receive guideline-recommended treatments (eg, 17.0% to 23.6% without aspirin within 24 hours of admission, 30.8% to 46.6% without beta-blockers at arrival/discharge). Admissions to small rural and isolated small rural hospitals were least likely to receive most treatments (eg, 69.2% urban, 68.3% large rural, 59.9% small rural, 53.4% isolated small rural received discharge beta-blocker prescriptions). Adjusted analyses found no treatment differences between admissions to large rural and urban area hospitals, but admissions to small rural and isolated small rural hospitals had lower rates of discharge prescriptions such as aspirin and beta-blockers than urban hospital admissions.

Conclusions: Many simple guidelines that improve AMI outcomes are inadequately implemented, regardless of geographic location. In small rural and isolated small rural hospitals, addressing barriers to prescription of beneficial discharge medications is particularly important. The best quality improvement practices should be identified and translated to the broadest range of institutions and providers.

acute myocardial infarction Medicare myocardial infarction quality of care rural rural hospital rural hospitals urban
Dunbar PJ, Mayer JD, Fordyce MA Availability of anesthesia personnel in rural Washington and Montana Anesthesiology 88(3):800-808 03-01-1998 URL The Provision of Anesthesia Services in Rural Hospitals anesthesiology hospitals nonsurgical rural surgical workforce
Dunbar P, Mayer JD, Fordyce MA A profile of anesthesia provision in rural Washington and Montana Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #39 05-01-1996 The Provision of Anesthesia Services in Rural Hospitals
Skillman SM, Andrilla CHA, Patterson DG, Fenton SH, Ostergard SJ Health information technology workforce needs of rural primary care practices J Rural Health 31(1):58-66 05-08-2014 URL Health Information Technology (HIT) Workforce Needs in Rural America

PURPOSE:

This study assessed electronic health record (EHR) and health information technology (HIT) workforce resources needed by ruralprimary care practices, and their workforce-related barriers to implementing and using EHRs and HIT.

METHODS:

Rural primary care practices (1,772) in 13 states (34.2% response) were surveyed in 2012 using mailed and Web-based questionnaires.

FINDINGS:

EHRs or HIT were used by 70% of respondents. Among practices using or intending to use the technology, most did not plan to hire new employees to obtain EHR/HIT skills and even fewer planned to hire consultants or vendors to fill gaps. Many practices had staff with some basic/entry, intermediate and/or advanced-level skills, but nearly two-thirds (61.4%) needed more staff training. Affordable access to vendors/consultants who understand their needs and availability of community college and baccalaureate-level training were the workforce-related barriers cited by the highest percentages of respondents. Accessing the Web/Internet challenged nearly a quarter of practices in isolated rural areas, and nearly a fifth in small rural areas. Finding relevant vendors/consultants and qualified staff were greater barriers in small and isolated rural areas than in large rural areas.

DISCUSSION/CONCLUSIONS:

Rural primary care practices mainly will rely on existing staff for continued implementation and use of EHR/HIT systems. Infrastructure and workforce-related barriers remain and must be overcome before practices can fully manage patient populations and exchange patient information among care system partners. Efforts to monitor adoption of these skills and ongoing support for continuing education will likely benefit rural populations.

electronic health records primary care technology workforce
Doescher MP, Keppel GA, Skillman SM Policy brief: the crisis in rural dentistry Seattle, WA: WWAMI Rural Health Research Center, University of Washington 04-01-2009
Policy brief
Health Care Reform Policy Briefs on Rural Health Workforce Issues
Doescher MP, Skillman SM, Rosenblatt RA Policy brief: the crisis in rural primary care Seattle, WA: WWAMI Rural Health Research Center, University of Washington 04-02-2009
Policy brief
Health Care Reform Policy Briefs on Rural Health Workforce Issues
Doescher MP, Lynge DC, Skillman SM Policy brief: the crisis in rural general surgery Seattle, WA: WWAMI Rural Health Research Center, University of Washington 04-04-2009
Policy brief
Health Care Reform Policy Briefs on Rural Health Workforce Issues
Skillman SM, Doescher MP, Rosenblatt RA Policy brief: threats to the future supply of rural registered nurses Seattle, WA: WWAMI Rural Health Research Center, University of Washington 04-03-2009
Policy brief
Health Care Reform Policy Briefs on Rural Health Workforce Issues
House PJ State-based evaluations of the Flex Program CAH/Flex National Tracking Project: Findings from the Field 3(4) 01-01-2003 National Rural Hospital Flexibility Program Tracking Project
Hagopian A, Johnson KE, Fordyce MA, Blades S, Hart LG Staffing the business office in critical access hospitals while meeting regulatory and payment system challenges CAH/Flex National Tracking Project: Findings from the Field 3(6) 01-01-2003 National Rural Hospital Flexibility Program Tracking Project
Hagopian A, Johnson KE, Fordyce MA, Blades S, Hart LG Health workforce recruitment and retention in critical access hospitals CAH/Flex National Tracking Project: Findings from the Field 3(5) 01-01-2003 National Rural Hospital Flexibility Program Tracking Project
Hagopian A, Thompson MJ, Kaltenbach E, Hart LG The role of international medical graduates in America's small rural "critical access" hospitals CAH/Flex National Tracking Project: Findings from the Field 3(1) 01-01-2003 National Rural Hospital Flexibility Program Tracking Project
Hagopian A, Hart LG Administration in critical access hospitals CAH/Flex National Tracking Project: Findings from the Field 2(3) 01-01-2001 National Rural Hospital Flexibility Program Tracking Project
Hagopian A, Hart LG Critical access hospitals and community development CAH/Flex National Tracking Project: Findings from the Field 2(4) 01-01-2001 National Rural Hospital Flexibility Program Tracking Project
Hagopian A The CAH start-up kit CAH/Flex National Tracking Project: Findings from the Field 1(1) 01-01-2000 National Rural Hospital Flexibility Program Tracking Project
Hagopian A Modeling economic changes in communities and their health systems CAH/Flex National Tracking Project: Findings from the Field 1(8) 01-01-2000 National Rural Hospital Flexibility Program Tracking Project
Flex/CAH Tracking Team Rural Hospital Flexibility Program: the Tracking Project third-year findings Seattle, WA: WWAMI Rural Health Research Center, University of Washington 01-01-2002 National Rural Hospital Flexibility Program Tracking Project
Flex/CAH Tracking Team The Rural Hospital Flexibility Program, the Tracking Project: second-year findings Seattle, WA: WWAMI Rural Health Research Center, University of Washington 01-01-2001 National Rural Hospital Flexibility Program Tracking Project
Hagopian A, Hart LG, Poley S, Flex/CAH Tracking Team Rural Hospital Flexibility Program: the Tracking Project first-year findings Seattle, WA: WWAMI Rural Health Research Center, University of Washington 01-01-2000 National Rural Hospital Flexibility Program Tracking Project
Rural Hospital Flexibility Program Tracking Project Year 02 report WWAMI Rural Health Research Center and five collaborating centers 01-01-2001 National Rural Hospital Flexibility Program Tracking Project
Hagopian A, Hart LG Rural Hospital Flexibility Program: the tracking project reports first-year findings J Rural Health 17(2):82-86 04-01-2001 URL National Rural Hospital Flexibility Program Tracking Project

TOPIC EDITORS NOTE: The Balanced Budget Act (BBA) of 1997 set in motion changes in how health care services are financed and organized. Legislation in 1999 and 2000 modifying the BBA confirmed a congressional sense that innovations in payment might precipitate changes in the delivery systems that could sustain those systems in rural areas. It is too early to judge whether or not new approaches, suck as critical access hospitals, will strengthen the financial viability of rural systems while sustaining and improving quality of care. However, this report from the research centers tracking responses to the legislation does tell us how hospitals and state governments are responding to new opportunities. From that knowledge, we gain a sense of whether or not the new model is workable, a prerequisite to its being successful. As we approach the final two years of the original authorization for the grant program, a careful assessment of what we have learned will inform decisions about further investments in the rural health care delivery infrastructure.      -Keith J Mueller, Ph.D., Health Policy Topic Editor

critical access hospitals (CAH) Flex Program hospitals rural rural health Rural Hospital Flexibility Program
Hart LG, Lishner DM, Larson EH Pathways to rural practice: a chartbook of family medicine residency training locations and characteristics Seattle, WA: WWAMI Rural Health Research Center, University of Washington 01-01-2005
Cover.
Introduction.
Chapter 1.
Chapter 2.
Chapter 3.
Chapter 4.
Chapter 5.
References.
Chartbook of Family Practice Graduate Medical Education Programs in Rural America
Chen FM, Andrilla CHA, Doescher MP, Morris C Family medicine residency training in rural locations Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #126 07-01-2010
Full report Policy brief
Rural Family Medicine Residency Training Follow-Up Survey Regarding Amount and Types of Rural Training Experiences
Patterson DG, Skillman SM, Fordyce MA Prehospital emergency medical services personnel in rural areas: results from a survey in nine states Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #149 08-03-2015
Final Report
The Pre-hospital Emergency Medical Services Workforce in Rural and Urban Areas
Grossman DC, Hart LG, Rivara FP, Maier RV, Rosenblatt RA From roadside to bedside: the regionalization of trauma care in a remote rural county J Trauma 38(1):14-21 01-01-1995 URL Regionalization of Rural Emergency Medical Services (EMS)

Objective  To determine the current role of rural hospitals and prehospital agencies in the care of motor vehicle crash victims in a remote, rural county prior to the statewide regionalization of trauma care. Specifically, we determined the proportion of crashes that required a response by emergency medical services (EMSs), the timeliness of the response, the proportion of patients treated in local hospitals, and the factors that predicted referral to trauma centers.

Design  Population-based retrospective cohort study linking emergency medical services, emergency department, and hospital discharge data to police motor vehicle crash reports and coroner data.

Setting  Okanogan County, Washington.

Subjects  All motor vehicle occupants, pedestrians or pedal-cyclists who were involved in a motor vehicle collision with a response by emergency medical system personnel or the county coroner.

Intervention  None.

Main Outcome Measures  EMS response times, emergency department and hospital discharge disposition, Injury Severity Scores, hospital length of stay, procedures, deaths.

Results  Twelve percent of 669 crashes reported to the police led to the dispatch of EMS. Crashes with EMS involvement were more likely to include occupants without restraints, who were ejected from the vehicle or who had alcohol as a contributing circumstance. The median interval between crash and EMS dispatch was 5 minutes (95th percentile: 40 minutes), the median scene time was 15 minutes (95th percentile: 35 minutes), and the median interval between dispatch and emergency department arrival was 48 minutes (95th percentile: 95 minutes). Among the 210 patients treated by EMSs, 67 (32%) were admitted to local hospitals, and 19 (9%) were referred to a distant trauma center. Of these, 17 were referred directly from the emergency department, one from the scene, and one after local admission. Compared with patients who were admitted locally, referred patients had a significantly higher mean Injury Severity Score (14.4 vs. 5.1), hospital length of stay (9.1 vs. 1.8 days), and rate of operative procedures (37% vs. 9%). Of the 13 crash-related deaths during the year, nine were declared dead at the scene before EMS arrival, three were asystolic at the time of EMS arrival at the scene, and one died at a referral hospital.

Conclusions  The linkage of data from police, prehospital agencies, and hospitals can reveal important information about the sequence of health care for trauma patients. The rural hospitals in this county currently play a major role in the stabilization and treatment of motor vehicle crash victims.

Emergency Medical Services EMS motor vehicle crash Okanogan County rural rural hospitals
Hart LG, Larson EH, Lishner DM Rural definitions for health policy and research Am J Public Health 95(7):1149-1155 07-01-2005 URL Description of Differences Between Seclected Rural-Urban Taxonomies

The term “rural” suggests many things to many people, such as agricultural landscapes, isolation, small towns, and low population density.However, defining “rural” for health policy and research purposes requires researchers and policy analysts to specify which aspects of rurality are most relevant to the topic at hand and then select an appropriate definition. Rural and urban taxonomies often do not discuss important demographic, cultural, and economic differences across rural places-differences that have major implications for policy and research. Factors such as geographic scale and region also must be considered. Several useful rural taxonomies are discussed and compared in this article. Careful attention to the definition of “rural” is required for effectively targeting policy and research aimed at improving the health of rural Americans.

rural rural definition rural taxonomy urban
Morrill R, Cromartie J, Hart LG Metropolitan, urban, and rural commuting areas: toward a better depiction of the US settlement system Urban Geog 20(8):727-748 01-01-1999 URL Rural Definition Reclassification Project
Wright GE, Andrilla CHA, Hart LG How many physicians can a rural community support? A practice income potential model for Washington State Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #45 04-01-2001
Full report
How Many Physicians Can a Rural Town Support?
Norris TE, Reese JW, Pirani MJ, Rosenblatt RA Are rural family physicians comfortable performing cesarean sections? J Fam Pract 43(5):455-460 11-01-1996 URL Rural C-Sections and Family Physicians

BACKGROUND:

Provision of obstetric care in the United States requires the capacity to perform cesarean sections. It is unknown who actually performs these procedures in rural hospitals and whether nonobstetricians feel comfortable performing cesarean sections.

METHODS:

We conducted a telephone survey of the 41 rural hospitals in Washington State, asking about the obstetric services offered and the composition and obstetrical practices of physician staff. A supplementary questionnaire was sent to the 112 family physicians providing obstetric services in the subset of hospitals with 50 or fewer beds, asking whether they performed cesarean sections. Eighty-six responded, for a response rate of 75%.

RESULTS:

Thirty-one (75%) of the rural hospitals provide obstetric services; of the 31 hospitals, 19 (61%) had no obstetricians on staff. In these hospitals the majority of physicians on staff both practice obstetrics and perform cesarean sections. Family physicians performed the majority of cesarean sections in all but the eight largest rural hospitals; even in these large hospitals (mean annual deliveries, 785), family physicians performed 28% of the cesarean sections. Most family physicians who performed cesarean sections felt very comfortable performing these operations. There was a strong association between the number of cesarean sections performed in formal residency training settings and the family physician’s comfort level.

CONCLUSIONS:

Cesarean sections remain an important service in those rural hospitals providing obstetric services. Most Washington State rural hospitals depend on family physicians for this operative intervention. Physicians’ comfort in doing cesarean sections appears to be closely related to prior formal training during residency. This relationship suggests that training programs preparing future rural physicians need to ensure adequate training in this area for their residents.

caesarean family physicians obstetric care rural rural hospitals
Norris TE, Reese JW, Rosenblatt RA Are rural family physicians comfortable performing cesarean sections? Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #37 03-01-1996 Rural C-Sections and Family Physicians
Patterson DG, Schmitz D, Longenecker R, Squire D, Skillman SM Graduate medical education financing: sustaining medical education in rural places Seattle, WA: WWAMI Rural Health Research Center, University of Washington 05-26-2015
Policy brief
Distributed Expertise: Sustaining Rural Training Tracks as a Strategy in Rural Medical Education
Patterson DG, Longenecker R, Schmitz D, Phillips RL Jr, Skillman SM, Doescher MP Policy brief: rural residency training for family medicine physicians: graduate early-career outcomes, 2008-2012 Seattle, WA: WWAMI Rural Health Research Center, University of Washington 01-28-2013
Policy brief
Distributed Expertise: Sustaining Rural Training Tracks as a Strategy in Rural Medical Education
Patterson DG, Longenecker R, Schmitz D, Xierali IM, Phillips Jr RL, Skillman SM, Doescher MP Policy brief: rural residency training for family medicine physicians: graduate early-career outcomes Seattle, WA: WWAMI Rural Health Research Center, University of Washington 01-27-2012
Policy brief
Distributed Expertise: Sustaining Rural Training Tracks as a Strategy in Rural Medical Education
Patterson DG, Longenecker R, Schmitz D, Skillman SM, Doescher MP Policy brief: training physicians for rural practice: capitalizing on local expertise to strengthen rural primary care Seattle, WA: WWAMI Rural Health Research Center, University of Washington 01-19-2011
Policy brief
Distributed Expertise: Sustaining Rural Training Tracks as a Strategy in Rural Medical Education
Cullen TJ, Hart LG, Whitcomb ME, Rosenblatt RA The National Health Service Corps: rural physician service and retention J Am Board Fam Pract 10(4):272-279 07-01-1997 URL National Health Service Corps Scholarship Recipient Retention Study

BACKGROUND:

The National Health Service Corps (NHSC) scholarship program is the most ambitious program in the United States designed to supply physicians to medically underserved areas. In addition to providing medical service to underserved populations, the NHSC promotes long-term retention of physicians in the areas to which they were initially assigned. This study uses existing secondary data to explore some of the issues involved in retention in rural areas.

METHODS:

The December 1991 American Medical Association (AMA) Masterfile was used to determine the practice location and specialty of the 2903 NHSC scholarship recipients who graduated from US medical schools from 1975 through 1983 and were initially assigned to nonmetropolitan counties. We used the AMA Masterfile to determine what percentage of the original cohort was still practicing in their initial county of assignment and the relation of original practice specialty and assignment period to long-term retention.

RESULTS:

Twenty percent of the physicians assigned to rural areas were still located in the county of their initial assignment, and an additional 20 percent were in some other rural location in 1991. Retention was highest for family physicians and lowest for scholarship recipients who had not completed residency training when they were first assigned. Retention rates were also higher for those with longer periods of obligated service. Substantial medical care service was provided to rural underserved communities through obligated and postobligation service. Nearly 20 percent of all students graduating from medical schools between 1975 and 1983 who are currently practicing in rural counties with small urbanized populations were initially NHSC assignees.

CONCLUSIONS:

Although most NHSC physicians did not remain in their initial rural practice locations, a substantial minority are still ruralpractitioners; those remaining account for a considerable proportion of all physicians in the most rural US counties. This study suggests that rural retention can be enhanced by selecting more assignees who were committed to and then completed family medicine residencies before assignment.

medically underserved areas National Health Service Corps (NHSC) Physicians retention rural
Cullen TJ, Hart LG, Whitcomb ME, Lishner DM, Rosenblatt RA The National Health Service Corps: rural physician service and retention Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #28 09-01-1994 National Health Service Corps Scholarship Recipient Retention Study
Ellsbury KE, Baldwin LM, Johnson KE, Runyan S, Hart LG Gender-related factors in the recruitment of generalist physicians to the rural Northwest Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #62 02-01-2001
Full report Policy brief
Best Strategies for Recruiting Women Physicians to Rural Practice
Ellsbury KE, Baldwin LM, Johnson KE, Runyan SJ, Hart LG Gender-related factors in the recruitment of physicians to the rural Northwest J Am Board Fam Pract 15(5):391-400 09-01-2002 URL Best Strategies for Recruiting Women Physicians to Rural Practice

Background: This study examines differences in the factors female and male physicians considered influential in their rural practice location choice and describes the practice arrangements that successfully recruited female physicians to rural areas.
Methods: This cross-sectional study was based on a mailed survey of physicians successfully recruited between 1992 and 1999 to towns of 10,000 or less in six states in the Pacific Northwest.

Results: Responses from 77 men and 37 women (response rate 61%) indicated that women were more likely than men to have been influenced in making their practice choice by issues related to spouse or personal partner, flexible scheduling, family leave, availability of childcare, and the interpersonal aspects of recruitment. Commonly reported themes reflected the  respondents’ desire for flexibility regarding family issues and the value they placed on honesty during recruitment.

Conclusions: It is very important in recruitment of both men and women to highlight the positive aspects of the community and to involve and assist the physician’s spouse or partner. If they want to achieve a gender-balanced physician workforce, rural communities and practices recruiting physicians should place high priority on practice scheduling, spouse-partner, and  interpersonal issues in the recruitment process.

gender Physicians practice choices recruitment rural workforce
Baldwin LM, Patel S, Andrilla CHA, Rosenblatt RA, Doescher MP Receipt of recommended radiation therapy among rural and urban cancer patients Cancer 118(20):5100-5109 10-09-2012 URL
Announcement
Use of Recommended Radiation Therapy in the Rural U.S.

BACKGROUND:

Rural populations have limited geographic access to radiation therapy. The current study examines whether rural patients with cancer are less likely than urban patients with cancer to receive recommended radiation therapy, and identifies factors influencing rural versus urban differences in radiation therapy receipt.

METHODS:

The current study included 14,692 rural and 107,834 urban patients with 5 cancer types and stages for which radiation therapy was recommended. The authors used 2000 to 2004 Surveillance, Epidemiology, and End Results (SEER) Limited-Use Data from 8 state-based (California, Connecticut, Hawaii, Iowa, Kentucky, Louisiana, New Mexico, and Utah) and 3 county-based (Atlanta, rural Georgia, and Seattle/Puget Sound) cancer registries. Adjusted radiation therapy receipt rates were calculated by rural versus urban residence overall, for different sociodemographic and cancer characteristics, and for different states based on logistic regression analyses using general estimating equation methods to account for patient clustering by county.

RESULTS:

Adjusted rates of radiation therapy receipt were lower for rural (62.1%) than urban (69.1%) patients with breast cancer (P ≤ .001). Among patients with breast cancerradiation therapy receipt differed more by sociodemographic characteristics (eg, rural patients aged < 50 years had a 67.1% receipt rate, whereas those aged ≥ 80 years had a radiation therapy receipt rate of 29.1%) than rural versus urban residence. Adjusted rates of radiation therapy receipt were similar for rural and urban patients with other cancer types overall (66.1% vs 68.2%; difference not significant), although there were differences between urban and rural patients with regard to radiation therapy receipt for patients with stage IIIA nonsmall cell lung cancer (66.2% vs 60.7%; P ≤ .01).

CONCLUSIONS:

Sociodemographics, cancer types and stages, and state of residence appear to have a greater influence over receipt of radiation therapy than rural versus urban residence location, suggesting that factors such as social support, receipt of other cancer treatments, and regional practice patterns are important determinants of radiation therapy receipt.

lung cancer radiation therapy regional practice rural rural vs urban SEER
Larson EH, Hart LG, Rosenblatt RA Is non-metropolitan residence a risk factor for poor birth outcome in the U.S.? Soc Sci Med 45(2):171-188 07-01-1997 URL The Process and Quality of Rural Perinatal Care: A National Study

The association between nondashmetropolitan residence and the risk of poor birth outcome in the United States was examined using the records of 11.06 million singleton births in the United States between 1985 and 1987. Rates of neonatal and post-neonatal death, low birth weight and late prenatal care among nondashmetropolitan residents were compared to the rates among metropolitan residents. The association between residence in a nondashmetropolitan area and the risk of poor birth outcome was assessed in national and state level regression analyses. Residence in a nondashmetropolitan county was not found to be associated with increased risk of low birth weight or neonatal mortality at the national level or in most states, after controlling for several demographic and biological risk factors. Nondashmetropolitan residence was associated with greater risk of post-neonatal mortality at the national level. Nondashmetropolitan residence was strongly associated with late initiation of prenatal care at both the national level and in a majority of the states. Residence in nondashmetropolitan areas does not appear to be associated with higher risk of adverse birth outcome. Regionalization of perinatal care and other changes in the rural health care system may have mitigated the risk associated with residing in areas relatively isolated from tertiary care. High levels of late prenatal care among nondashmetropolitan residents suggest a continuing problem of access to routine care for rural women and their infants that may be associated with higher levels of post-neonatal mortality and childhood morbidity.

infant mortality low birth weight prenatal care rural health
Larson EH, Hart LG, Rosenblatt RA Is rural residence a risk factor for poor birth outcomes? A national study Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #36 12-01-1995 The Process and Quality of Rural Perinatal Care: A National Study
Chen FM, Fordyce MA, Andes S, Hart LG Which medical schools produce rural physicians? A 15-year update Acad Med 85(4):594-598 04-01-2010 URL Which Training Programs Produce Rural Physicians? A National Health Workforce Study

PURPOSE:

Despite continued federal and state efforts to increase the number of physicians in rural areas, disparities between the supply of rural and urban physicians persist. The authors examined the training of the rural physician workforce in the United States.

METHOD:

Using a national cross-sectional analysis of the 2005 American Medical Association and American Osteopathic Association Masterfile physician data, the authors examined a 10-year cohort of clinically active MD and DO physicians who graduated from medicalschool between 1988 and 1997.

RESULTS:

Eleven percent (20,037) of the physician cohort were currently practicing in a rural location in 2005. Eighteen percent (2,045) of osteopathic medical school graduates were currently practicing in a rural location. Twenty-three percent (6,282) of family physician graduates practiced in rural areas. Women continue to be less likely than men to practice in rural areas, although the gap is narrowing. Rural residency trainees were over three times more likely to practice in rural areas (RR = 3.4, P < .001).

CONCLUSIONS:

The proportion and number of physicians entering rural practice has remained stable compared with earlier analyses. However, recent trends such as declining primary care interest are not yet reflected in these data and may portend worsening shortages of rural physicians.

DO MD Physicians primary care rural rural practice urban
Chen FM, Fordyce MA, Andes S, Hart LG U.S. rural physician workforce: analysis of medical school graduates from 1988-1997 Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #113 10-01-2008
Full report Policy Brief
Which Training Programs Produce Rural Physicians? A National Health Workforce Study
Geyman JP, Hart LG Primary care at a crossroads: progress, problems, and future projections J Am Board Fam Pract 7(1):60-70 02-01-1994 URL Primary Care at a Crossroads Project

The tension between generalist and specialist roles in medical education and practice has been marked by recurrent perceived crises for many years in the United States. Primary care was at a crossroads during the 1960s. There was much turmoil within the health care system, and many in the population were unable to gain access to and afford health care. As a result of this turbulence, a major effort was mounted at state and federal levels to increase the proportion and number of primary care physicians. New initiatives included efforts to increase the total number of physicians, passage of Medicare and Medicaid legislation, new emphasis on education programs in primary care, recognition of family practice as a specialty, and emergence of the National Health Service Corps.

Today, 25 years later, the health care system as a whole is unraveling and in crisis as a result of soaring costs, the difficulty of providing access to all citizens, and health care outcomes that have fallen short of those achieved in many other industrialized countries. It is ironic how many of the failings of today’s health care system mirror those of the 1960s, and how parallel the approaches to address these problems are to those taken a generation ago. Primary care finds itself again at a crossroads as intense pressures mount for fundamental reform of a health care system that has an inadequate primary care base.

It is timely to take stock of the progress achieved by the initiatives to expand primary care during the last 25 years. Accordingly, this report addresses the following four objectives: (1) to summarize the results of the initiatives of the 1960s in terms of changes in medical education, the evolving status of primary care, and both specialty and geographic distribution of physicians; (2) to discuss some of the factors affecting the decline of primary care; (3) to consider briefly the problems resulting from a health care system that does not have an adequate generalist base; and (4) to discuss the implications of the current situation with discussion of future projections for primary care.

generalist medical education Physicians practice primary care specialist
Geyman JP, Hart LG Primary care at a crossroads: progress, problems and policy options Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #22 05-01-1993 Primary Care at a Crossroads Project
Ellsbury KE, Doescher MP, Hart LG US medical schools and the rural family physician gender gap Fam Med 32(5):331-337 05-01-2000 URL The Rural/Urban Practice Location Patterns of Women Medical School Graduates

BACKGROUND:

Women comprise increasing proportions of medical school graduates. They tend to choose primary care but are less likely than men to choose rural practice.

METHODS:

This study used American Medical Association masterfile data on 1988-1996 medical school graduates to identify the US medicalschools most successful at producing rural family physicians and general practitioners of both genders.

RESULTS:

The number of listed rural female family physician or general practitioner graduates among schools ranged from 0-27 (0% to 4.4% of each school’s 1988-1996 graduates). There were approximately twice as many male as female rural family physicians and general practitioners. Publicly funded schools produced more rural female family physicians and general practitioners than their privately funded counterparts.

CONCLUSIONS:

Our findings suggest that a few schools, most of them public, may serve as models for schools that aim to train women who later enter rural practice.

family physicians gender general practitioners generalist Physicians rural workforce
Doescher MP, Ellsbury KE, Hart LG The distribution of rural female generalist physicians in the United States J Rural Health 16(2):111-118 04-01-2000 URL The Rural/Urban Practice Location Patterns of Women Medical School Graduates

Female physicians are underrepresented in rural areas. What impact might the increasing proportion of women in medicine have on the rural physician shortage? To begin addressing this question, we present data describing the geographic distribution of female physicians in the United States. We examine the geographic distribution of all active U.S. allopathic physicians recorded in the October 1996 update of the American Medical Association Physician Masterfile. Percentages and numbers of female physicians by professional activity, specialty type, and geographic location are reported. Findings reveal there were fewer than 7,000 female allopathic physicians practicing in rural America in 1996. The proportion of generalist female physicians who practice in rural settings was significantly lower than the proportion who practice in urban locations. Although members of the most recent 10-year medical school graduation cohort of female generalist physicians were slightly more likely to practice in rural areas than members of earlier cohorts, female physicians remained significantly underrepresented in rural areas. States varied dramatically in rural female generalist underrepresentation. Should female generalists continue to be underrepresented in rural locations, the rural physician shortage will not be resolved quickly. Effective strategies to improve rural female physician placement and retention need to be identified and implemented to improve rural access to physician care.

female allopathic physicians female generalist physicians gender rural
Ellsbury KE, Doescher MP, Hart LG The production of rural female generalists by U.S. medical schools Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #52 01-01-1999
Full report Policy brief
The Rural/Urban Practice Location Patterns of Women Medical School Graduates
Doescher MP, Ellsbury KE, Hart LG The distribution of rural female physicians in the United States Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #44 02-01-1998 The Rural/Urban Practice Location Patterns of Women Medical School Graduates
Schleuning D, Rice G, Rosenblatt RA Addressing barriers to perinatal care: a case study of the Access to Maternity Care Committee in Washington State Public Health Rep 106(1):47-52 01-01-1991 URL Policy-Related Activities of the Washington State Access to Maternity Care Committee (AMCC)

Access to obstetrical services has deteriorated in recent years, as large numbers of physicians have discontinued or restricted obstetrical practice. In Washington State, one response to this access crisis has been the establishment of the Access to  Maternity Care Committee (AMCC), an ad hoc group composed primarily of private sector obstetrical providers and representatives of State government responsible for the delivery of health care to women and children.

The major objective of the AMCC is to improve access to obstetrical services for socially vulnerable women, both rural inhabitants and the medically indigent. The committee has been successful in serving as a forum in which to resolve many of the administrative problems that have arisen between private sector obstetrical providers and the State’s Medicaid Program,
the major source of payment for the one-third of pregnant women who are medically indigent. Building upon the trust that the committee members developed in working together, the AMCC served as a major force in persuading the State legislature to expand substantially its investment in perinatal care by increasing Medicaid eligibility, raising provider reimbursement, and improving social services for pregnant women. Such ad hoc coalitions between the private and public sector may be quite effective in addressing obstetrical access problems in other States.

Medicaid medically indigent obstetrical services perinatal care Physicians reimbursement rural social services
Schleuning D, Rice G, Rosenblatt RA Addressing barriers to rural perinatal care: a case study of the access to maternity care committee in Washington State Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #5 10-01-1989 Policy-Related Activities of the Washington State Access to Maternity Care Committee (AMCC)
Rosenblatt RA, Schneeweiss R, Hart LG, Casey S, Andrilla CHA, Chen FM Family medicine training in rural areas JAMA 288(9):1063-1064 09-04-2002 URL Physician Residency Rural Training Baseline Study

To the Editor: The discipline of family medicine was created in the 1970s, in part, as a way to address the chronic shortage of US rural physicians.1 It was predicted that the new discipline would augment the supply of rural clinicians because family physicians are much more likely than other physicians to settle in rural areas.2

There is also empirical evidence that training family physicians in rural areas increases the likelihood that residency graduates will choose to settle in rural places.3– 6 However, the exact proportion of family medicine residency programs located in truly rural parts of the United States remains unknown, as does the extent to which training rural physicians is a priority of existing family medicine residency programs.

family medicine residency family physicians rural
Schneeweiss R, Rosenblatt RA, Dovey S The effects of the 1997 Balanced Budget Act on family practice residency training programs Fam Med 35(2):93-99 02-01-2003 URL Physician Residency Rural Training Baseline Study

BACKGROUND AND OBJECTIVES:

This study assessed the impact of the Balanced Budget Act (BBA) of 1997 on family practice residencytraining programs in the United States.

METHODS:

We surveyed 453 active family practice residency programs, asking about program closures and new program starts (including rural training tracks), changes in the number of residents and faculty, and curriculum changes. Programs were classified according to their urban or rural location, university or community hospital setting, and rural and/or urban underserved mission emphasis.

RESULTS:

A total of 435 (96%) of the programs responded. Overall, the impact of the BBA was relatively small. In 1998 and 1999, nationwide, there were 11 program closures, a net decrease of only 82 residents, and a net increase of 52 faculty across program settings and mission emphasis. The rate of family practice residency program closures increased from an average of 3.0 per year between 1988-1997to 4.8 per year in the 4 years following passage of the BBA.

CONCLUSIONS:

The 1997 BBA did not have an immediate significant negative impact on family practice residency programs. However, there is a worrisome increase in the rate of family practice residency closures since 1997. A mechanism needs to be established to monitor all primary care program closures to give an early warning should this trend continue.

family practice residency graduate medical education Primary care physician rural physicians teaching hospitals urban underserved
Chen FM, Phillips RL Jr, Schneeweiss R Accounting for graduate medical education funding in family practice training Fam Med 34(9):663-668 10-01-2002 URL Physician Residency Rural Training Baseline Study

BACKGROUND AND OBJECTIVES:

Medicare provides the majority of funding to support graduate medical education (GME). Following the flow of these funds from hospitals to training programs is an important step in accounting for GME funding.

METHODS:

Using a national survey of 453 family practice residency programs and Medicare hospital cost reports, we assessed residency programs’ knowledge of their federal GME funding and compared their responses with the actual amounts paid to the sponsoring hospitals by Medicare.

RESULTS:

A total of 328 (72%) programs responded; 168 programs (51%) reported that they did not know how much federal GME fundingthey received. Programs that were the only residency in the hospital (61% versus 36%) and those that were community hospital-based programs (53% versus 22%) were more likely to know their GME allocation. Programs in hospitals with other residencies received less of their designated direct medical education payment than programs that were the only residency in the sponsoring hospital (-45% versus +19%).

CONCLUSIONS:

More than half of family practice training programs do not know how much GME they receive. These findings call for improved accountability in the use of Medicare payments that are designated for medical education.

family practice residency federal funding graduate medical education hospitals Medicare
Rosenblatt RA, Schneeweiss R, Hart LG, Casey S, Andrilla CHA, Chen FM Family medicine residency training in rural areas: how much is taking place, and is it enough to prepare a future generation of rural family physicians? Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #69 03-01-2002
Full report
Physician Residency Rural Training Baseline Study
Chan L, Hart LG, Goodman DC Geographic access to health care for rural Medicare beneficiaries J Rural Health 22(2):140-146 03-01-2006 URL Access to Physician Care for the Rural Medicare Elderly

CONTEXT:

Patients in rural areas may use less medical care than those living in urban areas. This could be due to differences in travel distance and time and a utilization of a different mix of generalists and specialists for their care.

PURPOSE:

To compare the travel times, distances, and physician specialty mix of all Medicare patients living in Alaska, Idaho, North Carolina, South Carolina, and Washington.

METHODS:

Retrospective design, using 1998 Medicare billing data. Travel time was determined by computing the road distance between 2 population centroids: the patient’s and the provider’s zone improvement plan codes.

FINDINGS:

There were 2,220,841 patients and 39,780 providers in the cohort, including 6,405 (16.1%) generalists, 24,772 (62.3%) specialists, and 8,603 (21.6%) nonphysician providers. There were 20,693,828 patient visits during the study. The median overall 1-way travel distance and time was 7.7 miles (interquartile range 1.9-18.7 miles) and 11.7 minutes (interquartile range 3.0-25.7 minutes). The patients in rural areas needed to travel 2 to 3 times farther to see medical and surgical specialists than those living in urban areas. Ruralresidents with heart disease, cancer, depression, or needing complex cardiac procedures or cancer treatment traveled the farthest. Increasing rurality was also related to decreased visits to specialists and an increasing reliance on generalists.

CONCLUSIONS:

Residents of rural areas have increased travel distance and time compared to their urban counterparts. This is particularly true for rural residents with specific diagnoses or those undergoing specific procedures. Our results suggest that most rural residents do not rely on urban areas for much of their care.

Alaska distance Idaho Medicare North Carolina rural South Carolina travel time Washington
Chan L, Hart LG, Goodman DC Geographic access to health care for rural Medicare beneficiaries Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #97 04-01-2005
Full report
Access to Physician Care for the Rural Medicare Elderly
Rosenblatt RA, Saunders GR, Tressler CJ, Larson EH, Nesbitt TS, Hart LG The diffusion of obstetric technology into rural U.S. hospitals Int J Technol Assess Health Care 10(3):479-489 06-01-1994 URL Diffusion of New Perinatal Technology into Rural Areas of Washington State

We determined the distribution and sophistication of obstetric technologies in all 80 maternity hospitals in the state of Washington and examined the effect of rural or urban location, birth volume, and physician staffing on technological intensity. Although smaller and more rural hospitals refer most premature and low-birth-weight infants to regional referral centers, sophisticated prenatal and intrapartum technologies are available in the majority of even the smallest and most remote rural units. Rural hospitals have slightly lower obstetrical intervention rates than do their urban counterparts, but the differences are not great.

obstetric technologies physician rural rural hospitals rural vs urban urban
Rosenblatt RA, Saunders G, Tressler C, Larson EH, Nesbitt TS, Hart LG Do rural hospitals have less obstetric technology than their urban counterparts? A statewide study Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #20 03-01-1993 Diffusion of New Perinatal Technology into Rural Areas of Washington State
Whelan AR Geographical aspects of obstetrical care in Washington State Master of Arts thesis. Seattle, WA: University of Washington 01-01-1989 Obstetrical Access in Washington State
Rosenblatt RA, Whelan A, Hart LG Obstetric practice patterns in Washington State after tort reform: has the access problem been solved? Obstet Gynecol 76(6):1105-1110 12-01-1990 URL Obstetrical Access in Washington State

We surveyed all potential obstetric providers in Washington state in the spring of 1989 to determine whether the passage of tort reform in 1986 had improved access to care for rural and medically indigent women. We found that, although the exodus of family physicians from obstetric practice that had been observed between 1985-1986 appears to have slowed, there is still substantial net attrition among family physicians. As a result, rural patients are having increasing difficulty obtaining local access to obstetric care. By contrast, the supply of obstetricians and midwives seems to be stable. All three groups of providers are increasingly reluctant to provide care to the growing number of Medicaid patients. Although tort reform may have slowed the rate at which providers are quitting obstetrics, equilibrium has not yet been achieved. Shortages of rural physicians and inadequate Medicaid reimbursement rates must be addressed to improve obstetric access for underserved groups.

Medicaid medically indigent midwives obstetric practice obstetric providers obstetricians Physicians reimbursements rural tort reform
Rosenblatt RA, Whelan A, Hart LG Rural obstetrical access in Washington State: have we attained equilibrium? Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #6 01-01-1990 Obstetrical Access in Washington State
Skillman SM, Keppel GA, Doescher MP, Kaplan L, Andrilla CHA Assessing rural-urban nurse practitioner supply and distribution in 12 states using available data sources Seattle, WA: WWAMI Rural Health Research Center, University of Washington Policy Brief #143 08-01-2015
Policy brief
Assessing rural-urban nurse practitioner supply and distribution in 12 states using available data sources
Rosenblatt RA, Saunders G, Shreffler J, Pirani MJ, Larson EH, Hart LG Beyond retention: National Health Service Corps participation and subsequent practice locations of a cohort of rural family physicians J Am Board Fam Pract 9(1):23-30 01-01-1996 URL National Health Service Corps Evaluation

BACKGROUND:

This report addresses the long-term career paths and retrospective impressions of a cohort of family physicians who served in rural National Health Service Corps (NHSC) sites in return for having received medical school scholarships during the early 1980s.

METHODS:

We surveyed all physicians who graduated from medical school between 1980 and 1983, received NHSC scholarships, completed family medicine residencies, and served in rural areas. Two hundred fifty-eight physicians responded to our survey with complete information, 76 percent of the members of the cohort who could be located and met the study criteria.

RESULTS:

In 1994 one quarter of the respondents were still practicing in the county to which they had been assigned by the NHSC, an average of 6.1 years after the end of their obligation. Another 27 percent were still in rural practice. Of the entire group, less than 40 percent were in traditional urban private or managed care settings.

CONCLUSIONS:

Although only one quarter of NHSC assignees remain long term in their original assignment counties, they provide a large (and growing) amount of nonobligated service to those areas. Of those who leave, many remain in rural practice or work in community-oriented urban practices.

family medicine residency family physicians NHSC scholarship rural
Rosenblatt RA, Saunders G, Shreffler J, Pirani MJ, Larson EH, Hart LG Beyond retention: National Health Service Corps participation and subsequent practice locations of a cohort of rural family physicians J Am Board Fam Pract 9(1):23-30 01-01-1996 URL National Health Service Corps Evaluation
Rosenblatt RA, Saunders G, Shreffler J, Pirani MJ, Larson EH, Hart LG Beyond retention: National Health Service Corps participation and subsequent practice locations of a cohort of rural family physicians Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #33 04-01-1995 National Health Service Corps Evaluation
Muus KJ, Geller JM, Ludtke RL Comparing urban and rural primary care PAs: implications for recruitment J Am Acad Physician Assist 9(8):49-60 01-01-1996 National Study of Physician Assistants ohysician assistants primary care rural rural vs urban urban
Pan S, Geller JM, Muus KJ, Hart LG Predicting the degree of rurality of physician assistant practice location Hosp Health Serv Adm 41(1):105-119 04-01-1996 URL National Study of Physician Assistants

This study used a block multiple regression analysis to examine the impacts of different factors on the degree of rurality of physician assistants’ (PAs’) practice location and compared the power of each block of factors in predicting rurality. Differences in the models for PAs in primary care specialties and for PAs as a whole were also explored. The findings suggest that policies should provide support to PA students in primary care specialties and to rural-oriented PA education/training programs. Efforts to facilitate PA recruitment and retention should include, among other things, increasing practice responsibility/autonomy, broadening acceptance of PA prescriptive authority, and providing equitable reimbursement for nonphysician care of Medicare and Medicaid beneficiaries.

physician assistants practice location rural
Chan L, Hart LG, Ricketts TC, Beaver SK An analysis of Medicare's incentive payment program for physicians in health professional shortage areas J Rural Health 20(2):109-117 01-01-2004 URL Medicare Bonus Payments for Physician Care in HPSAs

CONTEXT:

Medicare’s Incentive Payment (MIP) program provides a 10% bonus payment to providers who treat Medicare patients in rural and urban areas where there is a shortage of generalist physicians.

PURPOSE:

To examine the experience of Alaska, Idaho, North Carolina, South Carolina, and Washington with the MIP program. We determined the program‘s utilization and which types of physicians received payments.

METHODS:

Retrospective cohort design, utilizing complete 1998 Medicare Part B data. Physician specialty was determined through American Medical Association data. Rural status was determined by linking the physician business ZIP code to its Rural-Urban Commuting Area code (RUCA).

FINDINGS:

There were 2,220,275 patients and 39,749 providers in the cohort, including 9,769 (24.6%) generalists, 21,331 (53.7%) specialists, and 8,649 (21.8%) nonphysician providers. Over $4 million in bonus payments (median payment = $173) were made to providers in HPSAs. Specialists and urban providers received 58% and 14% of the bonus reimbursements, respectively. Two million dollars in payments were not distributed because the providers did not claim them. Over $2.8 million in bonus claims were distributed to providers who likely did not work in approved HPSA sites.

CONCLUSIONS:

The MIP bonus payments given to providers are small. Many providers who should have claimed the bonus did not, and many providers who likely did not qualify for the bonus claimed and received it. Consideration should be given to focusing and enlarging the bonus payments to specific providers, rather than rewarding all providers equally. Policy makers should also consider a system that prospectively determines provider eligibility.

Health Professional Shortage Area (HPSA) Medicare Incentive Payment (MIP) North Carolina primary care physicians rural South Carolina urban
Chan L, Hart LG, Ricketts TC III, Beaver SK An analysis of Medicare's incentive payment program for physicians in health professional shortage areas Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #74 08-01-2003
Full report Policy brief
Medicare Bonus Payments for Physician Care in HPSAs
Geyman JP, Hart LG, Norris TE, Coombs JB, Lishner DM Educating generalist physicians for rural practice: how are we doing? J Rural Health 16(1):56-80 12-01-2000 URL Review of the Literature on Medical Education Programs Promoting Rural Practice Location

Although about 20 percent of Americans live in rural areas, only 9 percent of physicians practice there. Physicians consistently and preferentially settle in metropolitan, suburban and other nonrural areas. The last 20 years have seen a variety of strategies by medical education programs and by federal and state governments to promote the choice of rural practice among physicians. This comprehensive literature review was based on MEDLINE and Health STAR searches, content review of more than 125 relevant articles and review of other materials provided by members of the Society of Teachers of Family Medicine Working Group on Rural Health. To the extent possible, a particular focus was directed to “small rural” communities of less than 10,000 people. Significant progress has been made in arresting the downward trend in the number of physicians in these communities but 22 million people still live in health professions shortage areas. This report summarizes the successes and failures of medical education and government programs and initiatives that are intended to prepare and place more generalist physicians in rural practice. It remains clear that the educational pipeline to rural medical practice is long and complex, with many places for attrition along the way. Much is now known about how to select, train and place physicians in rural practice, but effective strategies must be as multifaceted as the barriers themselves.

generalist Health Professions Shortage Area (HPSA) Physicians rural
Geyman JP, Hart LG, Norris TE, Coombs JB, Lishner DM Physician education and rural location: a critical review Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #49 02-01-1999
Full report
Review of the Literature on Medical Education Programs Promoting Rural Practice Location
Larson EH, Hart LG, Hummel J Rural physician assistants: a survey of graduates of MEDEX Northwest Public Health Rep 109(2):266-274 03-01-1994 URL MEDEX Northwest Physician Assistant Study

Graduates of MEDEX Northwest, the physician assistant training program at the University of Washington, were surveyed to describe differences between physician assistants practicing in rural settings and those practicing in urban settings. Differences in demography, satisfaction with practice and community, practice history, and practice content were explored. Of the 341 traceable graduates, 295 (86.5 percent) responded to the mail survey. Although rural– and urban-practicing physician assistants are remarkably similar in most respects–income, hours worked, levels of practice satisfaction, for example–those in rural primary care reported performing a much wider range of medical and administrative tasks than those in urban practice. Half of the physician assistants who grew up in small towns were practicing in rural places compared with 18 percent of those from large towns. The broader scope of practice available to primary care physician assistants in rural areas may be of particular interest to those considering rural careers, to people who train physician assistants, and to rural communities trying to recruit and retain physician assistants. Results also suggest that recruitment of students for rural practice should focus on rural residents. Some problems that rural practitioners are more likely to face than urban ones, such as unreasonable night call schedules and lack of acknowledgement and respect for them as professionals, need to be addressed if rural communities are to be able to attract and retain physician assistants.

physician assistants primary care rural urban
Larson EH, Hart LG, Hummel J Rural physician assistants: results from a survey of graduates of MEDEX Northwest Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #17 05-01-1992 MEDEX Northwest Physician Assistant Study
Hummel J, Cortte R, Ballweg R, Larson E Physician assistant training for Native Alaskan community health aides: the MEDEX Northwest experience Alaska Med 36(4):183-188 10-01-1994 URL MEDEX Northwest Physician Assistant Study

BACKGROUND-From 1980 through 1990, 16 Native Alaskan Community Health Aides and 21 non-Native Alaskans began physician assistant training at MEDEX Northwest at the University of Washington. This study was done to assess the outcome of training Native Alaskan health workers as physician assistants, specifically whether Native Alaskan graduates are working in settings that serve Alaska Natives. METHODS-The backgrounds, educational experiences and deployment locations of Native and non-Native Alaskans accepted for training were compared using MEDEX Northwest student records. The 1991 graduate survey was used to compare differences in practice setting, specialty and salary between Native and non-Native graduates working in Alaska in 1991. RESULTS-All of the non-Natives and 81% of the Natives completed the program. Of those completing the program, 100% of the Natives returned to Alaska where 91% found work as primary care physician assistants in clinics serving predominantly Native communities. By comparison 78% of the non-Native graduates returned to Alaska to work as physician assistants, 60% of them in primary care and 15% of them in predominantly Native communities. There were no significant differences in salary or benefits between Native and non-Native graduates. CONCLUSIONS-Physician assistant training for entry level health workers is a viable strategy for increasing the number of under-represented minorities in the health professions. The Native graduates of MEDEX Northwest are returning to communities where they serve Native people both as health care providers and as professional role models.

MEDEX Native Alaskan physician assistants primary care
Pirani MJ, Hart LG, Rosenblatt RA Physician perspectives on the causes of rural hospital closure, 1980-1988 J Am Board Fam Pract 6(6):556-562 11-01-1993 URL Physician Perceptions of the Closing of their Small Rural Hospitals

BACKGROUND:

Few studies seeking to determine the causes of rural hospital closure have examined the opinions of individuals intimately involved with the closed facilities. The purpose of this research was to examine the reasons for small sole community general hospital closures from the perspective of local physicians and to compare these reasons with the perceptions of local mayors.

METHODS:

Hospitals in this study were selected from a list provided by the American Hospital Association. A two-page questionnaire was sent to every physician who had practiced in the towns in which a sole community general hospital had closed between 1980 and 1988.

RESULTS:

Physicians reported government reimbursement policies as the most important reasons for hospital closure, agreeing with the mayors’ opinions. Other reasons cited were general financial difficulties, competition from other hospitals, and bad board leadership. More than three-quarters of the physicians surveyed considered the quality of care provided by their facilities to be average or better.

CONCLUSIONS:

The closure of rural hospitals that physicians consider of average or better quality suggests that many of the closed hospitals could have continued to provide valuable services to the residents of their communities. Efforts must be made to ensure that rural communities are not losing viable and useful facilities.

Comment in

general hospitals hospital closures Physicians rural rural hospitals
Hart LG, Pirani MJ, Rosenblatt RA Causes and consequences of rural small hospital closures from the perspectives of mayors J Rural Health 7(3):222-245 06-01-1991 URL Mayor Perceptions of the Closing of their Small Rural Hospitals

Mayors of rural towns whose small general hospitals closed between 1980 and 1988 were surveyed. Only hospitals that were the sole hospitals in their towns and that had not reopened were included in the survey. Of the 132 hospitals meeting these criteria, 130 (98.5%) of the mayors of their communities responded to the survey. The typical study hospital had 31 beds, with an average daily census of 12. Three fourths of the hospital closures were in the North-Central and South census regions. Half of the hospital closures were for hospitals that were 20 miles or more from another hospital. Mayors attributed the closure of their hospitals primarily to governmental reimbursement policies, poor hospital management and lack of physicians. To a lesser extent, they also implicated competition from other hospitals, reputation for poor quality care, lack of provider teamwork, and inadequate hospital board leadership. Respondents reported they had little warning that their hospitals were in imminent danger of closing. Warnings of six months or less were reported by 49 percent of the mayors; only 33 percent of mayors of towns with for-profit hospitals reported having more than six months warning. Of the 132 hospital buildings that closed, only 38 percent were not in use in some capacity in the summer of 1989. Most were being utilized as some form of health care facility such as an ambulatory clinic, nursing home, or emergency room. More than three fourths of the mayors felt access to medical care had deteriorated in their communities after hospital closure, with a disproportionate impact on the elderly and poor. Nearly three fourths of the mayors also perceived that the health status of the community was worse because of the hospital closure, and more than 90 percent felt it had substantially impaired the community’s economy.

closures management Physicians reimbursement rural hospitals
Hart LG, Pirani MJ, Rosenblatt RA Causes and consequences of rural small hospital closures from the perspectives of mayors Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #9 09-01-1990 Mayor Perceptions of the Closing of their Small Rural Hospitals
Hart LG, Dobie SA, Baldwin LM, Pirani MJ, Fordyce M, Rosenblatt RA Rural and urban differences in physician resource use for low-risk obstetrics Health Serv Res 31(4):429-452 10-01-1996 URL Low-Risk Obstetric Care Resource Use

OBJECTIVE:

To explore the hypothesis that rural obstetricians (OBs) and family physicians (FPs) utilized fewer resources during the care of the low-risk women who initially booked with them than did their urban counterparts of the same specialties.

DATA SOURCES/STUDY DESIGN:

A stratified random sample of Washington state rural and urban OBs and FPs was selected during 1989. A participation rate of 89 percent yielded 209 participating physicians. The prenatal and intrapartum medical records of a random sample of the low-risk patients who initiated care with the sampled providers during a one-year period were abstracted in detail and analyzed with the physician as the unit of analysis. Complete data for 1,683 patients were collected. Resource use elements (e.g., urine culture) were combined by standardizing them with average charge data so that aggregate resource use could be analyzed. Intraspecialty comparisons for resource use by category and overall were performed.

FINDINGS/CONCLUSIONS:

Results show that rural physicians use fewer overall resources in caring for nonreferred low-risk-booking obstetric patients than do their urban colleagues. Resource use unit expenditures showed the hypothesized pattern for both specialties for total, intrapartum, and prenatal care with the exception of FPs for prenatal care. Approximately 80 percent of the resource units used by each physician type were related to hospital care. No differences were shown in patterns of care for most clinically important aspects of care (e.g., cesarean delivery rates), and no evidence suggested that outcomes differed. The overall differences were due to specific components of care (e.g., fewer intrapartum hospital days and less epidural anesthesia).

family physicians intrapartum obstetricians obstetrics prenatal rural rural vs urban
Hart LG, Dobie SA, Baldwin LM, Pirani MJ, Fordyce MA, Rosenblatt RA Rural and urban differences in physician resource use for low-risk obstetrics Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #32 03-01-1995 Low-Risk Obstetric Care Resource Use
Larson EH, Hart LG, Goodwin MK, Geller J, Andrilla CHA Dimensions of retention: a national study of the locational histories of physician assistants J Rural Health 15(4):391-402 09-01-1999 URL Physician Assistant Location and Geographic Trajectories: A National Study

This study describes the locational histories of a representative national sample of physician assistants and considers the implications of observed locational behavior for recruitment and retention of physician assistants in rural practice. Through a survey, physician assistants listed all the places they had practiced since completing their physician assistant training, making it possible to classify the career histories of physician assistants as “all rural,” “all urban,” “urban to rural” or “rural to urban.” The study examined the retention of physician assistants in rural practice at several levels: in the first practice, in rural practice overall and in states. Physician assistants who started their careers in rural locations were more likely to leave them during the first four years of practice than urban physician assistants, and female rural physician assistants were slightly more likely to leave than men. Those starting in rural practice had high attrition to urban areas (41 percent); however, a significant proportion of the physician assistants who started in urban practice settings left for rural settings (10 percent). This kept the total proportion of physician assistants in rural practice at a steady 20 percent. While 21 percent of the earliest graduates of physician assistant training programs have had exclusively rural careers, only 9 percent of physician assistants with four to seven years of experience have worked exclusively in rural settings. At the state level, generalist physician assistants were significantly more likely to leave states with practice environments unfavorable to physician assistant practice in terms of prescriptive authority, reimbursement and insurance.

physician assistants recruitment retention rural urban
Larson EH, Hart LG, Goodwin MK, Geller J, Andrilla CHA Dimensions of retention: a national study of the locational histories of physician assistants Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #47 04-01-1998
Full report
Physician Assistant Location and Geographic Trajectories: A National Study
Rosenblatt RA, Weitkamp G, Lloyd M, Schafer B, Winterscheid LC, Hart LG Why do physicians stop practicing obstetrics? The impact of malpractice claims Obstet Gynecol 76(2):245-250 08-01-1990 URL Impact of Malpractice Claims
Rosenblatt RA, Weitkamp G, Lloyd M Are rural family physicians less likely to stop practicing obstetrics than their urban counterparts: the impact of malpractice claims Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #7 04-01-1990 Impact of Malpractice Claims
Doescher MP, Fordyce MA, Skillman SM, Jackson JE, Rosenblatt RA Policy brief: persistent primary care health professional shortage areas (HPSAs) and health care access in rural America Seattle, WA: WWAMI Rural Health Research Center, University of Washington 09-30-2009
Policy brief
Persistent Primary Care Health Professional Shortage Areas (HPSAs) and Health Care Access in Rural America
Hart LG, Pirani MJ, Rosenblatt RA Most rural towns lost physicians after their hospitals closed Rural Development Perspectives 10(Oct):17-21 10-01-1994 URL Impact of Hospital Closures on Physician Supply

Between 1980 and 1988,132 rural hospitals closed, and left their towns with no general hospital. Most of those towns also lost physicians, and 19 were left with no physicians 2 years after closure. The smaller, more remote towns had few physicians to begin with and were more likely than larger towns to lose physicians along with their hospitals.

Physicians rural rural hospitals
Hart LG, Pirani MJ, Rosenblatt RA Rural hospital closure and physician supply: a national study Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #16 12-01-1991 Impact of Hospital Closures on Physician Supply
Andrilla CHA, Hart LG Results of the 2004 health center expansion and recruitment survey for health centers: analyses for Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI states) Seattle, WA: WWAMI Rural Health Research Center, University of Washington 11-14-2006
Full report
Results of the 2004 Health Center Expansion and Recruitment Survey for Health Centers: Analyses for Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI States)
WWAMI Rural Health Research Center, University of Washington Project summary: family physician vacancies in federally funded health centers 11-01-2005
Policy brief
Health Center Expansion and Recruitment Survey: Joint South Carolina Rural Health Research Center and WWAMI Rural Health Research Center Project
WWAMI Rural Health Research Center, University of Washington Project summary: dentist vacancies in federally funded health centers WWAMI Rural Health Research Center, University of Washington 12-01-2005
Policy brief
Health Center Expansion and Recruitment Survey: Joint South Carolina Rural Health Research Center and WWAMI Rural Health Research Center Project
Project summary: registered nurse vacancies in federally funded health centers WWAMI Rural Health Research Center, University of Washington 12-01-2006
Policy brief
Health Center Expansion and Recruitment Survey: Joint South Carolina Rural Health Research Center and WWAMI Rural Health Research Center Project
Andrilla CHA, Hart LG Health Center Expansion and Recruitment Survey 2004: results by Health and Human Services regions and health center geography Seattle, WA: WWAMI Rural Health Research Center, University of Washington 03-01-2007
Full report
Health Center Expansion and Recruitment Survey: Joint South Carolina Rural Health Research Center and WWAMI Rural Health Research Center Project
Rosenblatt RA, Andrilla CHA, Curtin T, Hart LG Shortages of medical personnel at community health centers: implications for planned expansion JAMA 295(9):1042-1049 03-01-2006 URL Health Center Expansion and Recruitment Survey: Joint South Carolina Rural Health Research Center and WWAMI Rural Health Research Center Project

Context The US government is expanding the capacity of community health centers (CHCs) to provide care to underserved populations.

Objective To examine the status of workforce shortages that may limit CHC expansion.

Design and Setting Survey questionnaire of all 846 federally funded US CHCs that directly provide clinical services and are within the 50 states and the District of Columbia, conducted between May and September 2004. Questionnaires were completed by the chief executive officer of each grantee. Information was supplemented by data from the 2003 Bureau of Primary Health Care Uniform Data System and weighted to be nationally representative.

Main Outcome Measures Staffing patterns and vacancies for major clinical disciplines by rural and urban location, use of federal and state recruitment programs, and perceived barriers to recruitment.

Results Overall response rate was 79.3%. Primary care physicians made up 89.4% of physicians working in the CHCs, the majority of whom are family physicians. In rural CHCs, 46% of the direct clinical providers of care were nonphysician clinicians compared with 38.9% in urban CHCs. There were 428 vacant funded full-time equivalents (FTEs) for family physicians and 376 vacant FTEs for registered nurses. There were vacancies for 13.3% of family physician positions, 20.8% of obstetrician/gynecologist positions, and 22.6% of psychiatrist positions. Rural CHCs had a higher proportion of vacancies and longer-term vacancies and reported greater difficulty filling positions compared with urban CHCs. Physician recruitment in CHCs was heavily dependent on National Health Service Corps scholarships, loan repayment programs, and international medical graduates with J-1 visa waivers. Major perceived barriers to recruitment included low salaries and, in rural CHCs, cultural isolation, poor-quality schools and housing, and lack of spousal job opportunities.

Conclusions CHCs face substantial challenges in recruitment of clinical staff, particularly in rural areas. The largest numbers of unfilled positions were for family physicians at a time of declining interest in family medicine among graduating US medical students. The success of the current US national policy to expand CHCs may be challenged by these workforce issues.

Residents of the United States lack universal access to health care, and millions of people have difficulty obtaining medical care.1,2 The year 2005 marked the 40th anniversary of one of the nation’s most enduring attempts to remedy this problem: the creation of community health centers (CHCs) as part of the “war on poverty.”3– 8 The national importance of these centers has grown during the ensuing 4 decades, and the federal government provides funding through a variety of categorical mechanisms under the collective term federally qualified health centers. CHCs provide medical, dental, and mental health care for migrant workers, the uninsured, the homeless, and others in need, and the number of people they have served has expanded rapidly in the 21st century.9

The role and responsibility of CHCs have increased as more people in the United States have difficulty gaining access to medical care.10 CHCs now provide care to more than 14 million US residents in more than 3500 communities.9 Governed by nonprofit boards with majority representation from the patient population served, CHCs are different from the private practices and for-profit entities that deliver most ambulatory care in the United States.11

A national decision to invest further in CHCs has occurred during a period when access to health care in the United States is limited for more people than ever before in the country’s history.10,12,13 Ongoing plans include a 5-year initiative that will increase federal spending on CHCs by at least $2.2 billion through fiscal year 2006 and substantially increase the number of treated patients.14– 17

We examined the status of the health care workforce in CHCs in the United States, with particular attention to the types of personnel who are most difficult to recruit and retain. Rural health care delivery systems are smaller and less well staffed than their urban counterparts; 20% of the US population lives in rural areas but only 9% of physicians practice there.18,19 We therefore also examined whether workforce shortages are more acute in rural CHCs and whether rural and urban CHCs differ in their staffing patterns, the source of their clinicians, and their ability to retain clinicians.

CHC community health centers nonphysician clinicians Physicians primary care rural underserved urban workforce
Dobie SA, Hagopian A, Kirlin BA, Hart LG Wyoming physicians are significant providers of safety net care J Am Board Fam Pract 18(6):470-477 11-01-2005 URL Health Care for the Uninsured: How Do the Uninsured Use the Rural Safety Net?

Background: This study describes the contributions of family and general practice physicians from Wyoming
to the health care safety net.

Methods: We surveyed family and general practice physicians in Wyoming about provider demographics,
practice composition, and policies for treating the underinsured or uninsured. Two-tailed 2
tests and limited logistic regressions were used to test for differences among characteristics of safety
net providers.

Results: From a 50% response rate, 61% made less than the national mean family physician income
($130,000), and women are less likely than men to make this mean income, even when controlling for
hours worked (OR, 0.09; CI, 0.009, 0.862). Close to two thirds claimed bad debt of over $10,000, and
29.3% noted forgiven debt of over $10,000. Physicians with less income than the prior year were more
likely to decrease their charity care.

Conclusions: Wyoming family and general practice physicians provide significant amounts of informal
safety net care, which is threatened by income loss. Thoughtful public policy is needed to ensure
that vulnerable rural Americans have access to care that is not tied to the financial well being of their
health care providers. ( J Am Board Fam Pract 2005;18:470 –7.)

charity care family practice general practice Physicians primary care rural safety net underinsured uninsured
Dobie SA, Hagopian A, Kirlin BA, Hart LG Wyoming physicians offer significant amounts of safety net care in their communities Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #88 03-01-2006
Full report
Health Care for the Uninsured: How Do the Uninsured Use the Rural Safety Net?
Rosenblatt RA, Chen FM, Lishner DM, Doescher MP The future of family medicine and implications for rural primary care physician supply Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #125 08-30-2010
Full report Policy brief
The Future of Family Medicine and Implications for Primary Care Physician Supply
Rosenblatt RA, Whitcomb ME, Cullen TJ, Lishner DM, Hart LG The effect of federal grants on medical schools' production of primary care physicians Am J Public Health 83(3):322-328 03-01-1993 URL Relationship Between Federal Funding and Medical School Output

OBJECTIVES. Title VII of the Health Professions Educational Assistance Act of 1976 was created to encourage the production of primary care physicians. This study explored recent trends in the proportion of US medical school graduates entering primary care in relationship to Title VII funding. METHODS. The American Medical Association Physician Masterfile was used to determine the specialty choice of all students graduating from American medical schools between 1960 and 1985. RESULTS. The proportion of graduates entering primary care rose from 19.7% in 1967 to 31.1% in 1976 and remained stable for the subsequent decade. The increase occurred before implementation of Title VII. Rural, state-owned medical schools with departments of family medicine tend to produce a greater proportion of primary care physicians than urban private schools without family medicine departments. CONCLUSIONS. The values of American medical schools and the reward structure of American medical practice favor the production of specialists over primary care physicians. Although Title VII helped to encourage and sustain the development of primary care educational programs at both the medical student and graduate levels, an increase in the proportion of primary care physicians will require fundamental changes.

family medicine medical schools primary care physicians
Rosenblatt RA, Whitcomb ME, Cullen TJ, Lishner DM, Hart LG Which medical schools produce rural physicians? JAMA 268(12):1559-1565 09-01-1992 URL Relationship Between Federal Funding and Medical School Output

Objective.  —To examine the hypothesis that medical schools vary systematically and predictably in the proportion of their graduates who enter rural practice.

Design.  —The December 1991 version of the American Medical Association Physician Masterfile was used to examine the rural and urban practice locations of physicians who graduated from American medical schools between 1976 and 1985. Selected characteristics of the medical schools—including location, ownership, and funding—were linked to the Physician Masterfile.

Main Outcome Measures.  —The percentage of the graduates from each medical school who were practicing in rural areas in December 1991, disaggregated by physician specialty.

Results.  —Of the practicing graduates from our study, 12.6% were located in rural counties; family physicians were much more likely than members of other specialties to select rural practice, particularly in the smallest and most isolated rural counties. Women were much less likely than men to enter rural practice. Medical schools varied greatly in the percentage of their graduates who entered rural practice, ranging from 41.2% to 2.3% of the graduating classes studied. Twelve medical schools accounted for over one quarter of the physicians entering rural practice in this time period. Four variables were strongly associated with a tendency to produce rural graduates: location in a rural state, public ownership, production of family physicians, and smaller amounts of funding from the National Institutes of Health.

Discussion.  —The organization, location, and mission of medical schools is closely related to the propensity of their graduates to select rural practice. Increasing policy coordination among medical schools and state and federal governmental entities would most effectively address residual problems of rural physician shortages.(JAMA. 1992;268:1559-1565)

medical schools Physicians practice location primary care rural specialties urban
Whitcomb ME, Cullen TJ, Hart LG, Lishner DM, Rosenblatt RA Comparing the characteristics of schools that produce high percentages and low percentages of primary care physicians Acad Med 67(9):587-591 09-01-1992 URL Relationship Between Federal Funding and Medical School Output

To examine whether the medical school environment is important in influencing students to choose careers in primary care, the authors in 1991 compared certain characteristics of the environments of schools that produced high percentages of primary care physicians with those of schools that produced low percentages over a five-year period. The authors used the American Medical Association Physician Masterfile to identify the percentage of graduates of each of 121 medical schools for the period 1981–1985 who entered primary care specialties. They then compared the 25 schools that produced low percentages (22–29%) with the 25 schools that produced high percentages (39–56%). The results demonstrate important differences between the two groups of schools in their commitments to primary care education, their research programs, and their clinical environments supporting required clerkships. The authors conclude that a school’s educational environment is an important factor in influencing some students to pursue careers in primary care medicine.

educational environment medical schools Physicians primary care specialties
Whitcomb ME, Cullen TJ, Hart LG, Lishner DM, Rosenblatt RA Impact of federal funding for primary care medical education on medical student specialty choices and practice locations: 1976-1985 Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #13 04-01-1991 Relationship Between Federal Funding and Medical School Output
Baldwin LM, Hart LG, West PA, Norris TE, Gore E, Schneeweiss R Two decades of experience in the University of Washington Family Medicine Residency Network: practice differences between graduates in rural and urban locations J Rural Health 11(1):60-72 11-01-1995 URL Long-Term Follow-Up Study of Graduates of Family Medicine Residency Network Programs

This study describes how graduates of the University of Washington Family Medicine Residency Network who practice in rural locations differ from their urban counterparts in demographic characteristics, practice organization, practice content and scope of services, and satisfaction. Five hundred and three civilian medical graduates who completed their residencies between 1973 and 1990 responded to a 27-item questionnaire sent in 1992 (84% response rate). Graduates practicing outside the United States in a specialty other than family medicine or for fewer than 20 hours per week in direct patient care were excluded from the main study, leaving 116 rural and 278 urban graduates in the study. Thirty percent of graduates reported practicing in rural counties at the time of the survey. Rural graduates were more likely to be in private and solo practices than urban graduates. Rural graduates spent more time in patient care and on call, performed a broader range of procedures, and were more likely to practice obstetrics than urban graduates. Fewer graduates in rural practice were women. A greater proportion of rural graduates had been defendants in medical malpractice suits. The more independent and isolated private and solo practice settings of rural graduates require more practice management skills and support. Rural graduates’ broader scope of practice requires training in a full range of procedures and inpatient care, as well as ambulatory careRural communities and hospitals also need to develop more flexible practice opportunities, including salaried and part-time positions, to facilitate recruitment and retention of physicians, especially women.

family medicine graduates practice location residency rural vs urban
Baldwin LM, Hart LG, Norris TE, West P, Gore E, Schneeweiss R Two decades of experience in the University of Washington Family Medicine Residency Network: practice differences between graduates in rural and urban places Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #25 11-01-1993 Long-Term Follow-Up Study of Graduates of Family Medicine Residency Network Programs
Hart LG, Norris TE, Lishner DM Attitudes of family physicians in Washington State toward physician-assisted suicide J Rural Health 19(4):461-469 09-01-2003 URL Family Physician Attitudes Toward Physician-Assisted Suicide

CONTEXT:

The topic of physician-assisted suicide is difficult and controversial. With recent laws allowing physicians to assist in a terminally ill patient’s suicide under certain circumstances, the debate concerning the appropriate and ethical role for physicians has intensified.

PURPOSE:

This paper utilizes data from a 1997 survey of family physicians (FPs) in Washington State to test two hypotheses: (1) older respondents will indicate greater opposition to physician-assisted suicide than their younger colleagues, and (2) male and rural physicians will have more negative attitudes toward physician-assisted suicide than their female and urban counterparts.

METHODS:

A questionnaire administered to all active FPs obtained a 68% response rate, with 1074 respondents found to be eligible in this study. A ZIP code system based on generalist Health Service Areas was used to designate those practicing in rural versus urban areas.

FINDINGS:

One-fourth of the respondents overall indicated support for physician-assisted suicide. When asked whether this practice should be legalized, 39% said yes, 44% said no, and 18% indicated that they did not know. Fifty-eight percent of the study sample reported that they would not include physician-assisted suicide in their practices even if it were legal. Responses disaggregated by age-groups closely paralleled the group overall. There was a significant pattern of opposition on the part of rural male respondents compared to urban female respondents. Even among those reporting support for physician-assisted suicide, many expressed reluctance about including it in their practices.

CONCLUSIONS:

These findings highlight the systematic differences in FP attitudes toward one aspect of health care by gender, ruralurban practice location, and other factors.

age educational background euthanasia family physicians gender general practitioners health care Oregon physician-assisted suicide Physicians practice characteristics rural urban
Hart LG, Norris TE, Lishner DM Attitudes of family physicians in Washington State toward physician-assisted suicide Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #58 02-01-2002
Full report Policy brief
Family Physician Attitudes Toward Physician-Assisted Suicide
West PA, Norris TE, Gore EJ, Baldwin LM, Hart LG The geographic and temporal patterns of residency-trained family physicians: University of Washington Family Practice Residency Network J Am Board Fam Pract 9(2):100-108 03-01-1996 URL Geographic Career Trajectories of Family Practice Physicians

BACKGROUND:

There is a clear national mandate to increase the proportion of generalist physicians within the medical community and to increase their numbers within rural and underserved urban locations. Little is known, however, about the geographic and temporal career patterns of family physicians or about how these patterns differ by sex and graduation cohort.

METHODS:

Using information from a follow-up survey of the University of Washington Family Practice Residency Network, we analyzed the characteristics of 358 graduate physicians and their 493 practices, including data on geographic practice locations.

RESULTS:

Two thirds of graduates began their practices in urban locations, and one third initially settled in rural communities. Female graduates were much less likely than their male peers to choose rural practice locations. Few physicians left practices after they had practiced in them for 5 or 6 years. The majority of graduates were still in the practice where they started as long as 18 years earlier.

CONCLUSIONS:

The most important career decision made by the graduate of a family medicine residency involves practice location. Because women are less likely to practice in rural areas, the increasing proportion of women graduating from family practice residencies might presage shortages of rural physicians in the future.

family physicians generalist physicians Physicians practice location rural underserved urban
West P, Norris TE, Gore E, Baldwin LM, Hart LG The geographic and temporal patterns of residency-trained family physicians: University of Washington Family Practice Residency Network Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #31 02-01-1995 Geographic Career Trajectories of Family Practice Physicians
Rosenblatt RA, Wright GE, Baldwin LM The effect of the doctor-patient relationship on emergency department use among the elderly Am J Public Health 90(1):97-102 01-01-2000 URL The Emergency Care of the Rural Elderly

OBJECTIVES: This study sought to determine the rate of emergency department use among the elderly and examined whether that use is reduced if the patient has a principal-care physician. METHODS: The Health Care Financing Administration’s National Claims History File was used to study emergency department use by Medicare patients older than 65 years in Washington State during 1994. RESULTS: A total of 18.1% of patients had 1 or more emergency department visits during the study year; the rate increased with age and illness severity. Patients with principal-care physicians were much less likely to use the emergency department for every category of disease severity. After case mix, Medicaid eligibility, and rural/urban residence were controlled for, the odds ratio for having any emergency department visit was 0.47 for patients with a generalist principal-care physician and 0.58 for patients with a specialist principal-care physician. CONCLUSIONS: The rate of emergency department use among the elderly is substantial, and most visits are for serious medical problems. The presence of a continuous relationship with a physician–regardless of specialty–may reduce emergency department use.

doctor-patient elderly emergency Medicare
Lishner DM, Rosenblatt RA, Baldwin LM, Hart LG Emergency department use by the rural elderly J Emerg Med 18(3):289-297 04-01-2000 URL The Emergency Care of the Rural Elderly

This study uses Medicare data to compare emergency department (ED) use by rural and urban elderly beneficiaries. The U.S. Health Care Financing Administration’s National Claims File was used to identify services provided to Medicare beneficiaries in Washington State in 1994. Patients were classified by urban, adjacent rural, or remote rural residence. We identified ED visits and associated diagnostic codes, assigned severity levels for presenting conditions, and determined the specialties of physicians providing ED services. The rural elderly living in remote areas are 13% less likely to visit the ED than their urban counterparts. Causes of ED use by the elderly do not vary meaningfully by location. Most ED visits by this group are for conditions that seem appropriate for this setting. Given the similarity of diagnostic conditions associated with ED visits, rural EDs must be capable of dealing with the same range of emergency conditions as urban EDs.

diagnoses elderly emergency Medicare rural
Lishner DM, Rosenblatt RA, Baldwin LM, Hart LG Emergency department use by the rural elderly Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #53 11-01-1998
Full report
The Emergency Care of the Rural Elderly
Skillman SM, Kaplan L, Andrilla CHA, Ostergard S., Patterson DG Support for rural recruitment and practice among U.S. nurse practitioner education programs Seattle, WA: WWAMI Rural Health Research Center, University of Washington Policy Brief #147 05-01-2014
Policy brief
What Strategies Are Nurse Practitioner Educational Programs Using to Encourage Rural Practice?
Larson EH, Murowchick E, Hart LG Did rural perinatal care systems stay regionalized between 1985 and 1997? Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #132 01-20-2010
Full report
Are Rural Perinatal Care Systems Deregionalizing?
Doescher MP, Andrilla CHA, Skillman SM, Morgan P, Kaplan L The contribution of physicians, physician assistants, and nurse practitioners toward rural primary care: findings from a 13-state survey Med Care 52(6):549-556 05-21-2014 URL The Current Contribution of Physicians, Advanced Practice Nurses, and Physician Assistants to the Rural Primary Care Workforce

Background: Estimates of the relative contributions of physicians, physician assistants (PAs), and nurse practitioners (NPs) toward rural primary care are needed to inform workforce planning activities aimed at reducing rural primary shortages.

Objectives: For each provider group, this study quantifies the average weekly number of outpatient primary care visits and the types of services provided within and beyond the outpatient setting.

Methods: A randomly drawn sample of 788 physicians, 601 PAs, and 918 NPs with rural addresses in 13 US states responded to a mailed questionnaire that measured reported weekly outpatient visits and scope of services provided within and beyond the outpatient setting. Analysis of variance and χ2 testing were used to test for bivariate associations. Multivariate regression was used to model average weekly outpatient volume adjusting for provider sociodemographics and geographical location.

Results: Compared with physicians, average weekly outpatient visit quantity was 8% lower for PAs and 25% lower for NPs (P<0.001). After multivariate adjustment, this gap became negligible for PAs (P=0.56) and decreased to 10% for NPs (P<0.001). Compared with PAs and NPs, primary care physicians were more likely to provide services beyond the outpatient setting, including hospital care, emergency care, childbirth attending deliveries, and after-hours call coverage (all P<0.001).

Conclusions: Although our findings suggest that a greater reliance on PAs and NPs in rural primary settings would have a minor impact on outpatient practice volume, this shift might reduce the availability of services that have more often been traditionally provided by rural primary care physicians beyond the outpatient clinic setting.

health care workforce outpatient visit quantity primary care rural populations
Patterson DG, Skillman SM National Consensus Conference on Community Paramedicine: summary of an expert meeting Seattle, WA: WWAMI Rural Health Research Center, University of Washington 03-07-2013
Full report
National Consensus Conference on Community Paramedicine: Development of a Community Paramedicine Research Agenda
Patterson DG, Skillman SM A national agenda for community paramedicine research Seattle, WA: WWAMI Rural Health Research Center, University of Washington 03-06-2013
Full report
National Consensus Conference on Community Paramedicine: Development of a Community Paramedicine Research Agenda
Jackson JE, Doescher MP, Hart LG A national study of lifetime asthma prevalence and trends in metro and non-metro counties, 2000-2003 Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #108 01-01-2007
Full report Policy brief
The Burden of Chronic Illness Among Rural Residents: A National Study
Skillman SM, Palazzo L, Hart LG, Butterfield P Changes in the rural registered nurse workforce from 1980 to 2004 Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #115 10-01-2007
Full report Policy brief
Long-Term Trends in Characteristics of the Rural Nurse Workforce: A National Health Workforce Study
Fordyce MA, Doescher MP, Chen FM, Hart LG Osteopathic physicians and international medical graduates in the rural primary care physician workforce Fam Med 44(6):396-403 06-01-2012 URL National Changes in Physician Supply

BACKGROUND AND OBJECTIVES:

Primary care physician (PCP) shortages are a longstanding problem in the rural United States. This study describes the 2005 supply of two important components of the rural PCP workforcerural osteopathic (DO) and international medical graduate (IMG) PCPs.

METHODS:

American Medical Association (AMA) and American Osteopathic Association (AOA) 2005 Masterfiles were combined to identify clinically active, non-resident, non-federal physicians aged 70 or younger. Rural-Urban Commuting Area codes were used to categorize practice locations as urban, large rural, small rural, or isolated small rural. National- and state-level analyses were performed. PCPs included family physicians, general internists, and general pediatricians.

RESULTS:

DOs comprised 4.9% and IMGs 22.2% of the total clinically active workforce. However, they contributed 10.4% and 19.3%, respectively, to the rural PCP workforce, although their relative representation varied geographically. DO PCPs were more likely than allopathic PCPs to practice in rural places (20.5% versus 14.9%, respectively). IMG PCPs were more likely than other PCPs to practice in rural persistent poverty locations (12.4% versus 9.1%). The proportion of rural PCP workforce represented by DOs increased with increasing rurality and that of IMGs decreased.

CONCLUSIONS:

DO and IMG PCPs constitute a vital portion of the rural health care workforce. Their ongoing participation is necessary in addressing existing rural PCP shortages and handling the influx of newly insured residents as the Patient Protection and Affordable Care Act (ACA) comes into effect. The impact on rural DO and IMG PCP supply of ACA measures intended to increase their numbers remains to be seen.

IMG international medical graduate osteopathic PCP Primary care physician rural workforce
Fordyce MA, Chen FM, Doescher MP, Hart LG 2005 physician supply and distribution in rural areas of the United States Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #116 11-01-2007
Full report Policy brief
National Changes in Physician Supply
Chan L, Giardino M, Rubenfeld G, Baldwin LM, Fordyce MA, Hart LG Geographic differences in use of home oxygen for obstructive lung disease: a national Medicare Study Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #117 09-03-2008
Full report Policy brief
National Study of Rural/Urban Differences in Use of Home Oxygen for Chronic Obstructive Lung Disease: Are Rural Medicare Beneficiaries Disadvantaged?
Chan L, Giardino N, Rubenfeld G, Baldwin LM, Fordyce MA, Hart LG Geographic differences in use of home oxygen for obstructive lung disease: a national Medicare study J Rural Health 26(2):139-145 03-01-2010 URL National Study of Rural/Urban Differences in Use of Home Oxygen for Chronic Obstructive Lung Disease: Are Rural Medicare Beneficiaries Disadvantaged?

RATIONALE:

Home oxygen is the most expensive equipment item that Medicare purchases ($1.7 billion/year).

OBJECTIVES:

To assess geographic differences in supplemental oxygen use.

METHODS:

Retrospective cohort analysis of oxygen claims for a 20% random sample of Medicare patients hospitalized for obstructive lungdisease in 1999 and alive at the end of 2000.

MEASUREMENTS AND MAIN RESULTS:

While 33.7% of the 34,916 hospitalized patients used supplemental oxygen, there was more than a 4-fold difference between states and a greater than 6-fold difference between hospital referral regions with high/low utilization. Rocky Mountain States and Alaska had the highest utilization, while the District of Columbia and Louisiana had the lowest utilization. After adjusting for patient characteristics and elevation, high-utilization communities included low-lying areas in California, Florida, Michigan, Missouri, and Washington. Patients who were younger, male, white, and who had more comorbidities, more hospital admissions, and lived at higher altitudes and in areas of greater income also had higher odds of using supplemental oxygen. Residing in rural areas was associated with higher unadjusted oxygen use rates. After adjustment, patients living in large rural areas had higher odds of using oxygen than patients living in urban areas or in small rural areas.

CONCLUSIONS:

There is significant geographic variation in supplemental oxygen use, even after controlling for patient and contextual factors. The Centers for Medicare & Medicaid Services should examine these issues further and enact changes that ensure patient health and fiscal responsibility.

chronic obstructive pulmonary disease durable medical equipment health services accessibility oxygen inhalation therapy pulmonary disease rural health services
Baldwin LM, MacLehose RF, Hart LG, Beaver SK, Every N, Chan L Quality of care for acute myocardial infarction in rural and urban U.S. hospitals J Rural Health 20(2):99-108 01-01-2004 URL Quality of Care for Acute Myocardial Infarction Patients in U.S. Rural Hospitals: 1994-1995

CONTEXT:

Acute myocardial infarction (AMI) is a common and important cause of admission to US rural hospitals, as transport of patients with AMI to urban settings can result in unacceptable delays in care.

PURPOSE:

To examine the quality of care for patients with AMI in rural hospitals with differing degrees of remoteness from urban centers.

METHODS:

This cohort study used data from the Cooperative Cardiovascular Project (CCP), including 4,085 acute care hospitals (408 remote small rural, 893 small rural, 619 large rural, and 2,165 urban) with 135,759 direct admissions of Medicare beneficiaries ages 65 and older for a confirmed AMI between February 1994 and July 1995. Outcomes included use of aspirin, reperfusion, heparin, and intravenous nitroglycerin during hospitalization; use of beta-blockers, aspirin, and angiotensin-converting enzyme (ACE) inhibitors at discharge; avoidance of calcium channel blockers at discharge; and 30-day mortality.

FINDINGS:

Substantial proportions of Medicare beneficiaries in both urban and rural hospitals did not receive the recommended treatments for AMI. Medicare patients in rural hospitals were less likely than urban hospitals‘ patients to receive aspirin, intravenous nitroglycerin, heparin, and either thrombolytics or percutaneous transluminal coronary angioplasty. Only ACE inhibitors at discharge was used more for patients in rural hospitals than urban hospitals. Medicare patients in rural hospitals had higher adjusted 30-day post-AMI death rates from all causes than those in urban hospitals (odds ratio for large rural 1.14 [1.10 to 1.18], small rural 1.24 [1.20 to 1.29], remote small rural 1.32 [1.23 to 1.41]).

CONCLUSIONS:

Efforts are needed to help hospital medical staffs in both rural and urban areas develop systems to ensure that patients receive recommended treatments for AMI.

acute myocardial infarction (AMI) hospital rural urban
Baldwin LM, MacLehose RF, Hart LG, Beaver SK, Every N, Chan L Quality of care for acute myocardial infarction in rural and urban U.S. hospitals Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #72 06-01-2002
Full report Policy brief
Quality of Care for Acute Myocardial Infarction Patients in U.S. Rural Hospitals: 1994-1995
Doescher MP, Jackson JE Trends in cervical and breast cancer screening practices among women in rural and urban areas of the United States J Public Health Manag Pract 15(3):200-209 05-01-2009 URL Breast, Cervical, Colorectal, and Prostate Cancer Screening in Rural America: Does Proximity to a Metropolitan Area Matter?

Objective: The objective of this study was to assess rural-urban differences in mammography and Papanicolaou (Pap) smear screening.

Methods: Data from the Behavioral Risk Factor Surveillance System (1994–2000, 2002, 2004) were used to examine trends in these two tests by rural-urban residence location.

Results: In 2004, 70.8 percent of rural and 75.7 percent of urban respondents had received timely mammography; this difference remained significant in adjusted analyses and was greatest for women in remote rural locations. Although overall participation in mammography increased over time, a persistent rural-urban gap was identified. In contrast, in 2004, while 83.1 percent of rural and 86.1 percent of urban respondents had received a timely Pap test, the adjusted difference was not significant and Pap testing did not improve over time. Advanced age and low socioeconomic status were associated with a lack of screening.

Conclusions: Over an 11-year interval, mammography screening improved nationally, but women living in rural locations remained less likely than their urban counterparts to receive this test. However, no secular improvement in Pap testing was found, and no significant rural-urban differences were observed.

Policy Implications: Interventions to improve breast cancer screening are needed for rural women. Such efforts should target older women and those with low socioeconomic status.

 

breast cancer screening cervical cancer screening prevalence rural location trends
Doescher MP, Jackson JE Trends in cervical and breast cancer screening practices among women in rural and urban areas of the United States Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #121 08-01-2008
Full report Policy brief
Breast, Cervical, Colorectal, and Prostate Cancer Screening in Rural America: Does Proximity to a Metropolitan Area Matter?
Baldwin LM, Cai Y, Larson EH, Dobie SA, Wright GE, Goodman DC, Matthews M, Hart LG Access to cancer services for rural colorectal cancer patients J Rural Health 24(4):390-399 10-01-2008 URL Access to Cancer Services for Rural Colorectal Cancer Medicare Patients: A Multi-State Study

CONTEXT:

Cancer care requires specialty surgical and medical resources that are less likely to be found in rural areas.

PURPOSE:

To examine the travel patterns and distances of rural and urban colorectal cancer (CRC) patients to 3 types of specialty cancercare services–surgery, medical oncology consultation, and radiation oncology consultation.

METHODS:

Descriptive cross-sectional study using linked Surveillance, Epidemiology, and End Results (SEER) cancer registry and Medicare claims data for 27,143 individuals ages 66 and older diagnosed with stages I through III CRC between 1992 and 1996.

FINDINGS:

Over 90% of rural CRC patients lived within 30 miles of a surgical hospital offering CRC surgery, but less than 50% of CRC patients living in small and isolated small rural areas had a medical or radiation oncologist within 30 miles. Rural CRC patients who traveled outside their geographic areas for their cancer care often went great distances. The median distance traveled by rural cancer patients who traveled to urban cancer care providers was 47.8 miles or more. A substantial proportion (between 19.4% and 26.0%) of all rural patientsbypassed their closest medical and radiation oncology services by at least 30 miles.

CONCLUSIONS:

Rural CRC patients often travel long distances for their CRC care, with potential associated burdens of time, cost, and discomfort. Better understanding of whether this travel investment is paid off in improved quality of care would help rural cancer patients, most of whom are elderly, make informed decisions about how to use their resources during their cancer treatment.

cancer care colorectal cancer rural urban
Project summary: access to cancer services for rural colorectal cancer patients. Seattle, WA - WWAMI Rural Health Research Center, University of Washington 10-31-2007
Policy brief
Access to Cancer Services for Rural Colorectal Cancer Medicare Patients: A Multi-State Study
Baldwin LM, Grossman DC, Casey S Perinatal and infant health among rural and urban American Indians/Alaska Natives Am J Public Health 92(9):1491-1497 09-01-2002 URL Perinatal Risk Factors, Prenatal Care Use, Birth Outcomes, and Infant Mortality of Rural and Urban American Indian Women

OBJECTIVES:

We sought to provide a national profile of rural and urban American Indian/Alaska Native (AI/AN) maternal and infant health.

METHODS:

In this cross-sectional study of all 1989-1991 singleton AI/AN births to US residents, we compared receipt of an inadequate pattern of prenatal care, low birthweight (< 2500 g), infant mortality, and cause of death for US rural and urban AI/AN and non-AI/AN populations.

RESULTS:

Receipt of an inadequate pattern of prenatal care was significantly higher for rural than for urban mothers of AI/AN infants (18.1% vs 14.4%, P </=.001); rates for both groups were over twice that for Whites (6.8%). AI/AN postneonatal death rates (rural = 6.7 per 1000; urban = 5.4 per 1000) were more than twice that of Whites (2.6 per 1000).

CONCLUSIONS:

Preventable disparities between AI/ANs and Whites in maternal and infant health status persist.

Alaska Native American Indian child Indian Health Service (IHS) infant infant death prenatal care rural urban urban health
Baldwin LM, Casey S, Freeman W Perinatal and infant health among rural and urban American Indians/Alaska Natives Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #54 06-01-1999
Full report. Policy brief.
Perinatal Risk Factors, Prenatal Care Use, Birth Outcomes, and Infant Mortality of Rural and Urban American Indian Women
Rosenblatt RA, Hagopian A, Andrilla CHA, Hart LG Project summary: will rural family medicine residency training survive? Seattle, WA: WWAMI Rural Health Research Center, University of Washington 01-01-2007
Policy brief.
Is Rural Residency Training of Family Physicians an Endangered Species? An Interim Follow-Up to the 1999 National BBA Study
Rosenblatt RA, Hagopian A, Andrilla CHA, Hart LG Will rural family medicine residency training survive? Fam Med. 38(10):705-711 11-01-2006 URL Is Rural Residency Training of Family Physicians an Endangered Species? An Interim Follow-Up to the 1999 National BBA Study

BACKGROUND AND OBJECTIVES:

Rural family medicine residencies may be more threatened by declining interest in family medicine than their urban counterparts. This study examines the recent performance of rural residencies in the National Resident Matching Program as an indicator of their viability.

METHODS:

We surveyed all 30 family medicine residencies located in rural areas during the summer of 2004 and a geographically matched sample of 31 urban residencies. We gathered information about the matching process for 2002, 2003, and 2004. The response rate was 70.5%.

RESULTS:

Rural programs offer about one third fewer first-year (postgraduate year 1 [PGY-1]) positions than their urban counterparts. Ruralprograms had lower Match rates (60.1%) than urban programs (72.5%) in 2004 but no meaningful differences in the proportion of international medical graduates (IMGs) or osteopathic physicians (DOs) who ultimately accepted positions. The 44.2% of residencies that predicted they would be thriving 2 years in the future filled an average of 81.3% of their slots on Match Day; there were no rural/urban differences. Programs with less-optimistic appraisals of their future had much lower Match rates. Two factors were associated with lower Match rates when other variables were taken into account: the proportion of IMGs in the 2 previous entering years and a stated rural mission.

CONCLUSIONS:

Rural programs appear to be slightly less stable than their urban counterparts, but the differences are minor. The viability of rural family medicine residency programs is probably affected more by the overall attractiveness of family medicine as a discipline rather than the rural or urban location of the residency.

family medicine National Resident Matching Program residency rural rural vs urban
Saver BG, Bowman R, Crittenden RA, Maudlin RK, Hart LG Barriers to residency training of physicians in rural areas Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #46 04-01-1998
Full report
Barriers to Rural Residencies Project
Kaplan L, Skillman SM, Fordyce MA, McMenamin PD, Doescher MP Understanding APRN distribution in the United States using NPI data. J Nurse Pract 8(8):626-635 09-14-2012 URL Advanced Practice Registered Nurse Distribution in Rural and Urban Areas of the U.S.

This study examined the 2010 Centers for Medicare and Medicaid Services National Plan and Provider Enumeration System’s National Provider Identifier (NPI) data to ascertain their usefulness to determine the distribution of advanced practice registered nurses (APRNs) in rural and urban areas of the United States. This study showed that certified registered nurse anesthetists were more likely to practice in rural areas in states with greater practice autonomy. For nurse practitioners, the findings were similar but were of borderline statistical significance. These findings imply that practice autonomy should be considered as a state-level strategy to encourage rural practice by APRNs.

APRN autonomy APRN workforce certified registered nurse anesthetists national provider identifier nurse practitioners
Skillman SM, Kaplan L, Fordyce MA, McMenamin PD, Doescher MP Understanding advanced practice registered nurse distribution in urban and rural areas of the United States using National Provider Identifier data. Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #137. 04-01-2012
Full report. Policy brief.
Advanced Practice Registered Nurse Distribution in Rural and Urban Areas of the U.S.
Rosenblatt RA, Baldwin LM, Chan L The quality of care received by diabetic patients in Washington State: a rural-urban comparison. Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #59. 03-01-2000
Full report. Policy brief.
Ambulatory Care and the Rural Elderly
Rosenblatt RA, Baldwin LM, Chan L Improving the quality of outpatient care for older patients with diabetes: lessons from a comparison of rural and urban communities. J Fam Pract. 50(8):676-680 08-01-2001 URL Ambulatory Care and the Rural Elderly

Objective

To assess how medical staffing mix changed over time in association with the adoption of electronic health records (EHRs) in community health centers (CHCs).

Study Setting

Community health centers within the 50 states and Washington, DC.

Study Design

Estimated how the change in the share of total medical staff full-time equivalents (FTE) by provider category between 2007 and 2013 was associated with EHR adoption using fractional multinomial logit.

Data Collection

2007–2013 Uniform Data System, an administrative data set of Section 330 federal grant recipients; and Readiness for Meaningful Use and HIT and Patient Centered Medical Home Recognition Survey responses collected from Section 330 recipients between December 2010 and February 2011.

Principal Findings

Having an EHR system did significantly shift the share of workers over time between physicians and each of the other categories of health care workers. While an EHR system significantly shifted the share of physician and other medical staff, this effect did not significantly vary over time. CHCs with EHRs by the end of the study period had a relatively greater proportion of other medical staff compared to the proportion of physicians.

Conclusions

Electronic health records appeared to influence staffing allocation in CHCs such that other medical staff may be used to support adoption of EHRs as well as be leveraged as an important care provider.

Fordyce MA, Doescher MP, Skillman SM Aging rural physician workforce Seattle, WA: WWAMI Rural Health Research Center, University of Washington Final Report #127 09-30-2013
Full report.
The Aging of the Rural Generalist Physician Workforce: Will Some Locations Be More Affected than Others?
Doescher MP, Fordyce MA, Skillman SM Aging rural physician workforce Seattle, WA: WWAMI Rural Health Research Center, University of Washington 06-01-2009
Policy brief.
The Aging of the Rural Generalist Physician Workforce: Will Some Locations Be More Affected than Others?
Nesbitt TS, Larson EH, Rosenblatt RA, Hart LG Access to and Outcomes of Obstetric Care Am J Public Health. 87(1):85-90. 01-01-1997 URL Relationship Between Access to Obstetrical Care and Process and Outcome of Care

OBJECTIVES:

This study sought to ascertain the effects of poor local access to obstetric care on the risks of having a neonate diagnosed as non-normal, a long hospital stay, and/or high hospital charges.

METHODS:

Washington State birth certificates linked with hospital discharge abstracts of mothers and neonates were used to study 29809 births to residents of rural areas. Births to women from rural areas where more than two thirds of the women left for care were compared with births to women from rural areas where fewer than one third left for care.

RESULTS:

Poor local access to providers of obstetric care was associated with a significantly greater risk of having a non-normal neonate for both Medicaid and privately insured patients. However, poor local access to care was consistently associated with higher charges and increased hospital length of stay only if the patient was privately insured.

CONCLUSIONS:

These results indicate that local maternity services may help prevent non-normal births to rural women and, among privately insured women, might decrease use of neonatal resources.

access maternity care neonatal obstetric care rural
Nesbitt TS, Larson EH, Rosenblatt RA, Hart LG Access to and Outcomes of Obstetric Care Seattle, WA: WWAMI Rural Health Research Center, University of Washington Working Paper #23. 08-01-1993 Relationship Between Access to Obstetrical Care and Process and Outcome of Care
Allen SM, Ballweg RA, Cosgrove EM, Engle KA, Robinson LR, Rosenblatt RA, Skillman SM, Wenrich MD Challenges and Opportunities in Building a Sustainable Rural Primary Care Workforce in Alignment With the Affordable Care Act: The WWAMI Program as a Case Study Acad Med. 2013 Dec;88(12):1862-9 12-01-2013 URL N/A

The authors examine the potential impact of the Patient Protection and Affordable Care Act (ACA) on a large medical education program in the Northwest United States that builds the primary care workforce for its largely rural region. The 42-year-old Washington, Wyoming, Alaska, Montana, and Idaho (WWAMIprogram, hosted by the University of Washington School of Medicine, is one of the nation’s most successful models for rural health training. The program has expanded training and retention of primary care health professionals for the region through medical school education, graduate medical education, a physician assistant training program, and support for practicing health professionals.The ACA and resulting accountable care organizations (ACOs) present potential challenges for rural settings and health training programs like WWAMI that focus on building the health workforce for rural and underserved populations. As more Americans acquire health coverage, more health professionals will be needed, especially in primary careRural locations may face increased competition for these professionals. Medical schools are expanding their positions to meet the need, but limits on graduate medical education expansion may result in a bottleneck, with insufficient residency positions for graduating students. The development of ACOs may further challenge building a rural workforce by limiting training opportunities for health professionals because of competing demands and concerns about cost, efficiency, and safety associated with training. Medical education programs like WWAMI will need to increase efforts to train primary carephysicians and increase their advocacy for student programs and additional graduate medical education for rural constituents.

ACA accountable care organizations ACO graduate medical education health professionals health training programs primary care rural rural primary care workforce