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PubMed2004

Immunization coverage levels among 19- to 35-month-old children in 4 diverse, medically underserved areas of the United States.

BACKGROUND: The National Immunization Survey demonstrates that national immunization coverage in 2002 remained near the all-time highs achieved in 2000. However, that survey cannot detect whether coverage is uniformly high within relatively small areas or populations. The measles resurgence in the early 1990s revealed that coverage was low in some areas, particularly among inner-city children from racial and ethnic minority groups. Today, identifying areas with low childhood-vaccination coverage remains important, particularly if these areas are at risk for the introduction of disease. In 1995, the Centers for Disease Control and Prevention launched a congressionally mandated demonstrated project now called the Childhood Immunization Demonstration project of Community Health Networks. This mandate specified an assessment to determine whether a network of primary care providers affiliated with university teaching hospitals could assume a public health responsibility for raising immunization levels among preschoolers in medically underserved communities. Communities with federally designated health professional shortage areas were invited to submit proposals, and 4 were selected: Detroit, MI, New York, NY, San Diego, CA, and rural Colorado. OBJECTIVES: To measure immunization coverage among preschool children in the 4 selected medically underserved areas and determine predictors of coverage levels. DESIGN AND SETTING: Surveys in the 4 areas were based on stratified cluster probability sample designs in which clusters of dwelling units were selected and all households in selected clusters were screened for the presence of children aged 12 to 35 months. Immunization histories were obtained from parents and providers for these children. For each age-eligible child, the information collected on utilization of immunization health services included a listing of all clinics or offices ever used for the child's well-child care and/or for obtaining immunizations. Information was also collected on whether the child currently had health insurance (public and/or private) and whether the child had a medical home. A child was classified as having a medical home if the survey respondent reported a source of well care that was the same as the source of sick care and that this place was not an emergency department. PARTICIPANTS: Children 12 to 35 months of age in Detroit, New York, San Diego, and rural Colorado. OUTCOME MEASURE: Community-wide up-to-date (UTD) immunization coverage levels at 19 to 35 months of age, defined as receipt of 4 doses of diphtheria and tetanus toxoids and pertussis vaccine, 3 doses of poliovirus vaccine, 1 dose of measles, mumps, and rubella vaccine, 3 doses of Haemophilus influenzae type B vaccine, and 3 doses of hepatitis B vaccine (the 4:3:1:3:3 series). ANALYSIS: We examined the association between coverage level and independent variables and performed chi2 and t tests to determine whether differences observed within and between groups and sites were significant. RESULTS: The overall response rate for eligible children ranged from 79.4% to 88.1%. Coverage levels for most individual vaccines were >90% in all sites except Detroit. Coverage for the 4:3:1:3:3 series was significantly higher for children in New York (84%) and San Diego (86%) than for children in Detroit (66%) and rural Colorado (75%). Demographic risk factors related to UTD immunization status varied by site. Although differences in coverage levels by ethnicity varied by site, differences were not significant. In Colorado and New York, coverage was slightly lower among Hispanic than white children (71% vs 76% and 83% vs 91%, respectively). In San Diego, coverage was lower among whites, compared with Hispanics (76% vs 85%). Coverage was also lower for African American than white children only in New York (75% vs 91%). However, in San Diego and Colorado, children receiving their vaccinations from private providers had lower coverage levels than children receiving their vaccinations from other providers (78% vs 91% and 71% vs 57%, respectively). Ictively). In all 4 sites, children for whom respondents reported having an immunization card at the time of the interview were more likely to have higher series coverage levels than children for whom a parent-held card was not available. Also, children who were UTD at 3 months of age had significantly higher vaccination-series coverage levels than children who were not UTD at 3 months of age. In addition, the vaccination coverage was lower for children in Detroit whose parents reported problems accessing the health care system because lack of transportation (46%), compared with those who did not report such problems (65%); however, this difference did not reach significance (chi2 = 6.0). In Colorado, the small proportion of children in families without a phone had a lower vaccination coverage level (58%) than those in households with a phone (75%) (chi2 = 6.3). In all sites, children who were UTD at 3 months of age and had a parent-held vaccination card were more likely to be UTD at 19 to 35 months of age. CONCLUSIONS: Preschoolers in these medically underserved areas were not at uniform risk for underimmunization. Because they were designated as health professional shortage areas, the 4 sites in this study were expected to have low immunization-coverage rates. However, this was not the case. In fact, coverage in 3 of the 4 areas was quite high compared with US national figures (73%); only Detroit had a much lower UTD rate (66%). Efforts are needed to improve methods to identify areas with low immunization coverage so that resources can be directed to places where interventions are needed. Our results reveal that an area's need for childhood immunization interventions is not well predicted by a low number of providers per capita. Other criteria must be developed to predict areas or populations with low immunization coverage. Understanding more about the characteristics of children/provider pairs for children who are UTD at 3 months and more about the role of parental hand-held cards, along with finding strategies to improve immunization delivery by providers in Vaccines for Children Program facilities, suggest potentially productive avenues for increasing and sustaining high coverage levels.

Child, Preschool↗
PubMed1975

An Ontario solution to medically underserviced areas: evaluation of an ongoing program.

In 1969 a program was established to place physicians in area of Ontario deemed to be medically underserviced. The main features of the program are area designation, physician subsidies, student bursaries, community participation and physician recruitment. From 1969 to March 1973, 162 communities were designated as underserviced and 196 physicians placed. As the program became active the rate of increase of numbers of physicians practising in northern rural areas (population, less than 15 000) increased sharply, exceeding that for the entire province. Fifty-three percent of bursaried students have honoured their commitment. Seventy-five communities have built modern medical centres that have been an important factor in attracting physicians. Still unanswered are whether the physicians will stay and whether the health of the population will be improved.

Community Health Services↗
PubMed2026

Cost-effectiveness analysis of a virtually administered pain coping skills training intervention in women with breast cancer in underserved areas.

OBJECTIVES: Women with cancer who live in medically underserved areas could benefit from behavioral pain interventions, but access is limited. A randomized trial reported that a 4-session virtual program incorporating pain coping skills training (mPCST) was effective in improving pain outcomes compared to an attention-control condition. We performed a cost-effectiveness analysis of mPCST vs. control. METHODS: Data on medical resource use, therapist time, and participants' attendance at intervention sessions and time associated with travel and using a mobile app were collected. The 5-level EuroQol 5-Dimension (EQ-5D-5L), a preference-weighted measure of health-related quality of life (HRQOL), was administered at baseline, after the intervention period, and 3 and 6 months later. Medicare payments were used to value medical resource use and therapist time to deliver mPCST. Patient time was valued using the average US wage. RESULTS: Medical resource utilization was similar for both groups, but hospitalizations trended higher in the mPCST group. EQ-5D-5L preference weights were higher by an average of 0.066 (p = 0.04) with mPCST across the follow-up period, representing an incremental gain of 0.04 quality-adjusted life years (QALYs) (95% CI: 0.00-0.08). When including the base-case cost of mPCST of \$500 vs. \$0 for the control group, the incremental cost-effectiveness ratio (ICER) was \$12,725 per QALY (95% CI: 5,566-69,343). Including the value of patient time added \$303 to mPCST costs resulting in an ICER of \$20,438 per QALY (95% CI: 9,051-111,403). SIGNIFICANCE OF RESULTS: mPCST is a cost-effective program that improves HRQOL for women with cancer living in medically underserved areas.

Humans↗
PubMed1995

Primary care physicians in underserved areas. Family physicians dominate.

Using the definitions of "medically underserved areas" developed by the California Health Manpower Policy Commission and data on physician location derived from a survey of California physicians applying for licensure or relicensure between 1984 and 1986, we examined the extent to which different kinds of primary care physicians located in underserved areas. Among physicians completing postgraduate medical education after 1974, board-certified family physicians were 3 times more likely to locate in medically underserved rural communities than were other primary care physicians. Non-board-certified family and general physicians were 1.6 times more likely than other non-board-certified primary care physicians to locate in rural underserved areas. Family and general practice physicians also showed a slightly greater likelihood than other primary care physicians of being located in urban underserved areas.

California↗
PubMedDate not supplied

An innovative, rational approach to rural health care.

Parts of rural, southern Illinois, like many rural areas throughout the world, are medically underserved. An innovative, rational solution to the physician shortage in those parts of rural, southern Illinois, which may be applied to other medically underserved areas, rural or urban, is proposed in this manuscript. To attract physicians to or near medically underserved, rural areas in southern Illinois it is proposed that Primary Care and Referral Centers be set up in southern Illinois. This could be done by adding well trained general practitioners, family physicians, or general internists to the staff of each emergency center of the Total Emergency Medical Service System for (southern) Illinois that is located in or near an otherwise medically underserved, rural area of southern Illinois. These additional physicians would diagnose and treat within their capabilities all non-emergency cases coming to the primary care centers and refer non-emergency cases needing referrals. Referrals would be either for secondary or tertiary health care. The Primary Care and Referral Centers should be self-supporting from pre-paid patient fees. For almost ten years a health center like a Primary Care and Referral Center has been operating at SIU/Edwardsville.

Community Health Services↗
PubMedDate not supplied

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↗
PubMed2006

Effect of a global longitudinal pathway on medical students' attitudes toward the medically indigent.

BACKGROUND: The increase in people with insufficient health insurance has largely been fueled by a record influx of immigrants, who often live in medically underserved areas of inner cities. An increase in the desire of medical students to practice in underserved areas is needed to counter low physician-to-population ratios in these areas. PURPOSE: To assess the effect of a Pathway on Serving Multicultural and Underserved Populations, which includes domestic and international experiences with recent immigrant groups, on the attitudes of students toward the indigent. METHODS: Students from the classes of 2002 and 2003, including a cohort in the Pathway program, were participants in this study. Changes in attitudes within Pathway and non-Pathway students were studied over their 4 years of medical school. RESULTS: There was no statistically significant difference between the two groups in the rate of change of attitudes over time. The determination of any potential difference was hampered by small sample sizes. Thus, interesting trends, especially related to a more rapid decline in attitudes of non-Pathway students, including their sense of professional responsibility, did not achieve statistical significance. CONCLUSIONS: Further research, both quantitative and qualitative, is needed before we can state more definitively that the Pathway curriculum supports positive attitudes toward serving the medically indigent.

Adult↗
PubMed2005

Incentives and physician specialty choice: a case study of Florida's Program in Medical Sciences.

The growing shortage of primary care physicians in medically underserved areas of the nation led medical schools and policymakers years ago to design and fund numerous innovative medical education programs to foster the development of a more balanced physician workforce. Florida's Program in Medical Sciences (PIMS) was an example of one such initiative that was established in fall 1971 at Florida State University (FSU). A precursor of the present-day FSU College of Medicine, this program was created specifically to address the growing need for primary care physicians in rural areas of northwest Florida. The results of empirical tests on the career choices of PIMS graduates in the first 20 years provide weak evidence that the program was more effective than the existing channels of medical education in producing additional primary care physicians to rural Florida counties.

Career Choice↗
PubMed1983

It's time to fund physician shortage programs by abandoning unrestricted state subsidies to medical schools.

Last fiscal year, New York State spent more than $135 million to subsidize medical education. More than 95 percent of these funds were used to defray the general operating costs of the state's nine private and four public medical schools. Only $7 million was spent directly to support physician shortage and minority recruitment programs. This article argues that unrestricted subsidies are inequitable, wasteful, unnecessary, and inflationary; therefore they should be abandoned, in favor of programs that contribute directly to the supply of primary care physicians in medically underserved areas.

Education, Medical↗