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Title Description Status Funder
Supply of and Demand for Therapy Services in Skilled Nursing Facilities Little is known about the employment of therapy staff within skilled nursing facilities (SNFs)...

Little is known about the employment of therapy staff within skilled nursing facilities (SNFs) relative to market needs. Therapy staff includes physical therapists (PTs), occupational therapists (OTs), physical therapy assistants (PTAs), occupational therapy assistants (OTAs), and therapy aides. The proposed study will compare wages and patterns of employment (e.g., full-time versus part-time, contracting, skill level- PT/OT versus PTA/OTA versus therapy aide) among therapy staff by market demand factors and SNF provider characteristics.

In Progress HRSA
Leveraging Data Phase IV: Mapping Movement of Allied Health Professionals This study will examine available supply of allied health occupations by mapping where they live...

This study will examine available supply of allied health occupations by mapping where they live and work, and how this pattern has changed over time. This is the fourth phase of a series of UW CHWS studies producing a robust data repository and body of research about the allied health workforce at the state and national level, with the goal of supporting future studies to inform policy makers and health workforce planners.

In Progress HRSA
Apprenticeships as Pathways to Healthcare Careers: Experiences of Employers Using Medical Assistant Apprenticeships This study will examine the experiences of healthcare employers who are, and who are not, using...

This study will examine the experiences of healthcare employers who are, and who are not, using Medical Assistant (MA) apprenticeships to sustain and expand their MA workforce. We will describe the range of employers’ experiences and factors likely to be associated with their decisions about whether or not to incorporate MA apprenticeship programs in their workforce planning.

In Progress HRSA
Role of Allied Health Professions in Treating Pain As the U.S. faces a growing opioid addiction crisis, the health care system needs to ensure access...

As the U.S. faces a growing opioid addiction crisis, the health care system needs to ensure access to, maximize the use of, and optimally deploy providers who can help patients prevent and manage pain in order to reduce use of opioid pain medications. This study will examine the role that allied health professionals currently in delivering evidence-based, non-opioid pain management interventions, and how their training and education may allow expanded use of these providers in addressing the growing opioid crisis.

In Progress HRSA
Demographic, Education, and Practice Characteristics of Registered Nurses in Washington State: Results of a 2018 Survey In 2018, with funding from the Washington Center for Nursing, the UW CHWS surveyed all of the...

In 2018, with funding from the Washington Center for Nursing, the UW CHWS surveyed all of the licensed registered nurses (RNs) in the state to obtain basic demographic, education, and practice information. Findings will provide policymakers, educators, and planners in Washington with useful information for assessing the supply, distribution and backgrounds of Washington’s RN workforce.

In Progress
Effects of Increasing Minimum Wage and Expanding Health Insurance Coverage on Job Stability among Long-Term Care Workers Recent efforts to raise the minimum wage rate across Washington State, along with expanded health...

Recent efforts to raise the minimum wage rate across Washington State, along with expanded health insurance coverage through the Affordable Care Act (ACA), may mitigate wage and health insurance barriers to steady employment. We will investigate how these policy changes influenced decisions by home health aides and home care aides to stay or leave the healthcare industry.

In Progress UW Harry Bridges Center for Labor Studies
Trends in the Supply and Demographics of Oral Health Providers in Rural Communities, 2005-2015 Our study will use ten-years of data from the American Community Survey to compare the supply...

Our study will use ten-years of data from the American Community Survey to compare the supply trends of dentists and dental hygienists in non-metro versus metro areas (proxies for rural and urban per available data). In particular, we will look at the aging trends among these providers, and additional demographics (e.g. gender, race/ethnicity) of these aging providers.

In Progress HRSA
State Incentive Programs that Encourage Allied Health Professionals to Provide Care for Underserved Populations Numerous state governments provide incentives for health professionals to practice in shortage...

Numerous state governments provide incentives for health professionals to practice in shortage areas, but we know little about these programs collectively and the lessons they offer about recruiting and retaining allied health professionals. This study will examine state incentive programs that encourage allied health professionals to provide care for rural and underserved communities, providing findings on programs’ goals, policies, practices, and impacts.

In Progress HRSA
Leveraging Data to Monitor the Allied Health Workforce: Phase III This study will examine trends in the supply, distribution, and characteristics of 13 allied health...

This study will examine trends in the supply, distribution, and characteristics of 13 allied health occupations. It is a new (third) phase of a series of UW CHWS studies producing a robust data repository and body of research about the allied health workforce at the state and national level, with the goal of supporting future studies to inform policymakers and health workforce planners.

In Progress HRSA
The Role of Apprenticeships in Meeting Employers’ Demand for Allied Health Occupations This study will identify the range of allied health occupations currently accessible through...

This study will identify the range of allied health occupations currently accessible through apprenticeships, describe the different apprenticeship models, and broaden information about healthcare apprenticeships’ value to employers. This study will begin developing data resources for future studies of apprenticeships’ impact on employers, employees, and patients/clients.

In Progress HRSA
Allied Health Professionals and the “Gig Economy”: Trends in Alternative Work Arrangements In a recent study of the “gig economy,” or alternative work arrangement (e.g., self-employed,...

In a recent study of the “gig economy,” or alternative work arrangement (e.g., self-employed, freelancers, on-call, temporary workers, and contract labor), Katz and Krueger (2016) noted that healthcare was one of two industries (the other being education) that experienced the fastest growth of workers over the last decade. This study will expand on preliminary work on “gig” work among aides in long-term care (LTC) to investigate how trends in gig work has changed over time for allied health professionals, including aides; whether geographic patterns in the growth of the gig economy in healthcare relate to patient needs; how gig work has affected the wage rates over time; and whether any changes in gig work has impacted transition rates (exit or entry rates) of allied health workers.

In Progress HRSA
Washington State Behavioral Health Workforce Assessment This study was conducted in collaboration with the Washington State Workforce Training and...

This study was conducted in collaboration with the Washington State Workforce Training and Education Coordinating Board. The purpose was to identify workforce-related issues that affect access to behavioral health care services in Washington. Many different occupations were found to comprise the overall behavioral health workforce, some providing solely behavioral care and others who had behavioral health along with medical care roles, such as in integrated behavioral/physical health settings. The assessment described and quantified the size, distribution, and education/training pathways of and demand for behavioral health occupations in Washington and uncovered some data limitations. With considerable stakeholder participation, policy and programmatic recommendations to address these workforce-related barriers were identified and, in January, 2018, were presented to the Governor and the 2018 Legislature and are described in the project’s reports.

Complete U.S. Dept. of Labor, Workforce Innovation and Opportunity Act
Expanding Role of Medical Assistants This study will examine how medical assistant (MA) characteristics, roles and career trajectories...

This study will examine how medical assistant (MA) characteristics, roles and career trajectories vary across practice settings in one state.

In Progress HRSA
Commuting Patterns of Allied Health Workers and Registered Nurses This study will assess how commuting impacts the availability of allied health professionals and...

This study will assess how commuting impacts the availability of allied health professionals and registered nurses in a community.

In Progress HRSA
Scope of Practice Alignment of Emergency Medical Services Personnel This study will investigate how well the care provided by prehospital emergency medical services...

This study will investigate how well the care provided by prehospital emergency medical services (EMS) personnel align with their credentials and recommended scope of practice, and to what extent EMS providers practice at the top of their scope.

In Progress HRSA
Phase II of Leveraging Data for Allied Health Occupations This study expands the 2015-2016 study on Data for

This study expands the 2015-2016 study on Data for Allied Health Workforce Research by adding one to two new allied health occupations, and by adding new and updated data.

In Progress HRSA
Multiracial Microaggressions in the Primary Care Setting This project focuses on exploring the racialized experiences of multiracial individuals and...

This project focuses on exploring the racialized experiences of multiracial individuals and families in the healthcare setting and the extent to which those experiences impact patient satisfaction outcomes, health-seeking behaviors, and patients’ provider preference. This study aims to further understand racial microaggressions and racial biases among healthcare providers and promote the provision of culturally relevant and responsive healthcare services for individuals and families of color, particularly the growing population of multiracial individuals and families.

In Progress UW Patient-Centered Outcomes Research (PCOR) K12, Agency for Healthcare Research and Quality
National Family Medicine Graduate Surveys This study generates and revises national certification and recertification surveys of family...

This study generates and revises national certification and recertification surveys of family medicine physicians. (PI: Freddy Chen, Department of Family Medicine, UW School fo Medicine)

American Board of Family Medicine
The Impact of Medicare’s Rural Add-on Payments in Home Health on Access to Care and Home Health Markets This study assesses the impact of Medicare rural add-on payments on delivery of home health...

This study assesses the impact of Medicare rural add-on payments on delivery of home health services. (PI: Tracy Mroz, Department of Rehabilitation Medicine, UW School of Medicine)

In Progress Agency for Healthcare Research and Quality
The Status of the Oral Health Workforce in Washington State This study used Washington state licensing data on dentists and hygienists; surveys of family...

This study used Washington state licensing data on dentists and hygienists; surveys of family physicians, pediatricians, and dentists; and key informant interviews with over 20 stakeholder organizations to provide a current assessment of Washington’s oral health workforce, including traditional oral health providers and physicians providing oral health preventive services.

Complete Washington Dental Service Foundation
Direct Access to Physical Therapists This study uses commercial health insurance claims data to identify how health care utilization...

This study uses commercial health insurance claims data to identify how health care utilization (e.g., imaging and opioid use) and spending patterns vary by whether the patient sees a physical therapist first or another provider. This study also looks at how state scope of practice laws allowing or restricting direct access to physical therapy impacts these patterns. This study was conducted under the State Health Policy Grant Program at the Health Care Cost Institute and in partnership with the National Academy of State Health Policy, and with sponsorship by the Arnold Family Foundation.

Complete Health Care Cost Institute/Arnold Family Foundation
Washington’s Health Workforce Industry Sentinel Network This project will develop and implement a “health workforce industry sentinel network” system...

This project will develop and implement a “health workforce industry sentinel network” system for Washington State that will collect key data at regular intervals from sentinel healthcare industry sites and provide rapid turnaround of information about demand “outbreaks” and emerging issues affecting employers, educators, training institutions, and other key stakeholders involved in health workforce development and deployment

Further project details and findings can be found on the WA State Workforce Board website.

In Progress CMMI – Washington Health Care Authority – Washington Workforce Board
Emerging Health IT Roles and Skillsets This study identifies how emerging health-IT related skills and roles are becoming incorporated...

This study identifies how emerging health-IT related skills and roles are becoming incorporated into the job descriptions of health workers.

Complete HRSA
Value of Athletic Trainers in Ambulatory Care Settings This study surveyed ambulatory care settings employing athletic trainers to understand the reasons...

This study surveyed ambulatory care settings employing athletic trainers to understand the reasons for hiring and the perceived value of athletic trainers to the practice.

Complete National Athletic Trainers' Association
Entry and Exit of Workers in Long-Term Care This study investigated the entry and exit trends over the last decade of workers in long-term care...

This study investigated the entry and exit trends over the last decade of workers in long-term care using the Current Population Survey. This study was conducted under a subcontract from the UCSF Health Workforce Research Center on Long-Term Care.

Complete UCSF Health Workforce Research Center on Long-Term Care
Impact of Electronic Health Records on Community Health Center Staffing This study examines the impact of the adoption of electronic health records on staffing...

This study examines the impact of the adoption of electronic health records on staffing configurations and thus productivity in community health centers. This study is conducted under a subcontract from The George Washington University Health Workforce Research Center.

Complete The George Washington University Health Workforce Research Center
The Role of Group Practice Managers in Veterans Healthcare System This study surveys ambulatory care practices in the Veterans Healthcare System to evaluate the...

This study surveys ambulatory care practices in the Veterans Healthcare System to evaluate the implementation of the initiative on Group Practice Managers, which aims to improve access to care for veterans. This study is in collaboration with the UW School of Public Health Department of Health Services.

Complete UW School of Public Health Department of Health Services
Impact of Innovations on Primary Care Workforce Configurations In this pilot, we conduct interviews with health care administrators to identify common themes on...

In this pilot, we conduct interviews with health care administrators to identify common themes on how team-based care is employed in primary care settings in the WWAMI region Practice and Research Network (WPRN). This study is funded through the UW Institute of Translational Health Sciences.

Complete UW Institute of Translational Health Sciences
Big Data Study on Team-Based Care for Diabetes Patients This study uses commercial health insurance and Medicare claims data to identify how health care...

This study uses commercial health insurance and Medicare claims data to identify how health care utilization and spending patterns vary by the type of primary care provider seen. This study is conducted under a subcontract from the National Center for Interprofessoinal Education at the University of Minnesota.

Complete National Center for Interprofessoinal Education at the University of Minnesota
Does Unrestricted Access to Physical Therapy Reduce Health Spending? This study uses commercial health insurance claims data to investigate whether timing of access to...

This study uses commercial health insurance claims data to investigate whether timing of access to physical therapists impacts health care utilization and costs for patients with lower back pain. This study is funded by the Health Care Cost Institute State Grant Program and the Arnold Foundation.

In Progress Health Care Cost Institute State Grant Program and the Arnold Foundation
Educating Health Professionals to Address the Social Determinants of Health Dr. Bianca Frogner was appointed by the Institute of Medicine to serve on a Consensus Study...

Dr. Bianca Frogner was appointed by the Institute of Medicine to serve on a Consensus Study Committee to develop a global framework on educating health professionals to address the social determinants of health.

Complete Institute of Medicine, National Academies of Science, Engineering and Medicine
Rural Physician Assistants Background: In the 1970s, graduates of physician assistant (PA) programs practiced largely in...

Background: In the 1970s, graduates of physician assistant (PA) programs practiced largely in primary care settings serving rural and other underserved populations. By the 1990s, PAs were practicing in a much wider variety of settings in many medical specialties. Aim: To describe the demography, practice arrangements and content of practice of a nationally representative sample of PAs collected in the 1990s. Methods: A stratified random sample of PAs was surveyed in 1993-1994. The demography, practice characteristics and content of PA practice were analyzed across practice location and medical specialty. Results: Of all the living PAs ever trained, 95% were active in the health care delivery system at the time of the survey. Eighty-seven percent of those trained were practicing as PAs, nearly all of whom were practicing full time. Rural PAs were more likely to be white and male than their urban counterparts and had lower levels of education prior to entering PA training. Generalist PAs performed many more outpatient visits than specialist PAs, and fewer inpatient visits. In urban areas, PAs were making a large contribution to surgical care. About three-fourths of the rural PAs were generalists. Conclusions: The broader scope of practice of generalist PAs, especially those serving rural populations, points to the need to ensure that training programs, especially those emphasizing generalist care for rural and underserved populations, provide sufficient breadth in medical training to meet those needs. Funded by HRSA’s ORHP.

Complete
Wyoming Physicians Workforce This study offers data on the size, distribution, demographics, specialties and education history...

This study offers data on the size, distribution, demographics, specialties and education history of Wyoming State’s physician workforce first conducted in 2014 and updated in 2016.

Complete
Wyoming Health Care Workforce This study described Wyoming's health workforce to identify gaps in access to health care providers...

This study described Wyoming’s health workforce to identify gaps in access to health care providers and options for policy to alleviate health workforce shortages. The project used existing data on the state’s health workforce and provided technical assistance for ongoing data collection. This work was funded by the Wyoming Healthcare Commission.

Complete
WWAMI Physicians 2005 This 2005 report examines the current supply and distribution of physicians in the WWAMI...

This 2005 report examines the current supply and distribution of physicians in the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) region. The analyses utilized the 2005 AMA Masterfile to determine the population-based supply of physicians at the state and county level, analyzed by the discipline of physician. This report also shows the proportion, by specialty and state, who graduated from or trained at the University of Washington. Funded by the Department of Family Medicine, University of Washington.

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WWAMI Physician Workforce Education
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WSU's Contributions to Nurse Supply This study examined how Washington State University's (WSU's) nursing programs contribute to the...

This study examined how Washington State University’s (WSU’s) nursing programs contribute to the current supply of nurses in Washington and estimated the impact of the college’s graduates on future nurse supply in the state. Using available data, the project described registered nurse (RN) graduation trends from the WSU College of Nursing, estimated the number of WSU graduates in the current RN workforce in Washington, and estimated future WSU contributions to state nurse supply.

Complete
Washington's Radiographer Workforce This study examined Washington's radiographer supply and demand from 2000 through 2020. Readily...

This study examined Washington’s radiographer supply and demand from 2000 through 2020. Readily available literature and data permited an extremely limited analysis of trends in radiographer supply and demand, and the projections are presented as a basis for discussion and critique. The limitations confronting workforce planning and the possibilities for improving the data and understanding of the field are presented. This 2004 study was funded by HRSA’s National Center for Health Workforce Analysis through a Congressional Appropriation to the UW CHWS.

Complete
Washington's Pharmacist Workforce This study examined Washington's pharmacist supply and demand from 2000 through 2020. Readily...

This study examined Washington’s pharmacist supply and demand from 2000 through 2020. Readily available literature and data permited an extremely limited analysis of trends in pharmacist supply and demand, and the projections are presented as a basis for discussion and critique. The limitations confronting workforce planning and the possibilities for improving the data and understanding of the field are presented. This 2004 study was funded by HRSA’s National Center for Health Workforce Analysis through a Congressional Appropriation to the UW CHWS.

Complete
Washington's Oral Health Workforce, 2009 We analyzed available data on dentists, dental hygienists, and relevant populations to assess the...

We analyzed available data on dentists, dental hygienists, and relevant populations to assess the size and distribution of the oral health workforce in Washington State. This included assessment of the current oral health workforce by analyzing DOH licensing records for dentists and dental hygienists and analyzing survey data for dentists and dental hygienists from the DOH health professions surveys conducted in 2007 and 2008; assessment of factors that affect future supply of dentists and dental hygienists, to include projections of retirement rates for dentists and dental hygienists and description of trends in educational output from Washington’s dentist and dental hygienist educational programs; and assessment of Medicaid oral health providers by county relative to the overall workforce and eligible populations, using data on Medicaid providers procured by DOH and available data on eligible populations. This study was funded by the Washington State Department of Health.

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Washington's Dental Hygienists' Characteristics This study reported the results of a 2004 survey of dental hygienists in Washington State. Question...

This study reported the results of a 2004 survey of dental hygienists in Washington State. Question topics included demographics, practice characteristics, and job satisfaction. Funded by HRSA’s National Center for Health Workforce Analysis through a Congressional Appropriation to the UW CHWS.

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Washington's Dental Hygienist Workforce This study examined Washington's dental hygienist supply and demand from 2000 through 2020. Readily...

This study examined Washington’s dental hygienist supply and demand from 2000 through 2020. Readily available literature and data permited an extremely limited analysis of trends in dental hygienist supply and demand, and the projections are presented as a basis for discussion and critique. The limitations confronting workforce planning and the possibilities for improving the data and understanding of the field are presented. This 2004 study was funded by HRSA’s National Center for Health Workforce Analysis through a Congressional Appropriation to the UW CHWS.

Complete
Washington RNs' Characteristics 2007 In 2007, Washington State surveyed all of the licensed registered nurses (RNs) in the state to...

In 2007, Washington State surveyed all of the licensed registered nurses (RNs) in the state to obtain basic demographic, education, and practice information. This study analyzed these survey responses and found that of all RNs with Washington licenses in 2007, 64% practiced in Washington, fewer than 10% were non-white, and 2% were Hispanic. Among Washington’s RNs, 49% worked in hospital inpatient settings and 62% provided direct patient care. The highest nursing degree attained by 43% of the state’s RNs was a BSN, and for 39% it was the ADN. Overall, 57% of Washington’s RNs obtained at least some of their nursing education in-state. RNs’ age at the time they obtained their initial nursing education was an average of nine years higher for those who obtained their degrees in 2005 or later than for RNs who obtained their degrees before 1980. More than 5% of RNs in Washington obtained their initial RN education outside of the United States. These demographic, practice, and education data provide policymakers, educators, and planners in Washington with useful information for assessing the status of Washington’s RN workforce.

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Washington RN Supply and Demand to 2031 This study projected trends in the supply and demand of registered nurses (RNs) in Washington State...

This study projected trends in the supply and demand of registered nurses (RNs) in Washington State from 2005 through 2031. The project used available data on RNs in the state to estimate the influence of different factors on RN supply and demand across 20 years (2011-2031). Another goal of the project was to describe the limitations of the models and the types of data that would improve the accuracy of these models in the future. Funded by the Washington Center for Nursing through Department of Health grant #N14191.

Complete
Washington RN Supply and Demand to 2025 This study projected trends in the supply and demand of registered nurses (RNs) in Washington State...

This study projected trends in the supply and demand of registered nurses (RNs) in Washington State from 2005 through 2025. The project used available data on RNs in the state to estimate the influence of different factors on RN supply and demand across 20 years. Another goal of the project was to describe the limitations of the models and the types of data that would improve the accuracy of these models in the future. Funded by the Washington Center for Nursing through Department of Health grant #N14191.

Complete
Washington Registered Nurse License Expirations 2008-2014 These analyses of Washington State registered nurse professional license data examined changes in...

These analyses of Washington State registered nurse professional license data examined changes in the numbers and ages of RNs whose licenses expired from 2008 to 2014. Results included the findings that RN licenses expiring annually in Washington increased in both actual numbers and in the percentage of the total RN supply, and the greatest increase was among the oldest RNs (age 60-75).

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Washington Physicians This study offers data on the size, distribution, demographics, specialties and education history...

This study offers data on the size, distribution, demographics, specialties and education history of Washington State’s physician workforce first conducted in 2014 and updated in 2016.

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Washington Obstetrical Providers and Liability Insurance Obstetrical providers (obstetrician/gynecologists, family physicians, certified nurse midwives and...

Obstetrical providers (obstetrician/gynecologists, family physicians, certified nurse midwives and licensed midwives) were surveyed in 2004 to assess their demographic and practice characteristics, liability insurance characteristics, practice changes and limitations due to liability insurance issues, obstetrical practices, and obstetrical practice environment changes. Funded by HRSA’s National Center for Health Workforce Analysis through a Congressional Appropriation to the UW CHWS.

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Washington Obstetrical Care This completed study characterized the distribution and supply of male and female obstetricians and...

This completed study characterized the distribution and supply of male and female obstetricians and gynecologists (ob-gyns) in Washington State, as well as the services they provide. This study used a cross-sectional analysis of 1998-1999 state licensing data linked with supplemental survey data. Findings show a significant shortage of ob-gyns, especially female ob-gyns, in rural areas. Funded by HRSA, National Center for Health Workforce Analysis.

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Washington LPNs' Characteristics 2007 In 2007, Washington State surveyed all of the licensed practical nurses (LPNs) in the state to...

In 2007, Washington State surveyed all of the licensed practical nurses (LPNs) in the state to obtain basic demographic, education, and practice information. This report describes LPNs in Washington using the 2007 survey responses, weighted to reflect the overall population. The descriptive statistics reflect LPNs who live in-state, and some sub-state analyses are provided. Of the 14,446 LPNs with Washington licenses in 2007, 72% practiced in Washington. The work setting in which the largest percentage were employed was long-term care (37%), and 65% of licensed LPNs in Washington reported they worked in primary care. Of the average 37 hours worked per week by LPNs, 25 hours on average were spent in direct patient care. The average age of practicing LPNs was 46, 12% were male, 18% were non-white, and 4% were Hispanic. Nearly three-quarters of Washington’s licensed LPNs received their LPN education in-state. Less than 2% of LPNs in Washington obtained their initial LPN education outside of the United States. Because of the high average age of Washington’s LPNs, the relatively slow rate at which the workforce is growing, and the fact that LPNs provide significant amounts of long-term and home care services, there is concern that the workforce may not be adequate to meet future needs. Subsequent surveys will allow examination of LPN workforce trends over time and assessment of the impact of health workforce-related decisions and policies now being implemented.

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Washington LPN Supply and Demand to 2025 This study projects trends in the supply and demand of licensed practical nurses (LPNs) in...

This study projects trends in the supply and demand of licensed practical nurses (LPNs) in Washington State from 2007 through 2025. The project used available data on LPNs in the state to estimate the influence of different factors on LPN supply and demand across nearly two decades. Funded by the Washington Center for Nursing through Department of Health grant #N14191.

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Washington Hospital Staffing With the Washington State Hospital Association, the UW CHWS has surveyed acute care hospitals in...

With the Washington State Hospital Association, the UW CHWS has surveyed acute care hospitals in Washington State in 2001, 2002, 2004, and 2005 to determine employment, contracting, and vacancy rates for 21 occupational categories, level of difficulty recruiting those staff, and level of difficulty credentialing physicians. Responses were analyzed at the level of state, hospital size, and workforce development area. The 2001 survey asked more detailed questions about the hospital nurse workforce; the 2002 and later surveys included questions about the hospital physician workforce. These studies were funded by HRSA’s National Center for Health Workforce Analysis (including through a Congressional Appropriation to the UW CHWS) and by the Health Work Force Institute of the Washington State Hospital Association.

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Washington ARNPs' Characteristics 2008 In 2008, Washington State surveyed all of the licensed advanced registered nurse practitioners in...

In 2008, Washington State surveyed all of the licensed advanced registered nurse practitioners in the state to obtain basic demographic, education, and practice information. This study analyzed these responses in order to provide policymakers, educators, and planners in Washington with useful information for assessing the status of Washington’s ARNP workforce.

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Veterans' Pathways to Allied Health This study describes programs and policies that expedite education paths and help reduce barriers...

This study describes programs and policies that expedite education paths and help reduce barriers faced by military veterans seeking careers in allied health occupations.

Complete HRSA
Veterans in Allied Health This study provides the current landscape of Veterans in health care jobs in order to develop a...

This study provides the current landscape of Veterans in health care jobs in order to develop a strategy to direct Veterans into health care careers.

Complete HRSA
Unhealthy Lifestyles of Rural/Urban Minorities: Obesity Background: Obesity is on the rise in the United States and has been implicated in serious chronic...

Background: Obesity is on the rise in the United States and has been implicated in serious chronic health problems. Obesity is very costly in terms of medical spending and lost productivity. Aim: To estimate the prevalence of and recent trends in obesity among U.S. adults residing in rural and urban locations. Methods: A telephone survey of adults aged 18 years and older residing in states participating in the Behavioral Risk Factor Surveillance System (BRFSS) in 1994-1996 and 2000-2001. The main outcome measure for the study was obesity, defined as a body mass index of 30 or greater, based on self-report. Results: In 2000-2001, the prevalence of obesity was 23.0% for rural adults and 20.5% for their urban counterparts, increases of 4.8% and 5.5%, respectively, since 1994-1996. The highest obesity prevalence occurred in rural counties of Mississippi, Texas and Louisiana. Only Rhode Island and Colorado had rural counties that met the HealthyPeople 2010 goal of a maximum of 15% obese for adults. Conclusions: Despite recent attention to the prevalence of obesity, obesity rates continue to rise across the United States and differentially affect inhabitants of rural and urban areas. Funded by HRSA’s ORHP.

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Unhealthy Lifestyles of Rural/Urban Minorities: Cigarettes Background: Cigarette smoking is the leading preventable cause of death in the United States. Aim:...

Background: Cigarette smoking is the leading preventable cause of death in the United States. Aim: To estimate the prevalence of and recent trends in smoking among adults residing in three types of rural locations. Methods: Telephone survey of adults aged 18 years or older who participated in the Behavioral Risk Factor Surveillance System in 1994-1996 and 2000-2001. Results: The prevalence of smoking changed little from the mid-1990s; it was 22.0% in urban areas, 24.9% in rural adjacent areas, 24.0% in large rural non-adjacent areas, and 24.9% in small rural non-adjacent areas. For rural locations combined, its prevalence was not below the 12% goal of HealthyPeople 2010 for any state. Its prevalence was ≥ 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% in California, Connecticut, Maryland, North Carolina, Tennessee, and Utah. However, it increased by 2% or more in 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. Funded by HRSA’s ORHP.

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Unhealthy Lifestyles of Rural/Urban Minorities: Alcohol Use Aim: To estimate the prevalence of and recent trends in alcohol use among U.S. adults in rural...

Aim: To estimate the prevalence of and recent trends in alcohol use among U.S. adults in rural areas. Methods: A telephone survey of adults aged 18 years or older residing in states participating in the Behavioral Risk Factor Surveillance System (BRFSS), in the years 1995/1997 and 1999/2001. Results: Urban counties led rural counties for moderate and heavy drinking in 1999/2001, and also saw the largest increases in heavy drinking between 1995/1997 and 1999/2001. Binge drinking was nearly as high in remote rural counties with a large town as in urban counties, and increased the most for remote rural counties with a large town. Urban whites were more likely than any other racial/ethnic group to report moderate or heavy drinking, while American Indians in remote rural counties with a large town were the most likely to report binge drinking. Significant increases in heavy and binge drinking were highest for rural residents in the Northeast and Midwest and lowest in the South Census region. Conclusions: Heavy drinking was highest and increased the most in urban counties; however, binge drinking increased the most in remote rural counties with a large town, and heavy and binge drinking increased for rural counties of all types. Funded by HRSA’s ORHP.

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Trends in Rural Perinatal Care of American Indians While there have been dramatic improvements in AI/AN maternal and child health since these measures...

While there have been dramatic improvements in AI/AN maternal and child health since these measures were first recorded in the mid-1950s, significant disparities persist between AI/AN and non-AI/AN populations in the United States. This study (1) examined trends in prenatal care use, low-birthweight rate, and the neonatal and postneonatal mortality rates in rural and urban AI/AN populations nationally between 1985 and 1997, and compared these trends in the white populations during the same time period; (2) examined trends in causes of death for rural and urban AI/AN populations nationally between 1985 and 1997, and compared these trends to the white population during the same time period; and (3) analyzed trends in our study measures for AI/AN and white populations by Census region, division, and Indian Health Service (IHS) Service Areas. The study used the National Linked Birth Death Data Set at three points in time: 1985-1987, 1989-1991, and 1995-1997, and compared rates of inadequate prenatal care, low birthweight, neonatal and postneonatal death, and causes of death between rural AI/ANs and Caucasians in each of the three time periods, as well as over time. Funded by HRSA’s ORHP.

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Trends in Rural Perinatal Care Little is known about long-term national trends in birth outcomes and use of prenatal care in the...

Little is known about long-term national trends in birth outcomes and use of prenatal care in the rural population of the United States, or about intrarural differences in adverse outcome and inadequate prenatal care. In this two-year study, we examined: (1) How have rates of adverse birth outcome and prenatal care among U.S. rural residents changed in the years between 1985-1987 and 1995-1997? and (2) How have adverse birth outcomes and prenatal care changed during these periods among rural residents from racial and ethnic minority groups? We examined data from the Linked Birth Death Data Set (LBDDS), a national compilation of birth certificate data from all 50 states and the District of Columbia. We assessed inter-decade changes in rural/urban and intrarural differences in the rate of low birthweight outcome, neonatal death, postneonatal mortality, and inadequate prenatal care. We also assessed the degree to which observed changes were concentrated in particular types of rural settings or regions. Funded by HRSA’s ORHP.

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Trends in Rural Dentistry This study used secondary data sources such as the Area Resource File, American Dental Association...

This study used secondary data sources such as the Area Resource File, American Dental Association data, and state-level professional licensure data to describe the supply of dental providers in several states, with particular attention to the supply of providers in rural areas. Surveys were administered to rural dentists in California, Maine, Missouri, and Alabama to describe the rural dental provider population in those states with respect to demography, practice characteristics, practice satisfaction, use of dental hygienists, Medicaid and CHIP practices, and attitudes towards the use of alternative sources of dental care such as using medical providers to apply sealants in the pediatric population. The study elucidates, from the dental provider perspective, the barriers to access to dental care for rural residents and what can be done to promote rural dental practice. Funded by HRSA’s ORHP.

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Tort Reform & Obstetrical Access As a consequence of the malpractice liability crisis, each of the four WAMI states at the time of...

As a consequence of the malpractice liability crisis, each of the four WAMI states at the time of this study had modified the existing tort and/or professional liability systems in their states. This project reviewed recent studies of physicians’ obstetrical practices and major changes in tort legislation and regulation. The majority of general and family physicians in the WAMI region no longer provided obstetrical care, while over 80% of the obstetrician/gynecologists in this area still practiced obstetrics. Most rural family physicians in all four states continued to deliver babies. The majority of physicians in these states limited the amount of care they provide to Medicaid patients. All four states adopted tort reforms, yet the cost of malpractice premiums and concerns over liability continued to limit the number of physicians willing to provide obstetrical care.

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The WWAMI Rural Health Workforce This project compiles and presents state-level information about the rural health workforce in the...

This project compiles and presents state-level information about the rural health workforce in the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) region. Information was derived from the American Medical Association Masterfile, the National Sample Survey of Registered Nurses, the Area Resource File, and other sources. This series of policy briefs describes WWAMI rural health workforce challenges and opportunities, workforce numbers, resources, the importance of rural definitions, and tools for workforce policymakers and planners.

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The Workforce Investment Act This 2002-2003 project identified and described the efforts that linked job seekers with the health...

This 2002-2003 project identified and described the efforts that linked job seekers with the health workforce through Workforce Investment Act of 1998 (WIA) programs throughout the United States. It enumerated the goals and strategies that states and their regional workforce boards were using to develop their health workforce using WIA funding. Funded by HRSA, National Center for Health Workforce Analysis.

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The Walkability Project This study is identifying built environmental correlates of walking in rural towns and evaluating...

This study is identifying built environmental correlates of walking in rural towns and evaluating the role of low socioeconomic status (SES) and Latino ethnicity on these relationships. By studying 9 rural towns from 3 diverse regions, Washington State, the Northeast, and Texas, with a varying range of socioeconomic and ethnic characteristics, this study is: (1) measuring built environmental correlates of walking among small town residents, using objective and perceived measures of the built environment and self-reported measures of walking; (2) evaluating the degree to which built environmental correlates of walking among rural town residents are influenced by SES and Latino ethnicity; and (3) validating the perceived correlates of walking using accelerometer and global positioning system measures. The study will first involve a survey of 1,800 residents of these towns on physical activity patterns and attributes of their towns that promote or impede walking, and will next recruit a sample of 270 respondents who agree to wear two small devices measuring their physical activity for 7 consecutive days. Objective measures of their physical activity will be compared to self-reported data. This work will lay the foundation for future research on the relationship between various aspects of the rural built environment and health behaviors and, ultimately, intervention trials to help rural towns better structure the built environment to promote walking and healthier life styles among their highest risk residents.

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The Rural Public Health Workforce Rural local health districts are often the only formal public health presence in small remote...

Rural local health districts are often the only formal public health presence in small remote communities. This study described the people who staff these departments in three western states, compared the per capita supply of public health professionals in rural and urban districts, and explored some of the major challenges faced by rural public health. This series of studies (1999 to 2001) was funded by HRSA, National Center for Health Workforce Analysis.

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The Public Health Workforce As part of a larger national study (led by the New York CHWS), the UW WWAMI CHWS carried out a case...

As part of a larger national study (led by the New York CHWS), the UW WWAMI CHWS carried out a case study of the staffing needs of local health departments in Montana. The national study describes local and state public health agencies’ staffing needs, with emphasis on nursing and physician staff, in Montana, New York, Texas, Georgia, New Mexico and California. Funded by the New York CHWS, through a contract with HRSA, Bureau of Health Professions.

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The Future of Health Workforce Data and Methods AcademyHealth, with funding from the Robert Wood Johnson Foundation, contracted with the University...

AcademyHealth, with funding from the Robert Wood Johnson Foundation, contracted with the University of Washington Center for Health Workforce Studies to participate in the development of several papers and presentations on ways to improve the research and data infrastructure for health workforce research.

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Survey of Washington Primary Care Physicians, NPs, and PAs The Washington State Office of Financial Management surveyed primary care physicians, nurse...

The Washington State Office of Financial Management surveyed primary care physicians, nurse practitioners, and physician assistants in Washington State to assess access to primary care for Washington’s residents. The WWAMI Center for Health Workforce Studies provided technical assistance to help facilitate the survey. This project was funded by the Washington State Office of Financial Management through a grant from the U.S. Department of Health and Human Services’ Health Resources and Services Administration.

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Surgical Procedures in Rural This report addresses rural/urban differences in surgical practices in commonly performed inpatient...

This report addresses rural/urban differences in surgical practices in commonly performed inpatient surgical procedures that are typically handled by general surgeons. National Inpatient Sample data from rural and urban hospitals in 24 states were used to examine the frequency of general surgical procedures, complications during hospitalizations and predicted resource demand.

Findings indicate that rural hospitals concentrated on relatively common, low complexity procedures that can be handled by general surgeons, especially if they have received additional training in obstetrics/gynecology and orthopedics. Resource demand, length of stay, complication rates and mortality were lower for patients undergoing common procedures in rural hospitals. Rural training tracks for general surgery that provide a high case load for common general surgery, obstetrics/gynecology and orthopedics procedures may help sustain the general surgery workforce in rural areas.

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Surgery in Rural/Urban Hospitals Washington State hospital abstracts for 1987 and 1988 with pseudo-personal identifiers added were...

Washington State hospital abstracts for 1987 and 1988 with pseudo-personal identifiers added were used in an analysis of readmission rates for four selected conditions by patient residential and hospital location. During the two-year period examined, there were no significant differences in readmission rates for surgeries performed in rural and urban hospitals. No evidence of low-quality care in Washington State rural hospitals was found when investigating readmission rates following common surgeries.

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Supply and Retention of Rural Surgeons Background: General surgeons form a crucial component of the medical workforce in rural areas of...

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. Aim: To determine the numbers, characteristics, and distribution of general surgeons currently practicing in the rural United States. Methods: The American Medical Association’s Physician Masterfile was used to identify all clinically active general surgeons as well as their location and characteristics. Their geographic distribution was examined using the ZIP code version of the Rural-Urban Commuting Areas (RUCAs). Results: Nationally, the number of general surgeons per 100,000 population 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 were female. General surgeons in the smallest rural areas were more likely than those in urban areas to be male (92.7% versus 88.3%), 50 years of age or older (51.6% versus 42.1%), or international medical graduates (25.2% versus 20.1%). Conclusions: The overall size of the rural general surgical workforce has remained static, but its demographic characteristics suggest that numbers will decline. Many rural residents have limited access to surgical services. This project was funded by HRSA’s FORHP, with the publication Thompson et al. 2005 and Final Report #77 as deliverables.

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Success Factors for AI/AN Medical School Applicants This study surveyed those AI/AN students who applied to the University of Washington School of...

This study surveyed those AI/AN students who applied to the University of Washington School of Medicine over two years to identify the supports and barriers they experienced in the application process, the path they have taken if rejected from medical school, and how their medical school rejection (if rejected) may have affected their plans to enter a health profession.

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State Workforce Planning Techn. Assist. (NGA) Through funding by and collaboration with the National Governors Association (NGA), this project...

Through funding by and collaboration with the National Governors Association (NGA), this project involves providing technical assistance to states that are awarded NGA grants to hold one-day health workforce planning meetings with the state’s leading health policy and program stakeholders. Susan Skillman, Deputy Director of the University of Washington Center for Health Workforce Studies, is working with NGA staff to help grantee states plan and carry out health workforce planning meetings, each with goals and objectives determined by the state.

State health workforce planning technical assistance meetings to-date:
Montana (8/13/13)
Washington (9/5/13)
Colorado (1/7/14)
Kentucky (1/17/14)

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State Rural Health Workforce Monograph The uneven distribution of health care providers across rural and urban areas of the United States...

The uneven distribution of health care providers across rural and urban areas of the United States continues to impede access to care for millions of rural residents. This book profiles that workforce with comparisons of the supply of health professionals across the 50 states and within the rural areas of each state. In addition to individual state workforce profiles, the book includes discussion of key policy and methodological issues in workforce analysis. The data and analysis show that the nature and magnitude of rural health workforce problems vary substantially both across states and within them, suggesting the dangers of “one-size-fits-all” policy solutions. This book provides a picture of the rural health workforce that will serve analysts and policy makers well as they search for workable solutions to the problem of inadequate supply of health care providers in rural America. Funded by HRSA’s FORHP.

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Staffing of Rural Hospital ERs All 37 rural Washington State hospitals with less than 100 beds were surveyed to determine how...

All 37 rural Washington State hospitals with less than 100 beds were surveyed to determine how rural emergency departments were staffed by physicians and to estimate rural hospital payments for these services. Study data were collected through telephone interviews with hospital administrators or directors of nursing services. Results indicated that 86% of rural hospitals contracted for emergency department coverage and 59% obtained some or all of this service from nonlocal physicians.

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Specialty Care for Rural American Indians Background: The Indian Health Service (IHS) expenditure for American Indian and Alaska Native...

Background: The Indian Health Service (IHS) expenditure for American Indian and Alaska Native (AI/AN) health services is less than half that spent per year on the U.S. civilian population. Many AI/ANs, especially in rural areas, depend on the IHS as their only source of funding for health care. Specialty services may be limited by a low level of contract funding. Aim: To examine access to specialty services among rural AI populations. Methods: A mail survey addressing access to specialty physicians, perceived barriers to access, and access to nonphysician clinical services was sent to primary care providers in rural Indian health clinics in Montana and New Mexico and primary care providers in rural non-Indian clinics within 25 miles of the Indian clinics. Results: Substantial proportions of rural Indian clinic providers in Montana and New Mexico reported fair or poor access to nonemergent specialty services for 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 most frequently cited financial barriers to specialty care. Indian clinic providers in both states reported better access to several nonphysician services than non-Indian clinic providers. Conclusions: Access to specialty care for rural Indian patients is limited, and is influenced by the organization of care systems and financial constraints. Funded by HRSA’s FORHP.

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Snapshot: RNs in Washington 2001, 2006, 2007, 2008, 2011, 2013, 2014 Demographic and employment characteristics of registered nurses (RNs) in Washington State are...

Demographic and employment characteristics of registered nurses (RNs) in Washington State are described in these snapshots of data from the state health professionals licensing and renewal survey database. Funded by the Washington Center for Nursing through a Department of Health grant.

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Snapshot: Pharmacists in Washington Demographic and employment characteristics of pharmacists in Washington State are described in this...

Demographic and employment characteristics of pharmacists in Washington State are described in this snapshot of data from the 1999 state health professionals licensing and renewal survey database. Funded by HRSA, National Center for Health Workforce Analysis.

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2018 Licensed Practical Nurses in Washington: Snapshot of Demographics and Employment Characteristics Demographic and employment characteristics of licensed practical nurses (LPNs) in Washington State...

Demographic and employment characteristics of licensed practical nurses (LPNs) in Washington State are described in these snapshots of data from analyses of the state health professionals licensing and renewal survey database. Funded by the Washington Center for Nursing through a Department of Health grant.

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Snapshot: ARNPs in Washington 2006, 2007, 2008, 2011, 2013, 2014 The number, geographic distribution, age, and gender of advanced registered nurse practitioners...

The number, geographic distribution, age, and gender of advanced registered nurse practitioners (ARNPs) in Washington State are described in these snapshots of data from the state health professionals licensing and renewal survey database. The reports also show changes in these characteristics since 1999. Funded by the Washington Center for Nursing through a Department of Health grant.

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Rural/Urban Obstetrical Care Quality Washington State vital statistics data from 1984 through 1988 were used to investigate differences...

Washington State vital statistics data from 1984 through 1988 were used to investigate differences in the process and outcome of obstetrical care based on the rural/urban locations of the mothers’ residences. This study compared rural and urban obstetrical care in terms of mortality, trimester prenatal care began, adequacy of the number of prenatal visits, and birthweight. Separate analyses (1) differentiated between rural mothers who delivered in rural locations and those that delivered in urban locales and (2) partitioned low and non-low risk women.

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Rural/Urban Generalists This two-year project used Medicare data provided by HCFA to describe the content of practice of...

This two-year project used Medicare data provided by HCFA to describe the content of practice of physicians in rural and urban areas of Washington State. The population studied included board-certified physicians in the 12 largest ambulatory medical specialties in Washington State who were in active medical practice in 1994 and who provided ambulatory care to at least ten Medicare patients per year during that period. The diagnostic and procedural breadth of rural and urban physicians in all specialties was found to be similar, with the exception of rural general surgeons and obstetrician-gynecologists, who were more likely to care for patients outside their specialty area. Funded by HRSA’s ORHP.

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Rural U.S. Perinatal Health This study examined perinatal outcomes in rural areas across the United States in 2005. Low birth...

This study examined perinatal outcomes in rural areas across the United States in 2005. Low birth weight, a key indicator of the health of the U.S. population, and adequacy of prenatal care, a critical indicator of access and quality of health care, were explored to discover how they are related to rural or urban location, race, and ethnicity.

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Rural RNs' Choice of Work Location While larger numbers of registered nurses (RNs) are living in rural areas, research from the WWAMI...

While larger numbers of registered nurses (RNs) are living in rural areas, research from the WWAMI RHRC shows that since 1980, a growing percentage are commuting from rural residences to work within urban and larger rural cities. This study explored factors that may be associated with RNs’ decisions to commute away from their rural areas of residence to work in less rural areas. Funded by HRSA’s ORHP.

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Rural RNs in the U.S.: 2000 This study used data from HRSA's 2000 National Sample Survey of Registered Nurses (NSSRN) to...

This study used data from HRSA’s 2000 National Sample Survey of Registered Nurses (NSSRN) to compare RNs in urban areas of the United States with nurses in three categories of rural areas. The study examined rural and urban RNs’ demographic characteristics, educational backgrounds and employment characteristics. It also explored whether the characteristics of nurses in more isolated rural areas differ from those in other rural areas, and whether education and employment patterns are consistent across regions of the United States. Funded by HRSA, National Center for Health Workforce Analysis.

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Rural Primary Care Workforce This two-year study will survey 10,000 rural primary care physicians, advanced practice nurses...

This two-year study will survey 10,000 rural primary care physicians, advanced practice nurses (APNs), and physician assistants (PAs) in 13 states to examine provider demographics, rural location type, practice type and arrangement, whether located in a primary care HPSA, history of rural practice, and practice autonomy. APNs likely to delivery primary care will be identified through state licensure records. A stratified random sample of actively practicing primary care physicians, APNs, and PAs with rural ZIP codes will be drawn from state licensure data to obtain an overall sample that is approximately representative of the rural United States (totaling 4,000-5,000 providers). The study will assess the total contribution to rural outpatient primary care made by each of these professions; how they vary by region of the country, degree of rurality, and practice autonomy; what the roles are of these provider types in offering primary care in rural primary care HPSAs; and what the role is of each provider type in inpatient care and after-hours call coverage. Obtaining accurate estimates of rural primary care productivity and scope of practice will help determine the relative contribution of different provider types, clarify workforce solutions, and guide training and recruitment/retention efforts.

In Progress
Rural Physicians Waivered to Treat Opioid Addiction Unintentional drug overdose deaths associated with prescription opioids rose 395% between 1999 and...

Unintentional drug overdose deaths associated with prescription opioids rose 395% between 1999 and 2007, and opiate misuse among adolescents is now twice as common as in the 1990s. Because methadone maintenance clinics are largely non-existent in rural areas, an effective alternative is training physicians in the use of buprenorphine, an effective addiction treatment that can be administered in outpatient practices. This study will determine the extent to which a trained workforce exists in rural America that has received the necessary waiver to treat opioid addiction in outpatient settings with buprenorphine, identifying areas with critical shortages and discussing policy options for expanding the supply of these qualified providers. Funded by HRSA’s Office of Rural Health Policy.

In Progress
Rural Physician, NP, PA Impact This WWAMI RHRC study will explore how many nurse practitioners (NPs), physician assistants (PAs),...

This WWAMI RHRC study will explore how many nurse practitioners (NPs), physician assistants (PAs), and physicians will be required to meet rural health care demand resulting from expanded access to health insurance through implementation of the Affordable Care Act (ACA). The study will also describe the ACA’s impact on types of primary care services that would be available under different provider mix scenarios. The study’s analyses will use simulated rural primary care demand data and rural primary care NP, PA, and physician productivity data from recent research by the WWAMI RHRC. Funded by HRSA’s Office of Rural Health Policy.

In Progress
Rural Pediatric Inpatient Care This study described the distribution of rural practitioners in Washington State who provide...

This study described the distribution of rural practitioners in Washington State who provide inpatient care to pediatric patients, elucidated the major diagnostic categories for which children are hospitalized in rural versus urban areas, contrasted the roles of pediatricians and family physicians providing pediatric care, and assessed the effectiveness of the system. The major source of data for this study was CHARS, which was linked to information on the training and discipline of the providers who cared for each of the patients in the study. Funded by HRSA’s ORHP.

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Rural Obstetrical Technology This study compared the approach to neonatal care in Wales and Washington State, studying the...

This study compared the approach to neonatal care in Wales and Washington State, studying the extent of perinatal regionalization, the distribution of neonatal technologies, and birthweight-specific neonatal outcomes. In Wales, most District General Hospitals (DGH) had all the neonatal equipment recommended for a maximal neonatal intensive care unit, whether or not the DGH was a designated regional or subregional center. Sophisticated neonatal technology in Washington was concentrated in designated referral hospitals. Almost every Welsh DGH cared for infants weighing less than 1,000 grams at birth, while in Washington State most very-low-birthweight neonates were born in referral centers and the few born elsewhere were transferred immediately after birth. Despite differences in the extent of regionalization, birthweight-specific neonatal mortality rates were similar in the two countries.

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Rural NSSNP Analysis This WWAMI RHRC study uses data from HRSA's first National Sample Survey of Nurse Practitioners...

This WWAMI RHRC study uses data from HRSA’s first National Sample Survey of Nurse Practitioners (NSSNPs) to expand on the agency’s basic descriptive analyses of rural and urban nurse practitioners (NPs). The study compares rural and urban NPs’ demographics, education, practice, and related characteristics; and estimates basic NP labor supply models. Funded by HRSA’s Office of Rural Health Policy.

In Progress
Rural Medicine Textbook This book explores what is known about the content, needs, and special problems of rural health...

This book explores what is known about the content, needs, and special problems of rural health care. The goal was to advance the knowledge base and describe strategies used by rural health professionals in developing quality of care for rural communities and their residents. The book includes an overview of rural health care, special clinical problems and approaches in rural health care, the organization and management of rural health care, approaches to quality improvement, and education for rural practice.

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Rural Issues and Health Reform Health care reform provides an array of opportunities to improve health care access and quality for...

Health care reform provides an array of opportunities to improve health care access and quality for rural Americans. The WWAMI RHRC will support HRSA’s efforts to inform this process by summarizing existing evidence characterizing the rural health care workforce and rural health care delivery and will conduct analyses exploring the potential impact on rural populations of proposed and newly-enacted health care reform legislation. Funded by HRSA’s ORHP.

In Progress
Rural Hospital Surgical Capacity This study examined the availability of several elective and urgent surgical procedures at rural...

This study examined the availability of several elective and urgent surgical procedures at rural hospitals, identified the specialties of rural surgery and anesthesia providers, and determined where rural residents obtained surgical services and how the utilization of services is influenced by the presence of local services. Data were obtained from telephone interviews with hospital administrators, directors of nursing services, and/or operating room charge nurses. Washington State complete hospital discharge data provided the number of selected and aggregate procedures for each hospital by diagnosis and procedure codes, as well as hospital reimbursement for surgical procedures.

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Rural Hospital Project The Rural Hospital Project (RHP) assisted six threatened rural hospitals in the WAMI region through...

The Rural Hospital Project (RHP) assisted six threatened rural hospitals in the WAMI region through a multifaceted approach to addressing their problems and strengthening health services. Subsequently, the RHP interventions were applied through a Community Health Services Development Model to other rural hospitals throughout the regional Area Health Education Centers (AHECs). This study examined the process of exporting the interventions from a university-based demonstration project to a community-based program disseminated by the AHECs.

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Rural Hospital Linkages Linkage refers to a rural hospital's formal and informal associations with outside entities (e.g.,...

Linkage refers to a rural hospital’s formal and informal associations with outside entities (e.g., joint purchasing arrangements and inter-hospital networks). This study (1) provided a descriptive analysis of rural hospital linkages in the WAMI states based on a literature review and key informant interviews, (2) determined how governmental regulations influence such linkages, and (3) performed case studies on two rural health care alliances located in different regions and formed 13 years apart.

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Rural Hospital Governing Boards Part C Background: Little research has been conducted to describe the factors and practices associated...

Background: Little research has been conducted to describe the factors and practices associated with the effectiveness of rural hospital governing boards. Aim: To identify activities and characteristics of the governing boards of small rural hospitals that are related to hospital success. Methods: We surveyed 89 rural hospital board chairs in Washington, Alaska, and Idaho about how they spent their time and how they were organized. We asked experts familiar with 74 hospitals with less than 100 beds to rate them in several key areas. Results: The eight activities of boards associated with “strong” hospitals included: one or more board retreats per year, annual review of mission and goals, lower percentage of time monitoring budget, use of board committees, clear recruitment plan to attract desirable board members, funds for continuing education of board members, owned or leased ownership, and larger hospital average daily census. In addition, the “strong” hospitals were found to have higher daily census than the “weak” hospitals (higher among hospitals with less than 100 beds). Conclusions: As long as the governance of rural hospitals is in the hands of volunteer boards, researchers and policy makers should assist these boards in identifying the most efficient and effective ways for them to spend their limited time and resources. Funded by HRSA’s ORHP.

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Rural Hospital Governing Boards Part B Background: To provide competent membership, a board member needs knowledge of health care...

Background: To provide competent membership, a board member needs knowledge of health care developments and the organization of the board. Aim: To provide information on the knowledge level of governing board members in hospitals in three northwestern states. Methods: This study included 130 hospitals with individual governing boards in rural areas of Alaska, Idaho, and Washington. As part of a larger survey of all rural hospital board members in these states, we asked board members questions relevant to competent membership on a governing board. This included questions concerning quantifiable aspects of the hospitals, planning, and financial reporting. Results: Knowledge on the part of the board members was strongest in the areas of the role of the governing board, planning, and scope of services. Board members were less able to quantify the capacities and utilization of services at their hospitals. Results were mixed in the area of knowledge of financial management. Length of service on the board and efficient board structures were associated with increased knowledge. Conclusions: While board members were knowledgeable about their roles and the services offered by their hospitals, their knowledge base in certain other crucial areas was limited, underscoring the need for programs that facilitate board member training. Funded by HRSA’s ORHP.

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Rural Hospital Governing Boards Part A Background: Literature about rural health providers has focused largely on physicians, mid-level...

Background: Literature about rural health providers has focused largely on physicians, mid-level providers, and hospitals and their administrators, but little has been written about the boards that govern those hospitals. Aim: To describe the role and composition of rural hospital governing boards. Methods: Hospitals in Washington, Alaska, and Idaho were included in this study. Surveys related to hospital governance were administered to rural hospital board members and board chairpersons of urban and rural hospitals. Results: Board members were typically white males over the age of 50 and retired. They served an average of seven years and most typically brought business and management expertise to their positions. Board members contributed more than a dozen hours per month to board business and attended about 90% of their board and committee meetings. Fewer than one in four rural hospital board chairs indicated his or her board had a formal recruitment program, and fewer than half of the boards spent more than three hours on board member orientation. Board chairs were more likely to rate highly the performance of other community leaders, as well as members of the medical staff. Conclusions: Boards are attracting the service of individuals who are well educated, experienced, and willing to contribute more than a dozen hours a month to their board service. However, small rural boards are not investing enough time and funds in orientation and training. Funded by HRSA’s ORHP.

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Rural Hospital CEO Turnover This study described the tenure, rate of and reasons for turnover of hospital administrators, and...

This study described the tenure, rate of and reasons for turnover of hospital administrators, and tracked the career trajectories of rural hospital administrators. The study was performed in partnership with the WAMI Area Health Education Center and the Washington State Hospital Association. Resumes from all Washington State hospital administrators contrasted the education and professional backgrounds of rural and urban administrators. A survey of all regional rural hospital administrators who left their position during the past three years provided information on hospital characteristics, reasons that they left, effects on the hospital and community, evaluation of their performance, and gaps in training. Questionnaires were sent to a hospital board member in the same community to ascertain why the administrator left, consequences of the departure, and adequacy of the administrator’s performance.

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Rural Hospital Care for Acute Myocardial Infarction: 2000-2001 This project examined whether overall improvements in the quality of care for acute myocardial...

This project examined whether overall improvements in the quality of care for acute myocardial infarction (AMI) among Medicare patients occurred in both rural and hospital settings. It used the Cooperative Cardiovascular Project Database and a database of measures of clinical performance, and included in the sample those Medicare beneficiaries with an AMI who were directly admitted for AMI care. Funded by HRSA’s ORHP.

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Rural Hospital Anesthesia Services Key to the ability of rural hospitals to maintain a surgery service is the availability of...

Key to the ability of rural hospitals to maintain a surgery service is the availability of anesthesia personnel, yet anecdotal evidence indicates that their supply is limited and their salary costs are high. This study surveyed administrators from rural hospitals in Washington and Montana regarding their experience in recruiting and retaining nurse and physician anesthetists. Aspects of anesthesia coverage such as financial arrangements, professionals working at multiple sites, outpatient and inpatient surgery, inter-provider type professional rivalries, and licensure constraints were examined. Funded by HRSA’s ORHP.

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Rural HIT Workforce Needs The goal of this study is to improve understanding of health information technology (HIT) workforce...

The goal of this study is to improve understanding of health information technology (HIT) workforce needs and constraints in rural primary care settings. This study will determine rural primary care practices’ current and projected level of electronic health record (EHR) and health information technology (HIT) adoption and estimate demand for workers with HIT skills. This study will survey a stratified sample (large and small rural areas) of approximately 1,600 rural primary care practices across the U.S. The questionnaire will assess EHR and HIT implementation at the facility level; their relative need for different components of the HIT workforce; and whether they train and develop HIT staff from within, hire new staff, employ consultants, and/or join forces with other institutions to fill these workforce needs. We will include questions about the institutions’ current HIT workforce, expected future demand, education and training resources available to the institution and its staff, and other workforce-related factors that support or impede the practices’ implementation and use of HIT. Our descriptive analyses will produce national rural and sub-rural estimates of findings. The study will also identify relationships between specific practice attributes and HIT workforce variables. Funded by HRSA’s Office of Rural Health Policy.

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Rural Health Policy Briefs University of Washington WWAMI RHRC researchers prepared four policy briefs in late Spring 2009 to...

University of Washington WWAMI RHRC researchers prepared four policy briefs in late Spring 2009 to inform policymakers about potential solutions to health workforce crises in rural America. The briefs address rural health workforce issues in general surgery, nursing, primary care, and dentistry.

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Rural FLEX Program In 1997, the U.S. Congress created the Rural Hospital Flexibility Program (Flex Program) as part of...

In 1997, the U.S. Congress created the Rural Hospital Flexibility Program (Flex Program) as part of the Balanced Budget Act (BBA). This program provides for cost-based reimbursement under Medicare to eligible small, relatively remote hospitals. A companion grant program supports state emergency medical services systems (EMS) and hospital participation in the program. The reimbursement component is the responsibility of the Center for Medicare and Medicaid Services (CMS), while the grant program is the responsibility of the Federal Office of Rural Health Policy (FORHP). Funding to support the monitoring efforts of the Flex Program Tracking Team was provided under the grant program appropriation. The Tracking Team was a consortium of six rural health research centers. Each Center had lead responsibility for several research components of the study. In 2002/2003, the WWAMI Rural Health Research Center took responsibility for assessing state program evaluations, evaluating a number of workforce issues faced by critical access hospitals (CAHs, and looking at the intersection of CAHs) and another federal program, the Mississippi Delta Hospital Performance Improvement Initiative. WWAMI also provided overall project direction and coordination to the participating centers. The main national goals for implementation of the grant component of the Flex Program in the states and participating hospitals included (1) preparing a state rural health plan, (2) converting eligible and willing hospitals to critical access hospital (CAH) status, (3) improving quality of care, (4) promoting networking among hospitals, and (5) improving emergency medical services.

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Rural Family Practice Residency Programs Chartbook This chartbook makes previously unreported information from our national survey of 453 FP residency...

This chartbook makes previously unreported information from our national survey of 453 FP residency directors available to medical educators and policy makers. As part of this survey, programs were asked to indicate the extent to which training rural physicians was part of their core mission and to specify where all residency training sponsored by their programs took place. Using the Rural-Urban Commuting Areas (RUCAs), the ZIP codes of these locations allowed us to determine the relative rurality of all U.S. family practice residency training. The chartbook presents national, regional, state, and division findings, presented by type of geography (i.e., isolated small rural, small rural, large rural, and urban), type of rural training experience (i.e., model family practice clinic, block rotations, rural training tracks, and continuity clinics), and other residency characteristics. Funded by HRSA’s ORHP.

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Rural Family Planning Services Considerable controversy exists about the types of family planning services that should be...

Considerable controversy exists about the types of family planning services that should be available in rural areas. This study constructed an inventory of family planning services available in rural Idaho, determined the factors associated with observed variations in the range of available services, and examined the policy implications of the findings. A questionnaire was sent to physicians who were the potential providers of such services to determine service volumes and access issues.

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Rural Family Medicine Residency Training Master File Little is known about how well various types of rural-focused family medicine residency training...

Little is known about how well various types of rural-focused family medicine residency training programs, particularly osteopathic residencies, produce physicians for rural practice. This study expands current work by the WWAMI RHRC to establish a comprehensive database of rural-focused family medicine residency training programs. We will use this database to create a typology of rural-focused family medicine training and evaluate program graduates’ outcomes and the success of different program models. This study is funded by HRSA’s Office of Rural Health Policy.

In Progress
Rural Family Medicine Residency Survey Follow-Up This two-year project updated an earlier WWAMI RHRC study of family medicine residency training in...

This two-year project updated an earlier WWAMI RHRC study of family medicine residency training in rural areas of the United States. In 2000 we conducted a national survey of all family medicine residency training programs in the nation to identify the type and extent of residency training that actually took place in rural locations. This study administered a follow-up mail survey to all family medicine residency training programs (about 440) using an instrument that was modified slightly to add a few key questions. This allowed us to examine changes since 2000 in the number of programs located in rural places, the nature of these programs, funding sources and staff configurations, as well as the amount of time that training takes place in federally funded health centers and other types of facilities.

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Rural EMS Workforce Rural populations frequently reside great distances from hospital emergency departments or urgent...

Rural populations frequently reside great distances from hospital emergency departments or urgent care facilities, underscoring the need for timely and effective pre-hospital emergency medical services (EMS). Numerous reports and anecdotal evidence indicate that rural EMS agencies face significant resource challenges in terms of sustainable funding, staff recruitment and retention, and staff skill maintenance. Reliable data to quantify the extent of these problems have been lacking. This project aims to quantify systematically workforce supply and demand disparities between rural and urban EMS systems in a sample of states distributed across the U.S. Study results will inform policy options to ensure an adequate supply of EMS personnel in rural areas. This study will analyze secondary data collected via a 2008 telephone survey of all ground-based pre-hospital EMS providers in nine states. Analyses of EMS agency service area coverage, patient volume, funding basis, organizational type, staffing, vacancies, and medical direction will yield statistical comparisons between urban and three subcategories of rural areas. Findings on rural-urban EMS resource distribution will also be displayed in maps for each state. Funded by HRSA’s Office of Rural Health Policy.

In Progress
Rural Emergency Medical Services This study retrieved data on every vehicular injury accident occurring in Okanogan County,...

This study retrieved data on every vehicular injury accident occurring in Okanogan County, Washington, in 1990. Information was collected on location of accident, type and severity of injury, initial pre-hospital response, initial transportation, involvement of local health care system, transfer to facility outside county, patient outcomes, and demographics. The study included (1) a description of the type and nature of crashes and injuries and the involvement of local and distant components of the EMS, (2) an examination of the extent to which the existing rural EMS is regionalized, and (3) policy-oriented recommendations.

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Rural Definitions We published an article entitled "Rural Definitions for Health Policy and Research" in the American...

We published an article entitled “Rural Definitions for Health Policy and Research” in the American Journal of Public Health in which we describe and compare various rural and urban taxonomies that were in use, describing their characteristics, strengths, and weaknesses depending on the purpose at hand.

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Rural Definition Reclassification This project created a ZIP-code approximation of the census tract-based Rural-Urban Commuting Area...

This project created a ZIP-code approximation of the census tract-based Rural-Urban Commuting Area (RUCA) codes.

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Rural Capacity for Family Physicians This paper addresses the ability of smaller and underserved rural communities to financially...

This paper addresses the ability of smaller and underserved rural communities to financially support needed physicians. We used Washington State data to test the feasibility of constructing physician income potential models. The total spending for primary care physicians was estimated using age-sex-poverty status coefficients from the National Medical Expenditure Survey, supplemented by unique Part B Medicare data on the proportion of rural physician revenue from non-office based services. Community size and the distance to other cities and towns were crucial determinants of market share and thus the capacity of small towns to attract and support primary care practices. The distribution of physicians among towns followed predicted economic potential. That potential varied dramatically even among towns with similar populations due to the pull of competing locations for primary care. Surprisingly, the types of rural communities most likely to have fewer physicians than suggested by the projected potential were not small isolated towns, but larger communities with above-average population growth, closer proximity to metropolitan areas and somewhat lower average family incomes. Strategies such as the National Health Service Corps use a one-time “signing bonus” to overcome physicians’ initial reluctance to locate in an underserved area. An alternative approach is to address long-term income disadvantages by offering continuous subsidies such as the enhanced Medicare payments for certified Rural Health Clinics or the 10% Medicare supplemental payments for care provided in a HPSA. Funded by HRSA’s ORHP.

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Rural C- Sections This project provided information on how physician training, community specialty mix and other...

This project provided information on how physician training, community specialty mix and other factors are related to the provision of c-sections in rural communities. We examined the percentage of the c-sections performed on rural service area residents that were done in small rural hospitals, whether family physicians did most of these procedures in rural hospitals where there are no obstetricians, their competence in performing c-sections, and factors associated with their performance of this procedure. Data were obtained through Computerized Hospital Discharge Database (CHARS) inpatient hospital abstracts supplemented by a telephone survey of all Washington State rural hospitals and a mail survey of rural physicians. Funded by HRSA’s ORHP.

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RUCA Development & Description The Rural-Urban Commuting Areas (RUCAs) were developed at the WWAMI RHRC in collaboration with, and...

The Rural-Urban Commuting Areas (RUCAs) were developed at the WWAMI RHRC in collaboration with, and with support from, HRSA’s ORHP and the Department of Agriculture. The RUCAs are a census tract-based classification scheme that utilizes the standard Bureau of Census Urbanized Area (UA) and Urban Place (UP) definitions with commuting information to characterize the nation’s Census tracts regarding their rural and urban status and relationships. The codes are based on whether a Census tract is located in a UA or UP and on the destination of its largest and second largest commuting flows. This project (1) produced and described the base 1998 demography of the RUCA code areas, (2) created quality state maps of the RUCA codes, and (3) has made this information and the codes easily available on the Web. The demographic description of the RUCA codes involved standard cross-tabulation analysis of the code areas nationally, regionally, and by state. Technical notes and maps are posted at Complete

RTT Technical Assistance Program This project is building a national partnership between professional groups, academic units,...

This project is building a national partnership between professional groups, academic units, governmental entities, and sustaining organizations to provide ongoing support and technical assistance to community-embedded rural health professions education. The project is (1) establishing a network of organizations and experts by visiting Rural Training Tracks (RTTs), creating RTT-state office of rural health coalitions, and convening stakeholder meetings; (2) building a Web portal with a virtual library of tools, information, and access to technical assistance; (3) developing new models and programs while sharing best practices; (4) initiating a process for identifying and training new leaders; and (5) publishing a final report. Under the NRHA umbrella and anchored by project directors and field offices in Idaho, Ohio, and Washington DC, the program is connecting RTT program directors, faculty, and staff with state offices of rural health, a rural assistance center, and a rural research center to bolster existing RTTs, foster new programs, and utilize community expertise in identifying systemic issues and remedies. While focused on rural medical education, the network will provide a model for community-embedded training and an infrastructure for training other rural health professions. UW WWAMI RHRC researchers are designing and maintaining a research data set and protocol for RTT site visits, including consents and IRB approval. The RHRC is the repository of these data-gathering efforts and will analyze and synthesize data underpinning reports and other dissemination activities. The RHRC is sharing data and coordinating its effort with the Graham Center in Washington DC to promote policy development, and assisting in the preparation of a final evaluation and report of this demonstration program.

In Progress
Family Physicians Choosing Rural Practice This project will survey physicians trained in rural-centric family medicine residencies to...

This project will survey physicians trained in rural-centric family medicine residencies to understand the characteristics, experiences, and attitudes that influenced their rural or urban practice choices. Understanding the factors that determine practice choices of RTT graduates can help improve recruitment of residents who will ultimately fulfill RTTs’ mission of preparing family physicians for rural practice.

In Progress
Retention of NHSC Recipients This study examined the retention and distribution of the 6,300 NHSC allopathic physician...

This study examined the retention and distribution of the 6,300 NHSC allopathic physician scholarship recipients graduating from medical schools for the years 1975 through 1983. The roster of these scholarship recipients was linked with American Medical Association data to provide information on their location, specialty, and practice status. Recipients were examined in terms of their propensity to remain in their original ZIP code, county, state, and rural/urban status location. In addition, their locational patterns were compared to other graduates. Recipients’ specialty, type of practice, and NHSC length of obligation were also evaluated.

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Retail Pharmacies in Washington This study surveyed retail pharmacies in Washington to estimate the demand for pharmacists,...

This study surveyed retail pharmacies in Washington to estimate the demand for pharmacists, pharmacy technicians and administrative/clerical staff in the state. The survey also provided data to describe the impact of implementation of the Health Insurance Portability and Accountability Act (HIPAA) on retail pharmacies. Funded by HRSA, National Center for Health Workforce Analysis, through a Congressional Appropriation to the UW CHWS.

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Recruitment of Rural Women Physicians This study examined differences in the factors female and male generalist physicians considered...

This study examined differences in the factors female and male generalist physicians considered influential in their rural practice location choice and identified the practice arrangements that successfully recruited female generalist physicians to rural areas. We mailed questionnaires to generalist physicians recruited between 1992 and 1999 to towns of 10,000 or less in six states in the Pacific Northwest. Compared to men, recruited women were younger, less likely to be married, had fewer children, and worked fewer hours. Women were more likely than men to have been influenced by issues related to spouse/personal partner, flexible scheduling, family leave, and availability of child care, as well as the interpersonal aspects of recruitment. Commonly reported themes reflected the desire for flexibility regarding family issues and the value placed on honesty during recruitment. Men and women were equally likely to consider community factors, practice content, practice partner compatibility, and financial issues. The most common methods for obtaining information about practice opportunities were personal networking, prior training experience, recruiters, and outreach by medical practices. This study concluded that rural communities and practices recruiting physicians should place high priority on practice scheduling, spouse/partner, and interpersonal issues if they want to achieve a gender-balanced physician workforce. Funded by HRSA’s ORHP.

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Recruiting American Indians/Alaska Natives into Medicine Understanding the factors that support recruitment and retention of American Indian and Alaska...

Understanding the factors that support recruitment and retention of American Indian and Alaska Native (AI/AN) health professionals is crucial in increasing the supply of health professionals most likely to serve the AI/AN population. To that end, project investigators have conducted a study to identify the factors that promote the recruitment and retention of AI/ANs into medicine. The study interviewed AI/AN medical students enrolled at the University of Washington. Funded by HRSA, National Center for Health Workforce Analysis.

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Radiation Therapy in Rural U.S. This study used cancer registry data from 10 U.S. states to examine which rural cancer patients...

This study used cancer registry data from 10 U.S. states to examine which rural cancer patients received recommended radiation therapy and what factors influenced receipt of recommended treatment. Identifying gaps in radiation therapy will inform cancer centers, rural program planners, and policy makers in rural cancer service location and cancer support program development. Funded by HRSA’s ORHP.

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Quality of Rural Perinatal Care The equitable provision of high-quality obstetric care is a major priority of our health care...

The equitable provision of high-quality obstetric care is a major priority of our health care system, and nowhere is access to such care more threatened than in rural areas. This project determined whether rural mothers receive less care and experience worse outcomes than their urban counterparts, whether racial and ethnic minorities living in rural areas experience different outcomes than their counterparts, and what other factors are associated with less care and poorer outcomes. Data were compiled from the National Center for Health Statistics’ Linked Birth/Death set and the Bureau of Health Professions’ Area Resource File. Measures of process of care included late or no prenatal care, lack of care in the first trimester, and inadequate care as measured by the Kotelchuck Index. Outcome measures included infant mortality and the percentage of children born at low and very low birthweight. This study also compared birth outcomes and process of care for minorities across rural areas and with their urban counterparts. Funded by HRSA’s ORHP.

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Prostate Cancer Treatment in Rural This research will use cancer registry data from 10 states to examine the degree to which rural...

This research will use cancer registry data from 10 states to examine the degree to which rural residents diagnosed with early-stage prostate cancer access the full range of surveillance, surgical, and radiation treatment options. Study findings will inform cancer centers, advocacy groups, rural program planners, and policymakers about services and programs needed to ensure that rural prostate cancer patients can choose from among all treatment options.

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Programs Producing Rural Physicians This national study used longitudinal data on medical school specialty and practice location choice...

This national study used longitudinal data on medical school specialty and practice location choice to determine the extent to which the nation’s medical schools and residency programs varied in their production of rural physicians. This facilitated the identification of medical school and residency program characteristics associated with the highest yield of rural physicians. Funded by HRSA’s ORHP.

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Programs Producing Rural PAs Physician assistants (PAs) are an important part of the rural health workforce, and their roles are...

Physician assistants (PAs) are an important part of the rural health workforce, and their roles are expected to grow. While PAs are more evenly distributed across the rural-urban continuum than physicians, long-term trends of medical specialization, increasing cost of training, and demographic change in the PA workforce have contributed toward decreasing PA participation in rural and primary care. This study will identify the PA training programs that are most successful at producing graduates who practice in rural areas, focusing particularly on PAs who graduated from training in the past ten years. Funded by HRSA’s Office of Rural Health Policy.

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Problem Drinking Among Rural Veterans This study will use national data to measure recent trends in problem drinking among VA-eligible...

This study will use national data to measure recent trends in problem drinking among VA-eligible adults in rural and urban locations and couple these data with the locations of VA services and substance abuse treatment facilities to identify rural locations where alcohol treatment services are limited. This project is funded by the Veterans Administration Office of Rural Health, through a contract with the northwest Portland, Oregon, Veterans Affairs Medical Center.

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Primary Care Trends This project critically reviewed the recent waning of primary care and its implications for rural...

This project critically reviewed the recent waning of primary care and its implications for rural populations. The paper chronicled historical changes and trends, put these changes in the larger health care system context, and concluded with a set of policy recommendations that detail options available to policy makers and leaders of the nation’s medical educational establishment.

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Practice Locations of Women Physicians While women are becoming an increasingly large percentage of the graduates of medical schools and...

While women are becoming an increasingly large percentage of the graduates of medical schools and of the generalist specialties in particular, they are much less likely to locate their practices in rural towns. If this trend were to persist, implications for access to care in rural areas would be substantial. This study involved a survey including questions about where the residents preferred to locate and how much they thought they would be practicing in the future. The study first examined national physician location patterns by medical school graduation cohort per gender differences. The second phase dealt with the production of female generalist physicians by medical schools. Funded by HRSA’s ORHP.

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Policy Activities of AMCC The AMCC is an ad hoc group composed primarily of private obstetrical providers and representatives...

The AMCC is an ad hoc group composed primarily of private obstetrical providers and representatives of state government responsible for the delivery of health care to women and children. The major objective of AMCC is to improve access to obstetrical care for socially vulnerable women. The committee successfully served as a forum in which to resolve administrative problems arising between private obstetrical providers and the state’s Medicaid program and was influential in persuading the state legislature to increase Medicaid eligibility, raise provider reimbursements, and improve social services to pregnant women.

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Physician Residency Rural Training The supply of rural physicians is in part determined by the number of family physicians who receive...

The supply of rural physicians is in part determined by the number of family physicians who receive residency training in rural areas. This study explored what proportion of all family medicine residency experience actually takes place in rural areas in the United States. Questionnaires were mailed to all 453 civilian family practice residencies in the United States in 2000. Programs were asked to indicate the extent to which training rural physicians was part of their core mission and to specify where all residency training sponsored by their programs took place. Using the Rural-Urban Commuting Areas, the ZIP codes of these locations allowed us to determine the relative rurality of all U.S. family practice residency training. Only 33 family medicine residency programs (7.4%) were located in rural areas. Most of the training sponsored by these rural programs occured in rural areas. Although over one-third of the urban programs listed rural training as an important part of their mission, only 2.3% of the training they supported took place in rural areas. For the nation, 7.5% of family medicine residency training occurred in rural areas, although 22.3% of the U.S. population lives in rural places. This study concluded that very little family medicine residency training actually took place in rural areas. To the extent that there was a link between the place of training and future practice, the lack of rural training contributed to the shortage of rural physicians. Funded by HRSA’s ORHP.

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Physician Assistant Workforce Trends This study described the historical development of the physician assistant (PA) profession since...

This study described the historical development of the physician assistant (PA) profession since 1967, with special emphasis on the demography of the PA population, the PA regulatory environment, the evolution of specialty roles, the emergence of practice location patterns, and the contribution by PAs to primary care for rural and underserved populations. The study used data from the American Academy of Physician Assistants, supplemented with data from secondary data sources such as the Area Resource File and an extensive review of the health services literature on PAs. Funded by HRSA, National Center for Health Workforce Analysis.

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Physician Assistant Productivity This 2000 study described the range of productivity in various practice settings as reported by a...

This 2000 study described the range of productivity in various practice settings as reported by a nationally representative sample of physician assistants (PAs) and determined the accuracy of counts of PAs, rather than FTEs, when estimating generalist shortage areas. Funded by HRSA, National Center for Health Workforce Analysis.

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Physician Access for Rural Elderly Patients in rural areas may utilize less medical care than urban patients because of differences...

Patients in rural areas may utilize less medical care than urban patients because of differences in travel distance and time and a utilization of a different mix of generalists and specialists for their care. This study compared travel times, distances, and physician specialty mix of Medicare patients in Alaska, Washington, North Carolina, South Carolina, and Idaho. We used a retrospective design, utilizing 1998 Medicare billing data. Travel time was determined by computing the road distance between the patient’s and the provider’s ZIP codes. There were 39,780 providers in the cohort: 16.1% generalists, 62% specialists, and 21% nonphysician providers. The median overall one-way travel distance and time was 7.7 miles and 11.7 minutes. Rural residents traveled two to three times farther to see medical and surgical specialists than urban residents. Rural residents with cancer, heart disease, depression, or needing complex cardiac procedures or cancer treatment traveled the farthest. Increasing rurality was related to decreased visits to specialists and increasing reliance on generalists. The majority of visits by those living in large rural areas were in large rural areas or the patients’ home ZIP codes. Residents of rural areas have increased travel distance and time compared to their urban counterparts, particularly true of rural residents with specific diagnoses or those undergoing specific procedures. Funded by HRSA’s ORHP.

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Perinatal Technology in Rural Washington One of the major issues confronting rural health care providers is the problem of acquiring complex...

One of the major issues confronting rural health care providers is the problem of acquiring complex and expensive new medical machinery, because of the relatively low volume of patients and encounters. This study described the patterns through which new perinatal technologies are adopted, the extent to which they are utilized in communities of varying sizes and levels of medical sophistication, and the impact of these technologies on obstetrical care in rural communities. We used surveys to determine which technologies are available in inpatient and ambulatory practice settings (100% response rate).

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PAs, NPs and CNMs: Changing Scope of Practice This case study in Oregon, part of a nationwide project led by the New York CHWS, investigated the...

This case study in Oregon, part of a nationwide project led by the New York CHWS, investigated the nature and effects on providers’ supply and access to care of changes in nurse practitioners’, certified nurse midwives’, and physician assistants’ scope of practice between 1992 and 2000. Using data from interviews and secondary sources, the UW CHWS’ contribtution to the project traced the emergence and establishment of NP, CNM, and PA professions in Oregon, the history and content of laws governing their practice, and the relationship of scope of practice to provider supply and delivery of care to underserved populations. Funded by the New York CHWS, through a contract with HRSA, Bureau of Health Professions.

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PAs and NPs in Rural Washington Quantified estimates of the total contribution of nurse practitioners (NPs) and physician...

Quantified estimates of the total contribution of nurse practitioners (NPs) and physician assistants (PAs) to primary care made by these non-physician clinicians (NPCs) are rare. This study used productivity data from the NPC and physician populations in Washington State to assess the contribution to generalist care made by NPCs, the role of NPCs in rural and underserved areas, and the role of women NPCs in the female provider population. Data on demography, medical specialty, place of practice and outpatient visits from license renewal surveys were used to estimate the productivity of generalist physicians and generalist NPCs. Head counts of physicians, NPs and PAs were adjusted for missing specialty and productivity data and converted into family physician full-time equivalents (FTEs) to facilitate comparisons and estimation of total contribution to care made by each provider type. A total of 4,189 generalist physicians produced only 2,760 family physician FTEs (1 FTE = 105 outpatient visits per week). Overall, generalist NPCs made up 23.4% of the generalist provider population and performed about 21.0% of the generalist outpatient visits in Washington State. NPC contribution was higher in rural areas of the state, about 24.7% of all generalist visits, and a bit lower in urban parts of the state, about 20.1% of generalist visits. In rural areas, female physicians provided 49.3% of the visits provided by female providers; female NPCs provided the remaining 50.3%. In urban areas, female physicians provided about 63.5% of the generalist care provided by women and female NPCs provided 46.5%. NPCs made similar contributions to total care in rural Health Professional Shortage Areas compared to rural non-shortage areas, though PAs appeared to contribute somewhat more care in HSAs with severe shortages of providers. NPs and PAs provided over 20% of the generalist outpatient visits in Washington State. Accurate estimates of available generalist care must take into account the contribution of NPs and PAs. Funded by HRSA’s ORHP and BHPr.

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Pacific Islands Continuing Clinical Education Program The Pacific Islands Continuing Clinical Education Program (PICCEP) at the University of Washington...

The Pacific Islands Continuing Clinical Education Program (PICCEP) at the University of Washington (2000-2004) provided continuing education to health professionals throughout the U.S.-associated jurisdictions in the Pacific. Based in Seattle, the University of Washington team worked in close association with other institutions to evaluate and meet continuing clinical education needs in American Samoa, Commonwealth of the Northern Marianas, Federated States of Micronesia, Guam, Republic of the Marshall Islands and the Republic of Palau. The program was funded by the U.S. Health Resources and Services Administration (HRSA) through the Bureau of Health Professions (BHPr) and the Bureau of Primary Health Care (BPHC).

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PA Students Entering Primary Care This study identifies the characteristics of Physician Assistant (PA) students planning to enter...

This study identifies the characteristics of Physician Assistant (PA) students planning to enter primary care practice upon completion of training.

 

**Peer-reviewed publication under review**

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Oral Health in Rural This study determined whether shortages of dentists in rural areas of the United States are...

This study determined whether shortages of dentists in rural areas of the United States are associated with impaired access to dental care and a higher prevalence of dental disease. Using detailed dentist supply data from the American Dental Association Dentist Masterfile and recent survey data from the nationally-representative Behavioral Risk Factor Surveillance System, we characterized dentist supply-oral health relationships by overall rural vs. urban location and a four-level, rural-urban grouping for the nation and individual states.

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Obstetrical Access in Washington A survey of all potential providers of obstetrical care in Washington State was conducted in 1989,...

A survey of all potential providers of obstetrical care in Washington State was conducted in 1989, and results were compared to an earlier survey to assess the extent to which obstetrical access had changed. Although the massive exodus of family physicians from obstetrical practice appeared to have slowed during the follow-up period, there was still substantial net attrition among this group of providers. By contrast, the supply of obstetricians and midwives seemed to be stable. Despite the greater obstetrical participation rate of rural practitioners, members of this group were also quitting obstetrics faster than they could be replaced.

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Nurse Practitioners in Washington This 2003 survey of nurse practitioners examined how many have been educated in-state, how many...

This 2003 survey of nurse practitioners examined how many have been educated in-state, how many work full versus part time, the extent to which they provide care to underserved populations, their use of newly acquired expanded drug authority, and other characteristics of their clinical practices. Funded by HRSA National Center for Health Workforce Analysis, through Congressional Appropriation to the UW CHWS.

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NP Distribution using Available Data This study compared estimates of nurse practitioner (NP) supply in 12 states (statewide and rural...

This study compared estimates of nurse practitioner (NP) supply in 12 states (statewide and rural vs. urban) derived from two sources: state license records and National Provider Identifier (NPI) data. Estimates of state NP supply from license data were found to be higher than NPI-derived estimates for most, but not all states. While data from both license and NPI sources can be useful for health workforce planning, the limitations of each source should be acknowledged and workforce comparisons should be limited to estimates derived from the same types of data.

In Progress
NHSC Evaluation A major impediment to access to care is the shortage of primary care physicians in rural locations...

A major impediment to access to care is the shortage of primary care physicians in rural locations and inner cities. This extension of an earlier study evaluated the National Health Service Corps (NHSC) scholarship program through a mail survey with phone encouragement of NHSC scholarship recipients who graduated from medical school during 1975-83. The study examined their retention experience, locational career patterns, demographic and practice characteristics, and service in rural sites. Funded by HRSA’s ORHP.

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National PA Study, 1996 The WWAMI RHRC collaborated with the North Dakota Center for Rural Health Services on a national...

The WWAMI RHRC collaborated with the North Dakota Center for Rural Health Services on a national survey of a random sample of physician assistants (PAs). The RHRC completed a follow-up survey of all the graduates of the University of Washington’s MEDEX Northwest PA program. The follow-up study, in which North Dakota Center for Rural Health Services staff took the lead, examined differences in rural and urban PA content of practice, satisfaction, practice type, practice characteristics, and demographic characteristics. Geographical and chronological career patterns of the PAs were investigated, as well as issues related to prescriptive authority and professional autonomy.

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National EMS Workforce Emergency medical technicians (EMTs) and paramedics are a critical component of any community's...

Emergency medical technicians (EMTs) and paramedics are a critical component of any community’s Emergency Medical Services (EMS) system. Assuring the continued viability of the prehospital EMS workforce is a key concern for many local, state, federal, and tribal EMS agencies, as well as national EMS organizations. As a first step in systematically addressing the issue, the National Highway Traffic Safety Administration, in partnership with the Health Resources and Services Administration’s (HRSA) Emergency Medical Services for Children program, supported a research project led by the Center for the Health Professions and School of Nursing at the University of California San Francisco with assistance from the Center for Health Workforce Studies at the University of Washington. The intent of this research was to provide guidance to the national EMS community in ensuring a viable EMS workforce for the future. The major objective of this research was to address issues relevant to the process of workforce planning. Research questions addressed the following: (1) Will the EMS workforce be of adequate size and composition to meet the needs of the U.S. population in the future? (2) How can potential workers be attracted to and encouraged to stay in the field of EMS? (3) How can adequate EMS workforce resources be available across all populations and geographic areas? (4) Do we have the data and information needed to address the future demand for and supply of EMTs and paramedics in the United States? What information is lacking and how might it be obtained? To research these questions, project staff used a variety of qualitative and quantitative approaches, including a critical review of EMS workforce literature, analysis of primary and secondary data, and interviews with experts in the field. Expert guidance for the project was provided by a steering committee and formal meetings with representatives from national EMS stakeholder organizations.

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Montana Physician Workforce This study offers data on the size, distribution, demographics, specialties and education history...

This study offers data on the size, distribution, demographics, specialties and education history of Montana State’s physician workforce first conducted in 2014 and updated in 2016.

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Montana Physician Supply 2009 The Center for Health Workforce Studies provided the University of Washington School of Medicine...

The Center for Health Workforce Studies provided the University of Washington School of Medicine and policymakers in Montana with analyses to inform their discussions about whether expansion of and/or modification to the medical school would alleviate future physician shortages in Montana.

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Middle Skilled Allied Health Occupations Bianca Frogner and Sue Skillman were commissioned in 2015 by an expert committee convened by The...

Bianca Frogner and Sue Skillman were commissioned in 2015 by an expert committee convened by The National Academies, acting for the National Research Council and the National Academy of Engineering, to prepare a paper examining the education and training pathways to middle skilled jobs in the health care field. This paper discusses the current supply of middle skilled jobs and the projected demand for these jobs, the policy and demographic context in which these jobs are demanded, and the education and training paths to enter these jobs and on which to build a long-term career. In this paper, we discuss the opportunities and challenges to identifying career pathways to middle skilled jobs in health care. The focus of this paper is on the set of health care jobs that have a pre-baccalaureate (i.e., less than a four-year degree) entry-level requirement.

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Mental Health Workforce in Washington This project analyzed 1999 Washington State licensing and survey data on the distribution and level...

This project analyzed 1999 Washington State licensing and survey data on the distribution and level of productivity of seven types of mental health providers–psychiatrists, psychologists, certified social workers, mental health counselors, marriage and family counselors, registered counselors, and hypnotherapists–in the 125 Washington Health Service Areas. It used this licensing data to develop two models (one that estimates the actual number of visits and one that adjusts the supply of visits for a reasonable workload) for estimating the supply of mental health visits by both psychiatrists and other mental health providers. Using data from the U.S. Census and the National Comorbidity Survey, the project team then estimated required psychiatric visits in Washington State and its six geographic subareas, and compared this to the available visits to identify areas with gaps in psychiatric services. Funded by HRSA, National Center for Health Workforce Analysis.

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Medicare Bonus Payments in HPSAs Medicare's Incentive Payment (MIP) program provides a 10% bonus payment to providers who treat...

Medicare’s Incentive Payment (MIP) program provides a 10% bonus payment to providers who treat Medicare patients in areas where there is a federally designated shortage of generalist physicians. This study examined the experience of Alaska, Idaho, North Carolina, South Carolina, and Washington with the MIP program using a retrospective cohort design utilizing 1998 Medicare Part B data. Physician specialty was determined through American Medical Association Masterfile data. Rural status was determined by linking this ZIP code to its Rural-Urban Commuting Area Code (RUCA). There were 39,780 providers in the study cohort: 24.9% generalists, 53.5% medical and surgical specialists, and 21.6% nonphysician providers. Over $4 million in bonus payments were made to providers in the Health Professional Service Area (HPSA) sites, with a median overall payment of $173. Specialists and urban providers received 58% and 14% of the bonus reimbursements respectively. Nearly a third of the potential bonus payments ($2 million) 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. Many providers who should have claimed the bonus did not, and many 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 as well as a system that prospectively determines provider eligibility. Funded by HRSA’s ORHP.

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Medical Student Debt This project examined the collision between rising debt and stagnant or falling primary care...

This project examined the collision between rising debt and stagnant or falling primary care salaries. It tested the hypothesis that the United States may be near the point at which students with large amounts of educational debt are unable to rationally choose to pursue primary care. The study used secondary analysis of two data sources to test this hypothesis: the Medical School Graduation Questionnaire (GQ) administered annually by the American Association of Medical Colleges (AAMC) to senior medical students, and the annual salary surveys of the MGMA. We examined the impact of debt for important sub-groups of the medical student population: underserved minorities, rural students, women, and differences across regions and public versus private medical schools. Funded by HRSA, National Center for Health Workforce Analysis.

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Medical Education and Rural Practice Review This literature review critically examined the research literature related to physician...

This literature review critically examined the research literature related to physician undergraduate and graduate medical education and rural practice location. While topics related to rural location choices such as federal and state programs and recruitment and retention were touched upon, the emphasis of the review was on the educational programs themselves. The main objective of the review was to determine what we currently know and what gaps in the literature need to be addressed in order to develop sound public policy. Funded by HRSA’s ORHP.

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Medicaid Primary Care Payment in Washington Enhanced payments for primary care services provided to Medicaid patients in 2013 and 2014,...

Enhanced payments for primary care services provided to Medicaid patients in 2013 and 2014, authorized by the federal Patient Protection and Affordable Care Act (ACA) of 2010, expire in 2015. This study assessed how the Medicaid payment increase affected primary care providers’ willingness to provide care for Medicaid patients in Washington State, how providers may respond if reimbursement rates revert to pre-2013 levels, and which strategies encourage providers to see Medicaid patients.

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MEDEX PA Study, 1994 This project, performed in partnership with MEDEX Northwest in the School of Public Health,...

This project, performed in partnership with MEDEX Northwest in the School of Public Health, examined the locational choices and role of physician assistants (PAs) in the WAMI states, explored the use of PAs as physician extenders, and described the evolution of PA training and function over the past two decades. We surveyed all MEDEX graduates to identify factors that predict selection of and retention in rural locations. Results of this study improved the ability of training programs to select trainees likely to pursue successful careers in underserved rural areas and identified the kinds of professional environments conducive to attracting and retaining mid-level health care providers.

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MD Views of Rural Hospital Closures This project surveyed the physicians of rural towns whose sole small general hospitals closed...

This project surveyed the physicians of rural towns whose sole small general hospitals closed between 1980 and 1988. All locatable physicians who were practicing in the hospital closure towns at the time of the closures were surveyed with a questionnaire similar to that employed in a parallel survey of hospital closure town mayors. The study concentrated on physician perceptions of the reasons the hospitals closed, the consequences of the hospital closures, and the role the physician played in the closure process. Government reimbursement policies and poor hospital management were cited as principal reasons for hospital closures.

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Mayor Views of Rural Hospital Closures This project involved a survey of 130 mayors of rural towns whose sole small general hospitals...

This project involved a survey of 130 mayors of rural towns whose sole small general hospitals closed between 1980 and 1988. Mayors attributed the closure of their hospitals primarily to government reimbursement policies, poor hospital management, and lack of physicians. They reported that they had little warning that their hospitals were in imminent danger of closing. Well over three-fourths of the mayors felt that access to medical care and health status had deteriorated in their community after hospital closure, and over 90% indicated that the hospital closure had substantially impaired the community’s economy.

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Maine physicians, NPs and PAs, 2014 This Brief offers data on the number and distribution of Maine's licensed physicians, nurse...

This Brief offers data on the number and distribution of Maine’s licensed physicians, nurse practitioners and physician assistants in 2014. Additional analyses detail the demographics, specialties and education history (medical school and residency state) of Maine’s practicing physician workforce. Analyses used data from Maine’s health professions licensure boards, and the American Medical Association Physician Masterfile.

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Low-Risk Obstetric Care This study, which was predominantly funded by AHCPR but was also supported through the HRSA's ORHP,...

This study, which was predominantly funded by AHCPR but was also supported through the HRSA’s ORHP, was part of a large multifaceted project that examined low-risk obstetric care in Washington State through surveying obstetric providers and abstracting detailed information about their patients. This study used the provider as the unit of analysis. Differences in resource use (e.g., visits, tests, and procedures) between rural and urban obstetricians and between rural and urban family physicians were examined in detail.

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Long-Term Care Paraprofessionals As part of a larger national study (led by the New York CHWS), this study examined the extent to...

As part of a larger national study (led by the New York CHWS), this study examined the extent to which policy makers in Wyoming have adequate data on certified nurse aides, home health aides, and other paraprofessional long-term care workers to address the critical issues they face. Information was collected via interviews with key players at the state, local and institutional level. Funded by the NY CHWS, through a contract with HRSA, Bureau of Health Professions.

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Location of PA Practices Despite the need for generalist care providers in rural areas experiencing shortages of generalist...

Despite the need for generalist care providers in rural areas experiencing shortages of generalist physicians, the percentage of physician assistants (PAs) that practice in small towns has been decreasing. This study examined PA rural and urban location behavior and their geographic trajectories over time based on national PA data collected in an earlier study. Data from sources such as the Area Resource File were used to characterize the areas where PAs were located. Factors such as PA demography, educational program type and location, preceptorship location, and previous health care provider status were examined. As the American health care delivery system changes, with workforce policies that focus more sharply on generalist care, the need to better understand PA practices is crucial. Funded by HRSA’s ORHP.

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International Medical Graduates: States' Use of Conrad 30 J-1 Visa Waivers States rely on international medical graduates (IMGs) to fill workforce gaps in rural and urban...

States rely on international medical graduates (IMGs) to fill workforce gaps in rural and urban underserved areas. This study will collect information from all states regarding their efforts to track IMG practice after their Conrad 30 program waiver obligations are satisfied, quantify long-term retention for states with available data, and assess how state policies shape IMG practice and long-term retention. Funded by HRSA’s Office of Rural Health Policy.

In Progress
International Medical Graduates: Sources and Distribution International medical graduates (IMGs--physicians educated in medical schools other than in the...

International medical graduates (IMGs–physicians educated in medical schools other than in the United States and Canada) account for nearly 25% of the nation’s practicing physicians. The UW CHWS has conducted a series of research studies about the sources and distribution of IMGs. Funded by HRSA, National Center for Health Workforce Analysis.

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International Medical Graduates' Contributions to Rural Health Care Delivery This study will identify trends and data needs regarding the contributions of international medical...

This study will identify trends and data needs regarding the contributions of international medical graduates (IMGs) on J-1 and H-1B visas to rural health care delivery. A workgroup of IMG research and policy stakeholders will be established to help identify IMG supply data trends, needs, and pressing policy issues; lay the groundwork for potential areas of study, data integration, and data collection; and strengthen the policy relevance of our work. Funded by HRSA’s ORHP.

In Progress
International Medical Graduates' Characteristics Over Time This study of the characteristics of international medical graduates (IMGs) over time examined...

This study of the characteristics of international medical graduates (IMGs) over time examined changes in the source countries for IMG education, distribution across the country, demographics of IMGs, and the kinds of medical practices they chose. Funded through a contract with HRSA, Bureau of Health Professions, National Center for Health Workforce Analysis.

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Impact of UW School of Medicine on Washington Physician Supply The Center for Health Workforce Studies provided the University of Washington School of Medicine...

The Center for Health Workforce Studies provided the University of Washington School of Medicine and policymakers in Washington with analyses to inform their discussions of whether expansion of the medical school would alleviate future physician shortages in eastern Washington.

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Impact of Malpractice We studied all family physicians (470) who purchased obstetrical malpractice insurance from the...

We studied all family physicians (470) who purchased obstetrical malpractice insurance from the largest malpractice insurer in Washington State (WSPIEA) from 1982 to 1988. One-third discontinued obstetrics but remained in practice, and these physicians were older, more likely to practice in an urban area, and more likely to be in solo practice. Rural family physicians were less likely to quit practicing obstetrics than their urban colleagues. Obstetrically related malpractice claims against family physicians were relatively infrequent and are not a factor in the decision of most family physicians who stop practicing obstetrics.

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Immigrants in Allied Health Professions This study provides a national snapshot of where immigrants work in the US healthcare system.

This study provides a national snapshot of where immigrants work in the US healthcare system.

Complete HRSA
IMG On-Line Atlas The on-line Atlas of International Medical Graduates (IMGs) displays trends in the geographic...

The on-line Atlas of International Medical Graduates (IMGs) displays trends in the geographic distribution of IMGs over the past 20 years through a series of maps. The maps are intended to provide useful information regarding changes in the global production of IMGs and the distribution of IMGs in the United States over time.

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Idaho's Physicians This study offers data on the size, distribution, demographics, specialties and education history...

This study offers data on the size, distribution, demographics, specialties and education history of Idaho State’s physician workforce first conducted in 2014 and updated in 2016.

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Idaho Physician Supply, 2009 The Center for Health Workforce Studies provided the University of Washington School of Medicine...

The Center for Health Workforce Studies provided the University of Washington School of Medicine and policymakers in Idaho with analyses to inform their discussions about whether expansion of and/or modification to the medical school would alleviate future physician shortages in Idaho.

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HPSAs and Rural Health Care Access This study examined the degree to which persistence of primary care health professional services...

This study examined the degree to which persistence of primary care health professional services area (HPSA) designation in rural counties is associated with lower population socioeconomic status and deficiencies in access to health care services. It used a five-level classification of rural counties measuring partial- vs. whole-county persistence of primary care HPSA designation that stratified rural populations by socioeconomic status (SES), race/ethnicity, primary care supply, health insurance uptake, and access to needed health care services. The study found that those U.S. rural counties that were persistently designated as whole-county HPSAs had much lower SES, and adults residing in these counties reported substantial financial obstacles to obtaining needed health care services. Rural counties that were persistently designated as whole-county HPSAs also faced severe provider shortages, and adults residing in these locations were less likely to have a regular primary care provider. This study was funded by HRSA’s Office of Rural Health Policy.

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HPSA Criteria Evaluation in Washington State One of the most pervasive aspects of the American health scene has been the maldistribution of...

One of the most pervasive aspects of the American health scene has been the maldistribution of health personnel in rural and urban areas. Notwithstanding much effort at the federal and state level, shortages of physicians and other health professionals persist both in rural and urban areas, especially the remote rural locations and the inner-city urban ones. The current paradox is that despite substantial increases in their numbers of physicians, many rural and urban areas remain underserved. Federal health personnel programs such as the National Health Service Corps (NHSC) are critical tools among relevant federal programs designed to address the geographic maldistribution of health personnel and other health-related resources. But not every community or organizational entity that would like to use these programs has a significant shortage of health personnel. Eligibility for federal health personnel programs such as the NHSC is triggered by designation of an area as a Health Professional Shortage Area (HPSA), and eligibility for other federal interventions requires designation as a Medically Underserved Area (MUA). In fact, eligibility for a considerable number of federal and state programs is based on whether an area or population meets the HPSA and MUA/P criteria. The main activity of this project was to use detailed Washington State data for the 124 generalist Health Service Areas (HSAs) to evaluate alternative variations of the HPSA criteria. Evaluations included examining how sensitive the designations were to changes in the designation methodology and in changes to the method of counting primary care providers. Project results provide comparative information on the numbers of HSAs receiving shortage designations using the various combinations of designation and provider counting methodologies. The project was funded by HRSA’s Office of Rural Health Policy (ORHP) and Bureau of Primary Health Care (BPHC).

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Hospital Closures and MD Supply This study determined whether the supply of physicians decreased subsequent to a rural hospital...

This study determined whether the supply of physicians decreased subsequent to a rural hospital closure during a nine-year period ending in 1988. The study (1) examined changes in physician manpower before, after, and at the time of the closure and (2) examined the association of town size, hospital size, and distance to other hospitals with hospital closure. The hospital closure towns most likely to lose physicians had few physicians before closure, were relatively remote from both urban areas and other hospitals, were located in sparsely populated counties, and tended to have for-profit ownership.

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Home Care Aides in Washington Beginning in 2011, long-term care workers in Washington who provide services to the elderly or...

Beginning in 2011, long-term care workers in Washington who provide services to the elderly or persons with disabilities in residential settings must be certified as home care aides. Estimating the current supply and future demand is difficult because these workers are not currently credentialed by the state. This project uses data on the number of Medicaid clients and facilities using home care aides to estimate current supply, and with estimates of the state’s population growth to 2030, projects the future demand for home care aides in Washington.

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HIT Workforce in Texas The WWAMI Center for Health Workforce Studies served as a technical consultant to Texas State...

The WWAMI Center for Health Workforce Studies served as a technical consultant to Texas State University’s Health Information Technology Workforce Needs Assessment Project. This project, funded by the State of Texas, inventoried statewide HIT workforce needs in order to help ensure that health care employers in Texas have access to well-trained HIT professionals. The study included focus groups and a survey of health care facilities in Texas.

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HIT Workforce Development in Rural Community Colleges Successful implementation of health information technology (HIT) in rural areas depends on the...

Successful implementation of health information technology (HIT) in rural areas depends on the availability of a well-trained HIT workforce. Community colleges are key educational resources for producing this workforce, but there is little information on the number, distribution, and types of HIT workforce development programs currently available to rural residents. This study will describe trends in the number of students completing HIT programs in community colleges located near rural populations in the United States; assess the extent to which these programs have incorporated, or plan to incorporate, components of the recently released community college curriculum by the Office of the National Coordinator for HIT into their programs; and identify factors that affect the ability of programs to reach rural student populations. Funded by HRSA’s Office of Rural Health Policy.

In Progress
Health Professions Education in Washington This study used the U.S. Department of Education's Integrated Postsecondary Education Data System...

This study used the U.S. Department of Education’s Integrated Postsecondary Education Data System (IPEDS) database to determine the number, sex and race/ethnicity of persons completing postsecondary health career education programs throughout Washington State. The report shows changes over time for 36 selected programs, ranging from physician, nursing, allied health, dental health, pharmacy and other health care education programs. The 2004 study was funded by the Washington State Workforce Training and Education Board. The 2002 study was funded by HRSA’s National Center for Health Workforce Analysis through a Congressional Appropriation to the UW CHWS.

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Health Center Expansion and Recruitment Rural health centers (HCs) faced major barriers in recruiting and retaining health professionals,...

Rural health centers (HCs) faced major barriers in recruiting and retaining health professionals, yet there were no projections of key health professions staffing needs for HCs and proposed new HCs. This collaborative study with the South Carolina RHRC described the staffing needs of rural HCs and ascertained the staffing, recruitment, and retention issues that HC CEOs regarded as most critical. The National Association of Community Health Centers administered a mail questionnaire to the CEOs of all CHCs in the nation (about 845) that profiled their current staff vacancies, projected staffing needs, recruitment and retention issues, center site expansion plans, and CEO perception of policies that would facilitate recruitment and retention. This joint center project was a collaborative one between HRSA’s FORHP, BPHC, and BHPr.

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Health Care Reform in Rural Since 2009, the WWAMI RHRC has carried out several rapid-turnaround analyses of rural issues...

Since 2009, the WWAMI RHRC has carried out several rapid-turnaround analyses of rural issues related to health care reform. The published products of these analyses have been posted to the WWAMI RHRC Web site.

In Progress
Health Care for the Rural Uninsured This study described the contributions of family and general practice physicians from Wyoming to...

This study described the contributions of family and general practice physicians from Wyoming to the health care safety net. We surveyed family and general practice physicians in Wyoming about provider demographics, practice composition, and policies for treating the underinsured or uninsured. From a 50% response rate, 61% made less than the national mean family physician income ($130,000), and women were less likely than men to make this mean income, even when controlling for hours worked. 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. Wyoming family physicians provide significant amounts of informal safety net care, which is threatened by income loss. Funded by HRSA’s ORHP.

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Future Supply of Family Medicine Physicians This study investigated the implications of declining medical school interest in primary care...

This study investigated the implications of declining medical school interest in primary care careers as it impacts rural and underserved areas. The study examined data from the American Association of Medical Colleges, the 2005 American Medical Association Masterfile, and the American Osteopathic Association Masterfile, as well as survey data from residency directors and students to describe recent trends in medical school interest and national match rates for family medicine and primary care. Funded by HRSA’s FORHP.

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Federal Funding and MD Production This study described the graduates of all American medical schools from 1976 to 1980 and from 1981...

This study described the graduates of all American medical schools from 1976 to 1980 and from 1981 to 1985 in terms of their specialty and geographic location and correlated these variables with the amount of Title VII funds received by specific schools during those periods. Two hypotheses that were tested were (1) Title VII has had a positive impact on increasing the proportion of graduates choosing primary care specialties and practicing in rural and underserved areas, and (2) graduates of community-based schools are more likely to choose careers in primary care and to practice in rural and underserved areas than are graduates of traditional medical schools. Data for each medical school were aggregated by school and linked with data on Title VII and other federal funding from 1976 to 1985.

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Family Medicine Residency Network Study This survey project contrasted the role, practice type, and characteristics of graduates from the...

This survey project contrasted the role, practice type, and characteristics of graduates from the residency network associated with the University of Washington Department of Family Medicine who were located in rural versus urban communities. The geographic trajectories by graduate cohort and program were analyzed. In addition, the extent to which the program has been successful in placing and retaining graduates within rural communities and the region was evaluated.

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Family MD Views of Assisted Suicide With recent laws allowing physicians to assist in a terminally ill patient's suicide under certain...

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. This study used data from a 1997 survey of family physicians (FPs) and general practitioners (GPs) in Washington State to determine factors associated with attitudes toward physician-assisted suicide. A questionnaire was mailed to all active FPs/GPs in Washington State. A ZIP code system based on generalist Health Service Areas was used to designate those practicing in rural versus urban areas. 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% did not know. Over half would not include physician-assisted suicide in their practices, even if it were legal. Attitudes about physician-assisted suicide varied significantly between urban females and rural males, with the former being more supportive of assisted suicide than the latter. Many respondents, especially females, were uncertain of their positions concerning the legalization of and their willingness to assist suicides. Substantial differences in opinion toward physician-assisted suicide existed between physicians based on gender and rural-urban practice location. There was a significant pattern of opposition on the part of rural male respondents compared to urban female respondents.

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Family MD Practice Locations In this study, responses to a survey of graduates from the residency network associated with the...

In this study, responses to a survey of graduates from the residency network associated with the University of Washington Department of Family Medicine were analyzed related to their rural and urban career trajectories. This study examined the locational patterns of the graduates in terms of initial site location, practice moves, lengths of stay, prior movement experience, gender, and graduation cohort.

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Emerging Roles in Allied Health Occupations This study identifies how emerging skills and roles are becoming incorporated into the job...

This study identifies how emerging skills and roles are becoming incorporated into the job descriptions of selected allied health occupations.

Complete HRSA
Emergency Care of Rural Elderly This study used Medicare data to compare emergency department (ED) use by rural and urban elderly...

This study used Medicare data to compare emergency department (ED) use by rural and urban elderly beneficiaries. The 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. This study found that the rural elderly living in remote areas were 13% less likely to visit the ED than their urban counterparts. Causes of ED use by the elderly did not vary meaningfully by location. Most ED visits by this group were for conditions that seem appropriate for this setting. Given the similarity of diagnostic conditions associated with ED visits, local EDs must be capable of dealing with the same range of emergency conditions as urban EDs. Funded by HRSA’s ORHP.

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Educational Strategies to Encourage Rural NP Practice Persistent shortages of primary care physicians in rural areas have increased the need to educate...

Persistent shortages of primary care physicians in rural areas have increased the need to educate nurse practitioners (NPs) for rural careers. Medical schools have identified factors associated with rural practice by physicians and used this knowledge to develop rural training programs, but less is known about factors associated with rural NP training and practice or the extent to which NP programs deploy such strategies. This study will quantify and describe NP education programs that encourage NPs to practice in rural areas and identify data sources that could be used in future studies of the effectiveness of these programs. This study is funded by HRSA’s Office of Rural Health Policy.

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Economic Impact of HRSA Rural Network & Outreach Grants This study analyzed the economic impact created by HRSA Network Development and Outreach grantees....

This study analyzed the economic impact created by HRSA Network Development and Outreach grantees. The analyses were conducted with the goal of creating transparent and easy-to-use tools that can be used by grantees and HRSA in future program efforts. While the project analyses focused on a cohort of grantees, the study used methods and data that potentially could be extended to other HRSA grantees and programs. The WWAMI RHRC had a subcontract to carry out this project in collaboration with The Lewin Group, through a grant from HRSA’s Office of Rural Health Policy.

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Do IMGs Fill Rural Gaps? Purpose: The contribution that international medical graduates (IMGs) make to reducing the...

Purpose: The contribution that international medical graduates (IMGs) make to reducing the rural-urban physician maldistribution in the United States has implications for medical workforce planning. This study compared the practice location of IMGs and U.S. medical graduates (USMGs) in primary care specialties. Method: We used the 2002 American Medical Association Physician Masterfile to determine the practice location of all primary care physicians. Their locations were linked to Rural-Urban Commuting Areas and aggregated into urban, large rural, small rural, and isolated small rural areas. We determined the difference between the percentages of IMGs and USMGs in each type of geographic area for each Census Division and state. Results: One-quarter of the 205,063 primary care physicians were IMGs. They were significantly more likely than USMGs to be female; older; practicing in internal medicine, general practice, or pediatrics; and less likely to practice family medicine. IMGs appeared more likely than USMGs to practice in urban areas, and, with the exception of the East South Central and West North Central Divisions, less likely to practice in rural areas. IMGs were more likely than USMGs to practice in urban areas in 7 states, and less likely to practice in urban areas of 13 states. For rural areas combined, there were 18 states in which IMGs were more likely to practice and 16 in which they were less likely to practice than USMGs. Conclusions: The practice location of IMGs in primary care specialties appeared similar to that of USMGs. While IMGs filled gaps in rural primary care, this varied widely across states. IMGs were a core component of the primary care system, and must be considered in planning the future medical workforce.

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Diversity of Washington Health Professionals The race and ethnicity of Washington's physicians, dentists, dental hygienists, physician...

The race and ethnicity of Washington’s physicians, dentists, dental hygienists, physician assistants and nurse practitioners were compared to that of the overall state population in this snapshot from analyses of the 1999 Washington State health professionals’ licensing and renewal survey data. Funded by HRSA, National Center for Health Workforce Analysis.

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Diversity of the Health Workforce This report explores racial and ethnic diversity among the healthcare workforce by 1)summarizing...

This report explores racial and ethnic diversity among the healthcare workforce by 1)summarizing the state of the evidence from peer-review and grey literature over the past five years on the effectiveness of pipeline programs that seek to promote racial and ethnic diversity in the health workforce, and 2)examining how the racial and ethnic diversity of the health workforce changed over a decade from 2004 to 2013 through analyses of data from the American Community Survey (ACS). This project was funded by HRSA, National Center for Health Workforce Analysis.

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Deregionalization of Rural Perinatal Care The regionalization of rural perinatal care during the 1980s significantly lowered neonatal...

The regionalization of rural perinatal care during the 1980s significantly lowered neonatal mortality among infants born to rural residents, yet recent trends could disrupt the efficiency of regionalized systems of care. This national study determined whether there was evidence of deregionalization of rural perinatal care for high-risk women and infants and whether deregionalization had adversely affected neonatal mortality among infants born to rural residents. We analyzed national Linked Birth Death Data Set data over a 10-year period. The study population included all low-birthweight infants born to rural residents. This study demonstrated the impact of managed care on the rural health care delivery system and outcomes. Funded by HRSA’s FORHP.

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Dental Workforce in Montana This project, conducted collaboratively with the Montana Department of Health and the Montana...

This project, conducted collaboratively with the Montana Department of Health and the Montana Dental Association, produced policy-relevant Montana dental workforce shortage information through data collected in a survey of that state’s dentists. The survey obtained information about practice characteristics of dentists and dental hygienists, including information about provider supply and the provision of care to the underserved populations of the state. Funded by HRSA, National Center for Health Workforce Analysis. Findings from this study were integrated for publication with findings from dental surveys in five other states (conducted through the WWAMI Rural Health Research Center).

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Dental Workforce and Unmet Needs in Washington This project used licensure data from Washington State to examine the supply of, and requirements...

This project used licensure data from Washington State to examine the supply of, and requirements for, dentists and dental hygienists in 125 generalist health service areas in the state. Funded by HRSA, National Center for Health Workforce Analysis.

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Demand for 5 Health Occupations in Washington With funding from the Washington State Workforce Training and Education Coordinating Board, CHWS...

With funding from the Washington State Workforce Training and Education Coordinating Board, CHWS researchers carried out a study to assess future demand for five specific occupations in Washington State: home care aides, nursing assistants certified, medical assistants, licensed practical nurses, and associate’s degree registered nurses. Of particular interest was how the roles of these occupations may be changing with implementation of the Affordable Care Act. The project included a subcontract with the Western Washington Area Health Education Center.

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Leveraging Data for Allied Health Workforce Research This study compares and discusses how estimates of nine allied health professionals vary across...

This study compares and discusses how estimates of nine allied health professionals vary across secondary data sets such as the American Community Survey, Current Population Survey, Occupational Employment Statistics, and the National Provider Identifier Registry. This study helps to identify gaps where future data collection and research are needed. The nine allied health occupations are occupational therapists, physical therapists, respiratory therapists, speech-language pathologists, clinical laboratory technologists/technicians, dental hygienists, diagnostic-related technologists/technicians, medical assistants, and social workers.

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Contributions of Physicians, APNs, and PAs to Rural Primary Care This multi-state study examined the practices of rural physicians, advanced practice nurses (APNs),...

This multi-state study examined the practices of rural physicians, advanced practice nurses (APNs), and physician assistants (PAs) regarding their primary care visit productivity and scope of practice. Through surveys, this study examined the contributions of physicians, APNs, and PAs by state, degree of practice rurality, practice characteristics, and primary care HPSA status in order to provide information on a range of rural primary care workforce needs in the coming decades. Funded by HRSA’s Office of Rural Health Policy.

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Community Paramedicine Research Consensus Conference Background: Community paramedicine is a new model of providing access to basic health care...

Background: Community paramedicine is a new model of providing access to basic health care services. Community paramedicine extends paramedics’ traditional emergency response roles through additional education that enables them to see patients in their home or community setting and perform procedures already in their skill set. Community paramedics provide care under the supervision of an ordering physician or advance practice provider. Community paramedics are providing these kinds of services for otherwise underserved communities in demonstration sites in the U.S. and Canada. While there are reports of successful implementation of this novel approach to expanding primary care access, there is a paucity of objective, systematic research on the outcomes of these programs. This project identified appropriate research questions and appropriate data to increase understanding of the outcomes of community paramedicine. Goal: This project developed a national research agenda for the emerging field of community paramedicine based on facilitated discussions at a National Consensus Conference on Community Paramedicine. Collaboration: The study was conducted collaboratively by researchers at the University of Washington (UW) WWAMI Rural Health Research Center (RHRC) and the North Central Emergency Medical Services Institute. Funding was from a conference grant by the Agency for Healthcare Research and Quality. The UW’s WWAMI RHRC researchers completed a summary of topics and key points discussed during the National Consensus Conference on Community Paramedicine (October 1-2, 2012) and a community paramedicine research agenda report.

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Chronic Illness among Rural Residents This study used data from the Behavioral Risk Factor Surveillance System (BRFSS) to examine...

This study used data from the Behavioral Risk Factor Surveillance System (BRFSS) to examine trends–by type of geographic area, race/ethnicity, and risk factors–in hypertension, diabetes, hypercholesterolemia, and asthma, as well as patterns of screening for two of these conditions. BRFSS is a nationally representative study of the adult population in the United States that collects health data on an annual basis. Funded by HRSA’s FORHP.

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Characteristics of RNs whose Washington Licenses have Expired This survey of RNs who did not renew Washington licenses in 2002-2003 examined why these RNs...

This survey of RNs who did not renew Washington licenses in 2002-2003 examined why these RNs dropped their Washington licenses, where they were located, and their views regarding the nursing profession. Funded by HRSA National Center for Health Workforce Analysis, through Congressional Appropriation to the UW CHWS.

Complete HRSA
Characteristics of National Rural Nurse Workforce This national study characterized changes in the demographic, education, and practice...

This national study characterized changes in the demographic, education, and practice characteristics of registered nurses (RNs) in rural and urban areas from 1980 to 2004. Study data came from the National Sample Survey of Registered Nurses (NSSRN) collected between 1980 and 2004. RNs were categorized into urban, large rural, small rural, and isolated small rural by residence and work location using the Rural-Urban Commuting Area taxonomy. The study examined changes since 1980 in rural RN number, percent employed in nursing, age, gender, race/ethnicity, age at first RN degree, types of degrees attained, type of work, salaries, the types of areas where the RNs work, and their likely commuting patterns. By examining trends in rural RNs characteristics over the past two decades, this study provided important information for projecting future trends in RN supply for rural communities.

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Changes in MD Supply National rural health policy development depends on an accurate and up-to-date assessment of...

National rural health policy development depends on an accurate and up-to-date assessment of physician supply. This project described the supply of generalist physicians and osteopaths in rural areas of the United States. We used data from the AMA and Area Resource File to determine the total supply of practicing physicians in metropolitan and nonmetropolitan counties in 2005. We used Urban Influence Codes to classify nonmetropolitan counties based on their adjacency to a metropolitan county and the size of the largest urban place within the county. We assessed the supply of physicians in the smallest and most isolated areas of the country and analyzed rural physician supply on a state-by-state and regional basis. Funded by HRSA’s FORHP.

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Career Paths of Allied Health Professionals Aims To explore career transitions among individuals in select entry‐level...

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

Background
Entry‐level healthcare occupations are among the fastest growing occupations in the United States. Public perception is that the healthcare industry provides an opportunity for upward career mobility given the low education requirements to enter many healthcare occupations. The assumption that entry‐level healthcare occupations, such as nursing assistant, lead to higher‐skilled occupations, such as registered nurse, is under‐explored.

Design
We analyzed data from the Panel Study of Income Dynamics, which is a nationally representative and publicly available longitudinal survey of US households.

Methods
Using longitudinal survey data, we examined the job transitions and associated characteristics among individuals in five entry‐level occupations at the aide/assistant level over a 10‐year timeline (2003‐2013) to determine whether they stayed in healthcare and/or moved up in occupational level over time.

Results/Findings
This study found limited evidence of career progression in healthcare in that only a few of the individuals in entry‐level healthcare occupations moved into occupations such as nursing, that required higher education. While many individuals remained in their occupations throughout the study period, we found that 28% of our sample moved out of these entry‐level occupations and into another occupation. The most common “other” occupation categories were “office/administrative” and “personal care/services occupations.” Whether these moves helped individuals advance their careers remains unclear.

Conclusion
Employers and educational institutions should consider efforts to help clarify pathways to advance the careers of individuals in entry‐level healthcare occupations.

Complete HRSA
Care for Lung Disease among Rural/Urban Medicare Beneficiaries This retrospective cohort study examined access of a sample of Medicare beneficiaries among rural...

This retrospective cohort study examined access of a sample of Medicare beneficiaries among rural and urban patients hospitalized with chronic obstructive lung disease to prescribed home oxygen and the needed equipment. Funded by HRSA’s FORHP.

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Care for Acute Myocardial Infarction in Rural Hospitals: 1994-1995 Acute myocardial infarction (AMI) is an important condition cared for in rural hospitals. Most...

Acute myocardial infarction (AMI) is an important condition cared for in rural hospitals. Most recommended interventions require no sophisticated technology and should be available in rural and urban hospitals. This study examined the quality of AMI care in rural hospitals. It was a cohort study using data from the 1994 and 1995 Centers for Medicare & Medicaid Services’ Cooperative Cardiovascular Project and the 1995 American Hospital Association’s Annual Survey of Hospitals. The study included U.S. acute-care hospitals caring for patients with AMI, and Medicare beneficiaries ages 65 and older directly admitted to four types of acute-care hospitals–remote small rural, small rural, large rural, and urban–for a confirmed AMI between 1994 and 1995. Substantial proportions of Medicare beneficiaries in both urban and rural hospitals did not receive recommended AMI treatments. Medicare patients treated in rural hospitals were less likely than urban hospitals’ patients to receive aspirin during hospitalization or at discharge, intravenous nitroglycerin, heparin, and either thrombolytics or percutaneous transluminal coronary angioplasty. Only one treatment–ACE inhibitors at discharge–was used more for patients in rural hospitals. Medicare patients in rural hospitals had significantly higher adjusted 30-day post-AMI death rates from all causes than those in urban hospitals. Efforts are needed to help hospital medical staffs, especially those in rural areas, develop systems to ensure that patients receive recommended AMI treatments. Funded by HRSA’s ORHP.

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Cancer Screening in Rural America This study examined Behavioral Risk Factor Surveillance System (BRFSS) national survey data to...

This study examined Behavioral Risk Factor Surveillance System (BRFSS) national survey data to explore the prevalence and trends in screening for four types of cancer (breast, colorectal, cervical, and prostate) among survey respondents from urban and various types of rural areas and among white compared to minority populations. BRFSS is a nationally representative study of the adult population in the United States that collects health data on an annual basis. Funded by HRSA’s FORHP.

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Cancer Care for Rural Colorectal Cancer Patients This study compiled a comprehensive database linking Surveillance Epidemiology and End Results...

This study compiled a comprehensive database linking Surveillance Epidemiology and End Results (SEER) cancer registry, Medicare claims, American Medical Association Masterfile, and other data to examine access to cancer services in a sample of rural, Medicare-insured colorectal cancer patients of different racial and ethnic groups. Funded by HRSA’s FORHP.

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Birth Care for Rural/Urban American Indians While American Indians (AIs) constitute a substantial minority population in many rural areas,...

While American Indians (AIs) constitute a substantial minority population in many rural areas, population-based research on the health status of AI women and infants is limited. This study used the National Linked Birth Death Certificate Data Set for 1989 and 1991 to compare the perinatal risk factors, prenatal care use, birth outcomes, and infant death rates of rural AIs, urban AIs, and whites. Results from this study should help administrators and policy makers to better understand the health care needs of this population, as well as the targeted interventions needed to improve birth outcomes and infant health status. Funded by HRSA’s ORHP.

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Behavioral/Mental Health workforce for Integrated Primary Care This study provides insight regarding the workforce needed to integrate behavioral health with...

This study provides insight regarding the workforce needed to integrate behavioral health with primary care in order to develop health workforce-related plans and policies, with an emphasis on state-level efforts, which will increase population-based access to behavioral health care services through primary care settings.

Complete HRSA
BBA and Rural Residency Training This national survey examined the proportion of rural-based family medicine residencies across the...

This national survey examined the proportion of rural-based family medicine residencies across the United States that have ceased operations since 2000, the residency match patterns of existing programs, changing proportions of International Medical Graduates (IMGs) and U.S. Medical Graduates (USMGs), and major issues facing rural residency programs. Funded by HRSA’s FORHP.

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Barriers to Rural Residencies This project examined issues related to establishment and maintenance of residencies and residency...

This project examined issues related to establishment and maintenance of residencies and residency tracks in rural America. The project involved both a literature review and interviews with key informants related to the issues surrounding rural residency programs. While the project emphasized generalist residencies, it was not limited to them. The policy paper discussed issues associated with retaining and starting rural residencies and tracks such as their training cost and clinical implications, credentialing constraints, and staffing problems. Understanding the issues surrounding the establishment of rural residencies is important for federal and state legislators and administrators as they revamp the nation’s graduate medical education system. Funded by HRSA’s ORHP.

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APRN Distribution in the U.S. This study analyzed 2010 Centers for Medicare and Medicaid Services' National Provider Identifier...

This study analyzed 2010 Centers for Medicare and Medicaid Services’ National Provider Identifier (NPI) records to assess the usefulness of the dataset to describe APRN distribution across the United States. There were adequate NPI data to describe urban and rural location of certified registered nurse anesthetists (CRNAs) and nurse practitioners (NPs) in the U.S. and relative per capita supply. Practice location was estimated by linking Rural-Urban Commuting Area codes to NPI provider ZIP codes. Chi-square testing examined provider supply by geographic locations. Multivariate hierarchical regression testing identified whether rural practice location was related to practice autonomy, per capita provider supply, or gender. Funded by the American Nurses Association.

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Ambulatory Care for Rural Elderly Diabetes is a common serious chronic disease where careful clinical monitoring can improve the...

Diabetes is a common serious chronic disease where careful clinical monitoring can improve the quality of care and patient outcomes. This study examined the extent to which Medicare patients in Washington State receive care that adheres to clinical guidelines and the extent to which the rural or urban residence affects the quality of care received. Medicare patients 65 years and older with two physician encounters for a diabetic condition in 1994 were included in this study. Patient residence was determined by using the ZIP code of the patient’s dwelling as listed in the Medicare National Claims History File. Adherence to guidelines was measured by determining the extent to which patients received three tests recommended by the major authoritative bodies during the study year: glycated hemoglobin, an eye examination, and a cholesterol measurement. 30,589 Medicare patients (8.4%) were considered to have diabetes; 29.1% lived in rural communities. Urban patients received virtually all their medical care in their local communities, as did over 80% of rural patients who lived in rural communities with more than 10,000 people; people living in smaller rural towns received almost half their outpatient care in other communities. Most diabetic care in all locations is provided by generalists. Patients living in large rural towns remote from metropolitan areas received higher quality care on these measures than all other groups, while those living in large communities adjacent to metropolitan areas had the lowest adherence rates. Patients who saw an endocrinologist at least once during the year were more likely to have received the recommended tests. Even though clear guidelines exist for certain routine monitoring tests–and even though Medicare pays for these tests–most patients do not get all the recommended interventions. Large rural towns remote from cities seem to have higher quality of care. Given that most diabetic care is given by generalists, the challenge is to create a system where patients and their primary care physicians can work together to improve the care of serious chronic conditions. Funded by HRSA’s ORHP.

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Allied Health Education in Community Colleges This study identified rural-serving community colleges across the United States and their five-year...

This study identified rural-serving community colleges across the United States and their five-year graduation trends for specific allied health professions, examined the spectrum of how rural allied health professions education currently is being allocated and delivered, and explored how community economic status and estimated regional allied health workforce demand is associated with the availability of rural community college allied health education programs. Funded by HRSA’s ORHP.

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Alaska Physicians This study offers data on the size, distribution, demographics, specialties and education history...

This study offers data on the size, distribution, demographics, specialties and education history of Alaska State’s physician workforce first conducted in 2014 and updated in 2016.

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Aging Rural Physician Workforce This study identifies rural locations with high proportions of generalist physicians nearing...

This study identifies rural locations with high proportions of generalist physicians nearing retirement age. As fewer young physicians choose generalist careers, the retirement of older physicians may place additional strain on rural generalist supply. This study quantifies the extent to which rural generalist physician shortages may be exacerbated by physician retirement, focusing on known shortage locations. The study used data from the American Medical Association and American Osteopathic Association 2005 Masterfiles. This study was funded by HRSA’s Office of Rural Health Policy.

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Access to and Outcomes of Obstetric Care Previous work conducted by the WWAMI RHRC demonstrated a relationship between access to obstetrical...

Previous work conducted by the WWAMI RHRC demonstrated a relationship between access to obstetrical care in rural communities and birth outcomes (see working paper #4). The Obstetrical Process and Outcome of Care Study compared rural versus obstetrical care and outcomes from birth certificates. This study examined the relationship between access to and availability of care (number of local providers available who provide obstetrical care and who care for pregnant Medicaid women) and quality and cost of care. Sources of data included Washington State birth certificates and hospital discharge abstracts, supplemented with information on hospitals, communities, and provider supply. Findings from this study further illuminate the connection between poor geographic access, Medicaid access, and poor quality care.

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2004 Rural-Urban Commuting Areas (V2) This project described the new version of the Rural/Urban Commuting Areas (RUCAs) taxonomy that...

This project described the new version of the Rural/Urban Commuting Areas (RUCAs) taxonomy that defines rural and urban based on Census Bureau definitions and work commuting patterns. The RUCA taxonomy is a tool based on the sizes of cities and towns and their functional relationships as reflected by commuter patterns. Funded by HRSA’s FORHP.

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Low Skilled, Low-wage Workers in Health Care This study identifies which allied health professions are at high financial risk, and examines the...

This study identifies which allied health professions are at high financial risk, and examines the greater societal implications of the financial risk that these workers face.

Complete HRSA
The Supply and Rural-Urban Distribution of the Obstetrical Care Workforce in the U.S. Access to obstetrical (OB) care in the rural U.S. has declined significantly in recent years, with...

Access to obstetrical (OB) care in the rural U.S. has declined significantly in recent years, with OB care by family physicians dropping substantially. Accurate supply estimates of OB providers by urban and rural geography, with attention to variation within different types of rural areas, will allow us to identify gaps in available care for communities in rural America. The types and numbers of OB providers who care for rural vs. urban populations differ substantially by geography. Uneven distribution of the OB workforce may continue to create disparities in access to OB care, even affecting areas that contain ample supply of other types of health care services. This study will describe the supply and distribution of OB care providers in the rural United States at national, regional and state levels.

Lead Researcher: Davis Patterson PhD
Contact Info: davisp@uw.edu, 206-543-1892

Healthcare access Maternal Health Physicians workforce
In Progress HRSA
The Supply and Distribution of the Primary Care Health Workforce in Rural America Rural Americans often depend on primary health care providers in ways that urban Americans do not. ...

Rural Americans often depend on primary health care providers in ways that urban Americans do not. The family physicians, general internists, general pediatricians, nurse practitioners, and physician assistants that make up the rural primary care workforce provide a wider range of direct patient care services than their urban counterparts and are crucially important in connecting patients with specialty care when it is required. A continuing challenge in rural health, especially in an era of substantial health care system change, is assuring that the supply of rural primary health care providers is sufficient to meet need. It is also important to understand that the distribution of those professionals is certainly not uniform. Even if overall supply is adequate, uneven distribution of the primary care workforce may continue to create disparities in access to health care. This study will describe the supply and distribution of primary care providers in the rural United States at national, regional and state levels using the most recent data available, including National Plan and Provider Enumeration System data, Urban Influence Codes and population data. A nuanced and up-to-date description of the variability in supply and geographic distribution of both the physician and non-physician primary care health workforce in rural America is essential for policy-makers, medical and nursing educators, and communities working to improve access to care in rural America.

Lead Researcher: Eric H. Larson, PhD
Contact Info: ehlarson@uw.edu, 206-616-9601

nurse practitioners physician assistants Physicians workforce
In Progress HRSA
Understanding the Prescribing Practices of Rural Nurse Practitioners and Physician Assistants with a DEA Waiver to Prescribe Buprenorphine The United States is in the midst of a severe and tragic opioid abuse epidemic. In 2015 more than 2...

The United States is in the midst of a severe and tragic opioid abuse epidemic. In 2015 more than 2 million Americans suffered from pain reliever disorder and more than half a million were using heroin. In 2016, an estimated 42,249 Americans died of an opioid drug overdose. Data suggest that rural areas are disproportionately impacted. Both death rates and non-medical use of prescription drugs have been rising more rapidly in rural than urban areas. The most effective treatment options for opioid use disorder (OUD) include buprenorphine-naloxone, a medication differing from methadone in that office-based physicians, nurse practitioners (NPs) and physician assistants (PAs) with a Drug Enforcement Administration (DEA) waiver can prescribe it. Several recent WWAMI RHRC studies have found a paucity of physicians located in rural areas who have a DEA waiver to prescribe buprenorphine as an office-based outpatient treatment for OUD and a relatively low percentage of physicians with a waiver who are prescribing, as well as described the barriers physicians report in providing this service. More than half of rural US counties (and 44% of all counties) lack even a single waivered provider. Additionally, the presence of a provider who has obtained a DEA waiver in a county does not necessarily mean that buprenorphine treatment is available there. In a recent national survey of rural physicians with a DEA waiver, more than half (53%) of physicians with the initial 30-patient waiver reported they were not treating any patients. No study has looked at the prescribing patterns of NPs and PAs in rural America who obtained a DEA waiver as allowed under the Comprehensive Addiction and Recovery Act. Other treatment options such as Opioid Treatment Centers are available in urban areas but are not readily available in rural locations. This study will extend our past work, describing the availability of office-based outpatient treatment for OUD in rural areas by surveying all rural NPs and PAs with a DEA waiver to prescribe buprenorphine. The survey will seek to quantify the number of rural NPs and PAs currently providing treatment, the number of patients being treated, and factors that facilitate or discourage these providers from offering treatment.

Lead Researcher: Holly Andrilla, MS
Contact Info: hollya@uw.edu, 206-685-6680

Nurse and nurse practitioners physician assistants Substance use and treatment
In Progress HRSA
Post-acute Care Quality for Rural Medicare Beneficiaries Over one-third of Medicare beneficiaries are discharged to post-acute care following inpatient...

Over one-third of Medicare beneficiaries are discharged to post-acute care following inpatient hospitalization, with initial post-acute care services provided by skilled nursing facilities and home health agencies about 80% of the time. Post-acute care is also a key driver of geographic variation in Medicare spending. Due to wide geographic variation in utilization, costs, and quality of post-acute care for Medicare beneficiaries, CMS is implementing value-based purchasing programs for skilled nursing facilities and home health agencies to incentivize high quality, efficient care. The skilled nursing facility value-based purchasing program started in 2017 and includes all Medicare-certified skilled nursing facilities across the country. The home health value-based purchasing demonstration started in 2016 and includes all Medicare-certified home health agencies in nine states. A nationwide home health value-based purchasing program is slated to launch by 2022. Both value-based purchasing programs include rural providers. Yet little is known about quality of care specifically among rural post-acute care providers and with respect to urban providers. Since rural post-acute care providers face unique challenges in delivering care and rural post-acute patients are often sicker and at higher risk for poor outcomes, rural providers may be at greater risk for penalties under value-based purchasing programs. Rural post-acute care providers that have Medicare payments substantially decreased for poor performance may not have the resources necessary to implement quality improvement initiatives to avoid further penalties. While high-quality care must remain a key goal for all providers, reductions in payments may disproportionately impact some rural providers, which in turn may exacerbate disparities for rural beneficiaries.

Lead Researcher: Tracy Mroz, PhD
Contact Info: tmroz@uw.edu, 206-598-5396

Home health Post-acute Care
In Progress HRSA
What are best practices for providing Buprenorphine Maintenance Treatment in rural primary care? Not all physicians with a Drug Enforcement Agency waiver to prescribe buprenorphine actually...

Not all physicians with a Drug Enforcement Agency waiver to prescribe buprenorphine actually provide this treatment or fully utilize their waiver capacity. This project will interview physicians successfully using their waivers to identify best practices for prescribing buprenorphine treatment for Opioid Use Disorder.

Complete HRSA
Do rural breast and colorectal cancer patients present at more advanced disease stages than their urban counterparts? This project will use the Surveillance, Epidemiology and End Results Program (SEER) data set to...

This project will use the Surveillance, Epidemiology and End Results Program (SEER) data set to examine the extent to which rural residents present at more advanced disease stages for breast and colorectal cancer diagnosis when compared to urban residents.

In Progress HRSA
Who provides mental health services to rural Medicare beneficiaries? This study will describe the provider workforce that cares for rural elderly patients with...

This study will describe the provider workforce that cares for rural elderly patients with depression/anxiety. It will also describe regional and rural-urban variation in mental health care provision.

In Progress HRSA
Post-acute care trajectories for rural Medicare beneficiaries This study will examine post-acute care utilization for rural Medicare beneficiaries following...

This study will examine post-acute care utilization for rural Medicare beneficiaries following acute hospitalization. Use of home health and skilled nursing care and trajectories of care across settings will be described.

In Progress HRSA
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 This study will investigate the possible effects on rural access to treatment for opioid use...

This study will investigate the possible effects on rural access to treatment for opioid use disorder if Drug Enforcement Administration (DEA) waivers to prescribe buprenorphine as an office-based outpatient treatment for opioid addiction were available to Physician Assistants (PAs) and Nurse Practitioners (NPs). Better understanding of the potential additional workforce available to treat the devastating opioid use epidemic will allow policy makers to make informed decisions on expanding waiver eligibility.

Complete HRSA
Geographic Access to Health Care for Rural Medicare Beneficiaries: An Update and National Look Rural residents generally use fewer medical services, travel farther for care and often have more...

Rural residents generally use fewer medical services, travel farther for care and often have more problems accessing medical and surgical specialists than their urban counterparts. These issues can be particularly problematic for older rural Medicare beneficiaries who need specialist services or for whom long travel distances may pose challenges. This objective of this study is to compare, at a national and census division level, where rural and urban Medicare beneficiaries receive ambulatory care, which types of specialists they utilize and how far beneficiaries are traveling to obtain care. In addition to rural/urban comparisons, intra-rural variation in utilization and travel distance will be evaluated and compared.

In Progress HRSA
Assessing Potential Unmet Need for Home Health Care in Rural Areas This study will estimate potential unmet need for home health care in rural areas for...

This study will estimate potential unmet need for home health care in rural areas for fee-for-service Medicare beneficiaries. We will compare rates of home health care utilization in rural areas with urban areas, accounting for acute hospital discharges and utilization of inpatient rehabilitation facilities and skilled nursing facilities. We will examine intra-rural variation in transition from hospital to different post-acute care providers and quantity of home health care services by diagnostic group. Findings from this study will help inform policies addressing access to and reimbursement of rural home health care and adequacy of home health care workforce supply.

In Progress HRSA
Prehospital Emergency Medical Services Personnel: Comparing Rural and Urban Provider Experience and Provision of Evidence-based Care This study will describe the relationship between prehospital emergency medical services (EMS)...

This study will describe the relationship between prehospital emergency medical services (EMS) providers’ accumulated experience and provision of evidence-based care for rural and urban populations using newly available data on EMS agencies, workforce, and patient care. Results will inform policies for ensuring that rural populations have timely and appropriate access to high-quality prehospital emergency care.

In Progress HRSA
Rural Physician Residencies under Unified Accreditation The impending unification of allopathic and osteopathic graduate medical education (GME) under a...

The impending unification of allopathic and osteopathic graduate medical education (GME) under a single accreditation system has uncertain implications for small and rural-focused residency programs. This proposed study aims to (1) quantify the rural practice outcomes of residencies in the rurally-relevant specialties of pediatrics, internal medicine, obstetrics/gynecology, emergency medicine, surgery, anesthesia, and psychiatry, and (2) interview key stakeholders to identify anticipated challenges of the accreditation merger and potential policies to strengthen vulnerable rural-focused residencies during the transition.

In Progress HRSA
Rural Home Health Services for High Risk Patients This study will examine outcomes of care for rural Medicare patients who were discharged from...

This study will examine outcomes of care for rural Medicare patients who were discharged from hospitals and admitted to home health care for post-acute services. Outcomes will include emergent care use and re-hospitalization during the home health admission and community discharge. Key predictors include type of rural community (large, small, isolated small), geographic region, types and amounts of home health services provided, home health agency workforce characteristics, and available community health care resources.

Complete HRSA
Rural Behavioral Health Workforce Data from the National Plan and Provider Enumeration System (NPPES) file, linked to RUCA codes and...

Data from the National Plan and Provider Enumeration System (NPPES) file, linked to RUCA codes and population data, will be used to identify behavioral health providers and describe their geographic (rural/urban, regional and intra-rural) distribution. Behavioral health professions identified in the file include psychiatrists, addiction medicine specialists, psychiatric nurse practitioners, clinical nurse specialists in mental health, clinical psychologists and licensed social workers.

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Programs Producing Rural PAs: Part 2 This study builds on a previous WWAMI RHRC study that identified the physician assistant (PA)...

This study builds on a previous WWAMI RHRC study that identified the physician assistant (PA) training programs that have produced high numbers and high proportions of graduates working in rural areas. This study will extend that work through a physician assistant program survey, identifying key characteristics, admission and training strategies, and missions of successful rural programs.

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Post-acute vs. Community-entry Home Health in Rural Areas This study will examine the differences in home health care for post-acute versus community-entry...

This study will examine the differences in home health care for post-acute versus community-entry episodes among rural Medicare beneficiaries. The proportion of community-entry episodes will be examined by type of rural geography and region. Predictors of community-entry, including clinical and non-clinical beneficiary characteristics, community health resources, and Medicaid programming, will be explored.

In Progress HRSA
Community Paramedicine Evidence Community paramedicine (CP) has been promoted as a strategy to help communities achieve the Triple...

Community paramedicine (CP) has been promoted as a strategy to help communities achieve the Triple Aim of improving healthcare and population health while lowering costs. This study is collecting descriptive information on CP programs that can be identified in the U.S., and for those programs with outcome data, comparing rural with urban programs in terms of their goals, services offered, outcomes measured, and results.

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Availability of Buprenorphine Services in Rural Areas This study will investigate the extent to which physicians who practice in rural areas and have a...

This study will investigate the extent to which physicians who practice in rural areas and have a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine as an office-based outpatient treatment for opioid use disorder are providing this treatment to their patients. This study will also estimate the need for office-based opioid disorder treatment in rural locations.

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Rural Physician Assistants Background: In the 1970s, graduates of physician assistant (PA) programs practiced largely in...

Background: In the 1970s, graduates of physician assistant (PA) programs practiced largely in primary care settings serving rural and other underserved populations. By the 1990s, PAs were practicing in a much wider variety of settings in many medical specialties. Aim: To describe the demography, practice arrangements and content of practice of a nationally representative sample of PAs collected in the 1990s. Methods: A stratified random sample of PAs was surveyed in 1993-1994. The demography, practice characteristics and content of PA practice were analyzed across practice location and medical specialty. Results: Of all the living PAs ever trained, 95% were active in the health care delivery system at the time of the survey. Eighty-seven percent of those trained were practicing as PAs, nearly all of whom were practicing full time. Rural PAs were more likely to be white and male than their urban counterparts and had lower levels of education prior to entering PA training. Generalist PAs performed many more outpatient visits than specialist PAs, and fewer inpatient visits. In urban areas, PAs were making a large contribution to surgical care. About three-fourths of the rural PAs were generalists. Conclusions: The broader scope of practice of generalist PAs, especially those serving rural populations, points to the need to ensure that training programs, especially those emphasizing generalist care for rural and underserved populations, provide sufficient breadth in medical training to meet those needs. Funded by HRSA’s ORHP.

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Unhealthy Lifestyles of Rural/Urban Minorities: Obesity Background: Obesity is on the rise in the United States and has been implicated in serious chronic...

Background: Obesity is on the rise in the United States and has been implicated in serious chronic health problems. Obesity is very costly in terms of medical spending and lost productivity. Aim: To estimate the prevalence of and recent trends in obesity among U.S. adults residing in rural and urban locations. Methods: A telephone survey of adults aged 18 years and older residing in states participating in the Behavioral Risk Factor Surveillance System (BRFSS) in 1994-1996 and 2000-2001. The main outcome measure for the study was obesity, defined as a body mass index of 30 or greater, based on self-report. Results: In 2000-2001, the prevalence of obesity was 23.0% for rural adults and 20.5% for their urban counterparts, increases of 4.8% and 5.5%, respectively, since 1994-1996. The highest obesity prevalence occurred in rural counties of Mississippi, Texas and Louisiana. Only Rhode Island and Colorado had rural counties that met the HealthyPeople 2010 goal of a maximum of 15% obese for adults. Conclusions: Despite recent attention to the prevalence of obesity, obesity rates continue to rise across the United States and differentially affect inhabitants of rural and urban areas. Funded by HRSA’s ORHP.

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Unhealthy Lifestyles of Rural/Urban Minorities: Cigarettes Background: Cigarette smoking is the leading preventable cause of death in the United States. Aim:...

Background: Cigarette smoking is the leading preventable cause of death in the United States. Aim: To estimate the prevalence of and recent trends in smoking among adults residing in three types of rural locations. Methods: Telephone survey of adults aged 18 years or older who participated in the Behavioral Risk Factor Surveillance System in 1994-1996 and 2000-2001. Results: The prevalence of smoking changed little from the mid-1990s; it was 22.0% in urban areas, 24.9% in rural adjacent areas, 24.0% in large rural non-adjacent areas, and 24.9% in small rural non-adjacent areas. For rural locations combined, its prevalence was not below the 12% goal of HealthyPeople 2010 for any state. Its prevalence was ≥ 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% in California, Connecticut, Maryland, North Carolina, Tennessee, and Utah. However, it increased by 2% or more in 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. Funded by HRSA’s ORHP.

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Unhealthy Lifestyles of Rural/Urban Minorities: Alcohol Use Aim: To estimate the prevalence of and recent trends in alcohol use among U.S. adults in rural...

Aim: To estimate the prevalence of and recent trends in alcohol use among U.S. adults in rural areas. Methods: A telephone survey of adults aged 18 years or older residing in states participating in the Behavioral Risk Factor Surveillance System (BRFSS), in the years 1995/1997 and 1999/2001. Results: Urban counties led rural counties for moderate and heavy drinking in 1999/2001, and also saw the largest increases in heavy drinking between 1995/1997 and 1999/2001. Binge drinking was nearly as high in remote rural counties with a large town as in urban counties, and increased the most for remote rural counties with a large town. Urban whites were more likely than any other racial/ethnic group to report moderate or heavy drinking, while American Indians in remote rural counties with a large town were the most likely to report binge drinking. Significant increases in heavy and binge drinking were highest for rural residents in the Northeast and Midwest and lowest in the South Census region. Conclusions: Heavy drinking was highest and increased the most in urban counties; however, binge drinking increased the most in remote rural counties with a large town, and heavy and binge drinking increased for rural counties of all types. Funded by HRSA’s ORHP.

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Trends in Rural Perinatal Care of American Indians While there have been dramatic improvements in AI/AN maternal and child health since these measures...

While there have been dramatic improvements in AI/AN maternal and child health since these measures were first recorded in the mid-1950s, significant disparities persist between AI/AN and non-AI/AN populations in the United States. This study (1) examined trends in prenatal care use, low-birthweight rate, and the neonatal and postneonatal mortality rates in rural and urban AI/AN populations nationally between 1985 and 1997, and compared these trends in the white populations during the same time period; (2) examined trends in causes of death for rural and urban AI/AN populations nationally between 1985 and 1997, and compared these trends to the white population during the same time period; and (3) analyzed trends in our study measures for AI/AN and white populations by Census region, division, and Indian Health Service (IHS) Service Areas. The study used the National Linked Birth Death Data Set at three points in time: 1985-1987, 1989-1991, and 1995-1997, and compared rates of inadequate prenatal care, low birthweight, neonatal and postneonatal death, and causes of death between rural AI/ANs and Caucasians in each of the three time periods, as well as over time. Funded by HRSA’s ORHP.

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Trends in Rural Perinatal Care Little is known about long-term national trends in birth outcomes and use of prenatal care in the...

Little is known about long-term national trends in birth outcomes and use of prenatal care in the rural population of the United States, or about intrarural differences in adverse outcome and inadequate prenatal care. In this two-year study, we examined: (1) How have rates of adverse birth outcome and prenatal care among U.S. rural residents changed in the years between 1985-1987 and 1995-1997? and (2) How have adverse birth outcomes and prenatal care changed during these periods among rural residents from racial and ethnic minority groups? We examined data from the Linked Birth Death Data Set (LBDDS), a national compilation of birth certificate data from all 50 states and the District of Columbia. We assessed inter-decade changes in rural/urban and intrarural differences in the rate of low birthweight outcome, neonatal death, postneonatal mortality, and inadequate prenatal care. We also assessed the degree to which observed changes were concentrated in particular types of rural settings or regions. Funded by HRSA’s ORHP.

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Trends in Rural Dentistry This study used secondary data sources such as the Area Resource File, American Dental Association...

This study used secondary data sources such as the Area Resource File, American Dental Association data, and state-level professional licensure data to describe the supply of dental providers in several states, with particular attention to the supply of providers in rural areas. Surveys were administered to rural dentists in California, Maine, Missouri, and Alabama to describe the rural dental provider population in those states with respect to demography, practice characteristics, practice satisfaction, use of dental hygienists, Medicaid and CHIP practices, and attitudes towards the use of alternative sources of dental care such as using medical providers to apply sealants in the pediatric population. The study elucidates, from the dental provider perspective, the barriers to access to dental care for rural residents and what can be done to promote rural dental practice. Funded by HRSA’s ORHP.

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Tort Reform & Obstetrical Access As a consequence of the malpractice liability crisis, each of the four WAMI states at the time of...

As a consequence of the malpractice liability crisis, each of the four WAMI states at the time of this study had modified the existing tort and/or professional liability systems in their states. This project reviewed recent studies of physicians’ obstetrical practices and major changes in tort legislation and regulation. The majority of general and family physicians in the WAMI region no longer provided obstetrical care, while over 80% of the obstetrician/gynecologists in this area still practiced obstetrics. Most rural family physicians in all four states continued to deliver babies. The majority of physicians in these states limited the amount of care they provide to Medicaid patients. All four states adopted tort reforms, yet the cost of malpractice premiums and concerns over liability continued to limit the number of physicians willing to provide obstetrical care.

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The WWAMI Rural Health Workforce This project compiles and presents state-level information about the rural health workforce in the...

This project compiles and presents state-level information about the rural health workforce in the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) region. Information was derived from the American Medical Association Masterfile, the National Sample Survey of Registered Nurses, the Area Resource File, and other sources. This series of policy briefs describes WWAMI rural health workforce challenges and opportunities, workforce numbers, resources, the importance of rural definitions, and tools for workforce policymakers and planners.

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The Walkability Project This study is identifying built environmental correlates of walking in rural towns and evaluating...

This study is identifying built environmental correlates of walking in rural towns and evaluating the role of low socioeconomic status (SES) and Latino ethnicity on these relationships. By studying 9 rural towns from 3 diverse regions, Washington State, the Northeast, and Texas, with a varying range of socioeconomic and ethnic characteristics, this study is: (1) measuring built environmental correlates of walking among small town residents, using objective and perceived measures of the built environment and self-reported measures of walking; (2) evaluating the degree to which built environmental correlates of walking among rural town residents are influenced by SES and Latino ethnicity; and (3) validating the perceived correlates of walking using accelerometer and global positioning system measures. The study will first involve a survey of 1,800 residents of these towns on physical activity patterns and attributes of their towns that promote or impede walking, and will next recruit a sample of 270 respondents who agree to wear two small devices measuring their physical activity for 7 consecutive days. Objective measures of their physical activity will be compared to self-reported data. This work will lay the foundation for future research on the relationship between various aspects of the rural built environment and health behaviors and, ultimately, intervention trials to help rural towns better structure the built environment to promote walking and healthier life styles among their highest risk residents.

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Surgical Procedures in Rural This report addresses rural/urban differences in surgical practices in commonly performed inpatient...

This report addresses rural/urban differences in surgical practices in commonly performed inpatient surgical procedures that are typically handled by general surgeons. National Inpatient Sample data from rural and urban hospitals in 24 states were used to examine the frequency of general surgical procedures, complications during hospitalizations and predicted resource demand.

Findings indicate that rural hospitals concentrated on relatively common, low complexity procedures that can be handled by general surgeons, especially if they have received additional training in obstetrics/gynecology and orthopedics. Resource demand, length of stay, complication rates and mortality were lower for patients undergoing common procedures in rural hospitals. Rural training tracks for general surgery that provide a high case load for common general surgery, obstetrics/gynecology and orthopedics procedures may help sustain the general surgery workforce in rural areas.

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Surgery in Rural/Urban Hospitals Washington State hospital abstracts for 1987 and 1988 with pseudo-personal identifiers added were...

Washington State hospital abstracts for 1987 and 1988 with pseudo-personal identifiers added were used in an analysis of readmission rates for four selected conditions by patient residential and hospital location. During the two-year period examined, there were no significant differences in readmission rates for surgeries performed in rural and urban hospitals. No evidence of low-quality care in Washington State rural hospitals was found when investigating readmission rates following common surgeries.

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Supply and Retention of Rural Surgeons Background: General surgeons form a crucial component of the medical workforce in rural areas of...

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. Aim: To determine the numbers, characteristics, and distribution of general surgeons currently practicing in the rural United States. Methods: The American Medical Association’s Physician Masterfile was used to identify all clinically active general surgeons as well as their location and characteristics. Their geographic distribution was examined using the ZIP code version of the Rural-Urban Commuting Areas (RUCAs). Results: Nationally, the number of general surgeons per 100,000 population 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 were female. General surgeons in the smallest rural areas were more likely than those in urban areas to be male (92.7% versus 88.3%), 50 years of age or older (51.6% versus 42.1%), or international medical graduates (25.2% versus 20.1%). Conclusions: The overall size of the rural general surgical workforce has remained static, but its demographic characteristics suggest that numbers will decline. Many rural residents have limited access to surgical services. This project was funded by HRSA’s FORHP, with the publication Thompson et al. 2005 and Final Report #77 as deliverables.

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State Rural Health Workforce Monograph The uneven distribution of health care providers across rural and urban areas of the United States...

The uneven distribution of health care providers across rural and urban areas of the United States continues to impede access to care for millions of rural residents. This book profiles that workforce with comparisons of the supply of health professionals across the 50 states and within the rural areas of each state. In addition to individual state workforce profiles, the book includes discussion of key policy and methodological issues in workforce analysis. The data and analysis show that the nature and magnitude of rural health workforce problems vary substantially both across states and within them, suggesting the dangers of “one-size-fits-all” policy solutions. This book provides a picture of the rural health workforce that will serve analysts and policy makers well as they search for workable solutions to the problem of inadequate supply of health care providers in rural America. Funded by HRSA’s FORHP.

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Staffing of Rural Hospital ERs All 37 rural Washington State hospitals with less than 100 beds were surveyed to determine how...

All 37 rural Washington State hospitals with less than 100 beds were surveyed to determine how rural emergency departments were staffed by physicians and to estimate rural hospital payments for these services. Study data were collected through telephone interviews with hospital administrators or directors of nursing services. Results indicated that 86% of rural hospitals contracted for emergency department coverage and 59% obtained some or all of this service from nonlocal physicians.

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Specialty Care for Rural American Indians Background: The Indian Health Service (IHS) expenditure for American Indian and Alaska Native...

Background: The Indian Health Service (IHS) expenditure for American Indian and Alaska Native (AI/AN) health services is less than half that spent per year on the U.S. civilian population. Many AI/ANs, especially in rural areas, depend on the IHS as their only source of funding for health care. Specialty services may be limited by a low level of contract funding. Aim: To examine access to specialty services among rural AI populations. Methods: A mail survey addressing access to specialty physicians, perceived barriers to access, and access to nonphysician clinical services was sent to primary care providers in rural Indian health clinics in Montana and New Mexico and primary care providers in rural non-Indian clinics within 25 miles of the Indian clinics. Results: Substantial proportions of rural Indian clinic providers in Montana and New Mexico reported fair or poor access to nonemergent specialty services for 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 most frequently cited financial barriers to specialty care. Indian clinic providers in both states reported better access to several nonphysician services than non-Indian clinic providers. Conclusions: Access to specialty care for rural Indian patients is limited, and is influenced by the organization of care systems and financial constraints. Funded by HRSA’s FORHP.

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Rural/Urban Obstetrical Care Quality Washington State vital statistics data from 1984 through 1988 were used to investigate differences...

Washington State vital statistics data from 1984 through 1988 were used to investigate differences in the process and outcome of obstetrical care based on the rural/urban locations of the mothers’ residences. This study compared rural and urban obstetrical care in terms of mortality, trimester prenatal care began, adequacy of the number of prenatal visits, and birthweight. Separate analyses (1) differentiated between rural mothers who delivered in rural locations and those that delivered in urban locales and (2) partitioned low and non-low risk women.

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Rural/Urban Generalists This two-year project used Medicare data provided by HCFA to describe the content of practice of...

This two-year project used Medicare data provided by HCFA to describe the content of practice of physicians in rural and urban areas of Washington State. The population studied included board-certified physicians in the 12 largest ambulatory medical specialties in Washington State who were in active medical practice in 1994 and who provided ambulatory care to at least ten Medicare patients per year during that period. The diagnostic and procedural breadth of rural and urban physicians in all specialties was found to be similar, with the exception of rural general surgeons and obstetrician-gynecologists, who were more likely to care for patients outside their specialty area. Funded by HRSA’s ORHP.

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Rural U.S. Perinatal Health This study examined perinatal outcomes in rural areas across the United States in 2005. Low birth...

This study examined perinatal outcomes in rural areas across the United States in 2005. Low birth weight, a key indicator of the health of the U.S. population, and adequacy of prenatal care, a critical indicator of access and quality of health care, were explored to discover how they are related to rural or urban location, race, and ethnicity.

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Rural RNs' Choice of Work Location While larger numbers of registered nurses (RNs) are living in rural areas, research from the WWAMI...

While larger numbers of registered nurses (RNs) are living in rural areas, research from the WWAMI RHRC shows that since 1980, a growing percentage are commuting from rural residences to work within urban and larger rural cities. This study explored factors that may be associated with RNs’ decisions to commute away from their rural areas of residence to work in less rural areas. Funded by HRSA’s ORHP.

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Rural Physicians Waivered to Treat Opioid Addiction Unintentional drug overdose deaths associated with prescription opioids rose 395% between 1999 and...

Unintentional drug overdose deaths associated with prescription opioids rose 395% between 1999 and 2007, and opiate misuse among adolescents is now twice as common as in the 1990s. Because methadone maintenance clinics are largely non-existent in rural areas, an effective alternative is training physicians in the use of buprenorphine, an effective addiction treatment that can be administered in outpatient practices. This study will determine the extent to which a trained workforce exists in rural America that has received the necessary waiver to treat opioid addiction in outpatient settings with buprenorphine, identifying areas with critical shortages and discussing policy options for expanding the supply of these qualified providers. Funded by HRSA’s Office of Rural Health Policy.

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Rural Physician, NP, PA Impact This WWAMI RHRC study will explore how many nurse practitioners (NPs), physician assistants (PAs),...

This WWAMI RHRC study will explore how many nurse practitioners (NPs), physician assistants (PAs), and physicians will be required to meet rural health care demand resulting from expanded access to health insurance through implementation of the Affordable Care Act (ACA). The study will also describe the ACA’s impact on types of primary care services that would be available under different provider mix scenarios. The study’s analyses will use simulated rural primary care demand data and rural primary care NP, PA, and physician productivity data from recent research by the WWAMI RHRC. Funded by HRSA’s Office of Rural Health Policy.

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Rural Pediatric Inpatient Care This study described the distribution of rural practitioners in Washington State who provide...

This study described the distribution of rural practitioners in Washington State who provide inpatient care to pediatric patients, elucidated the major diagnostic categories for which children are hospitalized in rural versus urban areas, contrasted the roles of pediatricians and family physicians providing pediatric care, and assessed the effectiveness of the system. The major source of data for this study was CHARS, which was linked to information on the training and discipline of the providers who cared for each of the patients in the study. Funded by HRSA’s ORHP.

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Rural Oral Health Challenges This review identifies the challenges to oral health in rural America and describes areas of...

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. This paper was part of a special issue of the Journal of Public Health Dentistry. The purpose of the special issue was to further develop ideas presented at the 2009 Institute of Medicine (IOM) workshop, “The Sufficiency of the U.S. Oral Health Workforce in the Coming Decade.” Using the IOM discussions as their starting point, the authors evaluate oral health care delivery system performance for specific populations’ needs and explore the roles that the workforce can play in improving the care delivery model. The contributing articles provide a broad framework for stimulating and evaluating innovation and change in the oral health care delivery system. The articles in this special issue point to many deficits in the current oral health care delivery system and provide compelling arguments and proposals for improvements.

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Rural Obstetrical Technology This study compared the approach to neonatal care in Wales and Washington State, studying the...

This study compared the approach to neonatal care in Wales and Washington State, studying the extent of perinatal regionalization, the distribution of neonatal technologies, and birthweight-specific neonatal outcomes. In Wales, most District General Hospitals (DGH) had all the neonatal equipment recommended for a maximal neonatal intensive care unit, whether or not the DGH was a designated regional or subregional center. Sophisticated neonatal technology in Washington was concentrated in designated referral hospitals. Almost every Welsh DGH cared for infants weighing less than 1,000 grams at birth, while in Washington State most very-low-birthweight neonates were born in referral centers and the few born elsewhere were transferred immediately after birth. Despite differences in the extent of regionalization, birthweight-specific neonatal mortality rates were similar in the two countries.

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Rural NSSNP Analysis This WWAMI RHRC study uses data from HRSA's first National Sample Survey of Nurse Practitioners...

This WWAMI RHRC study uses data from HRSA’s first National Sample Survey of Nurse Practitioners (NSSNPs) to expand on the agency’s basic descriptive analyses of rural and urban nurse practitioners (NPs). The study compares rural and urban NPs’ demographics, education, practice, and related characteristics; and estimates basic NP labor supply models. Funded by HRSA’s Office of Rural Health Policy.

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Rural Medicine Textbook This book explores what is known about the content, needs, and special problems of rural health...

This book explores what is known about the content, needs, and special problems of rural health care. The goal was to advance the knowledge base and describe strategies used by rural health professionals in developing quality of care for rural communities and their residents. The book includes an overview of rural health care, special clinical problems and approaches in rural health care, the organization and management of rural health care, approaches to quality improvement, and education for rural practice.

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Rural Hospital Surgical Capacity This study examined the availability of several elective and urgent surgical procedures at rural...

This study examined the availability of several elective and urgent surgical procedures at rural hospitals, identified the specialties of rural surgery and anesthesia providers, and determined where rural residents obtained surgical services and how the utilization of services is influenced by the presence of local services. Data were obtained from telephone interviews with hospital administrators, directors of nursing services, and/or operating room charge nurses. Washington State complete hospital discharge data provided the number of selected and aggregate procedures for each hospital by diagnosis and procedure codes, as well as hospital reimbursement for surgical procedures.

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Rural Hospital Project The Rural Hospital Project (RHP) assisted six threatened rural hospitals in the WAMI region through...

The Rural Hospital Project (RHP) assisted six threatened rural hospitals in the WAMI region through a multifaceted approach to addressing their problems and strengthening health services. Subsequently, the RHP interventions were applied through a Community Health Services Development Model to other rural hospitals throughout the regional Area Health Education Centers (AHECs). This study examined the process of exporting the interventions from a university-based demonstration project to a community-based program disseminated by the AHECs.

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Rural Hospital Linkages Linkage refers to a rural hospital's formal and informal associations with outside entities (e.g.,...

Linkage refers to a rural hospital’s formal and informal associations with outside entities (e.g., joint purchasing arrangements and inter-hospital networks). This study (1) provided a descriptive analysis of rural hospital linkages in the WAMI states based on a literature review and key informant interviews, (2) determined how governmental regulations influence such linkages, and (3) performed case studies on two rural health care alliances located in different regions and formed 13 years apart.

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Rural Hospital Governing Boards Part C Background: Little research has been conducted to describe the factors and practices associated...

Background: Little research has been conducted to describe the factors and practices associated with the effectiveness of rural hospital governing boards. Aim: To identify activities and characteristics of the governing boards of small rural hospitals that are related to hospital success. Methods: We surveyed 89 rural hospital board chairs in Washington, Alaska, and Idaho about how they spent their time and how they were organized. We asked experts familiar with 74 hospitals with less than 100 beds to rate them in several key areas. Results: The eight activities of boards associated with “strong” hospitals included: one or more board retreats per year, annual review of mission and goals, lower percentage of time monitoring budget, use of board committees, clear recruitment plan to attract desirable board members, funds for continuing education of board members, owned or leased ownership, and larger hospital average daily census. In addition, the “strong” hospitals were found to have higher daily census than the “weak” hospitals (higher among hospitals with less than 100 beds). Conclusions: As long as the governance of rural hospitals is in the hands of volunteer boards, researchers and policy makers should assist these boards in identifying the most efficient and effective ways for them to spend their limited time and resources. Funded by HRSA’s ORHP.

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Rural Hospital Governing Boards Part B Background: To provide competent membership, a board member needs knowledge of health care...

Background: To provide competent membership, a board member needs knowledge of health care developments and the organization of the board. Aim: To provide information on the knowledge level of governing board members in hospitals in three northwestern states. Methods: This study included 130 hospitals with individual governing boards in rural areas of Alaska, Idaho, and Washington. As part of a larger survey of all rural hospital board members in these states, we asked board members questions relevant to competent membership on a governing board. This included questions concerning quantifiable aspects of the hospitals, planning, and financial reporting. Results: Knowledge on the part of the board members was strongest in the areas of the role of the governing board, planning, and scope of services. Board members were less able to quantify the capacities and utilization of services at their hospitals. Results were mixed in the area of knowledge of financial management. Length of service on the board and efficient board structures were associated with increased knowledge. Conclusions: While board members were knowledgeable about their roles and the services offered by their hospitals, their knowledge base in certain other crucial areas was limited, underscoring the need for programs that facilitate board member training. Funded by HRSA’s ORHP.

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Rural Hospital Governing Boards Part A Background: Literature about rural health providers has focused largely on physicians, mid-level...

Background: Literature about rural health providers has focused largely on physicians, mid-level providers, and hospitals and their administrators, but little has been written about the boards that govern those hospitals. Aim: To describe the role and composition of rural hospital governing boards. Methods: Hospitals in Washington, Alaska, and Idaho were included in this study. Surveys related to hospital governance were administered to rural hospital board members and board chairpersons of urban and rural hospitals. Results: Board members were typically white males over the age of 50 and retired. They served an average of seven years and most typically brought business and management expertise to their positions. Board members contributed more than a dozen hours per month to board business and attended about 90% of their board and committee meetings. Fewer than one in four rural hospital board chairs indicated his or her board had a formal recruitment program, and fewer than half of the boards spent more than three hours on board member orientation. Board chairs were more likely to rate highly the performance of other community leaders, as well as members of the medical staff. Conclusions: Boards are attracting the service of individuals who are well educated, experienced, and willing to contribute more than a dozen hours a month to their board service. However, small rural boards are not investing enough time and funds in orientation and training. Funded by HRSA’s ORHP.

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Rural Hospital CEO Turnover This study described the tenure, rate of and reasons for turnover of hospital administrators, and...

This study described the tenure, rate of and reasons for turnover of hospital administrators, and tracked the career trajectories of rural hospital administrators. The study was performed in partnership with the WAMI Area Health Education Center and the Washington State Hospital Association. Resumes from all Washington State hospital administrators contrasted the education and professional backgrounds of rural and urban administrators. A survey of all regional rural hospital administrators who left their position during the past three years provided information on hospital characteristics, reasons that they left, effects on the hospital and community, evaluation of their performance, and gaps in training. Questionnaires were sent to a hospital board member in the same community to ascertain why the administrator left, consequences of the departure, and adequacy of the administrator’s performance.

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Rural Hospital Care for Acute Myocardial Infarction: 2000-2001 This project examined whether overall improvements in the quality of care for acute myocardial...

This project examined whether overall improvements in the quality of care for acute myocardial infarction (AMI) among Medicare patients occurred in both rural and hospital settings. It used the Cooperative Cardiovascular Project Database and a database of measures of clinical performance, and included in the sample those Medicare beneficiaries with an AMI who were directly admitted for AMI care. Funded by HRSA’s ORHP.

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Rural Hospital Anesthesia Services Key to the ability of rural hospitals to maintain a surgery service is the availability of...

Key to the ability of rural hospitals to maintain a surgery service is the availability of anesthesia personnel, yet anecdotal evidence indicates that their supply is limited and their salary costs are high. This study surveyed administrators from rural hospitals in Washington and Montana regarding their experience in recruiting and retaining nurse and physician anesthetists. Aspects of anesthesia coverage such as financial arrangements, professionals working at multiple sites, outpatient and inpatient surgery, inter-provider type professional rivalries, and licensure constraints were examined. Funded by HRSA’s ORHP.

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Rural Home Health Care Access to home health care can be challenging for rural Medicare clients. Key informants for this...

Access to home health care can be challenging for rural Medicare clients. Key informants for this study from across the U.S. detailed these obstacles, which include financial, regulatory, workforce, and geographic issues, as well as solutions that merit consideration. Rural communities, especially those served by small and non-profit home health agencies, will likely benefit from payment reforms that reward quality services while providing incentives to innovate and use best practices in home health care.

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Rural HIT Workforce Needs The goal of this study is to improve understanding of health information technology (HIT) workforce...

The goal of this study is to improve understanding of health information technology (HIT) workforce needs and constraints in rural primary care settings. This study will determine rural primary care practices’ current and projected level of electronic health record (EHR) and health information technology (HIT) adoption and estimate demand for workers with HIT skills. This study will survey a stratified sample (large and small rural areas) of approximately 1,600 rural primary care practices across the U.S. The questionnaire will assess EHR and HIT implementation at the facility level; their relative need for different components of the HIT workforce; and whether they train and develop HIT staff from within, hire new staff, employ consultants, and/or join forces with other institutions to fill these workforce needs. We will include questions about the institutions’ current HIT workforce, expected future demand, education and training resources available to the institution and its staff, and other workforce-related factors that support or impede the practices’ implementation and use of HIT. Our descriptive analyses will produce national rural and sub-rural estimates of findings. The study will also identify relationships between specific practice attributes and HIT workforce variables. Funded by HRSA’s Office of Rural Health Policy.

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Rural Health Policy Briefs University of Washington WWAMI RHRC researchers prepared four policy briefs in late Spring 2009 to...

University of Washington WWAMI RHRC researchers prepared four policy briefs in late Spring 2009 to inform policymakers about potential solutions to health workforce crises in rural America. The briefs address rural health workforce issues in general surgery, nursing, primary care, and dentistry.

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Rural FLEX Program In 1997, the U.S. Congress created the Rural Hospital Flexibility Program (Flex Program) as part of...

In 1997, the U.S. Congress created the Rural Hospital Flexibility Program (Flex Program) as part of the Balanced Budget Act (BBA). This program provides for cost-based reimbursement under Medicare to eligible small, relatively remote hospitals. A companion grant program supports state emergency medical services systems (EMS) and hospital participation in the program. The reimbursement component is the responsibility of the Center for Medicare and Medicaid Services (CMS), while the grant program is the responsibility of the Federal Office of Rural Health Policy (FORHP). Funding to support the monitoring efforts of the Flex Program Tracking Team was provided under the grant program appropriation. The Tracking Team was a consortium of six rural health research centers. Each Center had lead responsibility for several research components of the study. In 2002/2003, the WWAMI Rural Health Research Center took responsibility for assessing state program evaluations, evaluating a number of workforce issues faced by critical access hospitals (CAHs, and looking at the intersection of CAHs) and another federal program, the Mississippi Delta Hospital Performance Improvement Initiative. WWAMI also provided overall project direction and coordination to the participating centers. The main national goals for implementation of the grant component of the Flex Program in the states and participating hospitals included (1) preparing a state rural health plan, (2) converting eligible and willing hospitals to critical access hospital (CAH) status, (3) improving quality of care, (4) promoting networking among hospitals, and (5) improving emergency medical services.

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Rural Family Practice Residency Programs Chartbook This chartbook makes previously unreported information from our national survey of 453 FP residency...

This chartbook makes previously unreported information from our national survey of 453 FP residency directors available to medical educators and policy makers. As part of this survey, programs were asked to indicate the extent to which training rural physicians was part of their core mission and to specify where all residency training sponsored by their programs took place. Using the Rural-Urban Commuting Areas (RUCAs), the ZIP codes of these locations allowed us to determine the relative rurality of all U.S. family practice residency training. The chartbook presents national, regional, state, and division findings, presented by type of geography (i.e., isolated small rural, small rural, large rural, and urban), type of rural training experience (i.e., model family practice clinic, block rotations, rural training tracks, and continuity clinics), and other residency characteristics. Funded by HRSA’s ORHP.

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Rural Family Planning Services Considerable controversy exists about the types of family planning services that should be...

Considerable controversy exists about the types of family planning services that should be available in rural areas. This study constructed an inventory of family planning services available in rural Idaho, determined the factors associated with observed variations in the range of available services, and examined the policy implications of the findings. A questionnaire was sent to physicians who were the potential providers of such services to determine service volumes and access issues.

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Rural Family Medicine Residency Training Master File Little is known about how well various types of rural-focused family medicine residency training...

Little is known about how well various types of rural-focused family medicine residency training programs, particularly osteopathic residencies, produce physicians for rural practice. This study examined program content and training locations as well as rural and urban practice outcomes for graduates of rural-centric family medicine residency training programs. This study is funded by HRSA’s Office of Rural Health Policy.

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Rural Family Medicine Residency Survey Follow-Up This two-year project updated an earlier WWAMI RHRC study of family medicine residency training in...

This two-year project updated an earlier WWAMI RHRC study of family medicine residency training in rural areas of the United States. In 2000 we conducted a national survey of all family medicine residency training programs in the nation to identify the type and extent of residency training that actually took place in rural locations. This study administered a follow-up mail survey to all family medicine residency training programs (about 440) using an instrument that was modified slightly to add a few key questions. This allowed us to examine changes since 2000 in the number of programs located in rural places, the nature of these programs, funding sources and staff configurations, as well as the amount of time that training takes place in federally funded health centers and other types of facilities.

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Rural EMS Workforce Rural populations frequently reside great distances from hospital emergency departments or urgent...

Rural populations frequently reside great distances from hospital emergency departments or urgent care facilities, underscoring the need for timely and effective pre-hospital emergency medical services (EMS). Numerous reports and anecdotal evidence indicate that rural EMS agencies face significant resource challenges in terms of sustainable funding, staff recruitment and retention, and staff skill maintenance. Reliable data to quantify the extent of these problems have been lacking. This project aims to quantify systematically workforce supply and demand disparities between rural and urban EMS systems in a sample of states distributed across the U.S. Study results will inform policy options to ensure an adequate supply of EMS personnel in rural areas. This study will analyze secondary data collected via a 2008 telephone survey of all ground-based pre-hospital EMS providers in nine states. Analyses of EMS agency service area coverage, patient volume, funding basis, organizational type, staffing, vacancies, and medical direction will yield statistical comparisons between urban and three subcategories of rural areas. Findings on rural-urban EMS resource distribution will also be displayed in maps for each state. Funded by HRSA’s Office of Rural Health Policy.

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Rural Emergency Medical Services This study retrieved data on every vehicular injury accident occurring in Okanogan County,...

This study retrieved data on every vehicular injury accident occurring in Okanogan County, Washington, in 1990. Information was collected on location of accident, type and severity of injury, initial pre-hospital response, initial transportation, involvement of local health care system, transfer to facility outside county, patient outcomes, and demographics. The study included (1) a description of the type and nature of crashes and injuries and the involvement of local and distant components of the EMS, (2) an examination of the extent to which the existing rural EMS is regionalized, and (3) policy-oriented recommendations.

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Rural Definitions We published an article entitled "Rural Definitions for Health Policy and Research" in the American...

We published an article entitled “Rural Definitions for Health Policy and Research” in the American Journal of Public Health in which we describe and compare various rural and urban taxonomies that were in use, describing their characteristics, strengths, and weaknesses depending on the purpose at hand.

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Rural Definition Reclassification This project created a ZIP-code approximation of the census tract-based Rural-Urban Commuting Area...

This project created a ZIP-code approximation of the census tract-based Rural-Urban Commuting Area (RUCA) codes.

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Rural Capacity for Family Physicians This paper addresses the ability of smaller and underserved rural communities to financially...

This paper addresses the ability of smaller and underserved rural communities to financially support needed physicians. We used Washington State data to test the feasibility of constructing physician income potential models. The total spending for primary care physicians was estimated using age-sex-poverty status coefficients from the National Medical Expenditure Survey, supplemented by unique Part B Medicare data on the proportion of rural physician revenue from non-office based services. Community size and the distance to other cities and towns were crucial determinants of market share and thus the capacity of small towns to attract and support primary care practices. The distribution of physicians among towns followed predicted economic potential. That potential varied dramatically even among towns with similar populations due to the pull of competing locations for primary care. Surprisingly, the types of rural communities most likely to have fewer physicians than suggested by the projected potential were not small isolated towns, but larger communities with above-average population growth, closer proximity to metropolitan areas and somewhat lower average family incomes. Strategies such as the National Health Service Corps use a one-time “signing bonus” to overcome physicians’ initial reluctance to locate in an underserved area. An alternative approach is to address long-term income disadvantages by offering continuous subsidies such as the enhanced Medicare payments for certified Rural Health Clinics or the 10% Medicare supplemental payments for care provided in a HPSA. Funded by HRSA’s ORHP.

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Rural C- Sections This project provided information on how physician training, community specialty mix and other...

This project provided information on how physician training, community specialty mix and other factors are related to the provision of c-sections in rural communities. We examined the percentage of the c-sections performed on rural service area residents that were done in small rural hospitals, whether family physicians did most of these procedures in rural hospitals where there are no obstetricians, their competence in performing c-sections, and factors associated with their performance of this procedure. Data were obtained through Computerized Hospital Discharge Database (CHARS) inpatient hospital abstracts supplemented by a telephone survey of all Washington State rural hospitals and a mail survey of rural physicians. Funded by HRSA’s ORHP.

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RUCA Development & Description The Rural-Urban Commuting Areas (RUCAs) were developed at the WWAMI RHRC in collaboration with, and...

The Rural-Urban Commuting Areas (RUCAs) were developed at the WWAMI RHRC in collaboration with, and with support from, HRSA’s ORHP and the Department of Agriculture. The RUCAs are a census tract-based classification scheme that utilizes the standard Bureau of Census Urbanized Area (UA) and Urban Place (UP) definitions with commuting information to characterize the nation’s Census tracts regarding their rural and urban status and relationships. The codes are based on whether a Census tract is located in a UA or UP and on the destination of its largest and second largest commuting flows. This project (1) produced and described the base 1998 demography of the RUCA code areas, (2) created quality state maps of the RUCA codes, and (3) has made this information and the codes easily available on the Web. The demographic description of the RUCA codes involved standard cross-tabulation analysis of the code areas nationally, regionally, and by state. Technical notes and maps are posted at www.depts.washington.edu/uwruca”>UW RUCA.

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RTT Technical Assistance Program This project is building a national partnership between professional groups, academic units,...

This project is building a national partnership between professional groups, academic units, governmental entities, and sustaining organizations to provide ongoing support and technical assistance to community-embedded rural health professions education. The project is (1) establishing a network of organizations and experts by visiting Rural Training Tracks (RTTs), creating RTT-state office of rural health coalitions, and convening stakeholder meetings; (2) building a Web portal with a virtual library of tools, information, and access to technical assistance; (3) developing new models and programs while sharing best practices; (4) initiating a process for identifying and training new leaders; and (5) publishing a final report. Under the NRHA umbrella and anchored by project directors and field offices in Idaho, Ohio, and Washington DC, the program is connecting RTT program directors, faculty, and staff with state offices of rural health, a rural assistance center, and a rural research center to bolster existing RTTs, foster new programs, and utilize community expertise in identifying systemic issues and remedies. While focused on rural medical education, the network will provide a model for community-embedded training and an infrastructure for training other rural health professions. UW WWAMI RHRC researchers are designing and maintaining a research data set and protocol for RTT site visits, including consents and IRB approval. The RHRC is the repository of these data-gathering efforts and will analyze and synthesize data underpinning reports and other dissemination activities. The RHRC is sharing data and coordinating its effort with the Graham Center in Washington DC to promote policy development, and assisting in the preparation of a final evaluation and report of this demonstration program.

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Family Physicians Choosing Rural Practice This project will survey physicians trained in rural-centric family medicine residencies to...

This project will survey physicians trained in rural-centric family medicine residencies to understand the characteristics, experiences, and attitudes that influenced their rural or urban practice choices. Understanding the factors that determine practice choices of RTT graduates can help improve recruitment of residents who will ultimately fulfill RTTs’ mission of preparing family physicians for rural practice.

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Retention of NHSC Recipients This study examined the retention and distribution of the 6,300 NHSC allopathic physician...

This study examined the retention and distribution of the 6,300 NHSC allopathic physician scholarship recipients graduating from medical schools for the years 1975 through 1983. The roster of these scholarship recipients was linked with American Medical Association data to provide information on their location, specialty, and practice status. Recipients were examined in terms of their propensity to remain in their original ZIP code, county, state, and rural/urban status location. In addition, their locational patterns were compared to other graduates. Recipients’ specialty, type of practice, and NHSC length of obligation were also evaluated.

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Recruitment of Rural Women Physicians This study examined differences in the factors female and male generalist physicians considered...

This study examined differences in the factors female and male generalist physicians considered influential in their rural practice location choice and identified the practice arrangements that successfully recruited female generalist physicians to rural areas. We mailed questionnaires to generalist physicians recruited between 1992 and 1999 to towns of 10,000 or less in six states in the Pacific Northwest. Compared to men, recruited women were younger, less likely to be married, had fewer children, and worked fewer hours. Women were more likely than men to have been influenced by issues related to spouse/personal partner, flexible scheduling, family leave, and availability of child care, as well as the interpersonal aspects of recruitment. Commonly reported themes reflected the desire for flexibility regarding family issues and the value placed on honesty during recruitment. Men and women were equally likely to consider community factors, practice content, practice partner compatibility, and financial issues. The most common methods for obtaining information about practice opportunities were personal networking, prior training experience, recruiters, and outreach by medical practices. This study concluded that rural communities and practices recruiting physicians should place high priority on practice scheduling, spouse/partner, and interpersonal issues if they want to achieve a gender-balanced physician workforce. Funded by HRSA’s ORHP.

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Radiation Therapy in Rural U.S. This study used cancer registry data from 10 U.S. states to examine which rural cancer patients...

This study used cancer registry data from 10 U.S. states to examine which rural cancer patients received recommended radiation therapy and what factors influenced receipt of recommended treatment. Identifying gaps in radiation therapy will inform cancer centers, rural program planners, and policy makers in rural cancer service location and cancer support program development. Funded by HRSA’s ORHP.

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Quality of Rural Perinatal Care The equitable provision of high-quality obstetric care is a major priority of our health care...

The equitable provision of high-quality obstetric care is a major priority of our health care system, and nowhere is access to such care more threatened than in rural areas. This project determined whether rural mothers receive less care and experience worse outcomes than their urban counterparts, whether racial and ethnic minorities living in rural areas experience different outcomes than their counterparts, and what other factors are associated with less care and poorer outcomes. Data were compiled from the National Center for Health Statistics’ Linked Birth/Death set and the Bureau of Health Professions’ Area Resource File. Measures of process of care included late or no prenatal care, lack of care in the first trimester, and inadequate care as measured by the Kotelchuck Index. Outcome measures included infant mortality and the percentage of children born at low and very low birthweight. This study also compared birth outcomes and process of care for minorities across rural areas and with their urban counterparts. Funded by HRSA’s ORHP.

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Prostate Cancer Treatment in Rural This research will use cancer registry data from 10 states to examine the degree to which rural...

This research will use cancer registry data from 10 states to examine the degree to which rural residents diagnosed with early-stage prostate cancer access the full range of surveillance, surgical, and radiation treatment options. Study findings will inform cancer centers, advocacy groups, rural program planners, and policymakers about services and programs needed to ensure that rural prostate cancer patients can choose from among all treatment options.

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Programs Producing Rural Physicians This national study used longitudinal data on medical school specialty and practice location choice...

This national study used longitudinal data on medical school specialty and practice location choice to determine the extent to which the nation’s medical schools and residency programs varied in their production of rural physicians. This facilitated the identification of medical school and residency program characteristics associated with the highest yield of rural physicians. Funded by HRSA’s ORHP.

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Programs Producing Rural PAs Physician assistants (PAs) are an important part of the rural health workforce, and their roles are...

Physician assistants (PAs) are an important part of the rural health workforce, and their roles are expected to grow. While PAs are more evenly distributed across the rural-urban continuum than physicians, long-term trends of medical specialization, increasing cost of training, and demographic change in the PA workforce have contributed toward decreasing PA participation in rural and primary care. This study will identify the PA training programs that are most successful at producing graduates who practice in rural areas, focusing particularly on PAs who graduated from training in the past ten years. Funded by HRSA’s Office of Rural Health Policy.

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Problem Drinking Among Rural Veterans This study will use national data to measure recent trends in problem drinking among VA-eligible...

This study will use national data to measure recent trends in problem drinking among VA-eligible adults in rural and urban locations and couple these data with the locations of VA services and substance abuse treatment facilities to identify rural locations where alcohol treatment services are limited. This project is funded by the Veterans Administration Office of Rural Health, through a contract with the northwest Portland, Oregon, Veterans Affairs Medical Center.

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Primary Care Trends This project critically reviewed the recent waning of primary care and its implications for rural...

This project critically reviewed the recent waning of primary care and its implications for rural populations. The paper chronicled historical changes and trends, put these changes in the larger health care system context, and concluded with a set of policy recommendations that detail options available to policy makers and leaders of the nation’s medical educational establishment.

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Practice Locations of Women Physicians While women are becoming an increasingly large percentage of the graduates of medical schools and...

While women are becoming an increasingly large percentage of the graduates of medical schools and of the generalist specialties in particular, they are much less likely to locate their practices in rural towns. If this trend were to persist, implications for access to care in rural areas would be substantial. This study involved a survey including questions about where the residents preferred to locate and how much they thought they would be practicing in the future. The study first examined national physician location patterns by medical school graduation cohort per gender differences. The second phase dealt with the production of female generalist physicians by medical schools. Funded by HRSA’s ORHP.

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Policy Activities of AMCC The AMCC is an ad hoc group composed primarily of private obstetrical providers and representatives...

The AMCC is an ad hoc group composed primarily of private obstetrical providers and representatives of state government responsible for the delivery of health care to women and children. The major objective of AMCC is to improve access to obstetrical care for socially vulnerable women. The committee successfully served as a forum in which to resolve administrative problems arising between private obstetrical providers and the state’s Medicaid program and was influential in persuading the state legislature to increase Medicaid eligibility, raise provider reimbursements, and improve social services to pregnant women.

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Physician Residency Rural Training The supply of rural physicians is in part determined by the number of family physicians who receive...

The supply of rural physicians is in part determined by the number of family physicians who receive residency training in rural areas. This study explored what proportion of all family medicine residency experience actually takes place in rural areas in the United States. Questionnaires were mailed to all 453 civilian family practice residencies in the United States in 2000. Programs were asked to indicate the extent to which training rural physicians was part of their core mission and to specify where all residency training sponsored by their programs took place. Using the Rural-Urban Commuting Areas, the ZIP codes of these locations allowed us to determine the relative rurality of all U.S. family practice residency training. Only 33 family medicine residency programs (7.4%) were located in rural areas. Most of the training sponsored by these rural programs occured in rural areas. Although over one-third of the urban programs listed rural training as an important part of their mission, only 2.3% of the training they supported took place in rural areas. For the nation, 7.5% of family medicine residency training occurred in rural areas, although 22.3% of the U.S. population lives in rural places. This study concluded that very little family medicine residency training actually took place in rural areas. To the extent that there was a link between the place of training and future practice, the lack of rural training contributed to the shortage of rural physicians. Funded by HRSA’s ORHP.

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Physician Access for Rural Elderly Patients in rural areas may utilize less medical care than urban patients because of differences...

Patients in rural areas may utilize less medical care than urban patients because of differences in travel distance and time and a utilization of a different mix of generalists and specialists for their care. This study compared travel times, distances, and physician specialty mix of Medicare patients in Alaska, Washington, North Carolina, South Carolina, and Idaho. We used a retrospective design, utilizing 1998 Medicare billing data. Travel time was determined by computing the road distance between the patient’s and the provider’s ZIP codes. There were 39,780 providers in the cohort: 16.1% generalists, 62% specialists, and 21% nonphysician providers. The median overall one-way travel distance and time was 7.7 miles and 11.7 minutes. Rural residents traveled two to three times farther to see medical and surgical specialists than urban residents. Rural residents with cancer, heart disease, depression, or needing complex cardiac procedures or cancer treatment traveled the farthest. Increasing rurality was related to decreased visits to specialists and increasing reliance on generalists. The majority of visits by those living in large rural areas were in large rural areas or the patients’ home ZIP codes. Residents of rural areas have increased travel distance and time compared to their urban counterparts, particularly true of rural residents with specific diagnoses or those undergoing specific procedures. Funded by HRSA’s ORHP.

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Perinatal Technology in Rural Washington One of the major issues confronting rural health care providers is the problem of acquiring complex...

One of the major issues confronting rural health care providers is the problem of acquiring complex and expensive new medical machinery, because of the relatively low volume of patients and encounters. This study described the patterns through which new perinatal technologies are adopted, the extent to which they are utilized in communities of varying sizes and levels of medical sophistication, and the impact of these technologies on obstetrical care in rural communities. We used surveys to determine which technologies are available in inpatient and ambulatory practice settings (100% response rate).

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Oral Health in Rural This study determined whether shortages of dentists in rural areas of the United States are...

This study determined whether shortages of dentists in rural areas of the United States are associated with impaired access to dental care and a higher prevalence of dental disease. Using detailed dentist supply data from the American Dental Association Dentist Masterfile and recent survey data from the nationally-representative Behavioral Risk Factor Surveillance System, we characterized dentist supply-oral health relationships by overall rural vs. urban location and a four-level, rural-urban grouping for the nation and individual states.

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Obstetrical Access in Washington A survey of all potential providers of obstetrical care in Washington State was conducted in 1989,...

A survey of all potential providers of obstetrical care in Washington State was conducted in 1989, and results were compared to an earlier survey to assess the extent to which obstetrical access had changed. Although the massive exodus of family physicians from obstetrical practice appeared to have slowed during the follow-up period, there was still substantial net attrition among this group of providers. By contrast, the supply of obstetricians and midwives seemed to be stable. Despite the greater obstetrical participation rate of rural practitioners, members of this group were also quitting obstetrics faster than they could be replaced.

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NP Distribution using Available Data This study compared estimates of nurse practitioner (NP) supply in 12 states (statewide and rural...

This study compared estimates of nurse practitioner (NP) supply in 12 states (statewide and rural vs. urban) derived from two sources: state license records and National Provider Identifier (NPI) data. Estimates of state NP supply from license data were found to be higher than NPI-derived estimates for most, but not all states. While data from both license and NPI sources can be useful for health workforce planning, the limitations of each source should be acknowledged and workforce comparisons should be limited to estimates derived from the same types of data.

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NHSC Evaluation A major impediment to access to care is the shortage of primary care physicians in rural locations...

A major impediment to access to care is the shortage of primary care physicians in rural locations and inner cities. This extension of an earlier study evaluated the National Health Service Corps (NHSC) scholarship program through a mail survey with phone encouragement of NHSC scholarship recipients who graduated from medical school during 1975-83. The study examined their retention experience, locational career patterns, demographic and practice characteristics, and service in rural sites. Funded by HRSA’s ORHP.

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National PA Study, 1996 The WWAMI RHRC collaborated with the North Dakota Center for Rural Health Services on a national...

The WWAMI RHRC collaborated with the North Dakota Center for Rural Health Services on a national survey of a random sample of physician assistants (PAs). The RHRC completed a follow-up survey of all the graduates of the University of Washington’s MEDEX Northwest PA program. The follow-up study, in which North Dakota Center for Rural Health Services staff took the lead, examined differences in rural and urban PA content of practice, satisfaction, practice type, practice characteristics, and demographic characteristics. Geographical and chronological career patterns of the PAs were investigated, as well as issues related to prescriptive authority and professional autonomy.

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Medicare Bonus Payments in HPSAs Medicare's Incentive Payment (MIP) program provides a 10% bonus payment to providers who treat...

Medicare’s Incentive Payment (MIP) program provides a 10% bonus payment to providers who treat Medicare patients in areas where there is a federally designated shortage of generalist physicians. This study examined the experience of Alaska, Idaho, North Carolina, South Carolina, and Washington with the MIP program using a retrospective cohort design utilizing 1998 Medicare Part B data. Physician specialty was determined through American Medical Association Masterfile data. Rural status was determined by linking this ZIP code to its Rural-Urban Commuting Area Code (RUCA). There were 39,780 providers in the study cohort: 24.9% generalists, 53.5% medical and surgical specialists, and 21.6% nonphysician providers. Over $4 million in bonus payments were made to providers in the Health Professional Service Area (HPSA) sites, with a median overall payment of $173. Specialists and urban providers received 58% and 14% of the bonus reimbursements respectively. Nearly a third of the potential bonus payments ($2 million) 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. Many providers who should have claimed the bonus did not, and many 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 as well as a system that prospectively determines provider eligibility. Funded by HRSA’s ORHP.

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Medical Education and Rural Practice Review This literature review critically examined the research literature related to physician...

This literature review critically examined the research literature related to physician undergraduate and graduate medical education and rural practice location. While topics related to rural location choices such as federal and state programs and recruitment and retention were touched upon, the emphasis of the review was on the educational programs themselves. The main objective of the review was to determine what we currently know and what gaps in the literature need to be addressed in order to develop sound public policy. Funded by HRSA’s ORHP.

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MEDEX PA Study, 1994 This project, performed in partnership with MEDEX Northwest in the School of Public Health,...

This project, performed in partnership with MEDEX Northwest in the School of Public Health, examined the locational choices and role of physician assistants (PAs) in the WAMI states, explored the use of PAs as physician extenders, and described the evolution of PA training and function over the past two decades. We surveyed all MEDEX graduates to identify factors that predict selection of and retention in rural locations. Results of this study improved the ability of training programs to select trainees likely to pursue successful careers in underserved rural areas and identified the kinds of professional environments conducive to attracting and retaining mid-level health care providers.

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MD Views of Rural Hospital Closures This project surveyed the physicians of rural towns whose sole small general hospitals closed...

This project surveyed the physicians of rural towns whose sole small general hospitals closed between 1980 and 1988. All locatable physicians who were practicing in the hospital closure towns at the time of the closures were surveyed with a questionnaire similar to that employed in a parallel survey of hospital closure town mayors. The study concentrated on physician perceptions of the reasons the hospitals closed, the consequences of the hospital closures, and the role the physician played in the closure process. Government reimbursement policies and poor hospital management were cited as principal reasons for hospital closures.

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Mayor Views of Rural Hospital Closures This project involved a survey of 130 mayors of rural towns whose sole small general hospitals...

This project involved a survey of 130 mayors of rural towns whose sole small general hospitals closed between 1980 and 1988. Mayors attributed the closure of their hospitals primarily to government reimbursement policies, poor hospital management, and lack of physicians. They reported that they had little warning that their hospitals were in imminent danger of closing. Well over three-fourths of the mayors felt that access to medical care and health status had deteriorated in their community after hospital closure, and over 90% indicated that the hospital closure had substantially impaired the community’s economy.

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Low-Risk Obstetric Care This study, which was predominantly funded by AHCPR but was also supported through the HRSA's ORHP,...

This study, which was predominantly funded by AHCPR but was also supported through the HRSA’s ORHP, was part of a large multifaceted project that examined low-risk obstetric care in Washington State through surveying obstetric providers and abstracting detailed information about their patients. This study used the provider as the unit of analysis. Differences in resource use (e.g., visits, tests, and procedures) between rural and urban obstetricians and between rural and urban family physicians were examined in detail.

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Location of PA Practices Despite the need for generalist care providers in rural areas experiencing shortages of generalist...

Despite the need for generalist care providers in rural areas experiencing shortages of generalist physicians, the percentage of physician assistants (PAs) that practice in small towns has been decreasing. This study examined PA rural and urban location behavior and their geographic trajectories over time based on national PA data collected in an earlier study. Data from sources such as the Area Resource File were used to characterize the areas where PAs were located. Factors such as PA demography, educational program type and location, preceptorship location, and previous health care provider status were examined. As the American health care delivery system changes, with workforce policies that focus more sharply on generalist care, the need to better understand PA practices is crucial. Funded by HRSA’s ORHP.

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International Medical Graduates: States' Use of Conrad 30 J-1 Visa Waivers States rely on international medical graduates (IMGs) to fill workforce gaps in rural and urban...

States rely on international medical graduates (IMGs) to fill workforce gaps in rural and urban underserved areas. This study, funded by HRSA’s Federal Office of Rural Health Policy, collected quantitative and qualitative information from states to assess how state policies and practices shape IMG recruitment and practice in underserved areas through Conrad 30 J-1 visa waiver programs. The first  report provides quantitative data on trends in waiver usage. The second report describes findings from interviews with Conrad 30 program personnel in 32 states and includes information on J-1 waiver physician retention for states with available data.

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International Medical Graduates' Contributions to Rural Health Care Delivery This study will identify trends and data needs regarding the contributions of international medical...

This study will identify trends and data needs regarding the contributions of international medical graduates (IMGs) on J-1 and H-1B visas to rural health care delivery. A workgroup of IMG research and policy stakeholders will be established to help identify IMG supply data trends, needs, and pressing policy issues; lay the groundwork for potential areas of study, data integration, and data collection; and strengthen the policy relevance of our work. Funded by HRSA’s ORHP.

In Progress HRSA
Impact of Malpractice We studied all family physicians (470) who purchased obstetrical malpractice insurance from the...

We studied all family physicians (470) who purchased obstetrical malpractice insurance from the largest malpractice insurer in Washington State (WSPIEA) from 1982 to 1988. One-third discontinued obstetrics but remained in practice, and these physicians were older, more likely to practice in an urban area, and more likely to be in solo practice. Rural family physicians were less likely to quit practicing obstetrics than their urban colleagues. Obstetrically related malpractice claims against family physicians were relatively infrequent and are not a factor in the decision of most family physicians who stop practicing obstetrics.

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IMG On-Line Atlas The on-line Atlas of International Medical Graduates (IMGs) displays trends in the geographic...

The on-line Atlas of International Medical Graduates (IMGs) displays trends in the geographic distribution of IMGs over the past 20 years through a series of maps. The maps are intended to provide useful information regarding changes in the global production of IMGs and the distribution of IMGs in the United States over time.

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HPSAs and Rural Health Care Access This study examined the degree to which persistence of primary care health professional services...

This study examined the degree to which persistence of primary care health professional services area (HPSA) designation in rural counties is associated with lower population socioeconomic status and deficiencies in access to health care services. It used a five-level classification of rural counties measuring partial- vs. whole-county persistence of primary care HPSA designation that stratified rural populations by socioeconomic status (SES), race/ethnicity, primary care supply, health insurance uptake, and access to needed health care services. The study found that those U.S. rural counties that were persistently designated as whole-county HPSAs had much lower SES, and adults residing in these counties reported substantial financial obstacles to obtaining needed health care services. Rural counties that were persistently designated as whole-county HPSAs also faced severe provider shortages, and adults residing in these locations were less likely to have a regular primary care provider. This study was funded by HRSA’s Office of Rural Health Policy.

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Hospital Closures and MD Supply This study determined whether the supply of physicians decreased subsequent to a rural hospital...

This study determined whether the supply of physicians decreased subsequent to a rural hospital closure during a nine-year period ending in 1988. The study (1) examined changes in physician manpower before, after, and at the time of the closure and (2) examined the association of town size, hospital size, and distance to other hospitals with hospital closure. The hospital closure towns most likely to lose physicians had few physicians before closure, were relatively remote from both urban areas and other hospitals, were located in sparsely populated counties, and tended to have for-profit ownership.

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HIT Workforce Development in Rural Community Colleges Successful implementation of health information technology (HIT) in rural areas depends on the...

Successful implementation of health information technology (HIT) in rural areas depends on the availability of a well-trained HIT workforce, and community colleges are key educational resources for producing this workforce. This study examined HIT workforce development programs in community colleges in order to increase understanding of the types of programs offered, describe the characteristics and sources of community college HIT curricula, highlight how these programs may be reaching underserved populations and students with limitations to accessing classroom-based courses, and identify barriers faced by these programs in achieving their HIT education goals. Information about the strengths and needs of the nation’s community college HIT education programs should help inform future HIT skills training programs and contribute to growing and strengthening the HIT workforce.

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Health Professions Education in Washington This study used the U.S. Department of Education's Integrated Postsecondary Education Data System...

This study used the U.S. Department of Education’s Integrated Postsecondary Education Data System (IPEDS) database to determine the number, sex and race/ethnicity of persons completing postsecondary health career education programs throughout Washington State. The report shows changes over time for 36 selected programs, ranging from physician, nursing, allied health, dental health, pharmacy and other health care education programs. The 2004 study was funded by the Washington State Workforce Training and Education Board. The 2002 study was funded by HRSA’s National Center for Health Workforce Analysis through a Congressional Appropriation to the UW CHWS.

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Health Center Expansion and Recruitment in WWAMI States Federally qualified health centers (HCs) face major barriers in recruiting and retaining health...

Federally qualified health centers (HCs) face major barriers in recruiting and retaining health professionals, yet there have been no projections of key health professions staffing needs for HCs and proposed new HCs. A study by the University of Washington Rural Health Research Center (RHRC) and collaborators described the current staffing needs of HCs across the United States and the staffing, recruitment, and retention issues that HC chief executive officers (CEO) regard as most critical throughout the nation as a whole. Presented here is a subset of the findings from the larger national study for HCs located in Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) overall and by urban and rural geography.

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Health Center Expansion and Recruitment Rural health centers (HCs) faced major barriers in recruiting and retaining health professionals,...

Rural health centers (HCs) faced major barriers in recruiting and retaining health professionals, yet there were no projections of key health professions staffing needs for HCs and proposed new HCs. This collaborative study with the South Carolina RHRC described the staffing needs of rural HCs and ascertained the staffing, recruitment, and retention issues that HC CEOs regarded as most critical. The National Association of Community Health Centers administered a mail questionnaire to the CEOs of all CHCs in the nation (about 845) that profiled their current staff vacancies, projected staffing needs, recruitment and retention issues, center site expansion plans, and CEO perception of policies that would facilitate recruitment and retention. This joint center project was a collaborative one between HRSA’s FORHP, BPHC, and BHPr.

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Health Care Reform in Rural Since 2009, the WWAMI RHRC has carried out several rapid-turnaround analyses of rural issues...

Since 2009, the WWAMI RHRC has carried out several rapid-turnaround analyses of rural issues related to health care reform. The published products of these analyses have been posted to the WWAMI RHRC Web site.

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Health Care for the Rural Uninsured This study described the contributions of family and general practice physicians from Wyoming to...

This study described the contributions of family and general practice physicians from Wyoming to the health care safety net. We surveyed family and general practice physicians in Wyoming about provider demographics, practice composition, and policies for treating the underinsured or uninsured. From a 50% response rate, 61% made less than the national mean family physician income ($130,000), and women were less likely than men to make this mean income, even when controlling for hours worked. 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. Wyoming family physicians provide significant amounts of informal safety net care, which is threatened by income loss. Funded by HRSA’s ORHP.

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Future Supply of Family Medicine Physicians This study investigated the implications of declining medical school interest in primary care...

This study investigated the implications of declining medical school interest in primary care careers as it impacts rural and underserved areas. The study examined data from the American Association of Medical Colleges, the 2005 American Medical Association Masterfile, and the American Osteopathic Association Masterfile, as well as survey data from residency directors and students to describe recent trends in medical school interest and national match rates for family medicine and primary care. Funded by HRSA’s FORHP.

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Federal Funding and MD Production This study described the graduates of all American medical schools from 1976 to 1980 and from 1981...

This study described the graduates of all American medical schools from 1976 to 1980 and from 1981 to 1985 in terms of their specialty and geographic location and correlated these variables with the amount of Title VII funds received by specific schools during those periods. Two hypotheses that were tested were (1) Title VII has had a positive impact on increasing the proportion of graduates choosing primary care specialties and practicing in rural and underserved areas, and (2) graduates of community-based schools are more likely to choose careers in primary care and to practice in rural and underserved areas than are graduates of traditional medical schools. Data for each medical school were aggregated by school and linked with data on Title VII and other federal funding from 1976 to 1985.

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Family Medicine Residency Network Study This survey project contrasted the role, practice type, and characteristics of graduates from the...

This survey project contrasted the role, practice type, and characteristics of graduates from the residency network associated with the University of Washington Department of Family Medicine who were located in rural versus urban communities. The geographic trajectories by graduate cohort and program were analyzed. In addition, the extent to which the program has been successful in placing and retaining graduates within rural communities and the region was evaluated.

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Family MD Views of Assisted Suicide With recent laws allowing physicians to assist in a terminally ill patient's suicide under certain...

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. This study used data from a 1997 survey of family physicians (FPs) and general practitioners (GPs) in Washington State to determine factors associated with attitudes toward physician-assisted suicide. A questionnaire was mailed to all active FPs/GPs in Washington State. A ZIP code system based on generalist Health Service Areas was used to designate those practicing in rural versus urban areas. 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% did not know. Over half would not include physician-assisted suicide in their practices, even if it were legal. Attitudes about physician-assisted suicide varied significantly between urban females and rural males, with the former being more supportive of assisted suicide than the latter. Many respondents, especially females, were uncertain of their positions concerning the legalization of and their willingness to assist suicides. Substantial differences in opinion toward physician-assisted suicide existed between physicians based on gender and rural-urban practice location. There was a significant pattern of opposition on the part of rural male respondents compared to urban female respondents.

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Family MD Practice Locations In this study, responses to a survey of graduates from the residency network associated with the...

In this study, responses to a survey of graduates from the residency network associated with the University of Washington Department of Family Medicine were analyzed related to their rural and urban career trajectories. This study examined the locational patterns of the graduates in terms of initial site location, practice moves, lengths of stay, prior movement experience, gender, and graduation cohort.

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Emergency Care of Rural Elderly This study used Medicare data to compare emergency department (ED) use by rural and urban elderly...

This study used Medicare data to compare emergency department (ED) use by rural and urban elderly beneficiaries. The 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. This study found that the rural elderly living in remote areas were 13% less likely to visit the ED than their urban counterparts. Causes of ED use by the elderly did not vary meaningfully by location. Most ED visits by this group were for conditions that seem appropriate for this setting. Given the similarity of diagnostic conditions associated with ED visits, local EDs must be capable of dealing with the same range of emergency conditions as urban EDs. Funded by HRSA’s ORHP.

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Educational Strategies to Encourage Rural NP Practice Persistent shortages of primary care physicians in rural areas have increased the need to educate...

Persistent shortages of primary care physicians in rural areas have increased the need to educate nurse practitioners (NPs) for rural careers. Medical schools have identified factors associated with rural practice by physicians and used this knowledge to develop rural training programs, but less is known about factors associated with rural NP training and practice or the extent to which NP programs deploy such strategies. This study will quantify and describe NP education programs that encourage NPs to practice in rural areas and identify data sources that could be used in future studies of the effectiveness of these programs. This study is funded by HRSA’s Office of Rural Health Policy.

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Economic Impact of HRSA Rural Network & Outreach Grants This study analyzed the economic impact created by HRSA Network Development and Outreach grantees....

This study analyzed the economic impact created by HRSA Network Development and Outreach grantees. The analyses were conducted with the goal of creating transparent and easy-to-use tools that can be used by grantees and HRSA in future program efforts. While the project analyses focused on a cohort of grantees, the study used methods and data that potentially could be extended to other HRSA grantees and programs. The WWAMI RHRC had a subcontract to carry out this project in collaboration with The Lewin Group, through a grant from HRSA’s Office of Rural Health Policy.

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Deregionalization of Rural Perinatal Care The regionalization of rural perinatal care during the 1980s significantly lowered neonatal...

The regionalization of rural perinatal care during the 1980s significantly lowered neonatal mortality among infants born to rural residents, yet recent trends could disrupt the efficiency of regionalized systems of care. This national study determined whether there was evidence of deregionalization of rural perinatal care for high-risk women and infants and whether deregionalization had adversely affected neonatal mortality among infants born to rural residents. We analyzed national Linked Birth Death Data Set data over a 10-year period. The study population included all low-birthweight infants born to rural residents. This study demonstrated the impact of managed care on the rural health care delivery system and outcomes. Funded by HRSA’s FORHP.

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Contributions of Physicians, APNs, and PAs to Rural Primary Care This multi-state study examined the practices of rural physicians, advanced practice nurses (APNs),...

This multi-state study examined the practices of rural physicians, advanced practice nurses (APNs), and physician assistants (PAs) regarding their primary care visit productivity and scope of practice. Through surveys, this study examined the contributions of physicians, APNs, and PAs by state, degree of practice rurality, practice characteristics, and primary care HPSA status in order to provide information on a range of rural primary care workforce needs in the coming decades. Funded by HRSA’s Office of Rural Health Policy.

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Community Paramedicine Research Consensus Conference Background: Community paramedicine is a new model of providing access to basic health care...

Background: Community paramedicine is a new model of providing access to basic health care services. Community paramedicine extends paramedics’ traditional emergency response roles through additional education that enables them to see patients in their home or community setting and perform procedures already in their skill set. Community paramedics provide care under the supervision of an ordering physician or advance practice provider. Community paramedics are providing these kinds of services for otherwise underserved communities in demonstration sites in the U.S. and Canada. While there are reports of successful implementation of this novel approach to expanding primary care access, there is a paucity of objective, systematic research on the outcomes of these programs. This project identified appropriate research questions and appropriate data to increase understanding of the outcomes of community paramedicine. Goal: This project developed a national research agenda for the emerging field of community paramedicine based on facilitated discussions at a National Consensus Conference on Community Paramedicine. Collaboration: The study was conducted collaboratively by researchers at the University of Washington (UW) WWAMI Rural Health Research Center (RHRC) and the North Central Emergency Medical Services Institute. Funding was from a conference grant by the Agency for Healthcare Research and Quality. The UW’s WWAMI RHRC researchers completed a summary of topics and key points discussed during the National Consensus Conference on Community Paramedicine (October 1-2, 2012) and a community paramedicine research agenda report.

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Chronic Illness among Rural Residents This study used data from the Behavioral Risk Factor Surveillance System (BRFSS) to examine...

This study used data from the Behavioral Risk Factor Surveillance System (BRFSS) to examine trends–by type of geographic area, race/ethnicity, and risk factors–in hypertension, diabetes, hypercholesterolemia, and asthma, as well as patterns of screening for two of these conditions. BRFSS is a nationally representative study of the adult population in the United States that collects health data on an annual basis. Funded by HRSA’s FORHP.

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Characteristics of National Rural Nurse Workforce This national study characterized changes in the demographic, education, and practice...

This national study characterized changes in the demographic, education, and practice characteristics of registered nurses (RNs) in rural and urban areas from 1980 to 2004. Study data came from the National Sample Survey of Registered Nurses (NSSRN) collected between 1980 and 2004. RNs were categorized into urban, large rural, small rural, and isolated small rural by residence and work location using the Rural-Urban Commuting Area taxonomy. The study examined changes since 1980 in rural RN number, percent employed in nursing, age, gender, race/ethnicity, age at first RN degree, types of degrees attained, type of work, salaries, the types of areas where the RNs work, and their likely commuting patterns. By examining trends in rural RNs characteristics over the past two decades, this study provided important information for projecting future trends in RN supply for rural communities.

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Changes in MD Supply National rural health policy development depends on an accurate and up-to-date assessment of...

National rural health policy development depends on an accurate and up-to-date assessment of physician supply. This project described the supply of generalist physicians and osteopaths in rural areas of the United States. We used data from the AMA and Area Resource File to determine the total supply of practicing physicians in metropolitan and nonmetropolitan counties in 2005. We used Urban Influence Codes to classify nonmetropolitan counties based on their adjacency to a metropolitan county and the size of the largest urban place within the county. We assessed the supply of physicians in the smallest and most isolated areas of the country and analyzed rural physician supply on a state-by-state and regional basis. Funded by HRSA’s FORHP.

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Care for Lung Disease among Rural/Urban Medicare Beneficiaries This retrospective cohort study examined access of a sample of Medicare beneficiaries among rural...

This retrospective cohort study examined access of a sample of Medicare beneficiaries among rural and urban patients hospitalized with chronic obstructive lung disease to prescribed home oxygen and the needed equipment. Funded by HRSA’s FORHP.

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Care for Acute Myocardial Infarction in Rural Hospitals: 1994-1995 Acute myocardial infarction (AMI) is an important condition cared for in rural hospitals. Most...

Acute myocardial infarction (AMI) is an important condition cared for in rural hospitals. Most recommended interventions require no sophisticated technology and should be available in rural and urban hospitals. This study examined the quality of AMI care in rural hospitals. It was a cohort study using data from the 1994 and 1995 Centers for Medicare & Medicaid Services’ Cooperative Cardiovascular Project and the 1995 American Hospital Association’s Annual Survey of Hospitals. The study included U.S. acute-care hospitals caring for patients with AMI, and Medicare beneficiaries ages 65 and older directly admitted to four types of acute-care hospitals–remote small rural, small rural, large rural, and urban–for a confirmed AMI between 1994 and 1995. Substantial proportions of Medicare beneficiaries in both urban and rural hospitals did not receive recommended AMI treatments. Medicare patients treated in rural hospitals were less likely than urban hospitals’ patients to receive aspirin during hospitalization or at discharge, intravenous nitroglycerin, heparin, and either thrombolytics or percutaneous transluminal coronary angioplasty. Only one treatment–ACE inhibitors at discharge–was used more for patients in rural hospitals. Medicare patients in rural hospitals had significantly higher adjusted 30-day post-AMI death rates from all causes than those in urban hospitals. Efforts are needed to help hospital medical staffs, especially those in rural areas, develop systems to ensure that patients receive recommended AMI treatments. Funded by HRSA’s ORHP.

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Cancer Screening in Rural America This study examined Behavioral Risk Factor Surveillance System (BRFSS) national survey data to...

This study examined Behavioral Risk Factor Surveillance System (BRFSS) national survey data to explore the prevalence and trends in screening for four types of cancer (breast, colorectal, cervical, and prostate) among survey respondents from urban and various types of rural areas and among white compared to minority populations. BRFSS is a nationally representative study of the adult population in the United States that collects health data on an annual basis. Funded by HRSA’s FORHP.

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Cancer Care for Rural Colorectal Cancer Patients This study compiled a comprehensive database linking Surveillance Epidemiology and End Results...

This study compiled a comprehensive database linking Surveillance Epidemiology and End Results (SEER) cancer registry, Medicare claims, American Medical Association Masterfile, and other data to examine access to cancer services in a sample of rural, Medicare-insured colorectal cancer patients of different racial and ethnic groups. Funded by HRSA’s FORHP.

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Birth Care for Rural/Urban American Indians While American Indians (AIs) constitute a substantial minority population in many rural areas,...

While American Indians (AIs) constitute a substantial minority population in many rural areas, population-based research on the health status of AI women and infants is limited. This study used the National Linked Birth Death Certificate Data Set for 1989 and 1991 to compare the perinatal risk factors, prenatal care use, birth outcomes, and infant death rates of rural AIs, urban AIs, and whites. Results from this study should help administrators and policy makers to better understand the health care needs of this population, as well as the targeted interventions needed to improve birth outcomes and infant health status. Funded by HRSA’s ORHP.

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BBA and Rural Residency Training This national survey examined the proportion of rural-based family medicine residencies across the...

This national survey examined the proportion of rural-based family medicine residencies across the United States that have ceased operations since 2000, the residency match patterns of existing programs, changing proportions of International Medical Graduates (IMGs) and U.S. Medical Graduates (USMGs), and major issues facing rural residency programs. Funded by HRSA’s FORHP.

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Barriers to Rural Residencies This project examined issues related to establishment and maintenance of residencies and residency...

This project examined issues related to establishment and maintenance of residencies and residency tracks in rural America. The project involved both a literature review and interviews with key informants related to the issues surrounding rural residency programs. While the project emphasized generalist residencies, it was not limited to them. The policy paper discussed issues associated with retaining and starting rural residencies and tracks such as their training cost and clinical implications, credentialing constraints, and staffing problems. Understanding the issues surrounding the establishment of rural residencies is important for federal and state legislators and administrators as they revamp the nation’s graduate medical education system. Funded by HRSA’s ORHP.

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APRN Distribution in the U.S. This study analyzed 2010 Centers for Medicare and Medicaid Services' National Provider Identifier...

This study analyzed 2010 Centers for Medicare and Medicaid Services’ National Provider Identifier (NPI) records to assess the usefulness of the dataset to describe APRN distribution across the United States. There were adequate NPI data to describe urban and rural location of certified registered nurse anesthetists (CRNAs) and nurse practitioners (NPs) in the U.S. and relative per capita supply. Practice location was estimated by linking Rural-Urban Commuting Area codes to NPI provider ZIP codes. Chi-square testing examined provider supply by geographic locations. Multivariate hierarchical regression testing identified whether rural practice location was related to practice autonomy, per capita provider supply, or gender. Funded by the American Nurses Association.

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Ambulatory Care for Rural Elderly Diabetes is a common serious chronic disease where careful clinical monitoring can improve the...

Diabetes is a common serious chronic disease where careful clinical monitoring can improve the quality of care and patient outcomes. This study examined the extent to which Medicare patients in Washington State receive care that adheres to clinical guidelines and the extent to which the rural or urban residence affects the quality of care received. Medicare patients 65 years and older with two physician encounters for a diabetic condition in 1994 were included in this study. Patient residence was determined by using the ZIP code of the patient’s dwelling as listed in the Medicare National Claims History File. Adherence to guidelines was measured by determining the extent to which patients received three tests recommended by the major authoritative bodies during the study year: glycated hemoglobin, an eye examination, and a cholesterol measurement. 30,589 Medicare patients (8.4%) were considered to have diabetes; 29.1% lived in rural communities. Urban patients received virtually all their medical care in their local communities, as did over 80% of rural patients who lived in rural communities with more than 10,000 people; people living in smaller rural towns received almost half their outpatient care in other communities. Most diabetic care in all locations is provided by generalists. Patients living in large rural towns remote from metropolitan areas received higher quality care on these measures than all other groups, while those living in large communities adjacent to metropolitan areas had the lowest adherence rates. Patients who saw an endocrinologist at least once during the year were more likely to have received the recommended tests. Even though clear guidelines exist for certain routine monitoring tests–and even though Medicare pays for these tests–most patients do not get all the recommended interventions. Large rural towns remote from cities seem to have higher quality of care. Given that most diabetic care is given by generalists, the challenge is to create a system where patients and their primary care physicians can work together to improve the care of serious chronic conditions. Funded by HRSA’s ORHP.

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Allied Health Education in Community Colleges This study identified rural-serving community colleges across the United States and their five-year...

This study identified rural-serving community colleges across the United States and their five-year graduation trends for specific allied health professions, examined the spectrum of how rural allied health professions education currently is being allocated and delivered, and explored how community economic status and estimated regional allied health workforce demand is associated with the availability of rural community college allied health education programs. Funded by HRSA’s ORHP.

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Aging Rural Physician Workforce This study identifies rural locations with high proportions of generalist physicians nearing...

This study identifies rural locations with high proportions of generalist physicians nearing retirement age. As fewer young physicians choose generalist careers, the retirement of older physicians may place additional strain on rural generalist supply. This study quantifies the extent to which rural generalist physician shortages may be exacerbated by physician retirement, focusing on known shortage locations. The study used data from the American Medical Association and American Osteopathic Association 2005 Masterfiles. This study was funded by HRSA’s Office of Rural Health Policy.

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Access to and Outcomes of Obstetric Care Previous work conducted by the WWAMI RHRC demonstrated a relationship between access to obstetrical...

Previous work conducted by the WWAMI RHRC demonstrated a relationship between access to obstetrical care in rural communities and birth outcomes (see working paper #4). The Obstetrical Process and Outcome of Care Study compared rural versus obstetrical care and outcomes from birth certificates. This study examined the relationship between access to and availability of care (number of local providers available who provide obstetrical care and who care for pregnant Medicaid women) and quality and cost of care. Sources of data included Washington State birth certificates and hospital discharge abstracts, supplemented with information on hospitals, communities, and provider supply. Findings from this study further illuminate the connection between poor geographic access, Medicaid access, and poor quality care.

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2004 Rural-Urban Commuting Areas (V2) This project described the new version of the Rural/Urban Commuting Areas (RUCAs) taxonomy that...

This project described the new version of the Rural/Urban Commuting Areas (RUCAs) taxonomy that defines rural and urban based on Census Bureau definitions and work commuting patterns. The RUCA taxonomy is a tool based on the sizes of cities and towns and their functional relationships as reflected by commuter patterns. Funded by HRSA’s FORHP.

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