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Biomedical subjects

L G Hart

Publications and source records attributed to L G Hart.

103 records · Page 6Linked to original sources
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Neonatal mortality clusters: a new tool for classifying neonatal outcomes.

BACKGROUND: A method for assessing general hospital neonatal care performance is needed that is simple, is easy to use, and requires minimal data. METHODS: All neonatal deaths in Washington State obstetric hospitals from 1980 to 1983 were assigned to 10 mutually exclusive neonatal mortality clusters, a new classification method derived from information available on the death certificate. RESULTS: More than one-third (35.3 percent) of all neonatal deaths fell within one of the seven clusters considered to represent potentially preventable causes of death. The rate of possibly preventable deaths was much higher in level III hospitals than in level II or level I hospitals, a finding similar to that observed in other states using different analytic approaches. CONCLUSIONS: Neonatal mortality clusters offer a less complex method of classifying neonatal deaths and assessing hospital performance than other currently used techniques.

Birth Weight↗
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Issues in survey data on medical practice: some empirical comparisons.

In recent years, researchers and policymakers have used data from large-scale surveys of physicians to address important issues. A review of several of these surveys explores potential problems in this method of gathering data on physicians' services. To obtain a better grasp of the limitations such problems may pose, we examine several recent surveys, comparing response rates and survey findings, and in one survey the reliability of individual items. Response rates appear highly sensitive to differences in the approaches made to respondents and their perceptions of the goals of individual investigations. Reliability of survey items seems to depend on the specificity of information requested. Variation in the findings from different surveys may occur for many reasons, but is most likely to be found in response to items whose presentation differs in each survey's research instrument. Data from these surveys appear clearly useful for some important purposes. The large-scale medical practice survey seems particularly valuable in generating an understanding of differences among specialties in resources used in the delivery of care. Nevertheless, researchers and policymakers must understand the steps necessary to obtain reliable results and possible limitations in the accuracy of findings to make the best use of survey methodology as applied to medical practice.

Ambulatory Care↗
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Defensive medicine and obstetrics.

OBJECTIVE: To test the hypothesis that physicians with greater malpractice claims exposure, either through personal experience or in their practice environment, will use more prenatal resources and have a higher cesarean delivery rate than physicians with lesser claims exposure. DESIGN: Retrospective cohort study using county malpractice defendant rate data from the Washington State Physicians Insurance and Exchange Association and prenatal care, delivery method, and self-reported obstetric suit experience data from the Content of Obstetrical Care Study database. SETTING: Washington State obstetric practices. PARTICIPANTS: Stratified random samples of obstetrician-gynecologists and family physicians. MAIN OUTCOME MEASURES: The rates of obstetric ultrasound use, referral and consultation, prenatal care resource use, and cesarean delivery. RESULTS: After controlling for patient, physician, and sociodemographic characteristics, we found no difference in prenatal resource use or cesarean delivery rate for low-risk patients between physicians with more and less exposure to malpractice claims. CONCLUSIONS: This study does not support an association between the malpractice experience or exposure of individual physicians and an increase in the use of prenatal resources or ceserean deliveries for the care of low-risk obstetric patients.

Cesarean Section↗
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Identifying primary care disciplines by analyzing the diagnostic content of ambulatory care.

BACKGROUND: There is considerable controversy about which medical specialties are primary care disciplines. This paper addresses this issue by examining the extent to which the major physician disciplines provide comprehensive ambulatory care to large segments of the population, a characteristic central to the provision of primary care. METHODS: The study is based on ambulatory visits to office-based physicians recorded in the 1980-81 and 1989-90 versions of the National Ambulatory Medical Care Survey. Each diagnosis is aggregated into one of 120 mutually exclusive diagnostic clusters. A primary care encounter is defined as a nonreferred ambulatory visit for one of the top 20 clusters. RESULTS: Family medicine, general internal medicine, and general pediatrics provide the majority of nonreferred ambulatory care for common conditions in the United States. All three of these disciplines provide a comprehensive range of ambulatory care to large segments of the population. Obstetrician-gynecologists are an important source of care for women of childbearing age, but they tend to limit their care to obstetric and gynecologic problems; most care for adult women is provided by family physicians and general internists. CONCLUSIONS: Although most specialties provide outpatient services to different segments of the population, only the traditional primary care disciplines of family practice, general internal medicine, and general pediatrics provide comprehensive ambulatory care to broad population groups.

Adolescent↗
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A comparison of the content of army family practice with nonfederal family practice.

BACKGROUND: To assist with planning for education and practice, family physicians should know the practice content of their practices. The present study compared the content of nonfederal family practice with Army family practice to explore their differences. METHODS: This was a secondary analysis that compared the similar variables within two national data sets: The National Ambulatory Medical Care Survey and the Army's Ambulatory Care Data Base. RESULTS: Army patients were younger and more likely to be female than were nonfederal patients. Army family physicians spent more time with patients in all groups than did nonfederal family physicians. While 12 of the top 20 diagnosis clusters of each sector were the same, there were differences found in the percentages of total visits contained within the top 20 clusters. CONCLUSIONS: Both nonfederal and Army family practice have a wide variation in patients and diagnoses. The two sectors are different in patient age and the frequency of different diagnoses. Knowledge of these differences can assist with planning.

Adolescent↗
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Rural physician assistants: a survey of graduates of MEDEX Northwest.

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

Adult↗
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Physician perspectives on the causes of rural hospital closure, 1980-1988.

BACKGROUND: Few studies seeking to determine the causes of rural hospital closure have examined the opinions of individuals intimately involved with the closed facilities. The purpose of this research was to examine the reasons for small sole community general hospital closures from the perspective of local physicians and to compare these reasons with the perceptions of local mayors. METHODS: Hospitals in this study were selected from a list provided by the American Hospital Association. A two-page questionnaire was sent to every physician who had practiced in the towns in which a sole community general hospital had closed between 1980 and 1988. RESULTS: Physicians reported government reimbursement policies as the most important reasons for hospital closure, agreeing with the mayors' opinions. Other reasons cited were general financial difficulties, competition from other hospitals, and bad board leadership. More than three-quarters of the physicians surveyed considered the quality of care provided by their facilities to be average or better. CONCLUSIONS: The closure of rural hospitals that physicians consider of average or better quality suggests that many of the closed hospitals could have continued to provide valuable services to the residents of their communities. Efforts must be made to ensure that rural communities are not losing viable and useful facilities.

Adult↗
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The geographic and temporal patterns of residency-trained family physicians: University of Washington Family Practice Residency Network.

BACKGROUND: There is a clear national mandate to increase the proportion of generalist physicians within the medical community and to increase their numbers within rural and underserved urban locations. Little is known, however, about the geographic and temporal career patterns of family physicians or about how these patterns differ by sex and graduation cohort. METHODS: Using information from a follow-up survey of the University of Washington Family Practice Residency Network, we analyzed the characteristics of 358 graduate physicians and their 493 practices, including data on geographic practice locations. RESULTS: Two thirds of graduates began their practices in urban locations, and one third initially settled in rural communities. Female graduates were much less likely than their male peers to choose rural practice locations. Few physicians left practices after they had practiced in them for 5 or 6 years. The majority of graduates were still in the practice where they started as long as 18 years earlier. CONCLUSIONS: The most important career decision made by the graduate of a family medicine residency involves practice location. Because women are less likely to practice in rural areas, the increasing proportion of women graduating from family practice residencies might presage shortages of rural physicians in the future.

Career Choice↗
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Beyond retention: National Health Service Corps participation and subsequent practice locations of a cohort of rural family physicians.

BACKGROUND: This report addresses the long-term career paths and retrospective impressions of a cohort of family physicians who served in rural National Health Service Corps (NHSC) sites in return for having received medical school scholarships during the early 1980s. METHODS: We surveyed all physicians who graduated from medical school between 1980 and 1983, received NHSC scholarships, completed family medicine residencies, and served in rural areas. Two hundred fifty-eight physicians responded to our survey with complete information, 76 percent of the members of the cohort who could be located and met the study criteria. RESULTS: In 1994 one quarter of the respondents were still practicing in the county to which they had been assigned by the NHSC, an average of 6.1 years after the end of their obligation. Another 27 percent were still in rural practice. Of the entire group, less than 40 percent were in traditional urban private or managed care settings. CONCLUSIONS: Although only one quarter of NHSC assignees remain long term in their original assignment counties, they provide a large (and growing) amount of nonobligated service to those areas. Of those who leave, many remain in rural practice or work in community-oriented urban practices.

Cohort Studies↗
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The effect of a comprehensive Medicaid expansion on physicians' obstetric practices in Washington State.

BACKGROUND: In 1989 Washington State implemented a comprehensive expansion of its Medicaid perinatal program, augmenting services, increasing provider reimbursement, and broadening eligibility. This study examines the influence of this legislation on physicians' obstetric practices and attitudes toward caring for pregnant Medicaid patients. METHODS: Family physicians and obstetrician-gynecologists were surveyed at the start and 18 months after the Medicaid expansion. The study sample comprised physicians responding to the survey in both years. RESULTS: A greater proportion of family physicians provided unlimited obstetric care to Medicaid patients after the expansion. Sixty percent of family physicians and 56 percent of obstetrician-gynecologists were more willing to provide prenatal care to Medicaid patients as a result of the expansion. Physicians and their office staff were more comfortable with Medicaid patients in the later time period. Many physicians felt that they were better able to link their patients to a variety of social services after the expansion. CONCLUSIONS: A Medicaid expansion program can increase provider participation in Medicaid and increase provider comfort in caring for Medicaid patients.

Attitude of Health Personnel↗
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The National Health Service Corps: rural physician service and retention.

BACKGROUND: The National Health Service Corps (NHSC) scholarship program is the most ambitious program in the United States designed to supply physicians to medically underserved areas. In addition to providing medical service to underserved populations, the NHSC promotes long-term retention of physicians in the areas to which they were initially assigned. This study uses existing secondary data to explore some of the issues involved in retention in rural areas. METHODS: The December 1991 American Medical Association (AMA) Masterfile was used to determine the practice location and specialty of the 2903 NHSC scholarship recipients who graduated from US medical schools from 1975 through 1983 and were initially assigned to nonmetropolitan counties. We used the AMA Masterfile to determine what percentage of the original cohort was still practicing in their initial county of assignment and the relation of original practice specialty and assignment period to long-term retention. RESULTS: Twenty percent of the physicians assigned to rural areas were still located in the county of their initial assignment, and an additional 20 percent were in some other rural location in 1991. Retention was highest for family physicians and lowest for scholarship recipients who had not completed residency training when they were first assigned. Retention rates were also higher for those with longer periods of obligated service. Substantial medical care service was provided to rural underserved communities through obligated and postobligation service. Nearly 20 percent of all students graduating from medical schools between 1975 and 1983 who are currently practicing in rural counties with small urbanized populations were initially NHSC assignees. CONCLUSIONS: Although most NHSC physicians did not remain in their initial rural practice locations, a substantial minority are still rural practitioners; those remaining account for a considerable proportion of all physicians in the most rural US counties. This study suggests that rural retention can be enhanced by selecting more assignees who were committed to and then completed family medicine residencies before assignment.

Career Choice↗
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Understanding the interactions between physician assistants and their supervising physicians in the provision of patient care.

A great deal of discussion and debate has surrounded the issue of autonomy of practice among physician assistants (PAs) and other non-physician clinicians. This study further explores this issue by closely examining the interactions between PAs and their supervising physicians in the provision of patient care. Utilizing a national sample of 1,112 full-time practicing physician assistants, PA-MD interaction patterns are measured and weighted in a scale as a proxy for autonomy of practice. Further, these measures are then used as the dependent variable in a regression analysis to better explain the dynamics between PA personal and practice characteristics and autonomy of practice. Overall, the tested model explained 29% of the variation in PA-MD interaction patterns. Independent variables that were particularly influential in the model were proximity to supervisor, clinical productivity, the percentage of PA patients treated using written clinical guidelines, specialty of practice, and practice setting.

Humans↗