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Biomedical subjects

L G Hart

Publications and source records attributed to L G Hart.

At least 19 recordsLinked to original sources
PubMed2001

The role of gynecologists in providing primary care to elderly women.

BACKGROUND: Federal legislation has recently been proposed to designate obstetrician-gynecologists (OBGs) as primary care physicians. The Institute of Medicine identifies care unrestricted by problem or organ system as an essential characteristic of primary care. We examined the degree to which OBGs in the state of Washington offer this aspect of primary care to their elderly patients by investigating the type and amount of nongynecologic care they provide. METHODS: Using 1994 Part B Medicare claims data for Washington residents, we identified visits made by women aged 65 years and older to OBGs (N=10,522) and 9 other types of specialists. Diagnoses were classified as in or out of the domain of care traditionally provided by each specialty. Visit volumes, proportion of out of domain visits, and the frequency of diagnoses were reported. RESULTS: Of the patient visits to obstetrician-gynecologists, 12.2% had nongynecologic diagnoses. The median percentage of nongynecologic visits for individual OBGs was 6.7%. Patients who saw OBGs received 15.4% of their overall health care from an OBG; patients who saw family physicians received 42.9% of their total health care from a family physician. CONCLUSIONS: In 1994, a small amount of the care that Washington OBGs provided to their elderly patients was for nongynecologic conditions. Studies are needed to evaluate how the practices of OBGs have changed since the 1996 implementation of a primary care requirement in obstetrics-gynecology residencies, and if adopted, how legislation designating OBGs as primary care physicians affects the health care received by elderly women.

Age Factors↗
PubMed2001

Improving the quality of outpatient care for older patients with diabetes: lessons from a comparison of rural and urban communities.

OBJECTIVE: Our goal was to compare the quality of diabetic care received by patients in rural and urban communities. STUDY DESIGN: We performed a retrospective analysis of claims data captured by the Medicare program. POPULATION: We included all fee-for-service Medicare patients 65 years and older living in the state of Washington who had 2 or more physician encounters for diabetes care during 1994. OUTCOME MEASURES: The outcomes were the extent to which patients received 3 specific recommended services: glycated hemoglobin determination, cholesterol measurement, and eye examination. RESULTS: A total of 30,589 Medicare patients (8.4%) were considered to have diabetes; 29.1% lived in rural communities. Generalists provided most diabetic care in all locations. Patients living in small rural towns received almost half their outpatient care in larger communities. Patients living in large rural towns remote from metropolitan areas were more likely to have received the recommended tests than patients in all other groups. Patients who saw an endocrinologist at least once during the year were more likely to have received the recommended tests. CONCLUSIONS: Large rural towns may provide the best conditions for high-quality care: They are vibrant, rapidly growing communities that serve as regional referral centers and have an adequate-but not excessive-supply of both generalist and specialist physicians. Generalists provide most diabetic care in all settings, and consultation with an endocrinologist may improve adherence to guidelines.

Aged↗
PubMed2001

National estimates of physician assistant productivity.

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

Ambulatory Care↗
PubMed2000

Emergency department use by the rural elderly.

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

Aged↗
PubMed2000

Educating generalist physicians for rural practice: how are we doing?

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

Career Choice↗
PubMed2000

The use of community surveys for health planning: the experience of 56 northwest rural communities.

A rural health services development program of the University of Washington School of Medicine has worked for 15 years with communities throughout the five-state region of Alaska, Idaho, Montana, Washington and Wyoming to strengthen their health systems. In the course of that work, 56 communities were surveyed about their utilization and opinions of local health systems. This database allows the following generalizations to be made about rural Northwest communities: (1) People think highly of their local hospitals, physicians and other key components of the acute medical care system and want their hospitals to remain open. Older respondents are more satisfied than younger respondents; (2) the typical hospital market share is 36 percent, the typical physician market share is 50 percent (3) satisfaction with discrete, well-funded services such as pharmacy, ambulance and dentistry is quite high, whereas satisfaction with mental health and substance abuse treatment is significantly lower; (4) the most commonly cited serious problems in surveyed communities were "too few physicians or- services" and "care is too expensive"; and (5) there is great variation between communities in both satisfaction and utilization.

Alaska↗
PubMed2000

The distribution of rural female generalist physicians in the United States.

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

American Medical Association↗
PubMed2000

How many rural doctors do we have?

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

Efficiency↗
PubMed2000

The effect of the doctor-patient relationship on emergency department use among the elderly.

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

Aged↗
PubMed2000

Reproductive health services in rural Washington State: scope of practice and provision of medical abortions, 1996-1997.

OBJECTIVES: This study explored reproductive health care in rural Washington State, reasons given by providers for not offering abortions, and providers' willingness to use medical abortifacients. METHODS: Physicians, midwives, nurse practitioners, and physician assistants in rural Washington completed an inventory of reproductive health services that they provide, whether and why they do not perform abortions, and whether they would use medical abortifacients. RESULTS: Of the respondents, 89.2% reported providing reproductive health care. Only 1.2% reported performing surgical abortions, and 26.1% indicated that they would probably prescribe medical abortifacients. CONCLUSIONS: Few providers offer surgical abortions in rural Washington. Greater numbers report a willingness to prescribe medical abortifacients.

Abortifacient Agents↗
PubMed2000

US medical schools and the rural family physician gender gap.

BACKGROUND: Women comprise increasing proportions of medical school graduates. They tend to choose primary care but are less likely than men to choose rural practice. METHODS: This study used American Medical Association masterfile data on 1988-1996 medical school graduates to identify the US medical schools most successful at producing rural family physicians and general practitioners of both genders. RESULTS: The number of listed rural female family physician or general practitioner graduates among schools ranged from 0-27 (0% to 4.4% of each school's 1988-1996 graduates). There were approximately twice as many male as female rural family physicians and general practitioners. Publicly funded schools produced more rural female family physicians and general practitioners than their privately funded counterparts. CONCLUSIONS: Our findings suggest that a few schools, most of them public, may serve as models for schools that aim to train women who later enter rural practice.

American Medical Association↗
PubMed1999

Hospital peer review and the National Practitioner Data Bank: clinical privileges action reports.

CONTEXT: The National Practitioner Data Bank (NPDB) is believed to be an important source of information for peer review activities by the majority of those who use it. However, concern has been raised that hospitals may be underreporting physicians with performance problems to the NPDB. OBJECTIVE: To examine variation in clinical privileges action reporting by hospitals to the NPDB, changes in reporting over time, and the association of hospital characteristics with reporting. DESIGN: Retrospective cohort study of privileges action reports to the NPDB between 1991 and 1995, linked with the 1992 and 1995 databases from the Annual Survey of Hospitals conducted by the American Hospital Association. SETTING AND PARTICIPANTS: A total of 4743 short-term, nonfederal, general medical/surgical hospitals throughout the United States that were continuously open between 1991-1995 and registered with the NPDB. MAIN OUTCOME MEASURES: (1) Reporting of 1 or more privileges actions during the 5-year study period and (2) privileges action reporting rates (numbers of actions reported per 100000 admissions). RESULTS: Study hospitals reported 3328 privileges actions between 1991 and 1995; 34.2% reported 1 or more actions during the period. The range of privileges action reporting rates for these hospitals was 0.40 to 52.27 per 100000 admissions, with an overall rate of 2.36 per 100000 admissions. The proportion of hospitals reporting an action decreased from 11.6% in 1991 to 10.0% in 1995 (P=.008). After adjustment for other factors, urban hospitals had significantly higher reporting than rural hospitals (adjusted odds ratio [OR], 1.21 [95% confidence interval [CI], 1.02-1.43]), while members of the Council of Teaching Hospitals of the Association of American Medical Colleges had significantly lower reporting than nonmembers (adjusted OR, 0.54 [95% CI, 0.40-0.73]). There were notable regional differences in reporting, with the east south Central region having the lowest rate per 100000 admissions (1.49 [95% CI, 1.33-1.65]). CONCLUSIONS: The results of this study indicate a low and declining level of hospital privileges action reporting to the NPDB. Several potential explanations exist, 1 of which is that the information reported to the NPDB is incomplete.

Clinical Competence↗
PubMed1999

Rural and urban physicians: does the content of their Medicare practices differ?

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

Aged↗
PubMed1999

Dimensions of retention: a national study of the locational histories of physician assistants.

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

Adult↗
PubMed1998

The generalist role of specialty physicians: is there a hidden system of primary care?

CONTEXT: Despite increased emphasis on primary care in the United States, most care continues to be provided by specialists. The extent to which specialists incorporate elements of primary care in their approach to ambulatory patients is unknown. OBJECTIVES: To examine the extent to which selected medical and surgical subspecialties provide generalist care to Medicare patients, and to compare patterns of care between specialists and generalists. DESIGN: A cross-sectional study of all ambulatory care recorded in Part B of the Washington State Medicare Claims Database in 1994 and 1995. SETTING: Ambulatory practices in Washington State. PATIENTS: Medicare beneficiaries 65 years or older who made office visits to the study physicians. MAIN OUTCOME MEASURES: The extent to which individual specialties accounted for the majority of visits made by patients to physicians (a measure of continuity), provided care outside the traditional domain of their specialty (a measure of comprehensiveness), and provided influenza immunization. RESULTS: A total of 373 505 patients constituted the sample. Patients had an average of 7.48 outpatient visits per year; 9.6% saw only generalists, while 14.7% saw only specialists. The practices of general internists and family physicians differ systematically from the practices of most specialists. Approximately half (49.8%) of all ambulatory visits to general internists and family physicians are made by patients for whom they provide the majority of outpatient care, compared with 21.0% of medical specialist and 11.7% of surgical specialist visits. The rate of influenza immunization was 55.4% for patients who received the majority of their care from generalists, 47.7% from medical specialists, and 39.6% from surgical specialists. Pulmonologists, general surgeons, and gynecologists were more likely than other specialists to provide services outside their specialty. CONCLUSIONS: Most specialists do not assume the principal care responsibility for elderly patients, although a substantial proportion of patients see only specialists for their care. Selected specialties assume the generalist role more often, particularly when they provide the majority of outpatient care for an individual patient.

Aged↗
PubMed1998

How well do birth certificates describe the pregnancies they report? The Washington State experience with low-risk pregnancies.

OBJECTIVES: Birth certificates are a major source of population-based data on maternal and perinatal health, but their value depends on the accuracy of the data. This study assesses the validity of information recorded on the birth certificates for women in Washington State who were considered to be low risk at entry into care. METHODS: Birth certificates were matched to data abstracted from prenatal and intrapartum clinic and hospital records of a sample of 1937 Washington State obstetrical patients who were considered to be low risk at the beginning of their pregnancies. Accuracy of a variety of pregnancy characteristics (e.g., complications, procedures) on the birth certificate was analyzed using percentage agreement and sensitivity with record abstracts as the "gold standard." Next, we weighted the data from each source to produce estimates of pregnancy characteristics in the population. We compared these estimates from the two data sources to see whether they provide similar pictures of this subpopulation. RESULTS: Missing data for specific items on the birth certificates ranged from 0% to 24%. The birth certificate accurately captured gravidity and parity, but was less likely to report prenatal and intrapartum complications. The population estimates of the two data sources were significantly different. CONCLUSIONS: Because birth certificates significantly underestimated the complications of pregnancies, number of interventions, number of procedures, and prenatal visits, use of these data for health policy development or resource allocation should be tempered with caution.

Adult↗