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Articles -- Abstracts of manuscripts submitted to and published in peer-reviewed journals.
One-Pagers -- Research summaries pertinent to family practice advocacy.
Commentaries and Editorials -- References to editorials by Graham Center staff that have been published in peer-reviewed journals.
Monographs & Books -- Comprehensive studies, syntheses of evidence and compilations of conversations on the history and future of family medicine.
Presentations -- Given by Graham Center staff at various events.

Health Access and Equity


Ecology of Healthcare: The Need to Address Low Utilization in American Indians/ Alaska Natives - February 2014
Disparities in health and access to health care continue to persist among the American Indian/Alaska Native population, despite federal efforts to call attention to and address these disparities. (One-Pagers)


Migration After Family Medicine Residency: 56% of Graduates Practice Within 100 Miles of Training - November 2013
Using the 2009 American Medical Association Physician Masterfile, this one-pager notes that 56% of family medicine residents stay within 100 miles of where they graduate from residency. (One-Pagers)

Historic Growth Rates Vary Widely Across the Primary Care Physician Disciplines - October 2013
To better understand trends in the primary care physician workforce, we have examined the growth of family physicians, general pediatricians, and general internists providing direct patient care. (One-Pagers)

Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions - September 2013
This study developed and tested candidate GME outcome measures related to physician workforce. The findings can inform educators and policy makers during a period of increased calls to align the GME system with national health needs. (Articles)

Toward Defining and Measuring Social Accountability in Graduate Medical Education: A Stakeholder Study - September 2013
Since 1965, Medicare has publically financed graduate medical education (GME) in the United States. Given public financing, various advisory groups have argued that GME should be more socially accountable. Several efforts are underway to develop accountability measures for GME that could be tied to Medicare payments, but it is not clear how to measure or even define social accountability. (Articles)

A Needs-Based Method for Estimating the Behavioral Health Staff Needs of Community Health Centers - July 2013
Federally Qualified Health Centers are expanding to increase access for millions of more Americans with a goal of doubling capacity to serve 40 million people. Health centers provide a lot of behavioral health services but many have difficulty accessing mental health and substance use professionals for their patients. To meet the needs of the underserved and newly insured it is important to better estimate how many behavioral health professionals are needed. (Articles)

Trends in Physician Supply and Population Growth - April 2013
The physician workforce has steadily grown faster than the U.S. population over the past 30 years, context that is often absent in conversations anticipating physician scarcity. Policy makers addressing future physician shortages should also direct resources to ensure specialty and geographic distribution that best serves population health. (Articles)

The Primary Care Extension Program: A Catalyst for Change - March 2013
The Affordable Care Act authorized, but did not fund, the Primary Care Extension Program (PCEP). Much like the Cooperative Extension Program of the US Department of Agriculture sped the modernization of farming a century ago, the PCEP could speed the transformation of primary care. It could also help achieve other goals such as integrating primary care with public health and translating research into practice. The urgency of these goals and their importance to achieving the Triple Aim for health care should increase interest in rapidly building the PCEP, much as the need to feed the country did a century ago. (Articles)


Health Care Transition - December 2012
Youth with special health care needs who receive care within a patient-centered medical home (PCMH) are significantly more likely to receive services for transitioning to adult care. (One-Pagers)

Defining Service Areas for Federally Funded Community Health Centers in the United States - December 2012
Jennifer L. Rankin, PhD; Andrew Bazemore, MD, MPH; Robert L. Phillips, MD, MSPH; Sean C. Finnegan, MS; Benjamin Adler, BS (Presentations)

Projecting US Primary Care Physician Workforce Needs: 2010-2025 - November 2012
Researchers project the United States will need 52,000 additional primary care physicians by 2025 — a 25 percent increase in the current workforce — to address the expected increases in demand due to population growth, aging, and insurance expansion following passage of the Affordable Care Act. Analyzing nationally representative data, the researchers conclude population growth will be the single greatest driver of increased primary care utilization, requiring approximately 33,000 additional primary care physicians by 2025, while 10,000 additional physicians will be needed to accommodate population aging. Insurance expansion, they estimate, will require approximately 8,000 additional primary care physicians, a 3 percent increase in the current workforce. (Articles)

Comparison of Primary Care Service Areas and Estimated Drive Times - October 2012
Sean Finnegan, MS; American Public Health Association 140th Annual Meeting (Presentations)

Integrating community health centers into organized delivery systems can improve access to subspecialty care - August 2012
The Affordable Care Act is funding the expansion of community health centers to increase access to primary care, but this approach will not ensure effective access to subspecialty services. To address this issue, we interviewed directors of twenty community health centers. Our analysis of their responses led us to identify six unique models of how community health centers access subspecialty care, which we called Tin Cup, Hospital Partnership, Buy Your Own Subspecialists, Telehealth, Teaching Community, and Integrated System. We determined that the Integrated System model appears to provide the most comprehensive and cohesive access to subspecialty care. Because Medicaid accountable care organizations encourage integrated delivery of care, they offer a promising policy solution to improve the integration of community health centers into “medical neighborhoods.” (Articles)

Measures of social deprivation that predict health care access and need within a rational area of primary care service delivery - July 2012
The geographic index has utility for identifying areas in need of assistance and is timely for revision of 35-year-old provider shortage and geographic underservice designation criteria used to allocate federal resources. (Articles)

The percentage of family physicians attending to women's gender-specific health needs is declining - July 2012
As the largest and most widely distributed of primary care physicians, family physicians have an important role in providing women's health care, especially in rural and underserved areas. The proportion of family physicians who are attending to women is declining. Policy intervention may be needed to help family physicians maintain the comprehensiveness of care necessary to address the wide range of medical problems of women they encounter within their practices. (Articles)

Proportion of family physicians providing maternity care continues to decline - May 2012
Family physicians traditionally have played an integral role in delivering babies as a component of the comprehensive care they provide for women. The proportion of family physicians who report providing any maternity care continues to decrease. This trend is particularly concerning because family physicians are the most widely distributed specialty and are essential to health care access in rural areas. (Articles)

Medical school rural programs: A comparison with international medical graduates in addressing state-level rural family physician and primary care supply - April 2012
Despite their relatively small size, RPs had a significant impact on rural family physician and primary care supply compared with the much larger cohort of IMGs. Wider adoption of the RP model would substantially increase access to care in rural areas compared with increasing reliance on IMGs or unfocused expansion of traditional medical schools. (Articles)

Declining numbers of family physicians are caring for children - March 2012
Despite continued growth of the primary care workforce, profound maldistribution persists among providers available for the care of children. Family physicians (FPs) spend, on average, approximately 10% of their total practice time caring for children; however, given that, among physician specialties, FPs are geographically distributed most evenly across the US population, the self-reported decline in the share of FPs caring for children should be disturbing to policymakers, especially with the looming insurance expansion in 2014. (Articles)

The next phase of Title VII funding for training primary care physicians for America's health care needs - March 2012
Congress should act on the Council on Graduate Medical Education's recommendation to increase funding for Title VII, Section 747 roughly 14-fold to $560 million annually. This amount represents a small investment in light of the billions that Medicare currently spends to support graduate medical education, and both should be held to account for meeting physician workforce needs. Expansion of Title VII, Section 747 with the goal of improving access to primary care would be an important part of a needed, broader effort to counter the decline of primary care. Failure to launch such a national primary care workforce revitalization program will put the health and economic viability of our nation at risk. (Articles)

Increasing Graduate Medical Education (GME) in Critical Access Hospitals (CAH) could enhance physician recruitment and retention in rural America - January 2012
Critical Access Hospitals (CAHs) are essential to a functioning health care safety net and are a potential partner of rural Graduate Medical Education (GME), which is associated with greater likelihood of service in rural and underserved areas. Currently, very little Medicare funding supports GME in the CAH setting, highlighting a missed opportunity to improve access to care in rural America. (Articles)

Refocusing Geriatricians’ Role in Training to Improve Care for Older Adults - January 2012
The current number of geriatricians cannot keep up with the health care needs of the growing number of older adults. To fill the gap, more geriatricians should focus on training primary care and other specialty physicians to care for older adults. (One-Pagers)


Comprehensive medical school rural programs produce rural family physicians - December 2011
Health insurance expansion expected from the Affordable Care Act is likely to exacerbate the long-standing and critical shortage of rural and primary care physicians over the next decade. Comprehensive medical school rural programs, from which most graduates ultimately enter primary care disciplines and serve rural areas, offer policy makers an interesting potential solution. (One-Pagers)

Where the United States Falls Down and How We Might Stand Up - November 2011
(Commentaries and Editorials)

An international health track is associated with care for underserved US populations in subsequent clinical practice - June 2011
Presence of an international health track (IHT) was associated with increased care of underserved populations. After the institution of an IHT track, this association was seen among IHT participants and nonparticipants and was not associated with increased long-term service abroad. (Articles)

Rural-urban distribution of the U.S. geriatrics physician workforce - April 2011
Small numbers of geriatricians combined with a growing elderly population poses a challenge and an opportunity. Healthcare systems and policy-makers will need to modify care models to better use the skill of geriatricians in concert with other providers to provide quality care for older rural and urban Americans. (Articles)

Tackling primary care workforce demands in light of health care reform - January 2011
James C. Puffer, MD; Robert Phillips, MD, MSPH; Eric S. Holmboe, MD; and James A. Stockman III, MD; Washington Primary Care Forum #63 (Presentations)


Use of measures of socioeconomic deprivation in planning primary health care workforce and defining health care need in Australia - October 2010
Using remoteness areas alone to prioritize workforce incentive programs and training requirements has significant limitations. Including measures of socioeconomic disadvantage and workforce supply would better target health inequities and improve resource allocation in Australia. (Articles)

Illinois Health Connect and Your Healthcare Plus Case Statement - August 2010
(Monographs & Books)

Loss of primary care residency positions amidst growth in other specialties - July 2010
Since the 1997 Balanced Budget Act capped funding for graduate medical education (GME) programs, overall growth in GME has continued (+7.8 percent), but primary care specialties have experienced a substantial decline in their number of programs and residency positions. This decline will further exacerbate the current primary care shortage and severely affect future projections of primary care shortage. (One-Pagers)

The social mission of medical education: ranking the schools - June 2010
Medical schools vary substantially in their contribution to the social mission of medical education. School rankings based on the social mission score differ from those that use research funding and subjective assessments of school reputation. These findings suggest that initiatives at the medical school level could increase the proportion of physicians who practice primary care, work in underserved areas, and are underrepresented minorities. (Articles)

Avertable deaths associated with household income in Virginia - February 2010
If the mortality rates of the reference population had applied to the entire state, 24.3% of deaths in Virginia from 1990 through 2006 (range=21.8%–28.1%) would not have occurred. Further research must clarify the extent to which individual-level factors (e.g., earnings, education, race, health insurance) and community characteristics can improve health outcomes. (Articles)

The impact of a clinic move on vulnerable patients with chronic disease: A geographic information systems (GIS) analysis - January 2010
Maps created from practice management data revealed a shift in patients when a clinic moved. Geographic information systems tools are valuable aids in defining changing service areas of primary health care clinics. (Articles)

Harnessing Geographic Information Systems (GIS) to enable Community-Oriented Primary Care - January 2010
Analytic mapping was enthusiastically received and practically applied in the primary care setting, and was readily comprehended by clinic leaders for innovative purposes. This is a tool of particular relevance amid primary care safety-net expansion and increased funding of health information technology diffusion in these settings, particularly if the hurdles of cost and technological expertise are overcome by harnessing new advances in web-based mapping technology. (Articles)


Family physicians' present and future role in caring for the elderly - November 2009
The population of patients older than 65 years is projected to increase substantially in the coming years, particularly in rural areas. Family physicians are essential providers of geriatric care, especially in rural areas, but need payment reform to improve their capacity to meet the needs of older patients. (One-Pagers)

Race and ethnicity and rural mental health treatment - August 2009
Findings suggest that characteristics of the rural environment may disadvantage all residents with respect to mental health treatment. In more populated areas where mental health services are more plentiful, complex racial and service system factors may play a greater role in evident ethnic/racial treatment disparities. (Articles)

What influences medical student and resident choices? - April 2009
Bridget Teevan, MS; National AHEC Organization Spring Policy Days (Presentations)

Specialty and geographic distribution of the physician workforce: What influences medical student & resident choices? - March 2009
(Monographs & Books)


Impact of Title VII training programs on community health center staffing and national health service corps participation - September 2008
Continued federal support of Title VII training grant programs is consistent with federal efforts to increase participation in the NHSC and improve access to quality health care for underserved populations through expanded CHC capacity. (Articles)

Nonemergency medicine-trained physician coverage in rural emergency departments - April 2008
Nonemergency physicians provide a significant portion of emergency department care, particularly in rural areas. Medical specialties must cooperate to ensure the availability of high-quality emergency department care to all Americans regardless of physician specialty. (Articles)


ABC of patient safety: The healthcare policy context - June 2007
(Monographs & Books)

The Canadian contribution to the U.S. physician workforce - April 2007
Minimizing emigration, and perhaps recruiting physicians to return to Canada, could reduce physician shortages, particularly in subspecialties and rural areas. In light of competing physician shortages, it will be important to consider policy options that reduce emigration, improve access to care and reduce reliance on physicians from developing countries. (Articles)


National Health Service Corps staffing and the growth of the local rural non-NHSC primary care physician workforce - September 2006
These data suggest that the NHSC contributed positively to the non-NHSC primary care physician workforce in the rural underserved counties where its clinicians worked during the 1980s and 1990s. (Articles)

International medical graduates in family medicine in the United States of America: An exploration of professional characteristics and attitudes - July 2006
There are significant differences between IMG and USMG family physicians' professional profiles and attitudes. These differences from 1997 merit further exploration and possible follow-up, given the increased proportion of family physicians who are IMGs in the United States. (Articles)

Examining the impact of closing family medicine residency programs - May 2006
Jessica McCann, MA; Valerie Reese, MD; Andrew Bazemore, MD, MPH; and Robert Phillips, MD, MSPH; STFM Annual Conference (Presentations)

Medicare Part D: Practical and policy implications for family physicians - April 2006
(Commentaries and Editorials)

Family physicians help meet the emergency care needs of rural America - April 2006
Ensuring access to emergency care in rural areas remains a challenge. High costs and low patient volumes make 100 percent staffing of rural emergency departments (EDs) by emergency medicine residency–trained physicians (EPs) unlikely. As rurality increases, so does the dependence on family physicians (FPs) to provide quality emergent care. (One-Pagers)


Who will have health insurance in the year 2025? - November 2005
If current trends continue, U.S. health insurance costs will consume the average households annual income by 2025. As health care becomes unaffordable for most people in the United States, it will be necessary to implement innovative models to move the system in a more equitable and sustainable direction. (One-Pagers)

Excess, shortage, or sufficient physician workforce: How could we know? - November 2005
At least three models have been used to project the future physician workforce, and each produces different results. No physician workforce predictions can be relied on until there is more consideration of and agreement on desired health outcomes and what physicians must do to achieve them. (One-Pagers)

Number of persons who consulted a physician, 1997 and 2002 - September 2005
Most people in the United States consult a general physician each year, and some see other subspecialists. However, the proportion of people consulting a general physician who sees adults and children appears to be declining. (One-Pagers)

The family physician workforce: The special case of rural populations - July 2005
People living outside metropolitan areas, especially those living in rural counties, depend on family physicians. Resolving the disparities in physician distribution nationwide will require solutions to make rural practice a viable option for more health care workers. (One-Pagers)

Family physicians and the primary care physician workforce in 2004 - June 2005
In 2004, there were 91,600 family physicians (FPs) and general practitioners (GPs) and 222,000 primary care physicians actively caring for patients, one for every 1,321 persons. These primary care physicians represent the largest and best-trained primary care physician workforce that has ever existed in the United States. (One-Pagers)

Using the ecology model to describe the impact of asthma on patterns of health care - May 2005
The ecology model confirmed that having asthma changes the likelihood and pattern of care for Americans. More importantly, the ecology model identified a subgroup with asthma who sought only emergent or hospital services. (Articles)

What if we were equal? A comparison of the black-white mortality gap in 1960 and 2000 - March 2005
Using 2002 data, an estimated 83,570 excess deaths each year could be prevented in the United States if this black-white mortality gap could be eliminated. (Articles)

Patients' beliefs about racism, preferences for physician race, and satisfaction with care - March 2005
Many African Americans and Latinos perceive racism in the health care system, and those who do are more likely to prefer a physician of their own race or ethnicity. African Americans who have preferences are more often satisfied with their care when their own physicians match their preferences. (Articles)

Changes in age-adjusted mortality rates and disparities for rural physician shortage areas staffed by the National Health Service Corps: 1984-1998 - March 2005
From the early 1980s through the mid-1990s, the National Health Service Corps's goal to see health improve in rural health professional shortage areas was met, but its goal to diminish geographical health disparities was not. Because age-adjusted mortality rates improved in all county groups, the authors conclude that improvement was likely due to a variety of factors, including decreasing poverty and unemployment rates and increasing primary care physician-to-population ratios, to which the National Health Service Corps may have contributed. (Articles)


The health impact of resolving racial disparities: An analysis of US mortality data - December 2004
Achieving equity may do more for health than perfecting the technology of care. (Articles)

When do older patients change primary care physicians? - November 2004
Older patients, and particularly those who are older and have more education and income, tend to stay with their PCP until they are forced to change. The longer they stay in the relationship, the better they feel about the quality of the primary services they receive. Changes in the health care system may have increased the number of patients forced to change PCP. (Articles)

Variation in participation in health care settings associated with race and ethnicity - October 2004
Fewer blacks and Hispanics than whites received healthcare in physicians’ offices, outpatient clinics, and emergency departments in contrast to hospitals and home care. Research and programs aimed at reducing disparities in receipt of care specifically in the outpatient setting may have an important role in the quest to reduce racial and ethnic disparities in health. (Articles)

Modifiable determinants of healthcare utilization within the African-American population - September 2004
The three modifiable factors of poverty, uninsurance, and having a primary care medical home have a dramatic effect on patterns of care for African-American patients, and could be independently targeted for intervention (Articles)

The importance of having health insurance and a usual source of care - September 2004
The effects of insurance and having a usual source of care are additive. Efforts to improve health care access for all should provide a medical home and health insurance. (One-Pagers)

Geographic retrofitting: A method of community definition in community-oriented primary care practices - June 2004
This paper describes a technique called "geographic retrofitting" that has proved useful in establishing a rigorous definition of a practice's community based on current patterns of health care by the community. It also demonstrates how this approach, used in conjunction with geographic information systems software, facilitates more-powerful capabilities in community characterization and intervention. (Articles)

Who are the uninsured elderly in the United States? - April 2004
This study reveals important gaps in the availability of health insurance for the elderly, gaps that are likely to affect an increasing number of older Americans in the coming decade. (Articles)


The ecology of medical care for children in the United States: A new application of an old model reveals inequities that can be corrected - December 2003
If equal and adequate access to health care for children in the United States is a goal, we are failing. That failing is most prominent in the setting where most children receive care and preventive services—the doctor’s office. (One-Pagers)

Disparities in health care in the United States apparent in the ecology of medical care - October 2003
No abstract available. (Articles)

The U.S. primary care physician workforce: Minimal growth 1980-1999 - October 2003
Growth in the primary care physician workforce (physicians per capita) in the United States has trailed the growth of the specialist physician population in recent years. This has occurred despite calls during the same period for increased production of primary care physicians and educational reforms focusing on primary care. (One-Pagers)

Family physicians are an important source of newborn care: The case of the state of Maine - August 2003
FPs provided 30 percent of inpatient newborn care in Maine in the year 2000. FPs cared for a large proportion of newborns, especially those insured by Medicaid and in smaller, rural hospitals where FPs also delivered babies. Family medicine’s commitment to serve vulnerable populations of newborns requires continued federal, state, and institutional support for training and development of future FPs. (One-Pagers)

Variation in the ecology of medical care - July 2003
Frequency and location of health care delivery varies substantially with sociodemographic characteristics, insurance, and having a usual source of care. Understanding this variation can inform public consideration of policy related to access to care. (Articles)

Receipt of preventive care among adults: Insurance status and usual source of care - May 2003
Having a usual source of care and health insurance are both important to achieving national prevention goals. (Articles)

The ecology of medical care for children in the United States - May 2003
The ecology of children's medical care is similar to that of adults in the United States in that a substantial proportion of children receive health care each month, mostly in community-based, outpatient settings. In all settings except emergency departments, receipt of care varies significantly by children's age, race, ethnicity, income, health insurance status, and whether they have a usual source of care. (Articles)

International medical graduates and the primary care workforce for rural underserved areas - March 2003
IMGS appear to have been no more likely than USMGs were to practice primary care in RUAs, but the distribution by specialty differs. (Articles)

Mapping tools for monitoring the safety net - January 2003
(Monographs & Books)

Family physicians increase provision of well-infant care despite decline in prenatal services - January 2003
Over the past 20 years, both FP/GPs and pediatricians have upheld their commitment to preventive care for infants. Non-Metropolitan Statistical Areas (non-MSAs) depend on family physicians for almost half of their well-infant care. In fact, FP/GPs have increased their overall provision of well-infant care despite a decline in delivery of prenatal services. This commitment to child health care demands continued excellence of FP training in pediatric medicine, preventive care, and child advocacy. (One-Pagers)


Family physicians are the main source of primary health care for the Medicare population - December 2002
Of people 65 years and older who reported an individual provider as their usual source of health care, 60 percent identified a family physician or general practitioner. The Medicare population relies heavily on family physicians. (One-Pagers)

Family physicians' declining contribution to prenatal care in the United States - December 2002
There has been a substantial decline in prenatal care by family physicians over the past 20 years in all geographic regions of the country. Even so, during the past two decades, FP/GPs have provided over two million prenatal visits per year. As the field re-explores future scope, it should consider the erosion of the provision of prenatal care, its effect on the U.S. population and the specialty, and possibilities for revitalization of prenatal care in residency curricula and practice. (One-Pagers)

Accounting for graduate medical education funding in family practice training - September 2002
More than half of family practice training programs do not know how much GME they receive. These findings call for improved accountability in the use of Medicare payments that are designated for medical education. (Articles)

Title VII funding is associated with more family physicians and more physicians serving the underserved - August 2002
Title VII funding of departments of family medicine at U.S. medical schools is significantly associated with expansion of the primary care physician workforce and increased accessibility to physicians for the residents of rural and underserved areas. Title VII has been successful in achieving its stated goals and has had an important role in addressing U.S. physician workforce policy issues. (One-Pagers)

What physicians need to know about seniors and limited prescription benefits and why - July 2002
More and more often, seniors are faced with outpatient prescription benefits that have annual spending limits and may be forced to cut back on use of medications when they run out of benefits before the end of the year. Family physicians can play a valuable role by helping seniors choose the best value medications for their budgets and by checking whether or not seniors can afford their prescriptions. (One-Pagers)

The association of Title VII funding to departments of family medicine with choice of physician specialty and practice location - June 2002
Title VII has been successful in achieving its stated goals and legislative intent and has had an important role in addressing US physician workforce policy issues. (Articles)


Using geographic information systems to understand health care access - November 2001
Given the relative universality of such data collection from CHCs nationwide and recent political commitment to doubling the capacity of CHCs over the next five years, we suggest options for developing centralized processes for evaluating CHC service areas and local unmet health care access needs. (Articles)

The ecology of medical care revisited - October 2001
No abstract available. (Articles)

Hispanic versus white, non-Hispanic physician medical practices in Colorado - August 2001
These findings argue for special provision to admit ethnic minorities to undergraduate and graduate medical education programs. (Articles)

The United States relies on family physicians, unlike any other specialty - May 2001
Designation of a county as a Primary Care Health Personnel Shortage Area (PCHPSA) depends on the number of primary care physicians practicing there. Without family physicians, an additional 1332 of the United States' 3082 urban and rural counties would qualify for designation as primary care HPSAs. This contrasts with an additional 176 counties that would meet the criteria for designation if all internists, pediatricians and ob/gyns in aggregate were withdrawn. The United States relies on family physicians, unlike any other specialty. (One-Pagers)


The importance of having a usual source of health care - August 2000
Most people (82%) in the United States have and use a usual source of care, and a majority of them name a particular primary care physician as that source. Regardless of self-reported health status, people benefit from having a usual source of health care even if they are uninsured. (One-Pagers)

The effect of accredited rural training tracks on physician placement - July 2000
Accredited family practice rural training tracks place their graduates in rural settings at very high rates: 76% overall and 88% among programs implemented in the last ten years. Favorable, immediate results could be expected from their continuation and expansion, permitted by adjustments in the Balanced Budget Act of 1997. (One-Pagers)


Multi-method assessment of access to primary medical care in rural Colorado - March 1999
The results of simultaneous application of distance-to-care and provider-to-population techniques unrestricted by geographic boundaries, depict access to primary medical care and corresponding consumer difficulty more fully than previously done. Further combination of methods of needs assessment such as those used in this analysis may better inform the future efforts of organizations mandated to address health care underservice in rural areas. (Articles)