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Biomedical subjects

T R Konrad

Publications and source records attributed to T R Konrad.

At least 55 records · Page 3Linked to original sources
PubMed1996

Rural physician satisfaction: its sources and relationship to retention.

This study uses survey data to identify areas of satisfaction and dissatisfaction for primary care physicians working in rural areas across the country. It also identifies the specific areas of satisfaction associated with longer retention within a given rural practice, as well as the characteristics of individuals, practices, jobs, and communities associated with the areas of satisfaction that predict retention. Study subjects comprised a sample of 1,600 primary care physicians who moved to nonmetropolitan counties nationwide during the years 1987 through 1990, with oversampling of those who moved to federally designated health professional shortage areas (HPSAs). Physicians serving in the National Health Service Corps (NHSC) were excluded. Sixty-nine percent of the eligible subjects returned completed mail questionnaires in 1991. Analyses for this study were limited to the 620 primary care physicians who worked more than 20 hours per week in towns of fewer than 35,000 population; who were neither in the military nor the NHSC; and who were not in urgent care, emergency room, or full-time teaching positions. Analyses revealed that the areas of rural physicians' greatest satisfaction were their relationships with patients, clinical autonomy, the care they provided to medically needy patients, and life in small communities. Physicians were least satisfied with their access to urban amenities and the amount of time they spent away from their practices. Retention was independently associated only with physicians' satisfaction with their communities and their opportunities to achieve professional goals. Retention was also marginally related to physicians' satisfaction with their earnings. Among the areas of satisfaction not related to retention were satisfaction with autonomy, access to medical information and consultants, and the quality of doctor-patient relationships. In a subsequent series of analyses of the factors that predict the three areas of satisfaction that were associated with retention (satisfaction with the community, professional goal attainment, and earnings), a variety of physician, work, and community factors were identified. These findings reveal that specific features of rural physicians, their work, and their communities predict each of the various aspects of satisfaction and that only certain aspects of satisfaction predict rural physicians' retention. There are no magic bullets to make rural physicians satisfied in all ways. Nevertheless, there are identified approaches to elevate the specific aspects of rural physicians' satisfaction important to their retention. Programs to improve the satisfaction of rural physicians should focus on those areas of satisfaction that predict longer retention and other important outcomes.

Data Collection↗
PubMed1996

Pediatrician and family physician agreement with and adoption of universal hepatitis B immunization.

BACKGROUND: The purpose of this study was to assess (1) rates of agreement with and adoption of the universal hepatitis B vaccine recommendation among practicing pediatricians and family physicians in nine selected states; (2) physicians' attitudes related to hepatitis B immunization; and (3) physicians' perceptions of parental attitudes regarding the hepatitis B vaccine series. METHODS: Self-administered questionnaires were mailed to 3014 pediatricians and family physicians in selected metropolitan areas and non-metropolitan areas of nine states. Outcome variables were agreement with and adoption of the hepatitis B vaccine recommendation. Predictor variables included physicians' characteristics, practice type and location, and proportion of managed care and Medicaid patients. Other variables that were studied include physicians' attitudes related to hepatitis B immunization, sources of immunization recommendation information, personal completion of the hepatitis B immunization series, and physicians' impressions of parental attitudes about the vaccine. RESULTS: Pediatricians were more likely than family physicians to report that they knew "a lot" about the recommendation (95% vs 84%), agreed with it (83% vs 57%), and have adopted it into practice (90% vs 64%). More physicians in both specialties had adopted the recommendation than actually agreed with it. Doubt about long-term protection from the vaccine was a strong predictor of not agreeing with or adopting the recommendation. Parental resistance to or request for hepatitis B vaccine affected the likelihood of physicians adopting it. CONCLUSIONS: Pediatricians and family physicians continue to differ in both agreement with and adoption of universal hepatitis B immunization. Two years after the recommendation was made, less than two thirds of all family physicians have adopted this recommendation. Adoption is likely influenced by practice policy, physician attitudes, and perceived parental opinions. We recommend that as new vaccines are approved and recommended, research be conducted to explore and address issues germane to physician agreement and adoption.

Adult↗
PubMed1996

A comparison of dermatologists and generalists. Management of childhood atopic dermatitis.

BACKGROUND AND DESIGN: To compare the approaches of generalist physicians and dermatologists in the management of childhood atopic dermatitis (AD), a 6-page questionnaire was developed to assess specific practice characteristics and therapeutic preferences. Surveys were mailed to all board-certified dermatologists in North Carolina (n = 173) and to a sample of pediatricians (n = 200) and family medicine physicians (n = 300) randomly selected from the North Carolina Health Professions Database. There were 307 eligible respondents, defined as those who see children with AD, and 112 ineligible respondents. The response rate of eligible respondents was 62%. The specialty-specific response rates were as follows: 76% for dermatologists, 70% for pediatricians, and 49% for family medicine physicians. RESULTS: Dermatologists reported seeing the largest number of patients with AD, followed by pediatricians and family medicine physicians. Dermatologists also reported seeing the highest percentage of pediatric patients with moderate or severe AD (59%), followed by pediatricians (27%) and family medicine physicians (19%). Regardless of the severity of the AD, dermatologists consistently indicated a greater preference for more intensive therapy compared with generalists, as demonstrated by their preference for prescribing more potent topical steroids. Also, dermatologists were more likely than pediatricians (22%) and family medicine physicians (8%) to report "frequent use" of oral antibiotics for AD (63%). CONCLUSIONS: These striking interspecialty differences are likely to affect the outcome and cost of care of childhood AD. The data support the argument for conducting further studies of generalists' and dermatologists' approach to childhood AD, correlating therapeutic approaches with clinical outcomes and costs.

Child↗
PubMed1995

Self-care and assistance from others in coping with functional status limitations among a national sample of older adults.

Using data from the first wave of a new longitudinal data set collected in the late fall and winter of 1990-1991, the National Survey of Self-Care and Aging (NSSCA), we examined older adults' self-care practices in coping with functional status limitations based on in-person interviews with a national probability sample of 3,485 noninstitutionalized adults aged 65 or older selected from Medicare beneficiary files. A composite score of functional status was calculated to reflect the presence and severity of disability in three dimensions: basic, mobility, and instrumental activities of daily living. Three types of self-care coping strategies were defined: use of equipment or devices, changes in behavior, and modifications in one's environment. National estimates of self-care practices, assistance from others, and functional status measures were presented. Data revealed that the likelihood of engaging in self-care coping strategies increased as the severity of disability increased, except among the most severely disabled. Generally, those receiving assistance from others were more likely to engage in self-care activities, suggesting that receiving assistance supplements, rather than supplants, self-care coping strategies.

Activities of Daily Living↗
PubMed1995

Determination of supply and requirements in physical therapy: some considerations and examples.

This article is an exploration of the specific application of need-based and demand-based models for assessing health personnel supply requirements to the field of physical therapy. Definitions and examples of these models are offered. Problems presented in the field of physical therapy in accurately defining need and demand are presented. Specific examples of current data collection at a variety of levels (professional association, private sector, state, and federal) are given.

Health Planning↗
PubMed1994

The National Health Service Corps experience for rural physicians in the late 1980s.

OBJECTIVE: To learn from physicians in the National Health Service Corps (referred to as NHSC or the Corps) scholarship program about their experiences in rural health professional shortage areas (HPSAs), to contrast their experiences with those of other physicians working in rural HPSAs, and to learn how NHSC physicians' retention is associated with the quality of their experiences. DESIGN: Cohort study. PARTICIPANTS: Two groups of primary care physicians who moved to rural HPSAs nationwide from 1987 through 1990 were surveyed in 1991: group 1 consisted of all 675 physicians in the NHSC scholarship program, and group 2 consisted of a stratified random sample of 1000 non-Corps physicians. Response rates were 73.7% and 69.1%, respectively. Analyses used comparable subsets of 417 NHSC and 206 non-NHSC respondents. RESULTS: Among NHSC physicians, 51% initially anticipated working in underserved areas longer than 10 years, although only 14% expected to remain more than 5 years in their assigned practices. Three quarters of the Corps group felt there were few acceptable practice sites available to them, one third likely would have preferred urban sites, and two thirds were matched in states where they had not lived or trained earlier. Corps physicians felt their spouses' and children's needs were less well satisfied in their communities than non-Corps physicians. Corps physicians reported lower satisfaction in their work and personal lives and demonstrated poorer retention. Group differences in satisfaction and retention remained after controlling for various features of physicians and sites where they worked. Among NHSC physicians, retention was dramatically lower for those less well matched to their communities and those less satisfied. CONCLUSIONS: The needs and preferences of NHSC physicians and families are not well accommodated. Low morale and poor retention are endemic among NHSC physicians. The NHSC is challenged by twin goals of meeting the immediate needs of underserved communities and providing personally and professionally satisfying environments where physicians can pursue long-term careers.

Career Choice↗
PubMed1994

Is universal neonatal hemoglobinopathy screening cost-effective?

OBJECTIVE: To determine whether and where universal neonatal screening for hemoglobinopathies, chiefly sickle-cell disease, could be performed at socially acceptable costs. METHODS: We made projections of the cost-effectiveness of nonuniversal and universal sickle-cell disease screening throughout the United States. We then compared the cost-effectiveness of universal sickle-cell disease screening with that of universal phenylketonuria screening. Finally, we asked if "high-cost" states, that is, those in which the cost of finding a case of sickle-cell disease exceeded one half the cost of finding a case of phenylketonuria, could enhance their cost-effectiveness by joining demographically complementary states in screening cooperatives. RESULTS: If all states conducted independent screening and if the value of finding a case of sickle-cell disease were no more than one half that of finding a case of phenylketonuria, seven of the 19 states that do not currently conduct universal screening for hemoglobinopathies would begin to do so, but six of the 34 that currently do so would stop. Of the six that would stop, three have already formed a screening cooperative, reducing their projected average costs for finding either sickle-cell disease or phenylketonuria or both; the other three could similarly improve cost-effectiveness through cooperative arrangements. Nineteen states realize economies of scale in six cooperative groups; more could do so. CONCLUSION: Universal neonatal hemoglobinopathy screening can be made available at socially acceptable costs to the citizens of demographically various states.

Cost-Benefit Analysis↗
PubMed1994

Rural primary care program survival: an analysis of financial variables.

This study examines the effect of financial characteristics of rural primary care programs on the probability of their continuing as federally funded entities. A randomly selected national cohort of rural primary care programs (n = 162) was used to compare financial measures of programs that were continuing and those that were noncontinuing. Financial data were obtained from 1978-1987 Bureau Common Reporting Requirements (BCRR) forms submitted to the Bureau of Health Care Delivery and Assistance of the Department of Health and Human Services as part of the requirement to receive federal grant support for the programs. The results emphasize the importance of both outside funding and increased level of self-sufficiency in the continuation of rural primary care programs. Noncontinuing programs often suffer from both a lack of self-sufficiency and a lack of outside funding, mostly from federal sources. To a lesser extent, the number of patients also affects the program's chance of continuation. From a policy perspective, government intervention is both necessary and likely if rural primary care programs are to succeed and fulfill their mission of providing primary care for the medically underserved who are primarily poor, uninsured, and unable to pay.

Cohort Studies↗
PubMed1994

Studying the retention of rural physicians.

Rural communities and policy-makers struggle with efforts to enhance the retention of rural physicians. Research available to guide these efforts is often weak methodologically and thus may be pointing retention efforts in nonproductive directions. This article discusses a range of methodologic issues encountered in rural physician retention studies for the purpose of strengthening future studies. Ideal study approaches to answer causal questions, including questions about the "causes" of rural physician retention, must demonstrate good internal validity, for which chance, bias, and confounding are accounted. Retention studies that rely simply on asking physicians why they stay or leave rural areas can be useful at times, but are too prone to bias and their findings difficult to verify. Simply identifying what physicians find satisfying or dissatisfying about rural work also will not reliably reveal why they stay or leave, a related but still distinct question. Stronger approaches to studying retention include the traditional quantitative study--in which retention factors are identified when they are statistically related to physicians' retention, and the increasingly popular qualitative study--in which retention issues are revealed through prolonged, in-depth interactions with physicians. This article also discusses various definitions of retention, the use of survival curves to present retention findings, and the importance of studying retention in inception cohorts. The benefits and downside of studying retention with prospective and retrospective study designs are described.

Career Mobility↗
PubMed1994

Does subsidizing rural community health centers hurt private practice physicians?

One reason for the shortage of primary care physicians in rural areas may be these physicians' reluctance to compete for patients with federally subsidized Community Health Centers (CHCs). Yet little is known about the relationship between private practice physicians and physicians in federally subsidized practices who share service areas. We used surveys from a two-state subset of a nationally representative sample to compare practice characteristics of three types of physicians: those who work in CHCs; those in private practice within CHC service areas; and private practice physicians in other rural areas. We found that rural physicians who compete with CHCs earn incomes comparable to physicians in rural areas who do not compete with CHCs, and that the percentage of Medicaid and uninsured patients seen in private physician practices does not increase when a CHC is not in the county. We conclude that CHCs do not provide competitive barriers to physicians in private practice, although we do not know if the presence of a CHC inhibits new private physicians from entering practices in these communities.

Adult↗
PubMed1994

Medical education and the retention of rural physicians.

OBJECTIVE: This study inquires whether retention in rural practice settings is longer for graduates of public medical schools and community hospital-based residencies, and for those who participated in rural rotations as medical students and residents. These questions are addressed separately for "mainstream" rural physicians and physicians serving in the National Health Service Corps (NHSC). DESIGN: Design is a prospective cohort study. PARTICIPANTS: Study subjects were 202 primary care physicians who graduated from U.S. allopathic medical schools from 1970-1980, and who in 1981 were working in a nationally representative sample of externally subsidized rural practices. Nearly half were serving in the NHSC. Physicians were first identified in 1981 as part of an earlier study. INTERVENTION: In 1990, study subjects were re-located and sent a follow-up mail survey inquiring about their medical training backgrounds and their careers from the time of graduation until 1990. We examined associations between four features of physicians' medical training and their subsequent retention in rural practice settings. RESULTS: Among those not in the NHSC, rural retention duration did not differ for those from public versus private medical schools, those who trained in community hospitals versus university hospital-based residencies, or for those who completed versus did not complete rural rotations as students or residents. Among NHSC physicians, no retention duration differences were noted for those with rural experiences as students or residents, or for those trained in community hospital residencies. Contrary to common wisdom, public school graduates in the NHSC remained in rural areas for shorter periods than private school graduates. CONCLUSIONS: These findings call into question whether current rural-focused medical education initiatives prepare rural physicians in ways able to influence their retention in rural settings. For purposes of enhancing the rural practice retention of its alumni, the NHSC should not selectively award scholarships to students from public medical schools.

Adult↗
PubMed1994

Universal hepatitis B immunization of infants: reactions of pediatricians and family physicians over time.

OBJECTIVE: In November 1991 the Advisory Committee on Immunization Practice (ACIP) recommended universal hepatitis B immunization of infants. In February 1992 the American Academy of Pediatrics (AAP) and in August 1992 the American Academy of Family Physicians (AAFP) issued similar recommendations. The purpose of this study was to assess over time the effectiveness and impact of the dissemination efforts of the ACIP, AAP, and AAFP regarding this new recommendation and to determine the factors affecting its adoption. DESIGN: Cohort survey over time. SETTING: North Carolina. PARTICIPANTS: All 778 pediatricians and a random sample of 300 family physicians in North Carolina were surveyed by mail 3 months after publication of the ACIP recommendation (January/February 1992), but before the AAP and AAFP recommendations. Response rate was 78%. Of these, 83% responded to a follow-up survey 8 months later (October 1992). MAIN OUTCOME MEASURES: Rates of agreement and adoption of the recommendation for universal infant immunization with hepatitis B vaccine; factors affecting agreement and adoption of the recommendation. RESULTS: In the first survey (3 months after the ACIP recommendation) more pediatricians than family physicians were aware of the new recommendation (82% vs 48%), yet only 37% of pediatricians and 23% of family physicians agreed that immunization of all newborns in their practice was warranted. Eight months later, after the AAP and AAFP recommendation, 66% of pediatricians and 32% of family physicians agreed universal immunization was warranted, but still only 53% of pediatricians and 23% of family physicians had adopted it into practice. Factors associated with these low rates of adoption include physician and practice characteristics, cost, perceived need for the vaccine, and aversion to multiple injections. CONCLUSIONS: Federal, AAP, and AAFP efforts have not been effective thus far in fostering widespread agreement and adoption of this recommendation. If this and future vaccine programs are to succeed, research is needed to determine influences on implementation of new recommendations and to address the economic and noneconomic concerns of physicians and parents.

Attitude of Health Personnel↗
PubMed1993

The determinants of utilization of nonphysician providers in rural community and migrant health centers.

The use of nonphysician providers, such as nurse practitioners, physician assistants, and certified nurse midwives, in rural areas is critically important due to the continued primary care access problems. This study examines the major factors influencing the use of nonphysician providers in rural community and migrant health centers based on a 1991 national survey of the centers. This study demonstrates that the employment of nonphysician providers in rural community and migrant health centers is significantly influenced by both supply and demand factors. Among supply factors, there is a significant and positive relationship between the number of total staff and the number of nonphysician providers employed. There is a significant but inverse relationship between the number of physicians and the number of nonphysician providers employed, indicating nonphysician providers primarily serve as substitutes for physicians in rural community and migrant health centers. The supply of nonphysician providers, as measured by the number of affiliated training programs, is significantly related to the employment of nonphysician providers. The demand variable, geographic location, and the centers' staffing policies are also significant determinants of the use of nonphysician providers.

Community Health Centers↗
PubMed1993

Primary care physicians' views on access and health care reform: the situation in North Carolina.

BACKGROUND: This cross-sectional study assessed physicians' satisfaction with the current insurance-based reimbursement system and preferences for the two most frequently discussed health care reform proposals, and estimated the association between demographic and practice characteristics and attitudes toward health policy issues and reform plans. METHODS: A random sample of 300 physicians was drawn from state licensure files of general practitioners, family physicians, and pediatricians practicing in North Carolina. All sample physicians were sent a schematic outline of the two major health reform alternatives and a 1-page self-administered questionnaire to determine their attitudes toward the current health care system and their preferences for health reform alternatives. RESULTS: Sixty-nine percent of physicians responded to the survey. The responses indicated dissatisfaction with the current system and strong beliefs that access to care is inadequate in this diverse state with a large poor and rural population. Nearly one third of the physicians reported having insufficient information to choose between plans. Among physicians expressing a preference, 37% preferred managed competition, 38% preferred continuing the current system, and 25% preferred a single-payer system. CONCLUSIONS: A uniform opinion about health care policy is a thing of the past for American medicine. Because terms used in the health reform debate (especially "managed competition") are ambiguous and set in the context of an increasingly diverse medical profession, no single direction of health reform (much less a specific plan) secures widespread understanding or support from a large proportion of physicians. None of the plans will please all of the doctors all of the time.

Adult↗