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  • Teaching Population Health in the Digital Age: Community-Oriented Primary Care 2.0

    Articles | May 18, 2015 | Winston Liaw, MD, MPH; Andrew Bazemore, MD, MPH; and Jennifer Rankin, PhD

    Providers and educators lack the tools and models necessary to address community problems. We describe an online curriculum intended to teach learners how to adapt established Community-Oriented Primary Care (COPC) principles for an age of ready access to clinical and population data and geospatial technology.

  • More Comprehensive Care Among Family Physicians is Associated with Lower Costs and Fewer Hospitalizations

    Articles | May 11, 2015 | Andrew Bazemore, MD, MPH; Stephen Petterson, PhD; Lars Peterson, MD, PhD; and Robert Phillips, MD, MSPH

    Comprehensiveness is lauded as 1 of the 5 core virtues of primary care, but its relationship with outcomes is unclear. We measured associations between variations in comprehensiveness of practice among family physicians and healthcare utilization and costs for their Medicare beneficiaries.

  • Characteristics of Primary Care Physicians Working in the Same Practice as Behavioral Health Providers24 page PDF

    Presentations | May 01, 2015 | Stephen Petterson, PhD; Tracey Henry, MD, MOH; Benjamin Miller, PsyD; and Larry Green, MD

    2015 American Association of Medical Colleges Health Workforce Research Conference

  • Teenagers, Smoking, and Vaping

    Commentaries & Editorials | Apr 21, 2015 | Douglas Kamerow, MD

  • Estimating the Residency Expansion Required to Avoid Projected Primary Care Physician Shortages by 2035

    Articles | Mar 16, 2015 | Stephen M. Petterson, PhD; Winston R. Liaw, MD, MPH; Carol Tran, MD; and Andrew W. Bazemore, MD MPH

    The purpose of this study was to calculate the projected primary care physician shortage, determine the amount and composition of residency growth needed, and estimate the impact of retirement age and panel size changes.

  • U.S. Supreme Court v Obamacare: Round 2

    Commentaries & Editorials | Mar 11, 2015 | Douglas Kamerow, MD, MPH

    Subsidies, in the form of tax credits, have become the latest focal point for ACA controversy. A little known lawyer discovered four words in the 1000 page law that cast doubt on whether the subsidies could be given to around seven million people who were already receiving them.

  • Family Medicine Graduate Proximity to Their Site of Training: Policy Options for Improving the Distribution of Primary Care Access

    Articles | Feb 16, 2015 | Blake Fagan, MD; Claire Gibbons, PhD; Sean C Finnegan, MS; Stephen Petterson, PhD; Lars Peterson, MD, PhD; Robert L Phillips Jr, MD, MSHP; and Andrew Bazemore, MD, MPH

    The US Graduate Medical Education (GME) system is failing to produce primary care physicians in sufficient quantity or in locations where they are most needed. Decentralization of GME training has been suggested by several federal advisory boards as a means of reversing primary care maldistribution, but supporting evidence is in need of updating. We assessed the geographic relationship between family medicine GME training sites and graduate practice location.

  • Opting Out of Medicaid Expansion May Cost States Additional Primary Care Physicians

    One Pagers | Jan 01, 2015 | Mark W. Lin, MD; Stephen Petterson, Phd; Claire Gibbons, Phd; Sean Finnegan, MS; Andrew Bazemore, MD, MpH

    States currently electing not to expand Medicaid possibly forego the opportunity to expand their primary care workforces by a total of 1,525 physicians. Increased demand from expansion states and a limited primary care physician pool may provide a pull across state lines to the disadvantage of nonexpansion states.

  • GME Accountability and Community Benefit1 page PDF

    Presentations | May 01, 2015 | Melanie Raffoul, MD; Jennifer Rankin, PhD; Elena Cohen, BA; Robert Phillips, Jr., MD, MSPH

    215 American Association of Medical Colleges Health Workforce Research Conference

  • Office-Based Care for Women Aged 45-64 Years According to Physician Specialties1 page PDF

    Content Type, Presentations | May 01, 2015 | Melanie Raffoul, MD; Stephen Petterson, PhD; William Rayburn, MD, MBA; and Andrew Bazemore, MD, MPH

    2015 American Association of Medical Colleges Health Workforce Research Conference

  • My New Year's Wish is for an Effective Sunscreen

    Commentaries & Editorials | Dec 31, 2014 | Douglas Kamerow, MD, MpH

    The United States, bastion of high technology, may in the next year or two finally catch up to the rest of the world in the availability of effective sunscreen preparations. In a rare show of bipartisanship between Republicans and Democrats and of cooperation between Congress and the White House, Congress passed and the president has now signed into law the Sunscreen Innovation Act.

  • Trends in Office-Based Care for Reproductive-Aged Women According to Physician Specialty: A Ten-Year Study

    Articles | Dec 23, 2014 | Stephen Petterson, PhD; Andrew Bazemore, MD, MPH; Robert Phillips, MD, MSHP; and William Rayburn, MD

    The anticipated increase in access to health care has prompted an interest in where women go for their office-based care. The objectives of this study were to examine which types of office site are chosen by reproductive-aged women for their health care and to compare the reasons for their visits among these sites.

  • Do Residents Who Train in Safety Net Settings Return for Practice?

    Articles | Dec 15, 2014 | Phillips, Robert L. MD, MSPH; Petterson, Stephen PhD; Bazemore, Andrew MD, MPH

    This study examines the relationship between training during residency in a federally qualified health center (FQHC), rural health clinic (RHC), or critical access hospital (CAH) and subsequent practice in these settings.

  • Spending Patterns in Region of Residency Training and Subsequent Expenditures for Care Provided by Practicing Physicians for Medicare Beneficiaries

    Articles | Dec 15, 2014 | Candice Chen, MD; Stephen Petterson, PhD; Robert Phillips, MD, MSHP; Andrew Bazemore, MD, MPH; and Fitzhugh Mullan, MD

    Graduate medical education training may imprint young physicians with skills and experiences, but few studies have evaluated imprinting on physician spending patterns.

  • Aligning Expansion of Graduate Medical Education With Recent Recommendations for Reform

    Articles | Dec 15, 2014 | Richard E. Rieselbach, MD; Paul H. Rockey, MD, MPH; Robert L. Phillips Jr., MD, MSPH; Kathleen Klink, MD; and Malcolm Cox, MD

    Federal funds support graduate medical education positions, but expansion is needed in urban and rural areas that experience shortages in health professionals. This commentary discusses the need for existing funds to be used to expand primary care training programs and thus improve access to care in underserved areas.

  • Accounting for Complexity: Aligning Current Payment Models with the Breadth of Care by Different Specialties

    One Pagers | Dec 01, 2014 | Joshua Freeman, MD; Stephen Petterson, PhD; and Andrew Bazemore, MD, MPH

    Family physicians provide care for a wider range of conditions than do most specialists, introducing a high level of complexity into their practice. Historic assump­tions associating complexity with the intensity, skill, and training required to aceommodatea single task fail to capture the complexity of identifying and managing many interacting conditions. Payers and policy makers should recognize this dimension of complexity in care and revisit payment criteria.

  • Trends in Physician House Calls to Medicare Beneficiaries

    Articles | Nov 30, 2014 | Lars Peterson, MD, PhD; Stephen Landers, Andrew Bazemore, MD, MPH

    House calls (HCs) to older adults seemed to be headed for extinction in recent decades. HCs may be a tool to ensure access and reduce institutionalization of the elderly population. This study determines the number and distribution of HCs by physician specialty over time and analyzes associations of providing HCs with physician and area-level characteristics.

  • General Internists and Family Physicians: Partners in Geriatric Medicine?

    Commentaries & Editorials | Nov 30, 2014 | James W. Mold, MD, MPH, Larry A. Green, MD, and George E. Fryer, PhD

    General internists and family physicians: Partners in geriatric medicine?

  • Using Geographic Information Systems (GIS) to Identify Communities in Need of Health Insurance Outreach: An OCHIN Practice-based Research Network (PBRN) Report

    Articles | Nov 17, 2014 | Heather Angier, MPH, Sonja Likumahuwa, MID, MPH, Sean Finnegan, MS, Trisha Vakarcs, Christine Nelson, PhD, RN, Andrew Bazemore, MD, MPH, Mark Carrozza, MA and Jennifer E. DeVoe, MD, DPhil

    The Affordable Care Act (ACA) has provided new opportunities for individuals to obtain health insurance, yet many could still experience gaps in coverage because of switching between different programs. Health insurance facilitates access to health care services and improves outcomes; therefore these gaps are concerning. Electronic health record (EHR) functions used to manage chronic disease have been shown to be effective in tracking patients' health insurance coverage, and panel management systems could be adapted to identify patients and reach out to those without insurance.

  • A Retrospective Analysis of the Relationship Between Medical Student Debt and Primary Care Practice in the United States

    Articles | Nov 17, 2014 | Julie Phillips; Stephen Petterson, PhD; Andrew Bazemore, MD, MPH; and Robert Phillips, MD, MSHP

    A retrospective analysis of the relationship between medical student debt and primary care practice in the United States

  • How Will We Know if Obamacare has "Worked"?

    Commentaries & Editorials | Nov 14, 2014 | Douglas Kamerow, MD, MpH

    As the beginning of the second annual sign-up period for the US Affordable Care Act approaches, it is reasonable to ask whether or not the act, “Obamacare,” has been a success. As with most things, where you stand depends a lot on where you sit. Republicans commonly call Obamacare an utter failure, and Democrats defend it as increasingly successful. In reality, of course, it is way more complicated than that.

  • Another Risk to U.S. Travelers—Malaria

    Articles | Nov 10, 2014 | Winston Liaw, MD; Sarah Coleman, MD; Andrew Bazemore, 
MD, MPH; and Mark K. Huntington, MD, PhD

    Although malaria was eradicated as an endemic disease in the United States in the early 1950s,1 it still returns yearly in approximately 1500 individuals who travel to foreign countries2—most of whom neglected to use prophylactic measures or use them properly.3 In more than 60 documented cases, these infected individuals have been the source of local transmission in their communities.2 To reduce the individual and public health risks associated with malaria, this article focuses on steps that international travelers can take to limit their risk of the disease.

  • The Financial Health of Global Health Programs

    Articles | Oct 13, 2014 | Winston Liaw, MD, MPH; Andrew Bazemore, MD, MPH; Ranit Mishori, MD, MHS; Philip Diller, MD, PhD; Inis Bardella, MD; Newton Cheng, MS

    Interest in global health among medical students and residents has increased. According to recent surveys, medical school graduate participation in global health has increased from 20.2% in 2002 to 30.4% in 2012. Despite this growth, over a third of graduates (35.6%) rate their global health instruction as “inadequate.”

  • Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions 

    Articles | Sep 15, 2014 | Candice Chen, MD, MPH; Stephen Petterson, PhD; Robert L. Phillips, MD, MSPH; Fitzhugh Mullan, MD; Andrew Bazemore, MD, MPH; and Sarah D. O’Donnell, MPH.

    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.

  • Cost, Utilization, and Quality of Care: An Evaluation of Illinois’ Medicaid Primary Care Case Management Program

    Articles | Sep 15, 2014 | Robert L. Phillips Jr, MD, MSPH Meiying Han, PhD Stephen M. Petterson, PhD Laura Makaroff, DO Winston R. Liaw, MD, MPH

    In 2006, Illinois established Illinois Health Connect (IHC), a primary care case management program for Medicaid that offered enhanced fee-for-service, capitation payments, performance incentives, and practice support.

  • Factors Influencing Family Physicians’ Contribution to the Child Health Care Workforce

    Articles | Sep 15, 2014 | Laura A. Makaroff, DO; Imam M. Xierali, PhD; Stephen M. Petterson, PhD, MPH; Scott A. Shipman, MD, MPH; James C. Puffer, MD; and Andrew W. Bazemore, MD, MPH

    This article explores demographic and geographic factors associated with family physicians’ provision of care to children.

  • The Battle Between Big Tobacco and Vape Shops

    Commentaries & Editorials | Sep 15, 2014 | Douglas Kamerow, MD, MpH

    As the debate continues about whether e-cigarettes are a threat to public health or, paradoxically, our best hope to rescue the world from the death and devastation of tobacco products,3 big tobacco continues its relentless march to take over the e-cigarette market.

  • Follow-up on Family Practice Residents' Perspectives on Length and Content of Training

    Articles | Sep 15, 2014 | Marguerite Duane, MD, MHA; Susan M. Dovey, PhD; Lisa S. Klein, and Larry A. Green, MD

    BACKGROUND: The structure of family practice residency programs remains essentially unchanged from the model first proposed more than 35 years ago. Advances in medical technology and knowledge combined with increasing restrictions on resident work hours and decreasing medical student interest invite reconsideration of how family physicians are trained. METHODS: We resurveyed 442 third-year family practice residents who had participated in a prior study in 2000 to determine whether their opinions about the length and content of residency had changed and whether they would still choose to be a physician and a family physician. RESULTS: Thirty-seven percent of responding third-year residents favored extending family practice residency to 4 years. Compared as groups, there was relatively little change in opinion between first and third-year residents. However, residents' individual responses about the settings and content areas for which they would be willing to consider extending training varied considerably between years 1 and 3. Personal characteristics did not seem to influence residents' opinions about length and content of training. Reasons for favoring a 4-year program and barriers to change were similar to those reported previously. Residents' commitment to medicine and family medicine was still strong and was not associated with their opinions about length of training. CONCLUSION: Although most surveyed residents favored a 3-year residency program, a substantial minority still supported extending training to 4 years, and the majority would still choose to enter family medicine programs if they were extended. Given a lack of consensus about specific content areas, family medicine should consider a period of experimentation to determine how to best prepare future family physicians.

  • Modifiable Determinants of Healthcare Utilization Within the African-American Population

    Articles | Sep 15, 2014 | George Rust, MD, MPH; George E. Fryer, MSW, PhD; Robert L. Phillips, Jr., MD, MSPH; Elvan Daniels, MD; Harry Strothers, MD, MMM; and David Satcher, MD, PhD

    BACKGROUND: Significant health disparities directly affect the African-American population. Most previous studies of disparities in access to and utilization of health care have focused on black-white differences rather than focusing on “within-group” analysis of African-Americans. OBJECTIVE: To tease out the differential effects of modifiable risk factors (such as health insurance, usual source of care, and poverty) from personal characteristics (age, gender, rural residence) on health care utilization within the African-American population. METHODS: Secondary data analysis of 3,462 records from African-American respondents to the 1999 Medical Expenditure Panel Survey (MEPS) Household File, a nationally-representative survey of the civilian, non-institutionalized U.S. population in 1999. RESULTS: We found significant variation in the number of office visits, outpatient clinic visits, hospital discharges, days hospitalized, and fills of prescribed medication among 3,462 African-American respondents, who represent a U.S. population of 36,538,639 persons. Personal non-modifiable characteristics such as age and gender were significantly related to health care utilization. Poverty and rural residence were also significantly correlated, but the strongest modifiable predictors of health care utilization for African-American persons in 1999 were whether or not individuals had health insurance and/or a usual source of care. Emergency department visits were the only form of care that showed remarkably little variation based on these modifiable risk factors. CONCLUSIONS: 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

  • Lessons From a Fallen Hero

    Commentaries & Editorials | Aug 15, 2014 | Douglas Kamerow, MD, MpH

    While dealing with four serious cancers throughout her life, Jessie Grunman kept a laser focus on discovering and describing the process that she and many other patients with serious illnesses go through, so as to create useful tools and guidelines for all patients. She did it with admirable grace, humor, wit, and wisdom.

  • One in Fifteen Family Physicians Principally Provide Emergency or Urgent Care

    Articles | Aug 01, 2014 | Stephen Petterson, PhD; Lars Peterson, MD, PhD; Robert L. Phillips, MD, MSHP; Miranda Moore, PhD; Sean Finnegan, MS; Megan Coffman, MS; and Andrew Bazemore, MD, MPH

    A small but nontrivial proportion of US family physicians devote most of their time providing emergency or urgent care. With considerable attention focused on expanding access to primary care, it is important to account for providers principally working outside of traditional primary care.

  • Do Family Physicians Choose Self-Assessment Activities Based on What They Know or Don't Know?

    Articles | Jun 16, 2014 | Lars E. Peterson MD, PhD*, Brenna Blackburn MPH, Andrew Bazemore MD, MPH, Thomas O'Neill PhD andRobert L. Phillips Jr. MD, MSPH

    Maintenance of Certification (MOC) for Family Physicians (MC-FP) includes clinical Self-Assessment Modules (SAMs). Whether family physicians choose SAMs that reflect their aptitudes or knowledge gaps has not been studied.

  • Doctors Treating Their Families

    Commentaries & Editorials | Jun 15, 2014 | Douglas Kamerow, MD, MPH

    The American Medical Association states that “physicians generally should not treat themselves or members of their immediate families.” Reasons cited include the doctor’s possible lack of professional objectivity, potential failure to probe sensitive topics or perform an intimate examination, and possible feeling of obligation to perform care for which he or she is unqualified. Despite these stated—and oftentimes valid—concerns, many doctors in America admit to treating their families, neighbors, and friends.

  • Mental Health Treatment in the Primary Care Setting: Patterns and Pathways.

    Articles | Jun 09, 2014 | Stephen Petterson, PhD; Benjamin Miller, PsyD; Jessica Payne-Murphy, MA; Robert Phillips, MD, MSPH

    The redesign of primary care through the patient-centered medical home offers an opportunity to assess the role of primary care in treating mental health relative to the rest of the health care system. Better understanding the patterns of care between primary care and mental health providers helps guide necessary policy changes. This article reports the findings from 109,593 respondents to the 2002–2009 Medical Expenditure Panel Surveys (MEPS).

  • Which Family Physicians Work Routinely with Nurse Practitioners, Physician Assistants or Certified Nurse Midwives

    Articles | Jun 02, 2014 | Lars E. Peterson MD, PhD1; Brenna Blackburn MPH, Stephen Petterson PhD; James C. Puffer MD; Andrew Bazemore MD, MPH; and Robert L. Phillips MD, MSPH

    Facing rising numbers of insured with implementation of the Affordable Care Act, policy makers are interested in building teams of providers that can accommodate a growing demand for primary care services. Nurse Practitioners (NPs), Physician Assistants (PAs), and Certified Nurse Midwives (CNMs) already augment the physician workforce, particularly in rural areas. Our objective was to determine what physician and areal-level characteristics were associated with working with NPs, PAs or CNMs.

  • Proximity of Providers: Colocating Behavioral Health and Primary Care and the Prospects for an Integrated Workforce

    Articles | May 16, 2014 | Benjamin Miller, PsyD; Stephen Petterson, PhD; Bridget Teevan Burke, MPH; Robert Phillips, MD, MSPH; Larry Green, MD

    Integrated behavioral health and primary care is emerging as a superior means by which to address the needs of the whole person, but we know neither the extent nor the distribution of integration. Using the Centers for Medicare and Medicaid Services’ National Plan and Provider Enumeration System (NPPES) Downloadable File, this study reports where colocation exists for (a) primary care providers and any behavioral health provider and (b) primary care providers and psychologists specifically

  • The World's Deadliest Animal

    Commentaries & Editorials | May 15, 2014 | Douglas Kamerow, MD, MPH

    There are varying opinions in the U.S. and worldwide as to what the deadliest animal is. Discover which animal accounts for the highest number of human fatalities per year

  • The Changing Landscape of Primary Care HPSAs and the Influence on Practice Location

    One Pagers | May 01, 2014 | Sean C. Finnegan, MS; Newton Cheng, MS; Andrew W. Bazemore, MD, MPH; Jennifer L. Rankin, PhD, MPH, MHA; and Stephen M. Petterson, PhD

    Health professional shortage area (HPSA) designations were created to highlight areas of primary care shortage and direct incentives to physicians willing to practice in these areas. We demonstrate the volatility of these geographies by examining the HPSA status of primary care physicians whose practice locations were the same in 2008 and 2013. Although the change in the percentage of physicians practicing in HPSAs over this period was negligible, approximately 28% of the stationary physicians lost a primary care HPSA designation, whereas about 21% gained a designation.

  • Making the Case: Family Medicine for America's Health53 page PDF

    Presentations | Apr 15, 2014 | Andrew Bazemore, MD, MPH

  • The Poisonous "Juice" in e-Cigarettes

    Commentaries & Editorials | Apr 15, 2014 | Douglas Kamerow, MD, MPH

    Electronic cigarettes have continued to grow in popularity and sales. They are widely available in convenience stores and, increasingly, in specialty “vapor” shops. Although e-cigarettes are now regulated in Europe, we are still awaiting national regulation in the United States by the Food and Drug Administration (FDA)

  • Projected Impact of the Primary Care Residency Expansion Program Using Historical Trends in Graduate Placement

    One Pagers | Apr 01, 2014 | Rossan M Chen, MD, MSc; Stephen M. Petterson, PhD; and Andrew Bazemore, MD, MPH

    The Primary Care Residency Expansion (PCRE) program was created by the Health Resources and Services Administration in 2010 to help address the shortage of primary care physicians. If historical graduate placement trends for funded programs remain stable, the PCRE program would have a potential impact of more than 600 new physicians working in primary care.

  • Trends in Family Physicians Performing Deliveries, 2003-2010

    Articles | Mar 15, 2014 | William F. Rayburn MD, MBA; Stephen M. Petterson PhD; and Robert L. Phillips MD, MSPH

    This observational study examined the proportion of family physicians continuing to perform deliveries from 2003–2010. Presented at the 9th annual Association of American Medical Colleges Physician Workforce Research Conference, Alexandria, Virginia, USA, May 2, 2013.

  • The Impact of Insurance and a Usual Source of Care on Emergency Department Use in the United States

    Articles | Feb 15, 2014 | Liaw, Winston, MD, MPH; Petterson, Stephen, PhD; Rabin, David L., MPH; and Bazemore, Andrew, MD, MPH

    Finding a usual source of care (USC) is difficult for certain populations. This analysis determines how insurance type and having a USC affect the settings in which patients seek care.

  • Ecology of Healthcare: The Need to Address Low Utilization in American Indians/ Alaska Natives

    One Pagers | Feb 01, 2014 | Elise A.G. Meyers, BA; Stephen Petterson, PHD; Claire Gibbons, PHD; And Andrew Bazemore, MD, MPH

    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.

  • Patients with High-Cost Chronic Conditions Rely Heavily on Primary Care Physicians

    Articles | Jan 15, 2014 | Manisha, Sharma, MD; Newton Cheng, MS; Miranda Moore, PhD; Megan Coffman, MS; and Andrew Bazemore, MD, MPH

    Today’s US physician workforce principally comprises specialists trained in the care of specific chronic conditions in the outpatient setting. However, a majority of patients seeking care for most of 14 high-cost chronic conditions were more likely to see a primary care physician than a specialist physician.

  • Do Professional Development Programs for Maintenance of Certification (MOC) Affect Quality of Patient Care?

    Articles | Jan 01, 2014 | James M. Galliher, PhD, Brian K. Manning, MPH, Stephen M. Petterson, PhD, L. Miriam Dickinson, PhD, Elias C. Brandt, BS, Elizabeth W. Staton, MSTC, Robert L. Phillips, MD, MSPH and Wilson D. Pace, MD

    The objective of this study was to examine the relationship between physicians' completion of American Board of Family Medicine (ABFM) Maintenance of Certification (MOC) modules and the quality of medical care delivered.

  • Migration After Family Medicine Residency: 56% of Graduates Practice Within 100 Miles of Training

    One Pagers | Nov 15, 2013 | E. Blake Fagan, MD; Sean C. Finnegan, MS; Andrew W. Bazemore, MD, MpH; Claire B. Gibbons, Phd, MpH; And Stephen M. Petterson, Phd

    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.

  • Family Physicians in the Maternity Care Workforce: Factors Influencing Declining Trends.

    Articles | Nov 15, 2013 | Sebastian Tong, MD, MPH; Laura Makaroff, MD, MPH; Imam Xierali, PhD; James Puffer, MD; Warren Newton, MD; and Andrew Bazemore, MD, MPH

    Family physicians provide access to maternity care for a disproportionate share of rural and urban underserved communities. This paper aims to determine trends in maternity care provision by family physicians and the characteristics of family physicians that provide maternity care. We used American Board of Family Medicine survey data collected from every family physician during application for the Maintenance of Certification Examination to determine the percentage of family physicians that provided maternity care from 2000 to 2010.

  • State Patterns in Medical School Expansion, 2000-2010: Variation, Discord, and Policy Priorities

    Articles | Oct 15, 2013 | Adler, Benjamin; Biggs, Wendy S. MD; Bazemore, Andrew W. MD, MPH

    This study used established national health workforce and training site datasets to compare total medical school enrollment (2000-2010) with change in population, medical student retention in state (those returning to practice in the state where they graduated), and primary care supply.

  • Historic Growth Rates Vary Widely Across the Primary Care Physician Disciplines

    One Pagers | Oct 01, 2013 | Laura A. Makaroff, DO; Larry A. Green, MD; Stephen M. Petterson, PhD; James C. Puffer, MD; Robert L. Phillips, MD, MSPH; and Andrew W. Bazemore, MD, MPH.

    With continued population aging trends, low annual birth rate, and expected health insurance expansion, it is vital that physician workforce policy be aimed at meeting population needs to deliver optimal primary care. 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.

  • Toward Defining and Measuring Social Accountability in Graduate Medical Education: A Stakeholder Study

    Articles | Sep 15, 2013 | Anjani T. Reddy, Sonia A. Lazreg, Robert L. Phillips, Jr, Andrew W. Bazemore, and Sean C. Lucan.

    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.

  • Relying on NPs and PAs Does Not Avoid the Need for Policy Solutions for Primary Care

    One Pagers | Aug 15, 2013 | Stephen M. Petterson, PhD; Robert L. Phillips, Jr., M.D., MSPH; Andrew W. Bazemore, M.D., MPH; Bridget Teevan Burke, MPH, MS; Gerald T. Koinis, BA

    Physician assistants (PAs) and nurse practitioners (NPs) are often proposed as solutions to the looming shortage of primary care physicians. However, a large and growing number of PAs and NPs now work outside of primary care, which suggests that innovative policy solutions to increase access to primary care are still needed.

  • A Needs-Based Method for Estimating the Behavioral Health Staff Needs of Community Health Centers

    Articles | Jul 15, 2013 | Bridget Teevan Burke, Benjamin F Miller, Michelle Proser, Stephen M Petterson, Andrew W Bazemore, Eric Goplerud and Robert L Phillips.

    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.

  • Factors Influencing Family Physician Adoption of Electronic Health Records (EHRs)

    Articles | Jul 15, 2013 | Xierali IM, Phillips RL Jr, Green LA, Bazemore AW, Puffer JC.

    Physician and practice characteristics associated with family physician adoption of electronic health records (EHRs) remain largely unexplored but may be important for tailoring policies and interventions. Variation in EHR adoption is associated with physician and practice characteristics that may help guide intervention.

  • Unequal Distribution of the U.S. Primary Care Workforce

    One Pagers | Jun 01, 2013 | Stephen M. Petterson, PhD; Robert L. Phillips, Jr., MD, MSPH; Andrew W. Bazemore, MD, MPH; Gerald T. Koinis, BA

    The United States is facing a primary care physician shortage, but the most pressing problem is uneven distribution, particularly in poor and rural communities. Providing adequate access to care for the nearly 30 million uninsured people living in these communities will require potent incentives and policy.

  • Most Family Physicians Work Routinely with Nurse Practitioners, Physician Assistants, or Certified Nurse Midwives

    Articles | May 15, 2013 | Lars Peterson, MD, PhD; Robert Phillips, MD, MSHP; Andrew Bazemore, MD, MPH; and Stephen Petterson, PhD

    The U.S. physician workforce is struggling to keep pace with the demand for health care services, a situation that may worsen without efforts to enhance team-based care. More than half of family physicians work with nurse practitioners, physician assistants, or certified nurse midwives, and doing so helps ensure access to health care services, particularly in rural areas.

  • The Association Between Global Health Training and Underserved Care: Early Findings From Two Longstanding Tracks

    Articles | Apr 15, 2013 | Liaw W, Bazemore A, Xierali I, Walden J, Diller P, Morikawa MJ.

    Global health tracks (GHTs) improve knowledge and skills, but their impact on career plans is unclear. The objective of this analysis was to determine whether GHT participants are more likely to practice in underserved areas than nonparticipants. In this retrospective cohort study, using the 2009 American Medical Association Masterfile, we assessed the practice location of the 480 graduates from 1980--2008 of two family medicine residencies-Residency 1 and Residency 2. The outcomes of interest were the percentage of graduates in health professional shortage areas (HPSAs), medically underserved areas (MUAs), rural areas, areas of dense poverty, or any area of underservice.

  • Trends in Physician Supply and Population Growth

    Articles | Apr 15, 2013 | Makaroff LA, Green LA, Petterson SM, Bazemore AW.

    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.

  • Family Physicians Are Essential for Mental Health Care Delivery

    Articles | Apr 15, 2013 | Imam M. Xierali, PhD, Sebastian T. Tong, MD, MPH, Stephen M. Petterson, PhD, James C. Puffer, MD, Robert L. Phillips Jr., MD, MSPH and Andrew W. Bazemore, MD, MPH

    As the largest and most widely distributed of primary care physicians, family physicians have an important role in providing mental health care, especially in rural and underserved areas. However, the proportion of family physicians who report providing mental health care is low. Policy barriers such as payment for mental health services should be explored to ensure access to mental health care for patients across the urban to rural continuum.

  • Trends in Physician Supply and Population Growth

    One Pagers | Apr 01, 2013 | Laura A. Makaroff, Do; Larry A. Green, Md; Stephen M. Petterson, Phd; Andrew W. Bazemore, Md

    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.

  • The Primary Care Extension Program: A Catalyst for Change

    Articles | Mar 15, 2013 | Phillips RL Jr, Kaufman A, Mold JW, Grumbach K, Vetter-Smith M, Berry A, Burke BT.

    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.

  • Is NIH Research Funding to Medical Schools Associated With More Family Medicine?

    One Pagers | Feb 01, 2013 | Erica C. Brode, Md, Mph; Stephen M. Petterson, Phd; And Andrew W. Bazemore, Md, Mph

    National Institutes of Health (NIH) funding to family medicine departments is very low and has an inverse association with the production of family physicians at these medical schools. Clinical and Translational Science Awards and other efforts to include primary care in NIH research priorities should be considered to increase the family medicine workforce.

  • The Redistribution of Graduate Medical Education Positions in 2005 Failed to Boost Primary Care or Rural Training

    Articles | Jan 15, 2013 | Chen C, Xierali I, Piwnica-Worms K, Phillips R.

    Graduate medical education (GME), the system to train graduates of medical schools in their chosen specialties, costs the government nearly $13 billion annually, yet there is little accountability in the system for addressing critical physician shortages in specific specialties and geographic areas. Medicare provides the bulk of GME funds, and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 redistributed nearly 3,000 residency positions among the nation's hospitals, largely in an effort to train more residents in primary care and in rural areas. However, when we analyzed the outcomes of this recent effort, we found that out of 304 hospitals receiving additional positions, only 12 were rural, and they received fewer than 3 percent of all positions redistributed. Although primary care training had net positive growth after redistribution, the relative growth of nonprimary care training was twice as large and diverted would-be primary care physicians to subspecialty training. Thus, the two legislative and regulatory priorities for the redistribution were not met. Future legislation should reevaluate the formulas that determine GME payments and potentially delink them from the hospital prospective payment system. Furthermore, better health care workforce data and analysis are needed to link GME payments to health care workforce needs.

  • The Rise of Electronic Health Record Adoption Among Family Physicians

    Articles | Jan 15, 2013 | Xierali IM, Hsiao CJ, Puffer JC, Green LA, Rinaldo JC, Bazemore AW, Burke MT, Phillips RL Jr.

    Realizing the benefits of adopting electronic health records (EHRs) in large measure depends heavily on clinicians and providers' uptake and meaningful use of the technology. This study examines EHR adoption among family physicians using 2 different data sources, compares family physicians with other office-based medical specialists, assesses variation in EHR adoption among family physicians across states, and shows the possibility for data sharing among various medical boards and federal agencies in monitoring and guiding EHR adoption.

  • A Small Percentage of Family Physicians Report Time Devoted to Research

    Articles | Jan 15, 2013 | Voorhees JR, Xierali IM, Bazemore AW, Phillips RL Jr, Jaén CR, Puffer JC.

    Despite calls by family medicine organizations to build research capacity within the discipline, few family physicians report research activity. Policy that supports efforts in family medicine research and increases awareness of opportunities for primary care research in the practice setting is essential for family medicine to expand its scholarly foundations.

  • International Collaboration in Innovating Health Systems

    Articles | Jan 14, 2013 | Chris van Weel, MD, PhD; Deb Turnbull, MPsych, PhD; Emma Whitehead; Andrew Bazemore, MD, MPH; Felicity Goodyear-Smith, MBChB, MD; Claire Jackson, MD; CL Lam; BA van der Linden, D Meyers; M van den Muijsenbergh; Robert Phillips, MD, MSHP; JM Ramirez-Aranda; Robin Tamblyn; and Evelyn van Weel-Baumgarten, MD

    Strong primary health care is critical to secure sustainable health care. The International Implementation Research Network in Primary Care (IIRNPC) was founded to facilitate exchanges of experiences between countries in primary health care implementation. Involvement of all stakeholders, and focus on local conditions to approach health problems in a broad social, economic, political and cultural context are core components.

  • Blended Payment Models and Associated Care Management Fees21 page PDF

    Presentations | Nov 07, 2013 | The Robert Graham Center

  • Comparison of Primary Care Service Areas and Estimated Drive times25 page PDF

    Presentations | Oct 30, 2013 | Sean Finnegan, MS

    Comparison of Primary Care Service Areas and Estimated Drive Times: An Evaluation of the Geographic Accessibility to Primary Care Services for the Populations within Primary Care Service Areas

  • Training a Health Care Workforce to Meet Your State's Needs (and Wants)35 page PDF

    Presentations | Apr 15, 2013 | Andrew Bazemore, MD, MpH

    Training a Health Care Workforce to Meet Your State's Needs (and Wants): Addressing Challenges: Data, Tools and Primary Care

  • Coordinated Health Planning Project: Rhode Island71 page PDF

    Reports | Mar 04, 2013 | Stephen Petterson

    Coordinated Health planning Project: The current state of primary care in Rhode Island final results

  • Engagement of Family Physicians in Maintenance of Certification Remains High

    Articles | Dec 15, 2012 | James Puffer, MD; Andrew Bazemore, MD, MPH; CR Jaén CR, Imam Xierali, PhD; Robert Phillips, MD, MSHP; and SM Jones

    Maintenance of Certification for Family Physicians was created to enhance the quality of care delivered by family physicians but risked decreasing their engagement due to the increased burden of meeting additional requirements to remain board-certified. Participation by family physicians in Maintenance of Certification remains higher than predicted.

  • Health Care Transition

    One Pagers | Dec 01, 2012 | Patricia A. Stoeck, Md; Newton Cheng, Ms; Anne J. Berry, Ba; Andrew W. Bazemore, Md, Mph; And Robert L. Phillips, Jr., Md, Msph

    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. Broader implementation of the PCMH may contribute to wider use of health care transition counseling and enhanced support for such patients as they prepare to enter adulthood.

  • Projecting US Primary Care Physician Workforce Needs: 2010-2025

    Articles | Nov 15, 2012 | Stephen M. Petterson, PhD; Winston R. Liaw, MD, MPH; Robert L. Phillips, Jr, MD, MSPH; David L. Rabin, MD, MPH; David S. Meyers; Andrew W. Bazemore, MD, MPH.

    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.

  • Integrating Community Health Centers Into Organized Delivery Systems Can Improve Access to Subspecialty Care

    Articles | Aug 15, 2012 | Katherine Neuhausen, MD; Kevin Grumbach, MD; Andrew Bazemore, MD, MPH; Robert L. Phillips Jr, MD, MSPH

    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.”

  • Improving America's Health Requires Community-Level Solutions: Folsom Revisited

    One Pagers | Aug 15, 2012 | The American Board of Family Medicine Young Leaders Advisory Group

    Amidst sweeping changes to health care in the 1960s, the broadly influential Folsom Commission report, Health is a Community Affair, never fully achieved its vision of galvanizing the creation of Communities of Solution, which were empowered to improve health at the local level. Passage of health care reform, and persistent concern over poor health outcomes despite runaway spending, contemporizes Folsom’s call for nationally supported and evaluated, but community-driven, solutions to the nation’s health care challenges.

  • Measures of Social Deprivation That Predict Health Care Access and Need Within a Rational Area of Primary Care Service Delivery

    Articles | Jul 15, 2012 | Danielle C. Butler, MBBS, MPH; Stephen Petterson, PhD; Robert L. Phillips, MD, MSPH; and Andrew W. Bazemore, MD, MPH

    Objective: To develop a measure of social deprivation that is associated with health care access and health outcomes at a novel geographic level, primary care service area. Data Sources/Study Setting: Secondary analysis of data from the Dartmouth Atlas, AMA Masterfile, National Provider Identifier data, Small Area Health Insurance Estimates, American Community Survey, Area Resource File, and Behavioural Risk Factor Surveillance System. Data were aggregated to primary care service areas (PCSAs). Study Design: Social deprivation variables were selected from literature review and international examples. Factor analysis was used. Correlation and multivariate analyses were conducted between index, health outcomes, and measures of health care access. The derived index was compared with poverty as a predictor of health outcomes. Data Collection/Extraction Methods: Variables not available at the PCSA level were estimated at block level, then aggregated to PCSA level. Principle Findings: Our social deprivation index is positively associated with poor access and poor health outcomes. This pattern holds in multivariate analyses controlling for other measures of access. A multidimensional measure of deprivation is more strongly associated with health outcomes than a measure of poverty alone. Conclusions: This 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.

  • A Re-emerging Political Space for Linking Person and Community Through Primary Health Care

    Articles | Jun 15, 2012 | Sarah A. Sweeney, BS; Andrew Bazemore, MD, MPH; Robert L. Phillips Jr, MD, MSPH; Rebecca S. Etz, PhD; and Kurt C. Stange, MD, PhD

    Objectives: We sought to understand how national policy key informants perceive the value and changing role of primary care in the context of emerging political opportunities. Methods: We conducted 13 semistructured interviews in May 2011 with leaders of federal agencies, think tanks, nonprofits, and quality standard–defining organizations with influence over health care reform policies and implementation. We recorded the interviews and used an editing and immersion–crystallization analysis approach to identify themes. Results: We identified 4 themes: (1) affirmation of primary care as the foundation of a more effective health care system, (2) the patient-centered medical home as a transitional step to foster practice innovation and payment reform, (3) the urgent need for an increased focus on community and population health in primary care, and (4) the ongoing need for advocacy and research efforts to keep primary care on public and policy agendas. Conclusions: Current efforts to reform primary care are only intermediate steps toward a system with a greater focus on community and population health. Transformed and policy-enabled primary care is an essential link between personalized care and population health.

  • The Percentage of Family Physicians Attending to Women's Gender-Specific Health Needs is Declining

    Articles | Jun 15, 2012 | Imam M. Xierali, PhD; James C. Puffer, MD; Sebastian T. C. Tong, BA; Andrew W. Bazemore, MD, MPH; and Larry A. Green, MD

    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.

  • Integrating Public Health and Primary Care12 page PDF

    Presentations | May 15, 2012 | Paul Wallace, MD and Sean P. David, MD

  • Communities of Solution: The Folsom Report Revisited

    Articles | May 15, 2012 | Sarah Lesko, MD, MPH; Kim S. Griswold, MD, MPH; Sean P. David, MD, SM, DPhil; Andrew W. Bazemore, MD, MPH; Marguerite Duane, MD, MHA; Thomas Morgan, MD; John M. Westfall, MD, MPH; C. Everett Koop, MD, SciD; Betsy Garrett, MD; James C. Puffer, MD; and Larry A. Green, MD

    Efforts to address the current fragmented US health care structure, including controversial federal reform, cannot succeed without a reinvigoration of community-centered health systems. A blueprint for systematic implementation of community services exists in the 1967 Folsom Report—calling for “communities of solution.” We propose an updated vision of the Folsom Report for integrated and effective services, incorporating the principles of community-oriented primary care. The 21st century primary care physician must be a true public health professional, forming partnerships and assisting data sharing with community organizations to facilitate healthy changes. Current policy reform efforts should build upon Folsom Report’s goal of transforming personal and population health.

  • Proportion of Family Physicians Providing Maternity Care Continues to Decline

    Articles | May 15, 2012 | Sebastian T. C. Tong, BA; Laura A. Makaroff, DO; Imam M. Xierali, PhD; Parwen Parhat, MA; James C. Puffer, MD; Warren P. Newton, MD, MPH; and Andrew W. Bazemore, MD, MPH

    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.

  • Integrating Public Health & Primary Care through Communities of Solution32 page PDF

    Presentations | May 08, 2012 | Sean P. David, M.D., S.M., D.Phil., Andrew Bazemore, M.D., M.P.H., Marguerite R. Duane, M.D., M.H.A., Sarah Lesko, M.D., M.P.H. , Kim S. Griswold, M.D., M.P.H., Thomas M. Morgan, M.D. , John M. Westfall, M.D., M.P.H. , James C. Puffer, M.D. , Larry Green, M.D.

  • Medical School Rural Programs: A Comparison with International Medical Graduates in Addressing State-Level Rural Family Physician and Primary Care Supply

    Articles | Apr 15, 2012 | Howard K. Rabinowitz, MD; Stephen Petterson, PhD; James G. Boulger, PhD; Matthew L. Hunsaker, MD; James J. Diamond, PhD; Fred W. Markham, MD; Andrew Bazemore, MD, MPH; and Robert L. Phillips, Jr. MD, MSPH

    Purpose: Comprehensive medical school rural programs (RPs) have made demonstrable contributions to the rural physician workforce, but their relative impact is uncertain. This study compares rural primary care practice outcomes for RP graduates within relevant states with those of international medical graduates (IMGs), also seen as ameliorating rural physician shortages. Method: Using data from the 2010 American Medical Association Physician Masterfile, the authors identified all 1,757 graduates from three RPs (Jefferson Medical College's Physician Shortage Area Program; University of Minnesota Medical School Duluth; University of Illinois College of Medicine at Rockford's Rural Medical Education Program) practicing in their respective states, and all 6,474 IMGs practicing in the same states and graduating the same years. The relative likelihoods of RP graduates versus IMGs practicing rural family medicine and rural primary care were compared. Results: RP graduates were 10 times more likely to practice rural family medicine than IMGs (relative risk [RR] = 10.0, confidence interval [CI] 8.7-11.6, P <.001) and almost 4 times as likely to practice any rural primary care specialty (RR 3.8, CI 3.5-4.2, P <.001). Overall, RPs produced more rural family physicians than the IMG cohort (376 versus 254). Conclusions: 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.

  • Medical School Rural Programs: A Comparison With International Medical Graduates in Addressing State-Level Rural Family Physician and Primary Care Supply

    Articles | Apr 01, 2012 | Howard Rabinowitz, MD; Stephen Petterson, PhD; James Boulger, PhD; Matthew L. Hunsacker, MD; James J. Diamond, PhD; Fred W. Markham, MD; Andrew Bazemore, MD, MPH; and Robert L. Phillips, MD, MSPH

    The shortage of physicians in rural areas is one of the most persistent problems in the U.S. health care system, with serious implications for access to care. This shortage is especially critical regarding generalist physicians, with rural areas having only 63% of the per capita primary care physician supply that urban areas have—despite the similar need for locally available primary care.

  • The Next Phase of Title VII Funding for Training Primary Care Physicians for America's Health Care Needs

    Articles | Mar 15, 2012 | Robert L. Phillips Jr, MD, MSPH, and Barbara J. Turner, MD, MSED

    Health care reform will add millions of Americans to the ranks of the insured; however, their access to health care is threatened by a deep decline in the production of primary care physicians. Poorer access to primary care risks poorer health outcomes and higher costs. Meeting this increased demand requires a major investment in primary care training. Title VII, Section 747 of the Public Health Service Act previously supported the growth of the health care workforce but has been severely cut over the past 2 decades. New and expanded Title VII initiatives are required to increase the production of primary care physicians; establish high-functioning academic, community-based training practices; increase the supply of well-trained primary care faculty; foster innovation and rigorous evaluation of these programs; and, ultimately, improve the responsiveness of teaching hospitals to community needs. To accomplish these goals, 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.

  • Declining Numbers of Family Physicians are Caring for Children

    Articles | Mar 15, 2012 | Andrew W. Bazemore, MD, MPH; Laura A. Makaroff, DO; James C. Puffer, MD; Parwen Parhat, MA; Robert L. Phillips, MD, MSPH; Imam M. Xierali, PhD; and Jason Rinaldo, PhD

    http://www.graham-center.org/online/graham/home/publications/articles/2012/abazems-declining-numbers.html

  • Increasing Graduate Medical Education (GME) in Critical Access Hospitals (CAH) could enhance physician recruitment and retention in rural America

    Articles | Jan 15, 2012 | mam M. Xierali; Sarah A. Sweeney; Robert L. Phillips, Jr.; Andrew W. Bazemore; and Stephen M. Petterson, PhD

    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.

  • Refocusing Geriatricians’ Role in Training to Improve Care for Older Adults

    One Pagers | Jan 01, 2012 | Elizabeth J. Bragg, PhD, RN; Gregg A. Warshaw, MD; Stephen M. Petterson, PhD; Imam M. Xierali, PhD; Andrew W. Bazemore, MD, MPH; and Robert L. Phillips, Jr., MD, MSPH

    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.

  • A Large Retrospective Multivariate Analysis of the Relationship Between Medical Student Debt and Primary Care Practice in the United States22 page PDF

    Presentations | Dec 12, 2012 | Julie Phillips, MD, MPH; Stephen Petterson, PhD; Andrew Bazemore, MD, MPH; Robert Phillips, MD, MSPH.

  • Defining Service Areas for Federally-funded Community Health Centers in the United States16 page PDF

    Presentations | Dec 04, 2012 | Jennifer L. Rankin, PhD; Andrew Bazemore, MD, MPH; Robert L. Phillips, MD, MSPH; Sean C. Finnegan, MS; Benjamin Adler, BS

  • Comprehensive medical School Rural Programs Produce Rural Family Physicians

    One Pagers | Dec 15, 2011 | Howard K. Rabinowitz, MD; Stephen Petterson, PhD; James G. Boulger, PhD; Matthew L. Hunsaker, MD; Fred W. Markham, MD; James J. Diamond, PhD; Andrew Bazemore, MD, MPH; Robert L. Phillips, Jr., MD, MSPH

    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.

  • EHR Implementation Without Meaningful Use Can Lead to Worse Health Outcomes

    One Pagers | Dec 01, 2011 | Jesse C. Crosson, PhD; Andrew W. Bazemore, MD, MPH; and Robert L. Phillips, Jr., MD, MSPH

    Defying expectations, typical electronic health record (EHR) use in practices belonging to a primary care network has been associated with poorer diabetes care quality and outcomes. Current expansion of primary care EHR implementation must focus on use that improves care.

  • Research Productivity of Senior General Practice Academicians in Australia, Canada, England/Wales, New Zealand, Scotland, and the U.S.22 page PDF

    Presentations | Nov 15, 2011 | Susan Dovey, PhD; Andrew W. Bazemore, MD, MPH; Winston Liaw, MD, MPH; Robert L. Phillips, Jr., MD, MSPH

  • What Services Do Family Physicians Provide in a Time of Primary Care Transition?

    Articles | Nov 15, 2011 | Andrew W. Bazemore; Stephen Petterson; Nicole Johnson; Imam M. Xierali; Robert L. Phillips, Jr.; Jason Rinaldo; James C. Puffer; and Larry A. Green.

    The Future of Family Medicine Report envisioned a new model of practice “committed to providing the full basket of clinical services offered by Family Medicine.” In actuality, variation in that basket is considerable and may influence patients’ access to care as much as supply and distribution of physicians does in the wake of health care reform.

  • Rewarding Family Medicine While Penalizing Comprehensiveness? Primary Care Payment Incentives and Health Reform: The Patient Protection and Affordable Care Act (PPACA)

    Articles | Nov 15, 2011 | Stephen Petterson; Andrew W. Bazemore; Robert L. Phillips, Jr.; Imam M. Xierali; Jason Rinaldo; Larry A. Green; and James C. Puffer.

    Family physicians’ scope of work is exceptionally broad, particularly with increasing rurality. Provisions for Medicare bonus payment specified in the health care reform bill (the Patient Protection and Affordable Care Act) used a narrow definition of primary care that inadvertently offers family physicians disincentives to delivering comprehensive primary care.

  • Where the United States Falls Down and How We Might Stand Up

    Commentaries & Editorials | Nov 15, 2011 | Robert L. Phillips, Jr., MD, MSPH

    The Commonwealth Fund and Rand Europe announced this week that the United States ranks last among developed countries in “mortality amenable to health care” — that is, deaths that are considered preventable with timely and effective health care. Preventable death rates declined during the last decade, but the rate of improvement in the United States was slower compared with other countries such that we continue to fall further behind. Compared with other countries, the United States also has much wider disparities in health status and outcomes.

  • Better Integration of Mental Health Care Improves Depression Screening and Treatment in Primary Care

    One Pagers | Nov 01, 2011 | Robert L. Phillips, Jr., MD, MSPH; Benjamin F. Miller, PsyD; Stephen M. Petterson, PhD; and Bridget Teevan, MS

    Improving screening and treatment for depression in primary care will require better mental health care integration. Depression is common in primary care, yet screening for the condition remains low. Enhanced, coordinated financial support for the integration of mental health care into primary care could improve identification and treatment of depression.

  • Calling All Scholars to the Council of Academic Family Medicine Educational Research Alliance (CERA)

    Articles | Jul 15, 2011 | Navkiran Shokar; George Bergus; Andrew Bazemore; C. Randall Clinch; Andrew Coco; Betsy Jones; Arch G. Mainous III; Dean Seehusen; and Vijay Singh.

    The mission of CERA is to set within family medicine a standard for medical education research that is rigorous and generalizable, to provide mentoring and education to junior researchers, to facilitate collaboration between medical education researchers, and to guide the specialty by providing leadership and vision in the arena of medical education research.

  • An International Health Track is Associated with Care for Underserved US Populations in Subsequent Clinical Practice

    Articles | Jun 15, 2011 | Andrew W. Bazemore, Linda M. Goldenhar, Christopher J. Lindsell, Philip M. Diller, and Mark K. Huntington

    Background: Recent efforts to increase insurance coverage have revealed limits in primary care capacity, in part due to physician maldistribution. Of interest to policymakers and educators is the impact of nontraditional curricula, including global health education, on eventual physician location. We sought to measure the association between graduate medical education in global health and subsequent care of the underserved in the United States. Methods: In 2005, we surveyed 137 graduates of a family medicine program with one of the country's longest-running international health tracks (IHTs). We compared graduates of the IHT, those in the traditional residency track, and graduates prior to IHT implementation, assessing the anticipated and actual involvement in care of rural and other underserved populations, physician characteristics, and practice location and practice population. Results: IHT participants were more likely to practice abroad and care for the underserved in the United States in the first 5 years following residency than non-IHT peers. Their current practices were more likely to be in underserved settings, and they had higher percentages of uninsured and non–English-speaking patients. Comparisons between pre-IHT and post-IHT inception showed that in the first 5 years following residency, post-IHT graduates were more likely to care for the underserved and practice in rural areas and were likely to offer volunteer community health care services but were not more likely to practice abroad or to be in an academic practice. Conclusions: Presence of an 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.

  • The Importance of Time in Treating Mental Health in Primary Care

    Articles | Jun 15, 2011 | Benjamin F. Miller; Bridget Teevan; Robert L. Phillips, Jr.; Stephen M. Petterson; and Andrew W. Bazemore.

    Primary care plays a critical role in treating mental health conditions, but caring for patients with comorbid mental health and medical conditions increases visit length. Lack of appropriate reimbursement mechanisms and competing priorities make it difficult to integrate mental health into primary care. Caring for patients with mental health comorbidities requires time not now affordable in the primary care setting and demands a new payment policy to promote team-based, integrated care for mental and physical illness in a patient-centered medical home.

  • Evidence and Tools for Advocacy from the Robert Graham Center33 page PDF

    Presentations | May 15, 2011 | Jennifer Rankin, PhD

  • Family Physician Participation in Maintenance of Certification

    Articles | May 15, 2011 | Imam M. Xierali, PhD; Jason C. B. Rinaldo, PhD; Larry A. Green, MD; Stephen M. Petterson, PhD; Robert L. Phillips Jr, MD, MSPH; Andrew W. Bazemore, MD, MPH; Warren P. Newton, MD; and James C. Puffer, MD

    Purpose: The American Board of Family Medicine has completed the 7-year transition of all of its diplomates into Maintenance of Certification (MOC). Participation in this voluntary process must be broad-based and balanced for MOC to have any practical national impact on health care. This study explores family physicians’ geographic, demographic, and practice characteristics associated with the variations in MOC participation to examine whether MOC has potential as a viable mechanism for dissemination of information or for altering practice. Methods: To investigate characteristics associated with differential participation in MOC by family physicians, we performed a cross-sectional comparison of all active family physicians using descriptive and multinomial logistic regression analyses. Results: Eighty-five percent of active family physicians in this study (n = 70,323) have current board certification. Ninety-one percent of all active board-certified family physicians eligible for MOC are participating in MOC. Physicians who work in poorer neighborhoods (odds ratio [OR] = 1.105; 95% confidence interval [CI], 1.038–1.176), who are US-born or foreign-born international medical graduates (OR = 1.221; 95% CI, 1.124–1.326; OR = 1.444; 95% CI, 1.238–1.684, respectively), or who are solo practitioners (OR = 1.460; 95% CI, 1.345–1.585) are more likely to have missed initial MOC requirements than those from a large, undifferentiated reference group of certified family physicians. When age is held constant, female physicians are less likely to miss initial MOC requirements (OR = 0.849; 95% CI, 0.794–0.908). Physicians practicing in rural areas were found to be performing similarly in meeting initial MOC requirements to those in urban areas (OR = 0.966; 95% CI, 0.919–1.015, not significant). Conclusion: Large numbers of family physicians are participating in MOC. The significant association between practicing in underserved areas and lapsed board certification, however, warrants more research examining causes of differential participation. The penetrance of MOC engagement shows that MOC has the potential to convey substantial practice-relevant medical information to physicians. Thus, it offers a potential channel through which to improve health care knowledge and medical practice.

  • Evidence About the Role of the PCMH and ACOs in Improving Quality and Safety36 page PDF

    Presentations | May 15, 2011 | Robert L. Phillips, Jr., MD, MSPH

  • Innovations in Family Medicine Education: Early Learnings from the P4 Initiative18 page PDF

    Presentations | May 15, 2011 | Samuel M. Jones, MD; Warren Newton, MD, MPH

  • Accounting for Graduate Medical Education production of primary care physicians and general surgeons: Timing of measurement matters

    Articles | May 15, 2011 | S Petterson; M Burke; RL Phillips; and B Teevan

    PURPOSE: Legislation proposed in 2009 to expand GME set institutional primary care and general surgery production eligibility thresholds at 25% at entry into training. The authors measured institutions' production of primary care physicians and general surgeons on completion of first residency versus two to four years after graduation to inform debate and explore residency expansion and physician workforce implications. METHOD: Production of primary care physicians and general surgeons was assessed by retrospective analysis of the 2009 American Medical Association Masterfile, which includes physicians' training institution, residency specialty, and year of completion for up to six training experiences. The authors measured production rates for each institution based on physicians completing their first residency during 2005-2007 in family or internal medicine, pediatrics, or general surgery. They then reassessed rates to account for those who completed additional training. They compared these rates with proposed expansion eligibility thresholds and current workforce needs. RESULTS: Of 116,004 physicians completing their first residency, 54,245 (46.8%) were in primary care and general surgery. Of 683 training institutions, 586 met the 25% threshold for expansion eligibility. At two to four years out, only 29,963 physicians (25.8%) remained in primary care or general surgery, and 135 institutions lost eligibility. A 35% threshold eliminated 314 institutions collectively training 93,774 residents (80.8%). CONCLUSIONS: Residency expansion thresholds that do not account for production at least two to four years after completion of first residency overestimate eligibility. The overall primary care production rate from GME will not sustain the current physician workforce composition.

  • Primary Care Physician Workforce and Outcomes

    Commentaries & Editorials | May 15, 2011 | Robert L. Phillips, Jr; Stephen C. Petterson; and Andrew W. Bazemore.

    Primary Care Physician Workforce and Outcomes

  • FPs Lower Hospital Readmission Rates and Costs

    One Pagers | May 01, 2011 | Veerappa K. Chetty, PhD; Larry Culpepper, MD, MPH; Robert L. Phillips, Jr., MD, MSPH; Jennifer Rankin, PhD, MPH, MS, MHA; Imam Xierali, PhD; Sean Finnegan, BS; and Brian Jack, MD

    Hospital readmission after discharge is often a costly failing of the U.S. health care system to adequately manage patients who are ill. Increasing the number of family physicians (FPs) is associated with significant reductions in hospital readmissions and substantial cost savings.

  • Seeking Ethical Approval for an International Study in Primary Care Patient Safety

    Articles | Apr 15, 2011 | S Dovey; K Hall; M Makeham; W Rosser; A Kuzel; C Van Weel; A Esmail; and R Phillips

    Seeking ethics committee approval for research can be challenging even for relatively simple studies occurring in single settings. Complicating factors such as multicentre studies and/or contentious research issues can challenge review processes, and conducting such studies internationally adds a further layer of complexity. This paper draws on the experiences of the LINNAEUS Collaboration, an international group of primary care researchers, in obtaining ethics approval to conduct an international study investigating medical error in general practice in six countries. It describes the ethics review processes applied to exactly the same research protocol for a study run in Australia, Canada, England, the Netherlands, New Zealand, and the U.S. Wide variation in ethics review responses to the research proposal occurred, from no approval being deemed necessary to the study plan narrowly avoiding rejection. The authors' experiences demonstrated that ethics committees operate in their own historical and cultural context, which can lead to radically different subjective interpretations of commonly-held ethical principles, and raised further issues such as 'what is research?'. This first LINNAEUS study started when patient safety was a particularly sensitive subject. Although it is now a respectable area of inquiry, patient safety is still a topic that can excite emotions and prejudices. The LINNAEUS Collaboration now extends to more countries and continues to pursue an international research agenda, so reflection on the influences of history, social context, and structure of each country's ethical review processes is timely.

  • Rural-Urban Distribution of the U.S. Geriatrics Physician Workforce

    Articles | Apr 15, 2011 | LE Peterson; A Bazemore; EJ Bragg; I Xierali; and GA Warshaw

    OBJECTIVES: To determine the distribution of geriatricians across the rural-urban continuum from 2000 to 2008 and to compare with primary care physicians in 2008. DESIGN: County-level analysis of physician data from the American Medical Association Physician Masterfile for 2000, 2004, and 2008 merged with U.S. Census data on the number of older (≥65) county residents. Descriptive statistics for each year were stratified according to 2003 Rural Urban Continuum Codes (RUCCs). SETTING: United States. PARTICIPANTS: Physicians in the United States. MEASUREMENTS: Number of physicians per county elderly population. RESULTS: The number of self-identified geriatricians nationwide increased from 5,157 to 7,412 from 2000 to 2008. The number of geriatricians increased in each RUCC level, with nearly 90% of geriatricians residing in urban areas in all years. In 2008, the number of geriatricians per 10,000 older adults declined as rurality increased (from 1.48 in the most-urban areas to 0.80 in the most rural). General internal medicine physicians are more plentiful in urban counties and declined as rurality increased (from 27.29 to 3.85 per 10,000 older adults in 2008). In contrast, family physicians were more evenly distributed with the elderly population across the rural-urban continuum (22.02 to 14.27 per 10,000 older adults in 2008). CONCLUSION: 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.

  • Paul Ambrose Spring Forum: Primary Care Present and Future43 page PDF

    Presentations | Apr 15, 2011 | Robert L. Phillips, Jr., MD, MSPH

  • Evidence About the Role of the Patient Centered Medical Home and Accountable Care Organizations in Improving Quality and Safety6 page PDF

    Presentations | Apr 15, 2011 | Robert L. Phillips, Jr., MD, MSPH

  • A Preface Concerning Keystone III

    Articles | Apr 15, 2011 | Green LA, Graham R, Stephens GG, Frey JJ

    This article is part of a special issue of Family Medicine dedicated to The Keystone Papers: Formal Discussion Papers from Keystone III.

  • Establishing a Baseline: Health Information Technology Adoption Among Family Medicine Diplomates

    Articles | Mar 15, 2011 | A Bazemore; M Burke; I Xierali; S Petterson; J Rinaldo; LA Green; and J Puffer

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  • A New Journal of the American Board of Family Medicine Feature: The American Board of Family Medicine–Robert Graham Center Policy Brief

    Commentaries & Editorials | Mar 15, 2011 | Larry A. Green, MD

    In this issue of the Journal of the American Board of Family Medicine (JABFM), the editors initiate a new feature, The ABFM–Robert Graham Center Policy Brief, a direct result of the ABFM’s research partnership with the Robert Graham Center in Washington, D.C. Policy briefs, by definition, focus on pertinent policy issues and have as distinguishing features brevity, evidence, and a singular focus on movement in a particular direction for a reason. This new JABFM feature will provide an outlet for what the ABFM is learning with its partners and associates, particularly about Maintenance of Certification (MOC) and its effects and opportunities. This feature is expected, over time, to represent a portfolio of published work that can be cited and used constructively during this next period of the major redesign of U.S. health care. The intended audiences of these JABFM briefs are leaders who can make decisions that matter to family medicine and primary care, as well as those individuals subjected to the effects of such decisions, particularly ABFM Diplomates. The ABFM–Robert Graham Center Policy Briefs will be published after rigorous peer review, consistent with other JABFM articles. The JABFM and the ABFM Board of Directors will evaluate this new feature, and they welcome readers’ responses and suggestions for improvement.

  • Case Study of a Primary Care-Based Accountable Care System Approach to Medical Home Transformation

    Articles | Feb 15, 2011 | RL Phillips Jr; S Bronnikov; S Petterson; M Cifuentes; B Teevan; M Dodoo; WD Pace; and DR West

    We report a case study of a mature primary care-based accountable care organization that is both a health plan and a network of medical homes. Over 20 years, WellMed Inc. (San Antonio, Texas) implemented many patient-centered services, experimenting to find which belong within clinics and which operate best as system functions. The adjusted mortality rate is half that of the state for people older than 65 years. Hospitalization and readmission rates and emergency department visits have not changed over time, but preventive services have improved. Phased implementation across the network makes it difficult to link improvements to specific processes but they seem to have improved outcomes collectively.

  • Residencies as a high leverage policy target: learnings from the I3 PCMH collaboratives13 page PDF

    Presentations | Jan 15, 2011 | Robert Graham Center

  • Comparison Between U.S. Preventive Services Task Force Recommendations and Medicare Coverage

    Articles | Jan 15, 2011 | LI Lesser; AH Krist; DB Kamerow; and AW Bazemore

    The U.S. Preventive Services Task Force (USPSTF) is authorized by the U.S. government to review and disseminate the scientific evidence for clinical preventive services. The purpose of this study was to evaluate the alignment of Medicare preventive services coverage with the recommendations of the USPSTF before implementation of health reform. METHODS: We recorded all Medicare coverage for preventive services as listed in the Medicare preventive services guide of 2007 (including the 2009 update) for all recommended (A- or B-rated) USPSTF and not recommended (D-rated) guidelines for preventive screening and counseling in adults aged 65 years and older. We analyzed 2 components of preventive care: preventive coordination (risk assessment, patient motivation, and arranging of preventive service) and the preventive service itself. The main outcome measure was the percentage of agreement between USPSTF recommendations and Medicare coverage. RESULTS: The USPSTF recommended 15 preventive interventions for adults aged 65 years and older. Although Medicare partially reimbursed 93% of recommended services, full reimbursement for the preventive coordination, as well as the service, was available for only 7% of these services. This partial coverage is available mostly as part of the Welcome to Medicare Visit. Further, the USPSTF recommended against 16 preventive services; Medicare reimbursed clinicians for 44% of these services. CONCLUSIONS: Medicare coverage for preventive services needs to be reassessed, with special focus on preventive coordination. Continuing previous practices will likely promote both inadequate and excessive delivery of preventive services. The new health care reform law has the potential to improve the provision of preventive services to Medicare beneficiaries.

  • Using Maps to Strengthen Your Case: A Robert Graham Center Deep Dive19 page PDF

    Presentations | Jul 17, 2011 | Sean Finnegan, MS; Sarah Lesesne, MSPH; Mark Carrozza, MA; Michael Topmiller, MS et al

  • Innovations in Family Medicine Education: Early Learnings from the P4 Initiative18 page PDF

    Presentations | May 17, 2011 | Samuel M. Jones MD

  • Evidence About Your Value (and the Return on Investment)43 page PDF

    Presentations | May 15, 2011 | Robert L. Phillips, Jr., MD, MSPH

  • I LIVE PC: International Learning on Increasing the Value and Effectiveness of Primary Care253 page PDF

    Monographs & Books | Apr 15, 2011 | Robert Graham Center

  • You're Expecting Me to Become a GIS Expert?22 page PDF

    Presentations | Apr 11, 2011 | Jennifer Rankin MS, MPH, PhD

    You're Expecting Me to Become a GIS Expert? Teaching GIS to Users of Online Mapping Tools

  • Online Mapping and GIS22 page PDF

    Presentations | Apr 11, 2011 | Sean Finnegan, MS

    Online Mapping and GIS: Advances in Technology and Challenges of Putting the Power of GIS into the Hands of Non-Geographers

  • Use of Measures of Socioeconomic Deprivation in Planning Primary Health Care Workforce and Defining Health Care Need in Australia

    Articles | Oct 15, 2010 | Danielle C. Butler; Stephen Petterson; Andrew Bazemore; and Kirsty A. Douglas

    To examine whether measures of remoteness areas adequately reveal high need populations, measured against socioeconomic disadvantage and physician to population ratios. Design: Exploratory spatial analysis of relationships between remoteness areas, medical workforce supply and the index of relative socioeconomic disadvantage (IRSD). Bivariate analyses examined associations between remoteness areas and IRSD. From this analysis, a composite score of deprivation was constructed combining measures of remoteness areas, physician to population ratios and IRSD, and validated against health outcome measures. These measures included avoidable mortality per 100 000, risk behavior rate per 1000, diabetes rate per 1000. All analyses were conducted at the statistical local area level and weighted to be population representative. Results: The percentage of small areas and populations within the most socioeconomically disadvantaged quintile rose with increasing remoteness. However, 12.8% of small areas within major cities and 40.7% of outer regional areas were also within the lowest socioeconomic quintile. There was a strong relationship between our composite score of deprivation and avoidable mortality, risk rate, diabetes rate and percent Indigenous. Regression analysis examined the relationship between each element of the composite score and health outcomes. This revealed that the association between avoidable mortality and remoteness was lost after controlling for percent Indigenous. Conclusions: 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.

  • Primary Care and Health Care Reform43 page PDF

    Presentations | Sep 15, 2010 | Kevin Burke and Andrew Bazemore, MD, MPH

  • Income Disparities Shape Medical Student Specialty Choice

    One Pagers | Sep 15, 2010 | Venis Wilder, MD; Martey S. Dodoo, PhD; Robert L. Phillips, Jr., MD, MSPH; Bridget Teevan, MS; Andrew W. Bazemore, MD, MPH; Stephen M. Petterson, PhD; and Imam Xierali, PhD

    Currently, a gap of more than $135,000 separates the median annual subspecialist income from that of a primary care physician, yielding a $3.5 million difference in expected income over a lifetime. These income disparities dissuade medical students from selecting primary care and should be addressed to ensure sufficient patient access to primary care.

  • Building the Research Culture of Family Medicine with Fellowship Training

    Articles | Aug 15, 2010 | Shannon K. Bolon and Robert L. Phillips, Jr.

    Background and Objectives: The future of family medicine is closely tied to the strength of family medicine research. Physicians with fellowship training have been shown to be more productive researchers than those without fellowship training. This study’s objectives are to (1) identify fellowship programs available to family physicians, (2) explore how family medicine fellows are taught research skills, and (3) identify obstacles to enhancing research training in fellowships. Methods: Fellowship programs available to family physicians were identified by Internet searches and confirmed by telephone or e-mail. Directors of identified fellowships received a 33-item survey exploring research training provided by their program. Descriptive statistics were used to evaluate the quantitative data. Survey comments were analyzed qualitatively to identify themes. Results: We confirmed that 247 of 328 identified research fellowships are available to family physicians. Survey response rate from those 247 fellowships was 65%. Fellowships with and without a research focus are providing research training. They are threatened, however, by weak research infrastructure, inadequate funding, and attitudinal biases against family medicine research. Conclusions: There are many fellowship and research training opportunities for family physicians. But in many programs, research training is tenuous, and support for researchers is low. We recommend expanding research advocacy efforts within family medicine, Congress, and funding institutions.

  • Illinois Health Connect and Your Healthcare Plus Case Statement18 page PDF

    Monographs & Books | Aug 15, 2010 | Robert Graham Center

  • Loss of Primary Care Residency Positions Amidst Growth in Other Specialties

    One Pagers | Jul 15, 2010 | Nicholas A. Weida, BA; Robert L. Phillips, Jr., MD, MSPH; Andrew W. Bazemore, MD, MPH;, Martey S. Dodoo, PhD; Stephen M. Petterson, PhD; Imam Xierali, PhD; and Bridget Teevan, MS

    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.

  • The Social Mission of Medical Education: Ranking the Schools

    Articles | Jun 15, 2010 | Mullan F; Chen C; Petterson S; Kolsky G; and Spagnola M

    BACKGROUND: The basic purpose of medical schools is to educate physicians to care for the national population. Fulfilling this goal requires an adequate number of primary care physicians, adequate distribution of physicians to underserved areas, and a sufficient number of minority physicians in the workforce. OBJECTIVE: To develop a metric called the social mission score to evaluate medical school output in these 3 dimensions. DESIGN: Secondary analysis of data from the American Medical Association (AMA) Physician Masterfile and of data on race and ethnicity in medical schools from the Association of American Medical Colleges and the Association of American Colleges of Osteopathic Medicine. SETTING: U.S. medical schools. PARTICIPANTS: 60,043 physicians in active practice who graduated from medical school between 1999 and 2001. MEASUREMENTS: The percentage of graduates who practice primary care, work in health professional shortage areas, and are underrepresented minorities, combined into a composite social mission score. RESULTS: The contribution of medical schools to the social mission of medical education varied substantially. Three historically black colleges had the highest social mission rankings. Public and community-based medical schools had higher social mission scores than private and non-community-based schools. National Institutes of Health funding was inversely associated with social mission scores. Medical schools in the northeastern United States and in more urban areas were less likely to produce primary care physicians and physicians who practice in underserved areas. LIMITATIONS: The AMA Physician Masterfile has limitations, including specialty self-designation by physicians, inconsistencies in reporting work addresses, and delays in information updates. The public good provided by medical schools may include contributions not reflected in the social mission score. The study was not designed to evaluate quality of care provided by medical school graduates. CONCLUSION: 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.

  • Measuring Primary Care Expenses

    Articles | May 15, 2010 | Krist AH; Cifuentes M; Dodoo MS; and Green LA

    BACKGROUND: Significant investments and effort are being devoted to health care reform, yet little is known about the costs of improvements. Practical tools are needed to allow for systematic assessment of practice expenses. We report here a field trial of a standardized expenditure data collection instrument. METHODS: Combining economic and primary care practice consultation, an expenditure data collection instrument was created. The instrument underwent observed feasibility testing and was fielded by 10 practice-based research networks in 30 practices conducting 10 different health behavior change interventions. RESULTS: Start-up and operating expenses were successfully collected for 87% and 97% of the practices, respectively. Data collection time and effort were considerable but acceptable. Three elements were necessary to collect expenditure data: (1) an intervention-specific data collection instrument, (2) a field guide, and (3) economic oversight and assistance. Fully 90% of networks reported that they planned to collect expenditure data in the future and study participation increased the likelihood of their participation in a future expenditure study. CONCLUSIONS: It is feasible to systematically collect intervention-specific expenses in primary care using formal expenditure methods. However, most practices and researchers lack the knowledge, expertise, and resources to collect such data independently. Further assistance and education is necessary to obtain reliable information about the expenses to transform and improve primary care.

  • Primary Care and Why It Matters for U.S. Health System Reform

    Articles | May 15, 2010 | Robert L. Phillips, Jr, MD, MSPH and Andrew Bazemore, MD, MPH

    The term primary care is widely used as if it were consistently defined or well understood. In fact, neither is the case. This paper offers a definition of primary care derived from historical perspectives—from both the United States and abroad. We discuss the evidence for primary care’s important functions and international experiences with primary care. We also describe how and why the United States has deviated from this fuller realization of primary care, as well as the steps needed to achieve primary care and health outcomes on a par with those of other developed countries. These include doubling primary care financing to 10–12 percent of total health care spending—a step that would be likely to pay for itself via resulting reductions in overall health spending.

  • Greater Family Medicine Presence at NIH Could Improve Research Relevance and Reach

    One Pagers | May 15, 2010 | Sean C. Lucan, MD, MPH, MS; Andrew W. Bazemore, MD, MPH; Robert L. Phillips JR., MD, MSPH; Imam Xierali, PhD; Stephen Petterson, PhD; and Bridget Teevan, MS

    Advisory committees perform pivotal tasks at the National Institutes of Health (NIH), informing funding decisions, helping establish research priorities, and contributing to the vision for the nation's biomedical research agenda. Family medicine has not had a substantial role on these committees, but could, helping the NIH make research more patient centered and informing translational efforts to improve population health.

  • State Tort Reforms and Hospital Malpractice Costs

    Articles | Mar 15, 2010 | Charles R. Ellington; Martey Dodoo; Robert Phillips; Ronald Szabat; Larry Green; and Kim Bullock

    This study explored the relation between state medical liability reform measures, hospital malpractice costs, and hospital solvency. It suggests that state malpractice caps are desirable but not essential for improved hospital financial solvency or viability.

  • Avertable Deaths Associated with Household Income in Virginia

    Articles | Feb 15, 2010 | SH Woolf, MD, MPH; RM Jones, PhD, MPH; RE Johnson, PhD; RL Phillips Jr, MD, MSPH; MN Oliver, MD; AW Bazemore, MD, MPH; A Vichare, MPH

    Objectives: We estimated how many deaths would be averted if the entire population of Virginia experienced the mortality rates of the 5 most affluent counties or cities. Methods: Using census data and vital statistics for the years 1990 through 2006, we applied the mortality rates of the 5 counties/cities with the highest median household income to the populations of all counties and cities in the state. Results: 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. An annual mean of 12954 deaths would have been averted (range=10548–14569), totaling 220211 deaths from 1990 through 2006. In some of the most disadvantaged areas of the state, nearly half of deaths would have been averted. Conclusions: Favorable conditions that exist in areas with high household incomes exert a major influence on mortality rates. The corollary—that health suffers when society is exposed to economic stresses—is especially timely amid the current recession. 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.

  • Does Graduate Medical Education Also Follow Green?

    Articles | Feb 15, 2010 | Nicholas A. Weida, BA; Robert L. Phillips Jr, MD, MSPH; and Andrew W. Bazemore, MD, MPH

    Teaching hospitals have favored higher revenue generating specialty training over primary care positions. Expansion of positions in the “R.O.A.D.” disciplines (radiology, ophthalmology, anesthesia, and dermatology) and emergency medicine over the last 10 years parallels losses in family medicine, general pediatrics, and general internal medicine. General internal medicine positions increasingly serve as channels for revenue generating subspecialty programs, leaving fewer internal medicine positions dedicated to primary care. Policy makers hoping to realize the superior health outcomes and decreased costs associated with greater access to primary care may find this trend alarming. Our findings support the concern expressed by the COGME that instead of responding to policy aims to correct shortage in the primary care pipeline, hospitals are instead training to meet hospital goals.

  • American Board of Family Medicine (ABFM) Maintenance of Certification: Variations in Self-Assessment Modules Uptake Within the 2006 Cohort

    Articles | Jan 15, 2010 | Andrew W. Bazemore, MD, MPH, Imam M. Xierali, PhD, Stephen M. Petterson, PhD, Robert L. Phillips, Jr, MD, MSPH, FAAFP, Jason C.B. Rinaldo, PhD, James C. Puffer, MD and Larry A. Green, MD

    Introduction: In its recent shift to a Maintenance of Certification for Family Physicians (MC-FP) paradigm, the American Board of Family Medicine provides diplomates completing 3 self assessment modules (SAMs) in the first 3 years (or first stage of MC-FP) a pathway to extend their recertification cycle to 10 years provided additional requirements are met, versus a 7-year cycle for "non-completers." We use geographic information systems to report on variations in SAM participation and completion in a single cohort of diplomates followed during their first stage of MC-FP to better understand the communities impacted, barriers to uptake, and urban-rural differences. Methods: We merged data from 2006 MC-FP files, association workforce files, and the US Census and completed cross-sectional spatial, descriptive, and regression analyses of the uptake and timely completion of SAMs during a 3-year period. Specifically, we explored characteristics of diplomates who did not meet first-stage MC-FP requirements within 3 years versus those who did. Results: The cohort comprised 10,812 participants who passed their certification or recertification examination in 2005, of which 30.5% did not complete their MC-FP requirements by the end of 2008. Noncompleters were more likely to be older (P < .01), men (P < .0001), and from areas of dense poverty (P < .01) and underserved areas (P < .05). There were no significant differences in MC-FP completion across the rural-urban continuum (P = .7108). Conclusions: More than two-thirds of eligible, certified family physicians completed stage-one MC-FP requirements. Concerns that technical aspects of the new MC-FP paradigm would leave parts of a widely distributed, poorly resourced primary care workforce disadvantaged may hold true for providers in some underserved areas, but differential completion among rural and remote physicians was not found. Understanding barriers to uptake is essential if the specialty boards are to meet their obligations to the public to promote quality of care through Maintenance of Certification for all physicians.

  • The Impact of a Clinic Move on Vulnerable Patients with Chronic Disease: A Geographic Information Systems (GIS) Analysis

    Articles | Jan 15, 2010 | Andrew Bazemore, MD, MPH, Philip Diller, MD, PhD, and Mark Carrozza, MA

    Background: Changing locations disrupts the populations served by primary health care clinics, and such changes may differentially affect access to care for vulnerable populations. Methods: Online geographic information systems mapping tools were used to define how the relocation of a family medicine center impacted access to care for black and Hispanic patients with chronic disease. Results: Maps created from practice management data revealed a distinct shift in black and Hispanic patients with chronic disease being served in the new location. Conclusions: Geographic information systems tools are valuable aids in defining changing service areas of primary health care clinics.

  • Harnessing Geographic Information Systems (GIS) to enable Community-Oriented Primary Care

    Articles | Jan 15, 2010 | Andrew Bazemore, MD, MPH; Robert L. Phillips, MD, MSPH, FAAFP; and Thomas Miyoshi, MSW

    Background: Despite growing acceptance and implementation of geographic information systems (GIS) in the public health arena, its utility for clinical population management and coordination by leaders in a primary care clinical health setting has been neither fully realized nor evaluated. Methods: In a primary care network of clinics charged with caring for vulnerable urban communities, we used GIS to (1) integrate and analyze clinical (practice management) data and population (census) data and (2) generate distribution, service area, and population penetration maps of those clinics. We then conducted qualitative evaluation of the responses of primary care clinic leaders, administrators, and community board members to analytic mapping of their clinic and regional population data. Results: Practice management data were extracted, geocoded, and mapped to reveal variation between actual clinical service areas and the medically underserved areas for which these clinics received funding, which was surprising to center leaders. In addition, population penetration analyses were performed to depict patterns of utilization. Qualitative assessments of staff response to the process of mapping clinical and population data revealed enthusiastic engagement in the process, which led to enhanced community comprehension, new ideas about data use, and an array of applications to improve their clinical revenue. However, they also revealed barriers to further adoption, including time, expense, and technical expertise, which could limit the use of GIS and mapping unless economies of scale across clinics, the use of web technology, and the availability of dynamic mapping tools could be realized. Conclusions: 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.

  • Title VII is Critical to the Community Health Center and National Health Service Corps Workforce

    One Pagers | Jan 15, 2010 | Bridget Harrison, MD, MPH; Diane R. Rittenhouse, MD, MPH; Robert L. Phillips Jr., MD, MSPH; Kevin Grumbach, MD; Andrew W. Bazemore, MD, MPH; and Martey S. Dodoo, PhD

    Community health centers (CHCs) and the National Health Service Corps (NHSC) are essential to a functioning health care safety net, but they struggle to recruit physicians. Compared with physicians trained in residency programs without Title VII funding, those trained in Title VII-funded programs are more likely to work in CHCs and the NHSC. Title VII funding cuts threaten efforts to improve access to care for the underserved.

  • Improving the Delivery of Preventive Services to Medicare eneficiaries

    Commentaries & Editorials | Dec 23, 2009 | Lenard I. Lesser, MD and Andrew W. Bazemore, MD, MPH

    While policy makers emphasize increased use of preventive care as central to health reform's ability to lengthen lives and save costs, busy clinicians still lack financial incentives to coordinate and effect evidence-based prevention. To realize these ambitions, the Department of Health and Human Services should align payments from the CMS with the preventive evidence base produced by the USPSTF. Simultaneously, Congress should implement innovative payment reforms driving new models of preventive coordination and accountability, revisit previously authorized but unnecessary services, and increase support for research on their effectiveness and cost-effectiveness.

  • Family Physicians' Present and Future Role in Caring for the Elderly

    One Pagers | Nov 15, 2009 | Lars E. Peterson, MD, PhD; Andrew W. Bazemore, MD, MPH; Robert L. Phillips Jr., MD, MSPH; Bridget Teevan, MS; Martey S. Dodoo, PhD; Imam Xierali, PhD; and Stephen M. Petterson, PhD

    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

  • Title VII's Decline: Shrinking Investment in the Primary Care Training Pipeline

    One Pagers | Oct 15, 2009 | Bridget Harrison, MD MPH; Andrew Bazemore, MD MPH; Martey S. Dodoo, PhD; Bridget Teevan, MS; Hope R. Wittenberg, MA; and Robert L. Phillips, Jr. MD MSPH

    Title VII, Section 747 is a source of federal funding intended to strengthen the primary care workforce. Despite evidence that Title VII has been successful, its funding has declined over the past three decades, threatening the production of primary care physicians.

  • Estimated Effects of "America's Affordable Health Choices Act of 2009"10 page PDF

    Monographs & Books | Sep 15, 2009 | Robert Graham Center

  • A Comparison of Chronic Illness Care Quality in US and UK Family Medicine Practices Prior to Pay-for-Performance Initiatives

    Articles | Sep 11, 2009 | Jesse Crosson, PhD ; Pamela Ohman-Strickland, PhD; Stephen Campbell, MD; Robert L Phillips, MD, MSPH; Martin O Roland, PhD; Evangelos Kontopantelis, PhD; Andrew Bazemore, MD, MPH; Bijal Balasubramanian, MBBS, PhD; and Benjamin Crabtree, PhD

    The Quality and Outcomes Framework (QOF) has contributed to modest improvements in chronic illness care in the UK. US policymakers have proposed similar pay-for-performance (P4P) approaches to improve care.

  • Decreasing Self-Perceived Health Status Despite Rising health expenditures

    One Pagers | Sep 01, 2009 | David Rabin, MD MPH; Stephen M. Petterson, PhD; Andrew W. Bazemore, MD MPH; Bridget Teevan, MS; Robert L. Phillips Jr., MD MSPH; Martey S. Dodoo, PhD; and Imam Xierali, PhD

    Despite steady increases in U.S. health care spending, the population's self-perceived health status has been in a long-term decline. Increased support for public health, prevention, and primary care could reduce growth in spending and improve actual and perceived health.

  • Are Medicare GME Policies Adequate to Meet the Rising Need for Primary Care Physicians?22 page PDF

    Presentations | Aug 15, 2009 | Bob Phillips, MD, MSPH

  • Race and Ethnicity and Rural Mental Health Treatment

    Articles | Aug 15, 2009 | S Petterson, PhD; IC Williams, PhD; EJ Hauenstein, PhD, LCP, MSN, RN; V Rovnyak, PhD; E Merwin, PhD, RN, FAAN

    Objective: Research has shown that there is less use of mental health services in rural areas even when availability, accessibility, demographic, and need factors are controlled. This study examined mental health treatment disparities by determining treatment rates across different racial/ethnic groups. Methods: Data from the first four panels of the Medical Expenditure Panel Survey (MEPS) were used for these analyses. The sample consisted of 36,288 respondents yielding 75,347 person-year observations. The Economic Research Service’s Rural-Urban Continuum was used as a measure of rurality. Results: Findings show that rural residence does little to contribute to existing treatment disparities for racial/ethnic minorities living in these areas. Conclusions: 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.

  • How States Will Solve the Healthcare Workforce Crisis: What to Ask For from the Feds50 page PDF

    Presentations | Jun 15, 2009 | Bob Phillips, MD, MSPH

  • Health Care Reform Depends on Family Medicine: Walk Softly Keep the Stick Close44 page PDF

    Presentations | Jun 15, 2009 | Bob Phillips, MD, MSPH

  • Effects of proposed primary care incentive payments on average physician Medicare revenue and total Medicare allowed charges14 page PDF

    Monographs & Books | May 15, 2009 | Robert Graham Center

  • What influences medical student and resident choices?41 page PDF

    Presentations | Apr 15, 2009 | Bridget Teevan, MS

  • Is Colorado Ready for a Primary Care-based Health Care System?72 page PDF

    Presentations | Apr 15, 2009 | Bob Phillips, MD MSPH and Andrew Bazemore, MD MPH

  • Medical school expansion, primary care, and policy: Engaging primary care educators in evidence-based advocacy68 page PDF

    Presentations | Apr 15, 2009 | Andrew Bazemore, MD, MPH; Julie Phillips, MD, MPH; Amy McGaha, MD; Hope Wittenberg, MA

  • The Robert Graham Center Update: A Primary Care Perspective on Health Care Workforce and Expenditures50 page PDF

    Presentations | Mar 15, 2009 | Robert Graham Center

  • Health Care: The Next Mortgage Crisis32 page PDF

    Presentations | Mar 15, 2009 | ichael Fine, MD, and Shannon Brownlee, MS

  • Usual Source of Care: An Important Source of Variation in Health Care Spending

    Articles | Mar 15, 2009 | Bob Phillips, MD, MSPH; Martey Dodoo, PhD; Larry A Green, MD; George E Fryer, PhD; Andrew Bazemore, MD, MPH; Kristin McCoy; and Stephen Petterson, PhD

    Health care spending varies in unexplained ways, and physicians’ behavior is thought to explain much of the variation. We studied the spending effects of having different usual sources of care, focusing on variations associated with the type of facility or physician specialty. Based on analyses of data from the 2001–2004 Medical Expenditure Panel Surveys, we found significant differences in annual spending, especially for adults. Use of and spending for subspecialists were similar to those for general internists, and both were significantly higher than those for family physicians. Variation in spending might be the result of training differences among primary care specialties.

  • What Influences Medical Student & Resident Choices?102 page PDF

    Monographs & Books | Mar 15, 2009 | Robert Graham Center

  • Primary Care's Ecologic Impact on Obesity

    One Pagers | Mar 15, 2009 | Anne Gaglioti, MD; Stephen M. Petterson, PhD; Andrew W. Bazemore, MD, MPH; Robert L. Phillips Jr, MD, MSPH; Martey S. Dodoo, PhD; and Xingyou Zhang, PhD

    Increased primary care physician density on the county level is associated with decreased obesity rates. As we move to restructure the primary care workforce and engage our patients and communities in behavior change, the implications of this association merit closer investigation.

  • How Can Primary Care Cross the Quality Chasm?

    Articles | Mar 15, 2009 | Solberg LI; Elward KS; Phillips WR; Gill JM; Swanson G; Main DS; Yawn BP; Mold JW; and Phillips RL Jr

    The chasm between knowledge and practice decried by the Institute of Medicine (IOM) is the result of other chasms that have not been addressed. They include the chasm between what we know and what we need to know to improve care; the chasm between those who provide primary care and those who do not fund, study, support, or publish practical primary care studies; and the chasm between research and quality improvement (QI). These chasms are a result of problematic concepts, attitudes, traditions, time frames, and financing approaches among the various participants. If we are to facilitate the production and use of the knowledge needed for primary care to cross IOM’s chasm, major changes are needed. These changes include the following: (1) admission by all primary care professions that we have quality problems that require our unified attention and action; (2) conversion of the paradigm from “translate research into practice” to “optimizing health and health care through research and QI”; (3) development and facilitation of more partnerships among clinicians, researchers, and care delivery leaders for engaged scholarship in both research and QI; (4) modification of the agendas and methods of funders and researchers so they emphasize the problems of patients and patient care and support practical time frames and research designs; and (5) facilitation by funders and journals of the dissemination and implementation of lessons from QI and practical research.

  • Family Medicine, the NIH, and the Medical-Research Roadmap: Perspectives from Inside the NIH

    Articles | Mar 15, 2009 | Sean C. Lucan, MD, MPH; Frances K. Barg, PhD, MEd; Andrew W. Bazemore, MD, MPH; and Robert L. Phillips, Jr, MD, MSPH

    PURPOSE: Family medicine has had little engagement with the National Institutes of Health (NIH), and it is unclear what NIH officials think about this. METHODS: Purposive sampling identified 13 key informants at NIH for open-ended, semi-structured interviews. Evaluation was by content analysis. RESULTS: NIH officials expressed the perception that family physicians have strong relationships with patients and communities and focus on interdisciplinary collaboration but that they do limited research and have weak research infrastructure. They also indicated that NIH has repackaged its stated focus, to include areas of research that might be applicable to family medicine, but whether this represents real change is questionable; NIH still emphasizes basic science and exclusionary trials. While NIH officials suggested that family physicians still have no obvious NIH home, they also suggest that family physicians are well-poised to recruit patients and inform questions, if not lead research. Family physicians have opportunity with Clinical and Translational Science Awards (CTSAs) but need areas of expertise and additional formal research training to succeed with greater research participation. CONCLUSIONS: NIH key informants generally appreciated family medicine clinically but viewed family medicine research as underdeveloped. Some identified opportunities for family medicine to lead, particularly CTSAs. Greater self-advocacy, research training, and developing areas of expertise may improve family medicine’s engagement with NIH.

  • Arranging Generalism in the 2020 Primary Care Team26 page PDF

    Monographs & Books | Feb 15, 2009 | Dr. Victoria J. Palmer and Professor Jane M. Gunn

  • Having a Usual Source of Care reduces ED Visits

    One Pagers | Jan 15, 2009 | Stephen Petterson, PhD; David Rabin, MD, MPH; Robert L. Phillips, Jr., MD, MSPH; Andrew Bazemore, MD, MPH; and Martey S. Dodoo, PhD

    The recent growth in the use of emergency departments (EDs) is costly, undesirable, and unnecessary. This trend is partly due to a growing proportion of persons who lack a usual source of care. This group is increasingly likely to rely on EDs for their health care needs compared with those who have a usual source of care.

  • Universal Primary Care34 page PDF

    Presentations | Mar 26, 2009 | Michael Fine, MD, and Shannon Brownlee, MS

    Universal Primary Care - Health Care. Reform. Shovel Ready Now

  • What the Federal Government Should Do to Revitalize the Primary Care Practice Infrastructure & Quality in the United States37 page PDF

    Presentations | Jan 15, 2009 | Kevin Grumbach, MD

  • Off the Roadmap? Family Medicine's Grant Funding and Committee Representation at NIH

    Articles | Nov 15, 2008 | Sean Lucan, Bob Phillips and Andrew Bazemore

    PURPOSE: Family medicine is challenged to develop its own research infrastructure and to inform and contribute to a national translational-research agenda. Toward these ends, understanding family medicine's engagement with the National Institutes of Health (NIH) is important. METHODS: We descriptively analyzed NIH grants to family medicine from 2002 through 2006 and the current NIH advisory committee memberships. RESULTS: Grants (and dollars) awarded to departments of family medicine increased from 89 ($25.6 million) in 2002, to 154 ($44.6 million) in 2006. These values represented only 0.20% (0.15% for dollars) and 0.33% (0.22% for dollars), respectively, of total NIH awards. Nearly 75% of family medicine grants came from just 6 of NIH's grant-funding 24 institutes and centers. Although having disproportionately fewer grant continuations (62% vs 72%) and R awards (68% vs 74%)-particularly R01 awards (53% vs 84%)-relative to NIH grantees overall, family medicine earned proportionately more new (28% vs 21%) and K awards (25% vs 9%) and had more physician principal investigators (52% vs 15%). Ten of the nation's 132 departments of family medicine (7.6%) earned almost 50% of all family medicine awards. Representatives from family medicine were on 6.4% of NIH advisory committees (0.38% of all members); family physicians were on 2.7% (0.16% of members). CONCLUSIONS: Departments of family medicine, and family physicians in particular, receive a miniscule proportion of NIH grant funding and have correspondingly minimal representation on standing NIH advisory committees. Family medicine's engagement at the NIH remains near well-documented historic lows, undermining family medicine's potential for translating medical knowledge into community practice, and advancing knowledge to improve health care and health for the US population as a whole

  • Characterizing Breast Symptoms in Family Practice

    Articles | Nov 15, 2008 | Margaret Eberl, Bob Phillips, Henk Lamberts, Inge Okkes, and Martin Mahoney

    PURPOSE: The frequency and outcome of breast symptoms have not been well characterized in primary care settings. To enhance and inform physician practice, this study aims to establish the proportion of visits and resultant diagnoses by age by examining longitudinal data on breast-related reasons for encounter. METHODS: We used data from a prospective longitudinal sample of patients seeking care in Dutch family physician offices between 1985 and 2003 to provide routine family practice data on breast symptoms as the reason for encounter; all visits were coded using the International Classification of Primary Care. Data on breast symptom prevalence are based upon 84,285 active female patients and 367,834 total encounters. RESULTS: Overall breast symptoms were reported in about 3% of all visits by female patients (29.7 per 1,000 active female patients per year); breast pain and breast mass were the most common breast-related complaints. Breast symptom complaints were highest among women aged 25 to 44 years (48 of 1,000) and among women aged 65 years and older (33 per 1,000). Of the women complaining of breast symptoms, 81 (3.2%) had breast cancer diagnosed. Breast mass had a markedly elevated positive likelihood ratio for breast cancer (15.04; 95% confidence interval, 11.74-19.28). CONCLUSIONS: As expected, of patients with breast symptoms only a small subset was subsequently given a diagnosis of breast cancer (3.2%); however, the presence of a breast mass was associated with an elevated likelihood of breast cancer. These data illustrate the use of systematic data collection and classification from primary care offices to extract information regarding disease symptoms and diagnoses.

  • Changing Patient Health-Risk Behavior Requires New Investment in Primary Care

    One Pagers | Oct 15, 2008 | Martey S. Dodoo, PhD; Lenard I. Lesser, Robert L. Phillips Jr, Andrew W. Bazemore, Stephen M. Petterson, and Imam Xierali

    Evidence supports the effectiveness of primary care interventions to improve nutrition, increase physical activity levels, reduce alcohol intake, and stop tobacco use. However, implementing these interventions requires considerable practice expense. If we hope to change behavior to reduce chronic illness, the way we pay for primary care services must be modified to incorporate these expenses.

  • Navigating General Practice. The Use of Geographic Information Systems

    Articles | Oct 15, 2008 | Paul Grinzi, Andrew Bazemore and Bob Phillips

    Geographic information systems (GIS) are powerful tools for managing, analysing and mapping geographical and associated data. In the health care setting, GIS can be used to map and graph health care provider and social and environmental data. This article uses two hypothetical cases to explore applications of GIS in general practice.

  • Impact of Title VII Training Programs on Community Health Center Staffing and National Health Service Corps Participation

    Articles | Sep 15, 2008 | Diane Rittenhouse, Ed Fryer, Bob Phillips, Thomas Miyoshi, Christine Nielson, David Goodman, Kevin Grumbach

    PURPOSE: Community health centers (CHCs) are a critical component of the health care safety net. President Bush's recent effort to expand CHC capacity coincides with difficulty recruiting primary care physicians and substantial cuts in federal grant programs designed to prepare and motivate physicians to practice in underserved settings. This article examines the association between physicians' attendance in training programs funded by Health Resources and Services Administration (HRSA) Title VII Section 747 Primary Care Training Grants and 2 outcome variables: work in a CHC and participation in the National Health Service Corps Loan Repayment Program (NHSC LRP). METHODS: We linked the 2004 American Medical Association Physician Master-file to HRSA Title VII grants files, Medicare claims data, and data from the NHSC. We then conducted retrospective analyses to compare the proportions of physicians working in CHCs among physicians who either had or had not attended Title VII-funded medical schools or residency programs and to determine the association between having attended Title VII-funded residency programs and subsequent NHSC LRP participation. RESULTS: Three percent (5,934) of physicians who had attended Title VII-funded medical schools worked in CHCs in 2001-2003, compared with 1.9% of physicians who attended medical schools without Title VII funding (P<.001). We found a similar association between Title VII funding during residency and subsequent work in CHCs. These associations remained significant (P<.001) in logistic regression models controlling for NHSC participation, public vs private medical school, residency completion date, and physician sex. A strong association was also found between attending Title VII-funded residency programs and participation in the NHSC LRP, controlling for year completed training, physician sex, and private vs public medical school. CONCLUSIONS: 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.

  • Primary Care's Eroding Earnings: Is Congress Concerned

    Articles | Sep 15, 2008 | Yoshi Laing, Thomas Bodenheimer, Bob Phillips, and Andrew Bazemore

    PURPOSE: Despite increasing data demonstrating the positive impact primary care has on quality of care and costs, our specialty faces uncertainty. Its popularity among medical students is declining, and the income gap is growing between primary care and other specialties. Congress has the power to intervene in this impending crisis. If we want to influence lawmakers' actions, we need to know how they are thinking about these issues. METHODS: Using a set of questions covering several physician payment topics, we interviewed 14 congressional staff aides (5 aides on Medicare-oversight committees, 9 general staff aides) and one representative from each of 3 governmental agencies: the Medicare Payment Advisory Commission, Congressional Budget Office, and Government Accountability Office. RESULTS: Interviewees revealed that issues in primary care are not high on the congressional agenda, and that Medicare's Sustainable Growth Rate (SGR) is the physician-payment issue on the minds of congressional staff members. CONCLUSION: Attempts to solve primary care's reimbursement difficulties should be tied to SGR reform.

  • Will Patients Find Diversity in the Medical Home?

    One Pagers | Jul 15, 2008 | Eddie J. Turner, MD, Andrew W. Bazemore, MD, MPH, Robert L. Phillips, Jr., MD, MSPH and Larry A. Green, MD

    Mexican Americans and blacks experience disparities in health outcomes relative to white populations. During the past five to 10 years, fewer blacks and Mexican Americans are going to medical school and entering primary care professions. To assure the availability of a patient-centered medical home for all Americans, policy makers must work to support a culturally competent and diverse primary care workforce.

  • The Robert Graham Center Update 200847 page PDF

    Presentations | Jul 15, 2008 | Robert Graham Center

  • A Perfect Storm: Changes Impacting Medicare Threaten Primary Care Access in Underserved Areas

    One Pagers | Jun 15, 2008 | Imam Xierali, PhD; Andrew Bazemore, MD MPH; Bob Phillips, MD MSPH; Stephen Petterson, PhD; Martey Dodoo, PhD and Bridget Teevan, MIS

    A convergence of three policies could reduce physician Medicare payments by 14.9 to 22.3 percent in 2008, which could jeopardize access for Medicare beneficiaries in underserved areas. Congress and the Executive Branch should coordinate their roles in setting Medicare payment policy, because their overlapping decisions can have additive impact.

  • Testing Process Errors and Their Harms and Consequences Reported from Family Medicine Practices: A sSudy of the American Academy of Family Physicians National Research Network

    Articles | Jun 15, 2008 | Hickner J, Graham DG, Elder NC, Brandt E, Emsermann CB, Dovey S, Phillips R

    CONTEXT: Little is known about the types and outcomes of testing process errors that occur in primary care. OBJECTIVE: To describe types, predictors and outcomes of testing errors reported by family physicians and office staff. DESIGN: Events were reported anonymously. Each office completed a survey describing their testing processes prior to event reporting. SETTING AND PARTICIPANTS: 243 clinicians and office staff of eight family medicine offices. MAIN OUTCOME MEASURES: Distribution of error types, associations with potential predictors; predictors of harm and consequences of the errors. RESULTS: Participants submitted 590 event reports with 966 testing process errors. Errors occurred in ordering tests (12.9%), implementing tests (17.9%), reporting results to clinicians (24.6%), clinicians responding to results (6.6%), notifying patient of results (6.8%), general administration (17.6%), communication (5.7%) and other categories (7.8%). Charting or filing errors accounted for 14.5% of errors. Significant associations (p<0.05) existed between error types and type of reporter (clinician or staff), number of labs used by the practice, absence of a results follow-up system and patients' race/ethnicity. Adverse consequences included time lost and financial consequences (22%), delays in care (24%), pain/suffering (11%) and adverse clinical consequence (2%). Patients were unharmed in 54% of events; 18% resulted in some harm, and harm status was unknown for 28%. Using multilevel logistic regression analyses, adverse consequences or harm were more common in events that were clinician-reported, involved patients aged 45-64 years and involved test implementation errors. Minority patients were more likely than white, non-Hispanic patients to suffer adverse consequences or harm. CONCLUSIONS: Errors occur throughout the testing process, most commonly involving test implementation and reporting results to clinicians. While significant physical harm was rare, adverse consequences for patients were common. The higher prevalence of harm and adverse consequences for minority patients is a troubling disparity needing further investigation.

  • Residency Footprints: Assessing the Impact of Training Programs on the Local Physician Workforce and Communities

    Articles | May 15, 2008 | Reese VF, McCann JL, Bazemore AW, Phillips RL J

    BACKGROUND AND OBJECTIVES: National workforce models fail to capture the regional effect of residency programs, despite local control over decisions to open or close training sites. In the last 5 years, 37 (nearly 8% of total) family medicine residency programs have closed. We report on a novel approach to measuring the regional effect of residency training programs closures using a combination of quantitative and spatial methods. METHODS: American Medical Association Physician Masterfile records and residency graduate registries for 22 of 37 family medicine residency programs that closed between 2000-2006 were analyzed to determine regional patterns of physician practice, as well as the effect of graduates from closed programs on areas that otherwise would be Health Professional Shortage Areas (HPSAs). Program graduate data from two sampled programs were mapped using geographic information system software to display the distribution "footprint" of graduates regionally. RESULTS: Of the 1,545 graduates of the 22 programs, 21% of graduates practice in rural locations, and 68% are in full-county or partial-county HPSAs. Without the graduates of these programs, there would have been 150 additional full HPSA counties in 15 states. The spatial distribution of the graduates of two closed programs demonstrates their effect across multiple counties and states. CONCLUSIONS: The effect of closing family medicine residency programs is likely to go undetected for many years. Decisions regarding the fate of family medicine programs are often made without benefit of a full assessment. Local and regional effects on physician access are often recognized only after the fact. Novel approaches to analysis and display of local effects of closures are essential for policy decisions concerning physician workforce training.

  • Physician Distribution and Access: Workforce Priorities

    One Pagers | May 15, 2008 | Xingyou Zhang, PhD; Bob Phillips, MD MSPH; Andrew Bazemore, MD MPH; Martey Dodoo, PhD; Stephen Petterson, PhD; Imam Xierali, PhD, and Larry A. Green, MD

    Most Primary Care Health Professional Shortage Areas (HPSAs) exceed federal population-to-physician designation criteria, yet struggle to maintain access to primary care physicians. Policy options for recruiting and retaining primary care physicians to HPSAs, and new HPSA criteria that support access to primary care practices, should be considered.

  • Non-emergency Medicine-Trained Physician Coverage in Rural Emergency Departments

    Articles | Apr 15, 2008 | Peterson LE, Dodoo M, Bennett KJ, Bazemore A, Phillips RL Jr.

    Rural areas have fewer physicians compared to urban areas, and rural emergency departments often rely on community or contracted providers for staffing. The emergency department workforce is composed of a variety of physician specialties and clinicians. PURPOSE: To determine the distribution of emergency department clinicians and the proportion of care they provide across the rural-urban continuum. METHODS: Cross-sectional analysis of secondary data. The distribution of clinicians who provide emergency department care by county was determined using the 2003 Area Resource File. The percentage of emergency department care provided by clinician type was determined using 2003 Medicare claims data. Logistic regression analyses assessed the odds of being seen by different clinicians with a patient's rurality when presenting to the emergency department. FINDINGS: Board-certified emergency physicians provide 75% of all emergency department care, but only 48% for Medicare beneficiaries of the most rural of counties. The bulk of the remainder of emergency department care is largely provided by family physicians and general internists, with the percentage increasing with rurality. The likelihood of being seen by an emergency physician in the emergency department decreases 5-fold as rurality increases, while being seen by a family physician increases 7-fold. CONCLUSION: 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.

  • Why There Must be Room for Mental Health in the Medical Home

    One Pagers | Mar 15, 2008 | Stephen Petterson, PhD, Bob Phillips, MD MSPH, Andrew Bazemore, MD MPH, Martey Dodoo, PhD, Xingyou Zhang, PhD, and Larry A. Green, MD

    Most people with poor mental health are cared for in primary care settings, despite many barriers. Efforts to provide everyone a medical home will require the inclusion of mental health care if it is to succeed in improving care and reducing costs.

  • GIS and General Practice: Where are we going and when will we get there?41 page PDF

    Monographs & Books | Jan 15, 2008 | Dr. Paul Grinzi, Department of General Practice, University of Melbourne, Australia

  • Primary Care in the ACO: The Role of Primary Care in the Future Healthcare System1 page PDF

    Presentations | Nov 14, 2008 | Erica Brode, MD MPH; Andrew Bazemore, MD, MPH; Kevin Grumbach, MD

  • Access Transformed: Building a Primary Care Workforce in the 21st Century40 page PDF

    Monographs & Books | Aug 15, 2008 | Robert Graham Center

  • Brakes for a Runaway Train?48 page PDF

    Presentations | May 23, 2008 | Cathy Schoen, MS

    Brakes for a Runaway Train? The Medical Home's Role in Containing U.S. Health Care Expenditures

  • HealthLandscape 101: Putting Family Medicine on the Map5 MB PDF

    Presentations | May 15, 2008 | Robert Phillips, MD, MSHP

  • Integrating Primary Care and Mental Health/Substance Use22 page PDF

    Presentations | Mar 15, 2008 | Bob Phillips, MD, MSPH, and Mary Jane England, MD

  • Genomics and Healthcare: Will Primary Care Lead or Follow?37 page PDF

    Presentations | Dec 15, 2007 | Greg Feero, MD, PhD

  • The Patient Centered Medical Home: History, seven core features, evidence and transformational change32 page PDF

    Monographs & Books | Nov 15, 2007 | Robert Graham Center

  • Behavioral Change Counseling in the Medical Home

    One Pagers | Nov 15, 2007 | Bijal A. Balasubramanian, MBBS, MPH; Deborah J. Cohen, PhD; Martey S. Dodoo, PhD; Andrew W. Bazemore, MD, MPH; and Larry A. Green, MD

    Health-related behavioral counseling can and should be a central offering in the medical home. Primary care practices currently address unhealthy behaviors with their patients, but most practices lack the integrated approaches needed to effectively change these behaviors. Revisions in practice and financing are necessary to fully realize this capacity, which could affect the millions of patients served by the largest health care delivery platform in the United States.

  • Going Global: Considerations for Introducing Global Health into Family Medicine Training Programs

    Articles | Oct 15, 2007 | Evert J, Bazemore AW, Hixon A, Withy K

    Medical students and residents have shown increasing interest in international health experiences. Before attempting to establish a global health training program in a family medicine residency, program faculty must consider the goals of the international program, whether there are champions to support the program, the resources available, and the specific type of program that best fits with the residency. The program itself should include didactics, peer education, experiential learning in international and domestic settings, and methods for preparing learners and evaluating program outcomes. Several hurdles can be anticipated in developing global health programs, including finances, meeting curricular and supervision requirements, and issues related to employment law, liability, and sustainability.

  • The Shoulder to Shoulder Model: Channeling medical volunteerism toward sustainable health change

    Articles | Oct 15, 2007 | Heck JE, Bazemore A, Diller P

    BACKGROUND: Rapid growth in medical volunteerism in resource-poor countries presents an opportunity for improving global health. The challenge is to ensure that the good intentions of volunteers are channeled effectively into endeavors that generate locally acceptable, sustainable changes in health. METHODS: Started in Honduras in 1990, Shoulder to Shoulder is a network of partnerships between family medicine training programs and communities in Honduras and other resource-poor countries. The program involves short-term volunteering by US health professionals collaborating with community health boards in the host countries. The program has been implemented in seven US family medicine training programs and is supported by a small international staff. RESULTS: During the 16 years of program operation, more than 1,400 volunteers have made visits to host countries, which include Honduras, Ecuador, and Tanzania. Clinics have been established, school-based food programs and community-based water filtration programs developed, and cancer screening and pregnancy-care programs put in place. These and other programs have been implemented on a budget of less than $400,000, raised through donations and small grants. CONCLUSIONS: The Shoulder to Shoulder model allows health care professionals to channel short-term medical volunteerism into sustainable health partnerships with resource-poor communities. The resulting network of partnerships offers a powerful resource available to governments and foundations, poised to provide innovative interventions and cost-effective services directly to poor communities.

  • Harmonizing Primary Care: Clinical Classification and Data Standards132 page PDF

    Monographs & Books | Oct 15, 2007 | Robert L. Phillips, Jr., MD, MSPH; Michael Klinkman, MD, MS; and Larry A. Green, MD

  • Democratizing and Displaying Health Data: Introducing HealthLandscape.org

    Articles | Jul 15, 2007 | Andrew Bazemore, Mark Carrozza, Shiloh Turner, Xingyou Zhang, Bob Phillips

    Despite the power of geographic information systems (GIS) to interact and display data relating to health, broad adoption of the technology in this sector remains unrealized. To overcome the financial, technical, and temporal hurdles to using GIS in education and advocacy, four partners developed HealthLandscape. This interactive, web-based GIS platform allows health professionals, policy makers, academic researchers and planners to combine, analyze and display information in ways that promote understanding and improvement of health and healthcare. A collaborative effort of the American Academy of Family Physicians, the Robert Graham Center for Policy Studies, the Health Foundation of Greater Cincinnati, and the University of Cincinnati, this site has three components: 1) Community Health View, 2) the Primary Care Atlas, and 3) the Health Center Mapping Tool. We describe the development and applications of this innovative platform, and how HealthLandscape helps its users to understand health and health needs in their community, evaluate programs, and influence policy.

  • Seeking a Replacement for the Medicare Physician Services Payment Method: A New Approach Improves Health Outcomes and Achieves Budgetary Savings

    Articles | Jul 15, 2007 | Martey Dodoo, Bob Phillips, Larry Green

    Business and government spending on physician services have soared over the last few decades. Most payers for services traditionally peg their payment rates to Medicare. However, most consider the current Medicare single payment rate flawed because it fails to improve health outcomes or control spending. Everyone wants to replace it, but good replacements have not been identified. We estimated elasticities of the single-payment rate with respect to several of its determinants, proposed a replacement--a service-specific payment rate--for the single-payment rate, and estimated the budget implications of this replacement. Key findings are that the single-payment rate is relatively inelastic to the Sustained Growth Rate (SGR) and expenditure levels and that the proposed service-specific payment rate promotes primary care, controls spending, and saves money.

  • Medical School Expansion: An Immediate Opportunity to Meet Rural Health Care Needs

    One Pagers | Jul 15, 2007 | JL Hyer; Andrew Bazemore MD, MPH; R Bowman; Xingyou Zhang, PhD; Stephen Petterson, PhD; Robert Phillips, MD, MSPH

    The first expansion of allopathic medical education in 35 years is under way; this could eliminate rural physician shortage areas if students more likely to practice in rural areas are preferentially admitted and supported.

  • Primary Care Value Propositions31 page PDF

    Presentations | Jun 15, 2007 | Robert Phillips, MD, MSPH

  • Will Medical School Expansion Help Diversify the Physician Workforce?

    One Pagers | Jun 01, 2007 | D Lindsay; Andrew Bazemore, MD, MPH; R Bowman; Stephen Petterson, PhD; Lerry Green, MD; Robert Phillips, MD, MSPH

    The racial/ethnic composition of U.S. medical schools does not reflect the U.S. population. With proper planning, the current medical school expansion could improve physician diversity and reduce health disparities.

  • Economic Impact of Family Physicians in Virginia2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Iowa2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Delaware2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Use of Patient Registries in U.S. Primary Care Practices

    One Pagers | Jun 01, 2007 | Larry Green, MD et. al.

    Patient registries are necessary for high-quality health care, but even in innovative practices, their presence and utilization is inadequate. Registry uptake in primary care may be enhanced by improving the functionality of electronic health records (EHRs) and implementing payment models that reward registry use.

  • Rural Origins and Choosing Family Medicine Predict Future Rural Practice

    One Pagers | Jun 01, 2007 | JL Hyer, MB; Andrew Bazemore, MD, MPH; RC Bowman; Xingyou Zhang, PhD; Stephen Petterson, PhD; Robert Phillips, MD, MSPH

    The shortage of physicians in U.S. rural practice may impact access to health care for one in five citizens. Two medical student characteristics that predict eventual practice in rural settings are clear: being born in a rural county and choosing a residency in family medicine.

  • The Distribution of IMGs in US: The Interplay of Poverty, Rurality, and Length of Practice12 page PDF

    Presentations | May 15, 2007 | Xingyou Zhang, PhD Martey Dodoo, PhD Stephen Peterson, PhD Andrew Bazemore, MD, MPH Bob Phillips, MD, MSPH

  • Impact of Title VII Funding on Community Health Center Staffing and the National Health Service Corps12 page PDF

    Presentations | Apr 15, 2007 | Bob Phillips, MD, MSPH, and Diane R. Rittenhouse, MD, MPH

  • Giving Everyone the Health of the Educated: An Examination of Whether Social Change Would Save More Lives Than Medical Advances

    Articles | Apr 15, 2007 | Steven H. Woolf, MD, MPH, Robert E. Johnson, PhD, Robert L. Phillips, Jr, MD, MSPH and Maike Philipsen, PhD

    OBJECTIVES. Social determinants of health, such as inadequate education, contribute greatly to mortality rates. We examined whether correcting the social conditions that account for excess deaths among individuals with inadequate education might save more lives than medical advances (e.g., new drugs and devices). METHODS. Using US vital statistics data for 1996 through 2002, we applied indirect standardization techniques to estimate the maximum number of averted deaths attributable to medical advances and the number of deaths that would have been averted if mortality rates among adults with lesser education had been the same as those among college-educated adults. RESULTS. Medical advances averted a maximum of 178193 deaths during the study period. Correcting disparities in education-associated mortality rates would have saved 1369335 lives during the same period, a ratio of 8:1. CONCLUSIONS. Higher mortality rates among individuals with inadequate education reflect a complex causal pathway and the influence of confounding variables. Formidable efforts at social change would be necessary to eliminate disparities, but the changes would save more lives than would society’s current heavy investment in medical advances. Spending large sums of money on such advances at the expense of social change may be jeopardizing public health.

  • An Acess Deprivation Index & HealthLandscape14 page PDF

    Presentations | Apr 15, 2007 | Robert Phillips, MD, MSPH, and Andrew Bazemore, MD, MPH

  • The Canadian Contribution to the U.S. Physician Workforce

    Articles | Apr 15, 2007 | Robert L. Phillips Jr, Stephen Petterson, George E. Fryer Jr, Walter Rosser

    BACKGROUND: A physician shortage has been declared in both Canada and the United States. We sought to examine the migration pattern of Canadian-trained physicians to the United States, the contribution of this migration to the Canadian physician shortage and policy options in light of competing shortages in both countries. METHODS: We performed a cross-sectional analysis of the 2004 and 2006 American Medical Association Physician Masterfiles, the 2002 Area Resource File and data from the Canadian Institute for Health Information, the Canadian Medical Association and the Association of Faculties of Medicine of Canada. We describe the migration pattern of Canadian medical school graduates to the United States, the number of Canadian-trained physicians in the United States in 2006, the proportion who were in active practice, the proportion who were practising in rural or underserved areas and the annual contribution of Canadian-trained physicians to the US physician workforce. RESULTS: Two-thirds of the 12,040 Canadian-educated physicians living in the United States in 2006 were practising in direct patient care, 1023 in rural areas. About 186, or 1 in 9, Canadian-educated physicians from each graduating class joined the US physician workforce providing direct patient care. Canadian-educated physicians are more likely than US-educated physicians to practise in rural areas. INTERPRETATION: 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.

  • The NHSC in Rural Counties: A historical review and impact assessment25 page PDF

    Presentations | Mar 15, 2007 | Robert Phillips, MD, MSPH, and Andrew Bazemore, MD, MPH

  • How Well Do Family Physicians Manage Skin Lesions?

    Articles | Jan 15, 2007 | Dan Merenstein, David Meyers, Alex Krixst, Jose Delgado, Jessica L. McCann, Stephen Petterson and Robert L. Phillips

    PURPOSE: Little is known about the epidemiology of new skin lesions seen in primary care. Our primary objective was to determine the percentage of the skin lesions that improved after evaluation by family physicians. Secondarily, we sought to determine patient satisfaction with their care, as well as diagnostic concordance between family physicians and dermatologists in diagnosing and treating skin lesions. METHODS: A prospective cohort study was done in two practice-based research networks. Patients with new skin lesions were eligible. Digital photographs, lesion descriptions and brief patient histories were collected in the family physician's office and independently reviewed by two dermatologists. Patients were administered a telephone survey at days 7, 28 and 84 after the visit to assess the status of lesions and their overall satisfaction with care. RESULTS: After 7 days, 84% of lesions were "much better" or "better." After 28 and 84 days, 89% and 94% of lesions respectively were rated similarly. Overall, patients were satisfied with the dermatologic care provided by their family physician, with 55% of patients reporting highest satisfaction level and 34% reporting second highest on a five point scale at day 7. At days 28 and 84, 93% of the patients reported the two highest levels of satisfaction. Overall diagnostic agreement was 72% between dermatologists and family physicians, with over 80% agreement for the more common diagnoses. CONCLUSION: Our study demonstrates that most skin lesions seen by office-based family physicians resolve within three months, patients are generally satisfied with the care they receive, and the diagnostic and treatment decisions made by primary care physicians are not significantly different from those of their dermatologic colleagues.

  • Congruent Satisfaction: Is There Geographic Correlation Between Patient and Physician Satisfaction?

    Articles | Jan 15, 2007 | Jennifer DeVoe, George E. Fryer, Alton Straub, Jessica McCann, Gerry Fairbrother

    CONTEXT: Satisfaction among both physicians and patients is optimal for the delivery of high-quality healthcare. Although some links have been drawn between physician and patient satisfaction, little is known about the degree of satisfaction congruence among physicians and patients living and working in geographic proximity to each other. OBJECTIVE: We sought to identify patients and physicians from similar geographic sites and to examine how closely patients' satisfaction with their overall healthcare correlates with physicians' overall career satisfaction in each selected site. METHODS: We undertook a cross-sectional analysis of data from 3 rounds of the Community Tracking Study (CTS) Household and Physician Surveys (1996-1997, 1998-1999, 2000-2001), a nationally representative telephone survey of patients and physicians. We studied randomly selected participants in the 60 CTS communities for a total household population of 179,127 patients and a total physician population of 37,238. Both physicians and patients were asked a variety of questions pertaining to satisfaction. Results: Satisfaction varied by region but was closely correlated between physicians and patients living in the same CTS sites. Physician career satisfaction was more strongly correlated with patient overall healthcare satisfaction than any of the other aspects of the healthcare system (Spearman's rank correlation coefficient 0.628, P < 0.001). Patient trust in the physician was also highly correlated with physician career satisfaction (0.566, P < 0.001). CONCLUSIONS: Despite geographic variation, there is a strong correlation between physician and patient satisfaction living in similar geographic locations. Further analysis of this congruence and examination of areas of incongruence between patient and physician satisfaction may aid in improving the healthcare system.

  • Coding Medical Constructs: Creating Chaos out of Order11 page PDF

    Presentations | Oct 15, 2007 | Wilson Pace, MD

    Harmonizing primary care clinical classification and data standards: Expert panel presentations - Coding medical constructs: Creating chaos out of order

  • Primary Care Data Standards: What Do We Have now? What Do We Still Need?16 page PDF

    Presentations | Oct 15, 2007 | Michael Klinkman, MD, MS

    Harmonizing primary care clinical classification and data standards: Expert panel presentaions - Primary care data standards: What do we have now? What do we still need?

  • Data Standards Paths4 page PDF

    Presentations | Oct 15, 2007 | David Kibbe, MD, MBA, and Steven Waldren, MD, MS

    Harmonizing primary care clinical classification and data standards: Expert panel presentaions - Data Standards Paths

  • Some History of this Ground11 page PDF

    Content Type, Presentations | Oct 10, 2007 | Maurice Woods, MD

    Harmonizing primary care clinical classification and data standards: Expert panel presentations: Some History of this Ground

  • Why Is It So Important to Have Organizing Principles and Data Standards for Primary Care?12 page PDF

    Presentations | Oct 10, 2007 | Larry Green, MD

    Harmonizing primary care clinical classification and data standards: Expert panel presentions - Why is it so important to have organizing principles and data standards for primary care?

  • Access Granted: The Primary Care Payoff24 page PDF

    Monographs & Books | Aug 15, 2007 | Robert Graham Center

  • Access Denied: A Look at America's Medically Disenfranchised42 page PDF

    Monographs & Books | Aug 01, 2007 | The Robert Graham Center, National Association of Community Health Centers

  • Economic Impact of Family Physicians in Wyoming2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Wisconsin2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in West Virginia2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Washington2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Vermont2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Utah2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Texas2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Tennessee2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in South Dakota2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in South Carolina2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Rhode Island2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Pennsylvania2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Oregon2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Oklahoma2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Ohio2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in North Dakota2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in North Carolina2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in New York2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in New Mexico2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impac t of Family Physicians in New Jersey2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in New Hampshire2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Nevada2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Nebraska2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Montana2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Missouri2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Mississippi2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Minnesota2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Michigan2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Massachusetts2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Maryland2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Maine2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Louisiana2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Kentucky2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Impact of Family Physicians in Kansas2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Indiana2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Illinois2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Idaho2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Hawaii2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Georgia2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Florida2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in the Distrcit of Columbia2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Connecticut2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Colorado2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in California2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Arkansas2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Arizona2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians in Alaska2 page PDF

    Reports | Jun 01, 2007 | Robert Graham Center

  • Economic Impact of Family Physicians In Alabama2 page PDF

    Reports | Mar 01, 2007 | Robert Graham Center

  • Training on the Clock: Family Medicine Residency Directors' Responses to Resident Duty Hours Reform

    Articles | Dec 15, 2006 | Lars E. Peterson, Hillary Johnson, Perry A. Pugno, Andrew Bazemore, Robert L. Phillips Jr.

    Meta description must not be left blank. (See Content Tab under the Meta section) Creation date must not be left blank. (See Content Tab under the Content Review section)

  • Imperative Integration: Medical Care for Older Patients

    One Pagers | Oct 01, 2006 | Larry Green, MD, et. al.

    The ecology of medical care changes for older people, with increases in usage of residential and institutional care, emergency departments, and home care. Care integrated across multiple settings, as is proposed for new models of primary care, is essential for the care of older patients.

  • National Health Service Corps Staffing and the Growth of the Local Rural Non-NHSC Primary Care Physician Workforce

    Articles | Sep 15, 2006 | Donald E. Pathman, George E. Fryer, Robert L. Phillips, John Smucny, Thomas Miyoshi and Larry A. Green

    CONTEXT: Beyond providing temporary staffing, National Health Service Corps (NHSC) clinicians are believed by some observers to contribute to the long-term growth of the non-NHSC physician workforce of the communities where they serve; others worry that NHSC clinicians compete with and impede the supply of other local physicians. PURPOSE: To assess long-term changes in the non-NHSC primary care physician workforce of rural underserved counties that have received NHSC staffing support relative to workforce changes in underserved counties without NHSC support. METHODS: Using data from the American Medical Association and NHSC, we compared changes from 1981 to 2001 in non-NHSC primary care physician to population ratios in 2 subsets of rural whole-county health professional shortage areas: (1) 141 counties staffed by NHSC physicians, nurse practitioners, and/or physician assistants during the early 1980s and for many of the years since and (2) all 142 rural health professional shortage area counties that had no NHSC clinicians from 1979 through 2001. FINDINGS: From 1981 to 2001, counties staffed by NHSC clinicians experienced a mean increase of 1.4 non-NHSC primary care physicians per 10,000 population, compared to a smaller, 0.57 mean increase in counties without NHSC clinicians. The finding of greater non-NHSC primary care physician to population mean ratio increase in NHSC-supported counties remained significant after adjusting for baseline county demographics and health care resources (P < .001). The estimated number of "extra" non-NHSC physicians in NHSC-supported counties in 2001 attributable to the NHSC was 294 additional physicians for the 141 supported counties, or 2 extra physicians, on average, for each NHSC-supported county. Over the 20 years, more NHSC-supported counties saw their non-NHSC primary care workforces grow to more than 1 physician per 3,500 persons, but no more NHSC-supported than nonsupported counties lost their health professional shortage area designations. CONCLUSIONS: 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.

  • Learning from Different Lenses: Reports of Medical Errors in Primary Care by Clinicians, Staff, and Patients

    Articles | Sep 15, 2006 | Robert L. Phillips, Susan M. Dovey, Deborah Graham, Nancy C. Elder and John M. Hickner

    OBJECTIVES: To test whether family doctors, office staff, and patients will report medical errors and to investigate differences in how and what they report. METHODS: Clinicians, staff, and patients in 10 family medicine clinics of the American Academy of Family Physicians National Research Network representing a diversity of clinical and community settings were invited to report errors they observed. They were asked to report routinely during 10 weeks and to report every error on 5 specific days. They submitted anonymous reports via a Web site, paper forms, and a voice-activated phone system. RESULTS: Four hundred one clinicians and staff reported 935 errors within 717 events, 37% (265) of which came from the 5 intensive reporting days and 61% (440) from routine reports. Staff made 384 (53%) reports, and clinicians, 342 (47%) reports. Most (96%) errors reported were process errors, not related to knowledge or skill. Staff reported more errors in patient flow and communication; clinicians reported more medication and laboratory errors. Reports suggest that patients with complex health issues (31% versus 20%, P = 0.013) are vulnerable to more severe outcomes. Patients submitted 126 reports, 18 of which included errors. CONCLUSIONS: Clinicians and staff offer different and independently valuable lenses for understanding errors and their outcomes in primary care, but both predominantly reported process- or system-related errors. There is a clear need to find more effective ways to invite patients to report on errors or adverse events. These findings suggest that patient safety organizations authorized by recent legislation should invite reports from a variety of health care workers and staff.

  • Family Physicians in the Child Health Care Workforce: Opportunities for Collaboration in Improving the Health of Children

    Articles | Sep 15, 2006 | Robert L. Phillips, MD, MSPH; Andrew W. Bazemore, MD, MPH; Martey S. Dodoo, PhD; Scott A. Shipman, MD, MPH; Larry A. Green, MD

    Pediatric workforce studies suggest that there may be a sufficient number of pediatricians for the current and projected U.S. child population. These analyses do not fully consider the role of family medicine in the care of children. Family physicians provide 16% to 26% of visits for children, providing a medical home for one-third of the child population, but face shrinking panels of children. Family medicine's role in children's health care is more stable in rural communities, for adolescents, and for underserved populations. For these populations, in particular, family medicine's role remains important. The erosion of the proportion of visits to family medicine is likely caused by the rapid rise in the number of pediatricians relative to a declining birth rate. Between 1981 and 2004, the general pediatrician population grew at 7 times the rate of the U.S. population, and the family physician workforce grew at nearly 5 times the rate. The number of clinicians caring for children meets or exceeds most estimates of sufficiency; however, the workforce distribution is skewed, leaving certain populations and settings underserved. More than 5 million children and adolescents live in counties with no pediatrician. Unmet need, addressing health in the context of families and communities, and tackling "millennial morbidities" represent common ground for both specialties that could lead to specific, collaborative training, research, intervention, and advocacy.

  • Prometheus: Igniting Payment Reform2 page PDF

    Presentations | Jun 15, 2006 | Francois DeBrantes National Coordinator Bridges to Excellence

  • The U.S. Medical Liability System: Evidence for Legislative Reform

    Articles | Jun 15, 2006 | Janelle Guirguis-Blake, MD, George E. Fryer, PhD, Robert L. Phillips Jr, MD, MSPH, Ronald Szabat, JD, LLM, Larry A. Green, MD

    Meta description must not be left blank. (See Content Tab under the Meta section) Creation date must not be left blank. (See Content Tab under the Content Review section)

  • International Medical Graduates in Family Medicine in the United States of America: An Exploration of Professional Characteristics and Attitudes

    Articles | Jun 15, 2006 | Amanda L. Morris, Robert L. Phillips, Jr., George E. Fryer, Jr., Larry A. Green, Fitzhugh Mullan

    BACKGROUND: The number of international medical graduates (IMGs) entering family medicine in the United States of America has steadily increased since 1997. Previous research has examined practice locations of these IMGs and their role in providing care to underserved populations. To our knowledge, research does not exist comparing professional profiles, credentials and attitudes among IMG and United States medical graduate (USMG) family physicians in the United States. The objective of this study is to determine, at the time when a large influx of IMGs into family medicine began, whether differences existed between USMG and IMG family physicians in regard to personal and professional characteristics and attitudes that may have implications for the health care system resulting from the increasing numbers of IMGs in family medicine in the United States. METHODS: This is a secondary data analysis of the 1996-1997 Community Tracking Study (CTS) Physician Survey comparing 2360 United States medical graduates and 366 international medical graduates who were nonfederal allopathic or osteopathic family physicians providing direct patient care for at least 20 hours per week. RESULTS: Compared to USMGs, IMGs were older (p < 0.001) and practised in smaller (p = 0.0072) and younger practices (p < 0.001). Significantly more IMGs practised in metropolitan areas versus rural areas (p = 0.0454). More IMG practices were open to all new Medicaid (p = 0.018) and Medicare (p = 0.0451) patients, and a greater percentage of their revenue was derived from these patients (p = 0.0020 and p = 0.0310). Fewer IMGs were board-certified (p < 0.001). More IMGs were dissatisfied with their overall careers (p = 0.0190). IMGs and USMGs did not differ in terms of self-rated ability to deliver high-quality care to their patients (p = 0.4626). For several of the clinical vignettes, IMGs were more likely to order tests, refer patients to specialists or require office visits than USMGs. CONCLUSION: 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.

  • Examining the Impact of Closing Family Medicine Residency Programs4 page PDF

    Presentations | May 15, 2006 | Jessica McCann, MA Valerie Reese, MD Andrew Bazemore, MD, MPH Robert Phillips, MD, MSPH

  • Recent Studies of the Family Physician Workforce: Implications for Education and Training8 page PDF

    Presentations | May 15, 2006 | Bob Phillips, MD, MSPH Andrew Bazemore, MD, MPH Martey Dodoo, PhD Perry Pugno, MD

  • The Diminishing Role of FPs in Caring for Children

    One Pagers | May 01, 2006 | Andrew Bazemore, MD, MPH; Robert Phillips, MD, MSPH; Martey Dodoo, PhD; Jessica McCann, MD; Lawrence Klein, PhD; Larry Green, MD

    Nationwide, family physicians (FPs) deliver a smaller proportion of the outpatient care of children than they did 10 years ago. Millions of children depend on FPs for care. Family medicine should reevaluate how it will contribute to the care of the nation's children.

  • Family Medicine Training: Time to be Counterculture Again7 page PDF

    Presentations | Apr 15, 2006 | Bob Phillips, MD, MSPH

  • Medicare Part D: Practical and Policy Implications for Family Physicians

    Commentaries & Editorials | Apr 15, 2006 | Giridhar Mallya, M.D., and Andrew W. Bazemore, M.D.

    Medicare Part D: Practical and policy implications for family physicians

  • Family Physicians Help Meet the Emergency Care Needs of Rural America

    One Pagers | Apr 01, 2006 | Laura Peterson; Andrew Bazemore, MD, MPH; Martey Dodoo, PhD; Robert Phillips, MD, MSPH

    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.

  • Out-of-Pocket Prescription Costs a Continuing Burden Under Medicare Part D

    One Pagers | Feb 01, 2006 | G Mallya, MD; Andrew Bazemore, MD, MPH; Robert Phillips, MD, PSPH; Larry Green, MD; Lawrence Klein, PhD; Martey Dodoo, PhD

    Of 29 million expected Part D beneficiaries, 6.9 million are projected to have annual out-of-pocket medication expenses greater than $750. Accounting for one fourth of all Part D enrollees, these beneficiaries also are most likely to have high aggregate health care costs, putting them at continued financial risk unless additional policy options are considered.

  • Medicare Part D: Who Wins, Who Loses?

    One Pagers | Feb 01, 2006 | G Mallya, MD; Andrew Bazemore, MD, MPH; Robert Phillips, MD, MSPH; Larry Green, MD; Lawrence Klein, PhD; Martey Dodoo, PhD

    The Medicare Part D prescription drug benefit aims to relieve the burden of out-of-pocket prescription drug costs for persons older than 65 years, but its effects will vary. Persons with low income and those without prior prescription coverage are projected to save the most, whereas those who lose employer-based coverage are predicted to pay more for their existing regimens.

  • Mind the Gap: Medicare Part D's Coverage Gaps May Affect Patient Adherence

    One Pagers | Feb 01, 2006 | G Mallya, MD; Andrew Bazemore, MD, MPH; Robert Phillips, MD, MSPH; Larry Green, MD; Lawrence Klein, PhD; Martey Dodoo, PhD

    Medicare Part D will lower medication expenditures for many older patients. However, its complex design incorporates a staggered series of cost-sharing mechanisms that create gaps in coverage and may have a negative impact on medication adherence.

  • Evidence and Tools for Advoacy from the Robert Graham Center33 page PDF

    Presentations | Jan 15, 2006 | Jennifer Rankin

  • Access, Health, and Wealth: Impact of the National Health Service Corps in Rural America49 page PDF

    Monographs & Books | Sep 15, 2006 | George E. Fryer, PhD; Jessica L. McCann, MA; Martey S. Dodoo, PhD; Larry A. Green, MD; Thomas Miyoshi; Robert L. Phillips, MD, MSPH

  • Healthstat: Making America's Health Care More Affordable43 page PDF

    Presentations | Feb 15, 2006 | R. Eric Hart, MD

  • Primary Care in the United States: Problems and Possibilities

    Commentaries & Editorials | Dec 15, 2005 | Robert L. Phillips, Jr., MD, MSPH

    The United States has never had a more robust primary care workforce, but dysfunctional financing schemes and inability to compete for the hearts and minds of the next generation of young doctors threaten its future. Many of the problems are a direct result of the market approach to health care. Innovation is needed in how primary care functions are financed, protected, organised, and taught in order to identify options for a stable and robust health system built on primary care.

  • UK Lessons for US Primary Care

    Commentaries & Editorials | Nov 15, 2005 | Marey Dodoo, Martin Roland, and Larry A. Green

    Primary care is now acknowledged to be a foundation of effective, sustainable health care for populations, with favorable effects on access to care, comprehensiveness, continuity, efficiency, and equity. In addition, variation in health care arrangements and policies across nations presents opportunities to compare and learn across national boundaries about what is working and how well in primary care. It would be advantageous for key U.S. organizations devoted to optimizing primary care to sustain for the foreseeable future exchanges with other countries to enable the United States to see itself more clearly, import innovations of relevance, and elude avoidable mistakes. While there is much to learn in many countries, U.K.-U.S. exchanges present immediate opportunities with particularly great relevance. It is not as if there is little to learn from one another. Rather, it is how much can be learned that can find prompt application in the redesign of primary care that is underway.

  • Who Will Have Health Insurance in the Year 2025?

    One Pagers | Nov 15, 2005 | Jennifer DeVoe, MD, DPhil; Marty Dodoo, PhD; Robert Phillips, MD, MSPH; Larry Green, MD

    If current trends continue, U.S. health insurance costs will consume the average household's 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.

  • Excess, Shortage, or Sufficient Physician Workforce: How Could We Know?

    One Pagers | Nov 01, 2005 | Martey Dodoo, PhD; Robert Phillips, MD, MSPH; Larry Green, MD; Ginger Ruddy, MD; Jessica McCann, MD; Lawrence Klein, PhD

    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.

  • Physician Workforce: Legal Immigrants will Extend Baby Boom Demands

    One Pagers | Oct 15, 2005 | Martey Dodoo, PhD; Robert Phillips, MD, MSPH; Larry Green, MD; Ginger Ruddy, MD; Jessica McCann, MD; Lawrence Klein, PhD

    The baby boom generation will place large demands on the Medicare program and the U.S. health care system. These demands may be extended by a large legal immigrant population that will become Medicare-eligible soon after the baby boom generation does. The U.S. health care system should be prepared for sustained stress from this aging population.

  • Physician Assistant and Nurse Practitioner Workforce Trends

    One Pagers | Oct 01, 2005 | Jessica McCann, MD; Robert Phillips, MD, MSPH; Edward O'Neil, MD; Ginger Ruddy, MD; Martey Dodoo, PhD' Lawrence Klein, PhD

    The physician assistant (PA) and nurse practitioner (NP) workforces have realized explosive growth, but this rate of growth may be declining. Most PAs work outside primary care; however, the contributions of PAs and NPs to primary care and interdisciplinary teams should not be neglected.

  • Number of Persons who Consulted a Physician, 1997 and 2002

    One Pagers | Sep 15, 2005 | Ed Fryer, PhD; Martey Dodoo, PhD; Larry Green, MD; Robert Phillips, MD, MSPH; Ginger Ruddy, MD; Jessica McCann, MD

    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.

  • Patterns of Visits to Physicians' Offices, 1980 to 2003

    One Pagers | Sep 01, 2005 | Marey Dodoo, PhD; Ed Fryer, PhD; Larry Green, MD; Robert Phillips, MD, MSPH; Ginger Ruddy, MD; Jessica McCann, MD

    In the past quarter century, the number of office visits to physicians in the United States increased from 581 million per year to 838 million per year, with slightly more than one half of total visits since 1980 being made to primary care physicians. Most visits to primary care physicians were made to family physicians (FPs) and general practitioners (GPs) until the mid 1990s, when visits to general internists and general pediatricians exceeded visits to FPs and GPs.

  • Osteopathic Physicians and the Family Medicine Workforce

    One Pagers | Aug 15, 2005 | Ginger Ruddy, MS; Robert Phillips, MD, MSPH; Lawrence Klein, MD; Jessica McCann, MD; Martey Dodoo, PhD; Larry Green, MD

    Historically, osteopathic physicians have made an important contribution to the primary care workforce. More than one half of osteopathic physicians are primary care physicians, and most of these are family physicians. However, the proportion of osteopathic students choosing family medicine, like that of their allopathic peers, is declining, and currently is only one in five.

  • Who Filled First-Year Family Medicine Residency Positions from 1991 to 2004?

    One Pagers | Aug 01, 2005 | Lawrence Klein, MD; Ginger Ruddy, MD; Robert Phillips, MD, MSPH; Jessica McCann, MS; Martey Dodoo, PhD; Larry Green, MD

    Graduates of U.S. allopathic schools have filled less than one half of the family medicine positions offered in the National Resident Matching Program (NRMP) Match since 2001. Overall fill rates in July have been relatively stable at approximately 94 percent. Family medicine has become reliant on international medical graduates (IMGs), who in 2004 made up 38 percent of first-year residents.

  • Physician Workforce: The Special Case of Health Centers and the National Health Service Corps

    One Pagers | Jul 15, 2005 | Robert Phillips, MD, MSPH; Ed Fryer, PhD; Ginger Ruddy. MD; Jessica McCann; Martey Dodoo, PhD; CS Klein

    Federally funded health centers and the National Health Service Corps (NHSC) depend on family physicians (FPs) and general practitioners (GPs) to meet the needs of millions of medically underserved people. Policy makers and workforce planners should consider how changes in the production of FPs would affect these programs.

  • The Family Physician Workforce: The Special Case of Rural Populations

    One Pagers | Jul 01, 2005 | Ginger Ruddy MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH; Larry Green, MD; Martey Dodoo, PhD; Jessica McCann, MD

    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.

  • Overcoming Obstacles in U.S. Health Care Delivery With a New Practice Model for Family Practice

    Articles | Jun 15, 2005 | Martey S. Dodoo, PhD, and Andrew Bazemore, MD

    Despite brisk advances in science and technology and a bounty of medical knowledge, tools, and techniques to enhance patient care, US physicians still labor daily to provide the highest quality care to their patients at reasonable cost. They struggle against a complex collection of economic and business hurdles and obstacles imposed by the health care system. These challenges have made the current system unworkable for many physicians. Policy analysts have argued that the system cannot continue this way for much longer and have speculated that health care service delivery in the US will soon become a crisis unless it undergoes a major overhaul. This essay highlights some of the hurdles and obstacles that have hindered physicians and presents brief summaries of some proposals currently being discussed to overcome them.

  • The Family Physician Workforce: Quality Not Quantity

    Commentaries & Editorials | Jun 15, 2005 | Larry A. Green, MD, and Robert L. Phillips, Jr, MD, MSPH

    The family physician workforce: Quality not quantity

  • Cost-Effective Roles for Nurse Practitioners in Secondary Prevention

    Commentaries & Editorials | Jun 15, 2005 | Phillips RL, McCann J

    Who pays and who saves may stymie implementation in the US

  • Notes from Visit to National Primary Care Research and Development Centre24 page PDF

    Monographs & Books | Jun 15, 2005 | Larry A. Green, Martey S. Dodoo, Martin Roland

  • Family Physicians and the Primary Care Physician Workforce in 2004

    One Pagers | Jun 15, 2005 | Larry Green, MD; Ed Fryer, PhD; GR Ruddy; Martey Dodoo, PhD; Robert Phillips, MD; MSPH; Jessica McCann

    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.

  • Using the Ecology Model to Describe the Impact of Asthma on Patterns of Health Care

    Articles | May 15, 2005 | Barbara P. Yawn, George E. Fryer, Robert L. Phillips, Jr., Susan M. Dovey, David Lanier, Larry A. Green

    BACKGROUND: Asthma changes both the volume and patterns of healthcare of affected people. Most studies of asthma health care utilization have been done in selected insured populations or in a single site such as the emergency department. Asthma is an ambulatory sensitive care condition making it important to understand the relationship between care in all sites across the health service spectrum. Asthma is also more common in people with fewer economic resources making it important to include people across all types of insurance and no insurance categories. The ecology of medical care model may provide a useful framework to describe the use of health services in people with asthma compared to those without asthma and identify subgroups with apparent gaps in care. METHODS: This is a case-control study using the 1999 U.S. Medical Expenditure Panel Survey. Cases are school-aged children (6 to 17 years) and young adults (18 to 44 years) with self-reported asthma. Controls are from the same age groups who have no self-reported asthma. Descriptive analyses and risk ratios are placed within the ecology of medical care model and used to describe and compare the healthcare contact of cases and controls across multiple settings. RESULTS: In 1999, the presence of asthma significantly increased the likelihood of an ambulatory care visit by 20 to 30% and more than doubled the likelihood of making one or more visits to the emergency department (ED). Yet, 18.8% of children and 14.5% of adults with asthma (over a million Americans) had no ambulatory care visits for asthma. About one in 20 to 35 people with asthma (5.2% of children and 3.6% of adults) were seen in the ED or hospital but had no prior or follow-up ambulatory care visits. These Americans were more likely to be uninsured, have no usual source of care and live in metropolitan areas. CONCLUSION: 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.

  • COGME's 16th Report to Congress: Too Many Physicians Could be Worse than Wasted

    Commentaries & Editorials | May 15, 2005 | Robert L. Phillips, Jr., MD, MSPH; Martey Dodoo, PhD; Carlos R. Jaen, MD, PhD; and Larry A. Green, MD

    Departing from past reports, the latest Council on Graduate Medical Education (COGME) report warns of a physician deficit of 85,000 by 2020 and recommends increases in medical school and residency output. COGME notes that contributions of other clinicians and changes in how medical care is delivered in the future would likely offset physician deficits but chose not to modify their recommendations. COGME offers a relatively minor workforce correction in an otherwise flawed system of health care; however, the nation awaits a reassessment of its physician workforce based on what the nation wants and needs from physicians working in modern systems of care. Great caution should be exercised in expanding the physician workforce. Producing a physician surplus could be far worse than wasted, because the investment required and resulting rise in health care cost may harm, not help, the health of people in the United States. Instead, these resources could be applied in ways that improve health.

  • Four-Year Residency Training for the Next Generation of Family Physicians

    Commentaries & Editorials | May 15, 2005 | Marguerite Duane, MD, MHA, and Robert L. Phillips, Jr., MD, MSPH

    Four-year residency training for the next generation of family physicians

  • Adding More Specialists is Not Likely to Improve Population Health: Is Anybody Listening?

    Commentaries & Editorials | Mar 24, 2005 | Robert L. Phillips Jr., MD, MSPH; Martey S. Dodoo, and Larry A. Green, MD

    Before a shortage of physicians, and particularly subspecialists, in the United States is declared, it is worth reviewing the considerable evidence that calls into question whether further specialization automatically improves health. should lead to purposeful choices about what we want them to do and the outcomes we expect.

  • Changes in Age-Adjusted Mortality Rates and Disparities for Rural Physician Shortage Areas Staffed by the National Health Service Corps: 1984-1998

    Articles | Mar 15, 2005 | Donald E. Pathman, MD, MPH; George E. Fryer, PhD; Larry A. Green, MD; and Robert L. Phillips, MD, MSPH.

    OBJECTIVE: This study assesses whether the National Health Service Corps's legislated goals to see health improve and health disparities lessen are being met in rural health professional shortage areas for a key population health indicator: age-adjusted mortality. METHODS: In a descriptive study using a pre-post design with comparison groups, the authors calculated age-adjusted mortality rates at baseline (1981-1983) and follow-up (1996-1998) for the populations of 448 rural whole-county health professional shortage areas arrayed into 3 groups based on the number of study years they were staffed by National Health Service Corps physicians, physician assistants, and nurse practitioners (terms of 1 to 7, 8 to 11, and 12 to 15 years). The authors compared changes over time in age-adjusted mortality rates in the 3 county groups that had National Health Service Corps staffing with rate changes in 172 whole-county rural health professional shortage areas and 772 non-health professional shortage area rural counties that had no National Health Service Corps. RESULTS: At baseline age-adjusted mortality was higher in all 4 health professional shortage area county groups than in the non-health professional shortage area county group. Age-adjusted mortality rates improved with time in all groups, including health professional shortage area counties both with and without National Health Service Corps support, and non-health professional shortage area counties. Essentially, baseline differences in age-adjusted mortality rates between health professional shortage areas and non-health professional shortage area counties did not diminish with time, whether or not there was National Health Service Corps support. CONCLUSIONS: 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.

  • What if We Were Equal? A Comparison of the Black-White Mortality Gap in 1960 and 2000

    Articles | Mar 15, 2005 | David Satcher, George E. Fryer, Jr., Jessica McCann, Adewale Troutman, Steven H. Woolf, George Rust

    The United States has made progress in decreasing the black-white gap in civil rights, housing, education, and income since 1960, but health inequalities persist. We examined trends in black-white standardized mortality ratios (SMRs) for each age-sex group from 1960 to 2000. The black-white gap measured by SMR changed very little between 1960 and 2000 and actually worsened for infants and for African American men age thirty-five and older. In contrast, SMR improved in African American women. 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.

  • Patients' Beliefs about Racism, Preferences for Physician Race, and Satisfaction with Care

    Articles | Mar 14, 2005 | Frederick M. Chen, MD, MPH; George E. Fryer, Jr., PhD; Robert L. Phillips, Jr., MD, MSPH; Elisabeth Wilson, MD, MPH; and Donald E. Pathman, MD, MPH

    Few studies have attempted to link patients’ beliefs about racism in the health care system with how they use and experience health care.

  • Avoiding and Fixing Medical Errors in General Practice: Prevention Strategies Reported in the Linnaeus Collaboration's Primary Care International Study of Medical Errors

    Articles | Jan 15, 2005 | Murray Tilyard, Susan Dovey and Katherine Hall

    OBJECTIVE: To report tactics for avoiding and remedying medical errors observed by general practitioners in New Zealand and five other countries. METHODS: The Primary Care International Study of Medical Errors collected 66 reports of medical errors in New Zealand and 363 reports from general practitioners in Australia, Canada, England, the Netherlands, and the United States. Strategies for avoiding and overcoming errors were grouped by themes, for New Zealand and the five other countries combined. RESULTS: In all New Zealand reports and 336 (92.6%) reports from other countries, doctors offered at least one error prevention idea. The largest category of suggestions was ‘more diligence’ (New Zealand: 69.7% of reports, other countries: 55.3%). Other strategies were: ‘provide care differently’ (New Zealand 22.7%, other countries 36.4%); ‘improve communication’ (19.7% and 17.8% of reports); ‘education’ (7.8% and 11.0% of reports); and ‘more resources’ (12.1% and 14.0% of reports). CONCLUSIONS: In general practitioners’ medical errors reports, a culture of individual blame is more evident than recognized need for systems design. A minority of reports contained specific, pragmatic suggestions for changing health care systems to protect patients’ safety. Error reporting systems may be a practical way to generate innovative solutions to potentially harmful problems facing general practice patients.

  • Report to the Task Force on the Care of Children by Family Physicians79 page PDF

    Monographs & Books | Jan 15, 2005 | Robert L. Phillips, Jr., MD, MSPH; Martey S. Dodoo, PhD; Jessica L. McCann, MA; Andrew Bazemore, MD; George E. Fryer, PhD; Lisa S. Klein; Michael Weitzman, MD; Larry A. Green, MD

  • The Health Impact of Resolving Racial Disparities: An Analysis of U.S. Mortality Data

    Articles | Dec 15, 2004 | Steven H. Woolf, MD, MPH; Robert E. Johnson, PhD; George E. Fryer, Jr, PhD, MSW; George Rust MD, MPH; and David Satcher, MD, PhD

    The U.S. health system spends far more on the "technology" of care (e.g., drugs, devices) than on achieving equity in its delivery. For 1991 to 2000, we contrasted the number of lives saved by medical advances with the number of deaths attributable to excess mortality among African Americans. Medical advances averted 176 633 deaths, but equalizing the mortality rates of Whites and African Americans would have averted 886202 deaths. Achieving equity may do more for health than perfecting the technology of care.

  • When Do Older Patients Change Primary Care Physicians?

    Articles | Nov 15, 2004 | James W. Mold, MD, MPH; George E. Fryer, PhD; A. Michelle Roberts, BA.

    BACKGROUND: Concerns have been raised about changes in the health care system that may disrupt continuity of care and thereby reduce the quality of that care. The purpose of this study was to look at the reasons older patients say they last changed primary care physicians (PCP), and to look at relationships between the duration of the PCP-patient relationship and the perceived quality of primary care received. METHODS: We analyzed data collected during the first two years of a longitudinal study of primary care patients 65 years of age and older. Variables included socio-demographic characteristics, duration of relationship with current PCP, reasons for leaving last PCP, estimated numbers of visits to PCP, other clinics, emergency departments, and admissions to hospitals and nursing homes in the last year, self-rated health and two measures of health-related quality of life, and the Components of Primary Care Index (CPCI). RESULTS: 799 patients of 23 PCPs were enrolled in year one of the longitudinal study, and 579 were re-evaluated in year two. The mean and median PCP-patient relationship duration were 10.27 and 8 years. Duration of the PCP-patient relationship was associated with greater patient age, income, level of education, and number of visits to the PCP. Longer relationship duration was also associated with higher scores on all eight CPCI subscales. The distribution of reasons for changing PCP was associated with duration of relationship, those with a longer relationship being more likely to change involuntarily. Insurance-related reasons for changing PCP were more common in those who had changed more recently. One hundred and fourteen (14%) changed their PCP during the first year of the study. Three CPCI subscale scores predicted PCP change, accumulated knowledge, communication, and family orientation. Eighty-seven percent changed involuntarily, forty-four percent for insurance related reasons and 40% because their doctor moved, retired, or died. CONCLUSIONS: 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.

  • The Continuity of Care Record

    Commentaries & Editorials | Oct 15, 2004 | David C. Kibbe, MD, MBA; Robert L. Phillips, Jr., MD, MSPH; and Larry A. Green, MD

    The continuity of care record

  • The Phsyician Workforce of the United States: A Family Medicine Perspective197 page PDF

    Monographs & Books | Oct 15, 2004 | Larry A. Green, MD; Martey S. Dodoo, PhD; Ginger Ruddy, MD; George E. Fryer, PhD; Robert L. Phillips, MD, MSPH; Jessica L. McCann, MA; Edward H. O’Neil, MPA, PhD, FAAN; Lisa S. Klein

  • Variation in Participation in Health Care Settings Associated with Race and Ethnicity

    Articles | Oct 15, 2004 | Erika B. Bliss, MD; David S. Meyers, MD; Robert L. Phillips, Jr., MD, MSPH; George E. Fryer, PhD; Susan M. Dovey, MPH, PhD; and Larry A. Green, MD

    OBJECTIVE: To use the ecology model of health care to contrast participation of Black, Non-Hispanics (Blacks), White, Non-Hispanics (Whites), and Hispanics of any race (Hispanics) in five health care settings and determine whether disparities between those individuals exist among places where they receive care. DESIGN: 1996 Medical Expenditure Panel Survey data were used to estimate the number of Black, White, and Hispanic people per thousand receiving health care in each setting. SETTING: physicians’ offices, outpatient clinics, hospital emergency departments, hospitals, and people’s homes. MAIN OUTCOME MEASURE: Number of people per 1000 per month who had at least one contact in a health care setting. RESULTS: Fewer Blacks and Hispanics than Whites received care in physicians’ offices (154 vs 155 vs 244 per 1000 per month, respectively) and outpatient clinics (15 vs 12 vs 24 per 1000 per month, respectively). There were no significant differences in proportions hospitalized or receiving care in emergency departments. Fewer Hispanics than Blacks or Whites received home health care services (7 vs 14 vs 14 per 1000 per month, respectively). After controlling for 7 variables, Blacks and Hispanics were less likely than Whites to receive care in physicians’ offices [Odds Ratio (OR) = 0.65, 95% Confidence Interval (CI) = 0.60-0.69 for Blacks and OR = 0.79, 95% CI = 0.73-0.85 for Hispanics], outpatient clinics (OR = 0.73, 95% CI = 0.60-0.90 for Blacks and OR = .71, 95% CI = 0.58-0.88 for Hispanics), and hospital emergency departments (OR = 0.80, 95% CI = 0.69-0.94 for Blacks and OR = 0.80, 95% CI = 0.68-0.93 for Hispanics) in a typical month. There was no significant difference between the groups in the likelihood of receiving care in the hospital or at home. CONCLUSIONS: 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.

  • The Importance of Having Health Insurance and a Usual Source of Care

    One Pagers | Sep 15, 2004 | Robert Phillips, MD, MSPH; M Proser; Larry Green, MD; Ed Fryer, PhD; Jessica McCann, MD; Martey Dodoo, PhD

    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.

  • A String of Mistakes: The Importance of Cascade Analysis in Describing, Counting, and Preventing Medical Errors

    Articles | Aug 15, 2004 | Steven H. Woolf, MD, MPH; Anton J. Kuzel, MD, MHPE; Susan M. Dovey, MPH, PhD; and Robert L. Phillips, Jr., MD, MSPH

    BACKGROUND: Notions about the most common errors in medicine currently rest on conjecture and weak epidemiologic evidence. We sought to determine whether cascade analysis is of value in clarifying the epidemiology and causes of errors and whether physician reports are sensitive to the impact of errors on patients. METHODS: Eighteen US family physicians participating in a 6-country international study filed 75 anonymous error reports. The narratives were examined to identify the chain of events and the predominant proximal errors. We tabulated the consequences to patients, both reported by physicians and inferred by investigators. RESULTS: A chain of errors was documented in 77% of incidents. Although 83% of the errors that ultimately occurred were mistakes in treatment or diagnosis, 2 of 3 were set in motion by errors in communication. Fully 80% of the errors that initiated cascades involved informational or personal miscommunication. Examples of informational miscommunication included communication breakdowns among colleagues and with patients (44%), misinformation in the medical record (21%), mishandling of patients’ requests and messages (18%), inaccessible medical records (12%), and inadequate reminder systems (5%). When asked whether the patient was harmed, physicians answered affirmatively in 43% of cases in which their narratives described harms. Psychological and emotional effects accounted for 17% of physician-reported consequences but 69% of investigator-inferred consequences. CONCLUSIONS: Cascade analysis of physicians’ error reports is helpful in understanding the precipitant chain of events, but physicians provide incomplete information about how patients are affected. Miscommunication appears to play an important role in propagating diagnostic and treatment mistakes.

  • How Family Physicians are Funded in the United States

    Commentaries & Editorials | Jul 15, 2004 | Larry A. Green

    How family physicians are funded in the United States

  • Splitting the Difference: Patient Preference vs Conservation of Resources

    Commentaries & Editorials | Jun 15, 2004 | Robert Phillips, Jr., MD, MSPH

    Splitting the difference: Patient preference vs conservation of resources

  • Annals of Family Medicine is 1 Year Old: So What and Who Cares?

    Commentaries & Editorials | Jun 15, 2004 | Larry A. Green, MD

    Annals of Family Medicine is 1 year old: So what and who cares?

  • Geographic Retrofitting: A Method of Community Definition in Community-Oriented Primary Care Practices

    Articles | Jun 15, 2004 | Fitzhugh Mullan, MD; Robert L. Phillips, Jr, MD, MSPH; Edward L. Kinman, PhD

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  • Future of Family Medicine Recommendations Confirm Need for Increased Research From Family Physicians

    Articles | Jun 15, 2004 | Larry A. Green

    Future of family medicine recommendations confirm need for increased research from family physicians

  • Chiropractors Are Not a Usual Source of Primary Health Care

    One Pagers | Jun 01, 2004 | Jessica McCann, MD; Robert Phillips, MD, MSPH; Larry Green, MD; Ed Fryer, PhD

    Chiropractors are the largest source of office-based care in the United States that does not involve a physician, but people do not view chiropractors as primary providers of health care or advice. Unlike the care given by primary care providers, the majority of care provided by chiropractors is limited to musculoskeletal problems.

  • Few People in the United States can Identify Primary Care Physicians

    One Pagers | May 15, 2004 | Mary Stock Keister, MD; Larry Green, MD; Norman Kahn, MD; Robert Phillips, MD, MSPH; Jessica McCann. MD; Ed Fryer, PhD

    Almost one decade after the Institute of Medicine defined primary care, only one-third of the American public is able to identify any of the medical specialties that provide it, and only 17% were able to accurately distinguish primary care physicians from medical or surgical specialists and non-physicians. This lack of discrimination compromises the goal of achieving primary care for all and merits immediate attention.

  • What People Want from Their Family Physician

    One Pagers | May 15, 2004 | Mary Stock Keister, MD; Larry Green, MD; Norman Kahn, MD; Robert Phillips, MD, MSPH; Jessica McCann, MD; Ed Fryer, PhD

    The public wants and is satisfied by care provided within a patient-physician relationship based on understanding, honesty and trust. If the U.S. healthcare system is ever to become patient-centered, it must be designed to support these values and sustain, rather than fracture, relationships people have with their primary physician.

  • The Research Domain of Family Medicine

    Articles | May 15, 2004 | Larry A. Green, MD

    This article characterizes the large research domain of family medicine. It is a domain that can be productively explored from different perspectives, including: (1) the ecology of medical care and its focus on the environments of health care and interactions among them (2) the realm of causation and important opportunities to discover how people lose and regain their health (3) knowing medicine in different ways, focusing on what things mean in the inner and outer realities of individuals and groups of individuals (4) the nature of the work of family physicians, such as first-contact care for any type of problem, sticking with patients regardless of their diagnoses, incorporating context into decision making, development of relevant technologies, articulating useful theory, and measuring what happens in family medicine (5) the standard research categories of basic, clinical, health services, health policy, and educational research, and (6) thinking of family medicine research as both a linear process of translation and a wheel of knowledge with iterative loops of discovery that come from within family medicine. The domain of family medicine research is important and ripe for fuller discovery, and it invites the thinking and imagination of the best investigators. It seems unlikely that medical research can ever be complete without a robust family medicine research enterprise. As the domain of family medicine research is explored, not a few, but billions of people will benefit.

  • Learning from Malpractice Claims about Negligent, Adverse Events in Primary Care in the United States

    Articles | Apr 15, 2004 | RL Phillips Jr, LA Bartholomew, SM Dovey, GE Fryer JR, TJ Miyoshi and LA Green

    BACKGROUND: The epidemiology, risks, and outcomes of errors in primary care are poorly understood. Malpractice claims brought for negligent adverse events offer a useful insight into errors in primary care. METHODS: Physician Insurers Association of America malpractice claims data (1985–2000) were analyzed for proportions of negligent claims by primary care specialty, setting, severity, health condition, and attributed cause. We also calculated risks of a claim for condition-specific negligent events relative to the prevalence of those conditions in primary care. RESULTS: Of 49 345 primary care claims, 26 126 (53%) were peer reviewed and 5921 (23%) were assessed as negligent; 68% of claims were for negligent events in outpatient settings. No single condition accounted for more than 5% of all negligent claims, but the underlying causes were more clustered with "diagnosis error" making up one third of claims. The ratios of condition-specific negligent event claims relative to the frequency of those conditions in primary care revealed a significantly disproportionate risk for a number of conditions (for example, appendicitis was 25 times more likely to generate a claim for negligence than breast cancer). CONCLUSIONS: Claims data identify conditions and processes where primary health care in the United States is prone to go awry. The burden of severe outcomes and death from malpractice claims made against primary care physicians was greater in primary care outpatient settings than in hospitals. Although these data enhance information about error related negligent events in primary care, particularly when combined with other primary care data, there are many operating limitations.

  • Specialist Physicians Providing Primary Care Services in Colorado

    Articles | Apr 15, 2004 | George E. Fryer, Jr.; Rachel Consoli; Thomas J. Miyoshi; Susan M. Dovey; Robert L. Phillips, Jr.; and Larry A. Green

    BACKGROUND: There is general consensus that the size of the US physician workforce now exceeds the health care needs of the American public. There is a greater proportion of specialists than primary care physicians, a specialty mix different from that of most other developed countries. METHODS: The Colorado Board of Medical Examiners sent a one-page questionnaire to all physicians licensed to practice in the state. It contained the question: "How many hours in the last week did you provide primary care services, defined as either preventive care, routine physical exams, or treatment of common ailments?" The responses of physicians who reported non-primary-care medical specialties were analyzed with respect to their personal and practice characteristics. RESULTS: Just under half (46.5%) of the 2745 specialist respondents reported having provided primary care services. As a group, however, 27.9% of specialist physicians’ direct patient care time was devoted to primary care activities. The amount of primary care services being provided was greater among those not board-certified in their specialties, osteopathic physicians, and specialists spending less time in direct patient care. CONCLUSION: Additional evaluation is needed with a more comprehensive definition of primary care than used in this article, which includes important but difficult-to-measure elements, such as the integration of services, a sustained partnership with patients, and practice in the context of family and community. To the extent possible, this definition should not rely on physician self-definition of which examinations are routine and which ailments are common. However, the contribution of specialists should be considered in future primary care needs assessments, and specialists who experience low demand for their particular specialties may be especially inclined to provide primary care services.

  • Who are the Uninsured Elderly in the United States?

    Articles | Apr 15, 2004 | James W. Mold, MD, MPH; George E. Fryer, PhD; and Cynthia H. Thomas, MSW

    Because of the Medicare program, a common assumption is made that virtually all older Americans have health insurance coverage. Data from the 2000 National Health Interview Survey were analyzed to estimate the number of people aged 65 and older without health insurance, their stated reasons for being uninsured, and the associations between lack of insurance and sociodemographic variables, health status, and access to and use of healthcare services. In 2000, there were approximately 350,000 older Americans with no health insurance. Those without insurance were more likely to be younger, Hispanic, nonwhite, unmarried (widowed, divorced, or never married), poor, and foreign-born. They were less likely to hold U.S. citizenship. Despite relatively high rates of chronic medical conditions, they were unlikely to receive outpatient or home healthcare services. The most common reason given for lack of insurance was its cost. 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.

  • The New Model of Primary Care: Knowledge Brought Dearly24 page PDF

    Monographs & Books | Mar 15, 2004 | Robert L. Phillips, Jr., MD, MSPH; Larry A. Green, MD; George E. Fryer, Jr., PhD; Jessica McCann, MA

  • The Balanced Budget Act of 1997 and the Financial Health of Teaching Hospitals

    Articles | Jan 15, 2004 | Robert L. Phillips, Jr, MD, MSPH; George E. Fryer, PhD; Frederick M. Chen, MD, MPH; Sarah E. Morgan, MD; Larry A. Green, MD; Ernest Valente, MA, PhD; and Thomas J. Miyoshi, MSW

    BACKGROUND: We wanted to evaluate the most recent, complete data related to the specific effects of the Balanced Budget Act of 1997 relative to the overall financial health of teaching hospitals. We also define cost report variables and calculations necessary for continued impact monitoring. METHODS: We undertook a descriptive analysis of hospital cost report variables for 1996, 1998, and 1999, using simple calculations of total, Medicare, prospective payment system, graduate medical education (GME), and bad debt margins, as well as the proportion with negative total operating margins. RESULTS: Nearly 35% of teaching hospitals had negative operating margins in 1999. Teaching hospital total margins fell by nearly 50% between 1996 and 1999, while Medicare margins remained relatively stable. GME margins have fallen by nearly 24%, however, even as reported education costs have risen by nearly 12%. Medicare+Choice GME payments were less than 10% of those projected. CONCLUSIONS: Teaching hospitals realized deep cuts in profitability between 1996 and 1999; however, these cuts were not entirely attributable to the Balanced Budget Act of 1997. Medicare payments remain an important financial cushion for teaching hospitals, more than one third of which operated in the red. The role of Medicare in supporting GME has been substantially reduced and needs special attention in the overall debate. Medicare+Choice support of the medical education enterprise is 90% less than baseline projections and should be thoroughly investigated. The Medicare Payment Advisory Commission, which has a critical role in evaluating the effects of Medicare policy changes, should be more transparent in its methods.

  • The Ecology of Medical Care for Children in the United States: A New Application of an Old Model Reveals Inequities That Can be Corrected

    One Pagers | Dec 15, 2003 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    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.

  • Exploring Residency Match Violations in Family Practice

    Articles | Nov 15, 2003 | Robert L. Phillips, Jr, MD, MSPH; Katherine A. Phillips, PhD; Frederick M. Chen, MD, MPH; and Allegra Melillo, MD, MS.

    BACKGROUND AND OBJECTIVES: This study's objective was to learn what student applicants to family practice residency programs in 2002 understood about National Resident Matching Program guideline violations, whether they experienced violations, and how they were affected by perceived violations. METHODS: We used qualitative analysis of in-depth interviews with 15 key informant students. RESULTS: Only six of the 15 students believed that they had experienced a violation. Only two students had experienced an actual Match guideline violation, and two more experienced potential violations. There was substantial confusion about what constituted a violation. The sources of confusion involved failure to attend Match orientation, lack of clarity in published information, confusing messages from programs, rumors and word-of-mouth, and students' own personal moral values. Equal Employment Opportunity Commission violations were interpreted by some as Match violations. Some students judged programs based on threats to the integrity of the Match, whether or not they experienced actual violations. CONCLUSIONS: Real and potential Match violations did occur, but there is also considerable confusion about what constitutes a violation. There are opportunities to investigate violations, train students to recognize and deal with violations, and clarify actual violation definitions and for programs to avoid the real and perceived violations that affect their recruiting.

  • A Study of Closure of Family Practice Residency Programs

    Articles | Nov 15, 2003 | English H. Gonzalez, MD, MPH; Robert L. Phillips, Jr, MD, MSPH; and Perry A. Pugno, MD, MPH, CPE.

    BACKGROUND: Between July 1, 2000, and July 1, 2002, the Residency Review Committee for Family Practice had received requests for voluntary withdrawal from 27 residency programs. This number represents a significant increase in the rate of program closure over previous years. OBJECTIVES: We compared descriptive data on these closing programs and explored factors contributing to the closure. METHODS: Descriptive program data were collected from the Accreditation Council for Graduate Medical Education, National Resident Matching Program, the American Academy of Family Physicians, and the American Board of Family Practice. Program directors from closing programs were invited to participate in a semi-structured interview to discuss factors contributing to the closure of their program. RESULTS: Seventy-five percent of closing programs were community based, median program age was 11 years, board pass rate averaged 98%, and 69% cared for underserved communities. Financial, political, and institutional leadership changes were most frequently cited by program directors as primary reasons for program closure. CONCLUSIONS: The rate of program closure is increasing, affecting programs that meet most measures of high quality. Quality programs are being lost, and the ultimate impact is yet to be seen. Program directors offer warning signs and advice that is generally applicable to other family practice residency programs.

  • Using Geographic Information Systems to Understand Health Care Access

    Articles | Nov 10, 2003 | Robert L. Phillips, Jr., MD MSPH, Michael L. Parchman, MD, Thomas J. Miyoshi, MSW

    Determining a community's health care access needs and testing interventions to improve access are difficult. This challenge is compounded by the task of translating the relevant data into a format that is clear and persuasive to policymakers and funding agencies. Geographic information systems can analyze and transform complex data from various sources into maps that illustrate problems effortlessly for experts and nonexperts.

  • The Need for Research in Primary Care

    Articles | Oct 15, 2003 | Jan M De Maeseneer, Mieke L van Driel, Larry A Green and Chris van Weel

    Making evidence from scientific studies available to clinical practice has been expected to directly improve quality of care, but this expectation has not been realised. The notion of quality of care is complex, and quality improvement needs medical, contextual, and policy evidence. In primary care, research is needed that takes into account the specific characteristics of its population and the presentation and prevalence of illness and disease. The context of the doctor-patient encounter plays a major part, and needs better understanding. At the policy level, issues of equity must be addressed. The knowledge base for family practice must be expanded by integration of multiple methods of comprehension, so we can bridge the gap between evidence and practice.

  • Why Does a U.S. Primary Care Physician Workforce Crisis Matter?

    Commentaries & Editorials | Oct 15, 2003 | Robert L. Phillips, Jr. MD, MSPH, and Barbara Starfield, MD, MPH

    Offers evidence that a primary care workforce crisis may once again be taking shape. The 1990s saw alignment of public policy and funding efforts to increase the primary care workforce, and indeed family medicine training capacity grew by 34 percent.

  • The U.S. Primary Care Physician Workforce: Undervalued Service

    One Pagers | Oct 15, 2003 | Holly Biola, MD; Larry Green, MD; Robert Phillips, MD MSPH; Janelle Guirguis-Blake, MD; Ed Fryer, PhD

    Primary care physicians work hard, but their compensation is not correlated to their work effort when compared with physicians in other specialties. This disparity contributes to student disinterest in primary care specialties.

  • The U.S. Primary Care Physician Workforce: Persistently Declining Interest in Primary Care Medical Specialties

    One Pagers | Oct 15, 2003 | Holly Biola, MD; Larry Green, MD; Robert Phillips, MD; MSPH; Janelle Guirguis-Blake, MD; Ed Fryer, PhD

    A persistent, six-year trend in the choice of specialty training by U.S. medical students threatens the adequacy of the physician workforce of the United States. This pattern should be reversed and requires the attention of policy makers and medical educators.

  • The U.S. Primary Care Physician Workforce: Minimal Growth 1980-1999

    One Pagers | Oct 15, 2003 | Holly Biola, MD; Larry Green, PhD; Robert Phillips, MD, MSPH; Janelle Guirguis-Blake, MD; ED Fryer, PhD

    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.

  • Family Physicians Are an Important Source of Newborn Care: The Case of the State of Maine

    One Pagers | Aug 15, 2003 | Donna Cohen, PhD; Janelle Guirguis-Blake, MD; David Jack, MD; V.K. Chetty, PhD; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    Family physicians (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.

  • Family Physicians Make a Substantial Contribution to Maternity Care: The Case of the State of Maine

    One Pagers | Aug 01, 2003 | Donna Cohen, PhD; Janelle Guirguis-Blake, MD; David Jack, MD; V.K. Chetty, PhD; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    Family physicians provided nearly 20 percent of labor and delivery care in Maine in the year 2000. A substantial proportion of this care was provided to women insured by Medicaid and those delivering in smaller, rural hospitals and residency-affiliated hospitals. As family medicine explores its future scope, research identifying regional variations in the maternity care workforce may clarify the need for maternity care training in residency and labor and delivery services in practice.

  • Variation in the Ecology of Medical Care

    Articles | Jul 15, 2003 | George E. Fryer, Jr., PhD; Larry A. Green, MD; Susan M. Dovey, PhD; Barbara P. Yawn, MD; Robert L. Phillips, MD, MSPH; and David Lanier, MD

    BACKGROUND: We wanted to quantify how the location in which medical care is delivered in the United States varies with the sociodemographic characteristics and health care arrangements of the individual person. METHODS: Data from the 1996 Medical Expenditures Panel Survey (MEPS) were used to estimate the number of persons per 1,000 per month in 1996 who had at least 1 contact with physicians’ offices, hospital outpatient departments, or emergency departments, hospitals, or home care. These data were stratified by age, sex, race, ethnicity, household income, education of head of household, residence in or out of metropolitan statistical areas, having health insurance, and having a usual source of care. RESULTS: Physicians’ offices were overwhelmingly the most common site of health care for all subgroups studied. Lacking a usual source of care was the only variable independently associated with a decreased likelihood of care in all 5 settings, and lack of insurance was associated with lower rates of care in all settings but emergency departments. Generally, more complicated patterns emerged for most sociodemographic characteristics. The combination of having a usual source of care and health insurance was especially related to higher rates of care in all settings except the emergency department. CONCLUSION: 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.

  • Oral Vitamin D3 Decreases Fracture Risk in the Elderly

    Articles | Jun 16, 2003 | Janelle Guirguis-Blake, MD, and Robert L. Phillips, Jr., MD, MSPH

    Vitamin D3 (or its physiologic equivalent, ergocalciferol), administered at a dose of 100,000 IU every 4 months for 5 years, is effective for primary prevention of fractures in the active elderly aged 65 to 85 years. This treatment regimen has no effect on cardiovascular, cancer, or all-cause mortality. Despite a seemingly large dose averaging 800 IU per day, this regimen is a safe, cheap (<$2 per year), and effective therapy for primary prevention of fractures.

  • The Ecology of Medical Care for Children in the United States

    Articles | May 15, 2003 | Susan Dovey, PhD, MPH, Michael Weitzman, MD, George Fryer, PhD, Larry Green, MD, Barbara Yawn, MD, MSc, David Lanier, MD, Robert Phillips, MD, MSPH

    BACKGROUND: Medical care ecology has previously been investigated for adults, but no similar exploration has been made specifically for children. OBJECTIVE: To describe proportions of children receiving care in 6 types of health care setting on a monthly basis and to identify characteristics associated with receipt of care in these settings. METHODS: Nationally representative data from the 1996 Medical Expenditure Panel Survey were used to estimate the number of children per 1000 per month who received care at least once in each type of setting. Multivariate analyses assessed associations between receiving care in various settings and children's sociodemographic factors (age, sex, ethnicity, poverty, parent's education, urban or rural residence, insurance status, and whether or not the child had a usual source of care). RESULTS: Of 1000 children aged 0 to 17 years, on average each month 167 visited a physician's office, 82 a dentist's office, 13 an emergency department, and 8 a hospital-based outpatient clinic. Three were hospitalized and 2 received professional health care in their home. Younger age was associated with increased proportions of children receiving care in all health care settings except dentists' clinics. Poverty, lack of health insurance, black race, and Hispanic ethnicity were associated with decreased receipt of care in physicians' and dentists' offices. Only age (<2 years and 13--17 years) and poverty status were associated with hospitalization (P < .05 for each). Rural residence was not associated with any significant variation in proportions of children receiving care in any setting. Having a usual source of care was associated with increased receipt of care in all settings except hospitals. CONCLUSIONS: 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.

  • Receipt of Preventive Care Among Adults: Insurance Status and Usual Source of Care

    Articles | May 15, 2003 | DeVoe JE, Fryer GE, Phillips R, Green L

    OBJECTIVES: This study ascertained the separate and combined effects of having insurance and a usual source of care on receiving preventive services. METHODS: Descriptive and multivariate analyses of 1996 Medical Expenditure Panel Survey data were conducted. RESULTS: Receipt of preventive services was strongly associated with insurance and a usual source of care. Significant differences were found between insured adults with a usual source of care, who were most likely to have received services, compared with uninsured adults without regular care, who were least likely to have received services. Those with either a usual source of care or insurance had intermediated levels of preventive services. CONCLUSIONS: Having a usual source of care and health insurance are both important to achieving national prevention goals.

  • Family Physicians Are an Important Source of Mental Health Care

    One Pagers | Apr 01, 2003 | Anu Subramanian PhD; Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    While comprising about 15 percent of the physician workforce, family physicians provided approximately 20 percent of physician office-based mental health visits in the United States between 1980 and 1999. This proportion has remained stable over the past two decades despite a decline in many other types of office visits to family physicians. Family physicians remain an important source of mental health care for Americans.

  • International Medical Graduates and the Primary Care Workforce for Rural Underserved Areas

    Articles | Mar 15, 2003 | Fink KS, Phillips RL, Fryer GE, Koehn N

    The proportion of international medical graduates (IMGs) serving as primary care physicians in rural underserved areas (RUAs) has important policy implications. We analyzed the 2000 American Medical Association Masterfile and Area Resource File to calculate the percentage of primary care IMGs, relative to U.S. medical graduates (USMGs), working in RUAs. We found that 2.1 percent of both primary care USMGs and IMGs were in RUAs, where USMGs were more likely to be family physicians but less likely to be internists or pediatricians. IMGs appear to have been no more likely than USMGs were to practice primary care in RUAs, but the distribution by specialty differs.

  • Family Physicians' Solutions to Common Medical Errors

    One Pagers | Mar 15, 2003 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    In two U.S. studies about medical errors in 2000 and 2001, family physicians offered their ideas on how to prevent, avoid, or remedy the five most often reported medical errors. Almost all reports (94 percent) included at least one idea on how to overcome the reported error. These ideas ranged from “do not make errors” (34 percent of all solutions offered to these five error types) to more thoughtfully proposed solutions relating to improved communication mechanisms (30 percent) and ways to provide care differently (26 percent). More education (7 percent) and more resources such as time (2 percent) were other prevention ideas.

  • Consequences of Medical Errors Observed by Family Physicians

    One Pagers | Mar 01, 2003 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    In two studies about medical errors, family physicians reported health, time, and financial consequences in nearly 85 percent of their error reports. Health consequences occurred when the error caused pain, extended or created illness, or placed patients, their families, and others at greater risk of harm. Care consequences included delayed diagnosis and treatment (sometimes of serious health conditions such as cancer), and disruptions to care that sometimes even resulted in patients needing care in a hospital. Other important consequences were financial and time costs to patients, health care providers, and the health system generally. However, sometimes no consequence was apparent.

  • The Effects of the 1997 Balanced Budget Act on Family Practice Residency Training Programs

    Articles | Feb 15, 2003 | Schneewiss R, Rosenblatt RA, Dovey S, Hart LG, Chen FM, Casey S, Fryer GE

    BACKGROUND AND OBJECTIVES: This study assessed the impact of the Balanced Budget Act (BBA) of 1997 on family practice residency training programs in the United States. METHODS: We surveyed 453 active family practice residency programs, asking about program closures and new program starts (including rural training tracks), changes in the number of residents and faculty, and curriculum changes. Programs were classified according to their urban or rural location, university or community hospital setting, and rural and/or urban underserved mission emphasis. RESULTS: A total of 435 (96%) of the programs responded. Overall, the impact of the BBA was relatively small. In 1998 and 1999, nationwide, there were 11 program closures, a net decrease of only 82 residents and a net increase of 52 faculty across program settings and mission emphasis. The rate of family practice residency program closures increased from an average of 3.0 year between 1988-1997 to 4.8 per year in the 4 years following passage of the BBA. CONCLUSIONS: The 1997 BBA did not have an immediate significant negative impact on family practice residency programs. However, there is a worrisome increase in the rate of family practice residency closures since 1997. A mechanism needs to be established to monitor all primary care program closures to give an early warning should this trend continue.

  • Types of Medical Errors Commonly Reported by Family Physicians

    One Pagers | Feb 15, 2003 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    In a group of studies about medical errors in family medicine, the five error types most often observed and reported by U.S. family physicians were: (1) errors in prescribing medications; (2) errors in getting the right laboratory test done for the right patient at the right time; (3) filing system errors; (4) errors in dispensing medications; and (5) errors in responding to abnormal laboratory test results. “Errors in prescribing medications” was the only one of these five error types that was also commonly reported by family physicians in other countries.

  • Family Physicians Increase Provision of Well-Infant Care Despite Decline in Prenatal Services

    One Pagers | Jan 01, 2003 | Janelle Guirguis-Blake, MD; Ed Fryer, PhD; Mark Deutchman, MD, MPH; Larry Green, PhD; Susan Dovey, MD, MPH; and Robert Phillips, MD, MSPH

    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.

  • Family Physicians' Declining Contribution to Prenatal Care in the United States

    One Pagers | Dec 15, 2002 | Janelle Guirguis-Blake, MD; Ed Fryer, PhD; Mark Deutchman, MD; Larry Green, MD; Susan Dovey, MD, MPH; Robert Phillips, MD, MSPH

    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.

  • Family Physicians Are the Main Source of Primary Health Care for the Medicare Population

    One Pagers | Dec 01, 2002 | James Mold, MD, MPH; Ed Fryer, PhD; Robert Phillips, MD, MSPH; Susan Dovey, MD, MPH; Larry Green, MD

    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.

  • Classification of Medical Errors and Preventable Adverse Events in Primary Care: A Synthesis of the Literature

    Articles | Nov 15, 2002 | Elder NC, Dovey SM

    OBJECTIVE: To describe and classify process errors and preventable adverse events that occur from medical care in outpatient primary care settings. STUDY DESIGN: Systematic review and synthesis of the medical literature. DATA SOURCES: We searched MEDLINE and the Cochrane Library from 1965 through March 2001 with MESH term medical errors, modified by adding family practice, primary health care, physicians/family, or ambulatory care and limited the search to English-language publications. Published biblographies and web sites from patient safety and primary care organizations were also reviewed for unpublished reports, presentations, and leads to other sites, journals, or investigators with relevant work. Additional papers were identified from the references of the papers reviewed and from seminal papers in the field. OUTCOMES MEASURED: Process errors and preventable adverse events. RESULTS: Four original research studies directly studied and described medical errors and adverse events in primary care, and 3 other studies peripherally addressed primary care medical errors. A variety of quantitative and qualitative methods were used in the studies. Extraction of results from the studies led to a classification of 3 main categories of preventable adverse events: diagnosis, treatment, and preventive services. Process errors were classified into 4 categories: clinician, communication, administration, and blunt end. CONCLUSIONS: Original research on medical errors in the primary care setting consists of a limited number of small studies that offer a rich description of medical errors and preventable adverse events primarily from the physician's viewpoint. We describe a classification derived from these studies that is based on the actual practice of primary care and provides a starting point for future epidemiologic and interventional research. Missing are studies that have a patient, consumer, or other health care provider input.

  • A Preliminary Taxonomy of Medical Errors in Family Practice

    Articles | Sep 15, 2002 | Dovey SM, Meyers DS, Phillips RL, Green LA, Fryer GE, Galliher JM, Kappus J, Grob P

    OBJECTIVE: To develop a preliminary taxonomy of primary care medical errors. DESIGN: Qualitative analysis to identify categories of error reported during a randomized controlled trial of computer and paper reporting methods. SETTING: The National Network for Family Practice and Primary Care Research. PARTICIPANTS: Family physicians. MAIN OUTCOME MEASURES: Medical error category, context, and consequence. RESULTS: Forty-two physicians made 344 reports: 284 (82.6%) arose from healthcare systems dysfunction; 46 (13.4%) were errors due to gaps in knowledge or skills; and 14 (4.1%) were reports of adverse events, not errors. The main subcategories were: administrative failures (102; 30.9% of errors), investigation failures (82; 24.8%), treatment delivery lapses (76; 23.0%), miscommunication (19; 5.8%), payment systems problems (4; 1.2%), error in the execution of a clinical task (19; 5.8%), wrong treatment decision (14; 4.2%), and wrong diagnosis (13; 3.9%). Most reports were of errors that were recognized and occurred in reporters' practices. Affected patients ranged in age from 8 months to 100 years, were of both sexes, and represented all major US ethnic groups. Almost half the reports were of events which had adverse consequences. Ten errors resulted in patients being admitted to hospital and one patient died. CONCLUSIONS: This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors.

  • Accounting for Graduate Medical Education Funding in Family Practice Training

    Articles | Sep 15, 2002 | Chen FM, Phillips RL, Schneeweiss R, Andrilla, CHA, Hart G, Fryer GE, Casey S, Rosenblatt RA

    BACKGROUND AND OBJECTIVES: Medicare provides the majority of funding to support graduate medical education (GME). Following the flow of these funds from hospitals to training programs is an important step in accounting for GME funding. METHODS: Using a national survey of 453 family practice residency programs and Medicare hospital cost reports, we assessed residency programs' knowledge of their federal GME funding and compared their responses with the actual amounts paid to the sponsoring hospitals by Medicare. RESULTS: A total of 328 (72%) programs responded; 168 programs (51%) reported that they did not know how much federal GME funding they received. Programs that were the only residency in the hospital (61% versus 36%) and those that were community hospital-based programs (53% versus 22%) were more likely to know their GME allocation. Programs in hospitals with other residencies received less of their designated direct medical education payment than programs that were the only residency in the sponsoring hospital (-45% versus +19%). CONCLUSIONS: More than half of family practice training programs do not know how much GME funding they receive. These findings call for improved accountability in the use of Medicare payments that are designated for medical education.

  • Can Nurse Practitioners and Physicians Beat Parochialism into Plowshares?

    Articles | Sep 15, 2002 | Robert L. Phillips Jr.; Doreen C. Harper; Mary Wakefield; Larry A. Green; and George E. Fryer Jr.

    Nurse practitioners have evolved into a large and flexible workforce. Far too often, nurse practitioner and physician professional organizations do not work together but rather expend considerable effort jousting in policy arenas. Turf battles interfere with joint advocacy for needed health system change and delay development of interdisciplinary teams that could help patients. A combined, consistent effort is urgently needed for studying, training, and deploying a collaborative, integrated workforce aimed at improving the health care system of tomorrow. The country can ill afford doctors and nurses who ignore one another's capabilities and fail to maximize each other's contributions cost-effectively.

  • Family Practice in the United States: Position and Prospects

    Articles | Aug 15, 2002 | Green LA, Fryer GE

    Family practice became the 20th U.S. medical specialty in 1969. It has delivered on its promise to reverse the decline of general practice and care for people with diverse problems in all areas of the country. But many important health care problems remain unsolved, in part because of poor role delineation for family physicians, poor differentiation of family practice from other fields, and insufficient changes in the cultural and political environment. Family practice's problems include confusion about whether it is a reform movement or an incumbent specialty; disagreement about its role in controlling and assuring care; confusion about whether family physicians are generalists or specialists; lack of clarity about family practice as vital for all versus a possible option for some; misunderstanding about the knowledge requirements for family practice; and inadequate business models. Family practice's mistakes include expending much effort on justification and less on assuring practical means to accomplish its work; permitting an erosion of public trust; failing to strengthen relationships with interfacing specialties and organizations; and neglecting research. Nonetheless, there are promising opportunities to improve health and health care through strengthening family practice that depend in part on redesigning the family practice setting, defining carefully critical interactions with other elements of the health care system, fostering discovery of family practice, and further differentiating family practice as a scientific and caring field. Another period of adaptation by family practice is already under way; this may be the first time in history that its ambitious aspirations are actually achievable.

  • Title VII Funding is Associated with More Family Physicians and More Physicians Serving the Underserved

    One Pagers | Aug 15, 2002 | David Meyers, MD; Gregory Krol, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH; Larry Green, MD

    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.

  • GME Financing Reform: The Saga Continues

    Commentaries & Editorials | Aug 15, 2002 | Robert L. Phillips, Jr., MD, MSPH; George E. Fryer, Jr. PhD; and Larry A. Green, MD

    GME financing reform: The saga continues

  • An International Taxonomy for Errors in General Practice: A Pilot Study

    Articles | Jul 15, 2002 | Makeham MAB, Dovey SM, County M, Kidd MR

    OBJECTIVES: To develop an international taxonomy describing errors reported by general practitioners in Australia and five other countries. DESIGN AND SETTING: GPs in Australia, Canada, the Netherlands, New Zealand, the United Kingdom and the United States reported errors in an observational pilot study. Anonymous reports were electronically transferred to a central database. Data were analysed by Australian and international investigators. PARTICIPANTS: Non-randomly selected GPs: 23 in Australia, and between 8 and 20 in the other participating countries. MAIN OUTCOME MEASURES: Error categories, and consequences. Results: In Australia, 17 doctors reported 134 errors, compared with 301 reports by 63 doctors in the other five countries. The final taxonomy was a five-level system encompassing 171 error types. The first-level classification was "process errors" and "knowledge and skills errors". The proportion of errors in each of these primary groups was similar in Australia (79% process; 21% knowledge and skills) and the other countries (80% process; 20% knowledge and skills). Patient harm was reported in 32% of reports from Australia and 30% from other countries. Participants considered the harm "very serious" in 9% of Australian reports and 3% of other countries' reports. CONCLUSIONS: This pilot study indicates that errors are likely to affect primary care patients in similar ways in countries with similar primary healthcare systems. Further comparative studies are required to improve our understanding of general practice error differences between Australia and other countries.

  • What Physicians Need to Know About Seniors and Limited Prescription Benefits and Why

    One Pagers | Jul 15, 2002 | Chien-Wen T, Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    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.

  • The Increase in International Medical Graduates in Family Practice Residency Programs

    Articles | Jun 15, 2002 | Koehn NN, Fryer GE, Phillips RL, Miller JB, Green LA

    BACKGROUND AND OBJECTIVES: The number of filled positions in family practice residency programs decreased by 18.6% from 1997–2001. This study sought to determine the degree of reliance on international medical graduates (IMGs) to fill family practice residency positions and the relative proportion of US citizen IMGs. METHODS: We analyzed the 1992–2001 National Resident Matching Program results, the 2000 American Medical Association Masterfile, and the 1992–2001 American Academy of Family Physicians Annual Survey of Family Practice Residency Programs. RESULTS: The percentage of IMGs matching in family practice remained stable between the years of 1992–1996 (10.0%–11.8%) but since 1997 has increased to a high of 21.4% in 2001. This rise in IMGs corresponds with a drop in the total percentage of family practice residency positions filled in the Match from 90.5% in 1996 to 76.3% in 2001. Despite the drop in Match numbers, the percentage of first-year family practice positions filled in July has remained in the range of 95.5%–97.8% since 1996. IMGs account for an increasing percentage of post-Match fills from 16.7% in 1996 to 47.9% in 2001. In 1999, a majority of family practice programs (279 [55.6%]), had at least one IMG. Of these, 48 programs (9.6%) had at least 50% of residents who were IMGs, and eight programs (1.6%) were entirely composed of IMGs. In five states (Connecticut, Illinois, Michigan, New Jersey, and New York), more than 25% of family practice residents were IMGs. CONCLUSIONS: Family practice is becoming increasingly reliant on IMGs to fill residency positions.

  • The Association of Title VII Funding to Departments of Family Medicine with Choice of Physician Specialty and Practice Location

    Articles | Jun 15, 2002 | George E. Fryer, Jr, PhD; David S. Meyers, MD; David M. Krol, MD; Robert L. Phillips, MD, MSPH; Larry A. Green, MD; Susan M. Dovey, MPH; and Thomas J. Miyoshi, MSW

    BACKGROUND: Title VII predoctoral and departmental grants for departments of family medicine are intended to increase the number of family and primary care physicians in the United States and increase the number of practices in rural and underserved communities. This study assessed the relationships of Title VII funding with physicians' choices of practice specialty and location. METHODS: Non-federal direct patient care physicians who graduated from US medical schools from 1981-1993 were identified in the 2000 American Medical Association Masterfile. A grant history file was used to annotate Masterfile records with Title VII funding data for the physicians' 4-year medical school enrollment. Characteristics of the county in which they practice were taken from the Area Resource File. Title VII funding variables were then related to practice specialty and location. RESULTS: Predoctoral training and departmental development funding were strongly related to attainment of each of the Title VII program objectives evaluated. CONCLUSIONS: 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.

  • First Morning Back

    Articles | Jun 15, 2002 | Larry A. Green, MD

    This diary-based report documented the increasing difficulty of practicing in primary care settings. Medical knowledge and skills are, in general, the easy part; getting into a position to apply them is the challenge.

  • Making Choices About the Scope of Family Practice

    Commentaries & Editorials | May 15, 2002 | Phillips RL, Green LA.

    Making choices about the scope of family practice

  • Primary Care Research: Revisiting its Definition and Rationale

    Commentaries & Editorials | Mar 15, 2002 | Mold JW, Green LA

    Too often the questions of basic biomedical research have been mistaken to represent the critical scope of all medical research, and traditional laboratory methods have been seen as necessary and sufficient methods for understanding human health and illness. As a result, approximately 90% of National Institutes of Health (NIH) funding is spent on research within the traditional biomedical sciences (anatomy, biochemistry, genetics, microbiology, molecular biology, physiology, and so forth). The smaller amount of federal funding available for clinical research has been spent primarily on specific disease entities, such as cancer and heart disease. These funding decisions have resulted in the neglect of a large proportion of the problems and issues that confront primary care physicians and their patients.

  • The Delicate Task of Workforce Determination

    Commentaries & Editorials | Mar 15, 2002 | Dovey SM, Green LA, Phillips RL, Fryer GE

    The delicate task of workforce determination

  • Does Career Dissatisfaction Affect the Ability of Family Physicians to Deliver High-Quality Patient Care?

    Articles | Mar 15, 2002 | DeVoe J, Fryer GE, Hargrave JL, Phillips RL, Green LA

    OBJECTIVES: A usual source of care is associated with better health outcomes. Dissatisfaction among family physicians and general practitioners (FP/GPs) may compromise the accessibility of a usual source of care and the quality of services. We examined the association between FP/GP dissatisfaction and an inability to deliver high-quality care. STUDY DESIGN: We performed a secondary analysis of the Community Tracking Study (CTS) Physician Survey (1996-1997). POPULATION: The study included a nationally representative sample of more than 12,000 non-federal physicians practicing direct patient care in the United States. OUTCOMES MEASURED: We measured associations of career dissatisfaction with physicians’ perceptions of their ability to provide high-quality care as defined by 6 survey items. Multivariate analysis controlled for the effects of personal, professional, and practice characteristics. RESULTS: Among FP/GPs in 1996-1997, more than 17% were dissatisfied. Age was the most significant personal factor associated with dissatisfaction; 25.1% of those aged 55 to 64 years reported dissatisfaction compared with only 10.1% of those younger than 35 years. Other personal or professional characteristics significantly associated with FP/GP dissatisfaction included osteopathic training, graduation from a foreign medical school, full practice ownership, and an income of less than $100,000. Physicians dissatisfied with their careers were much more likely to report difficulties in caring for patients, strong disagreeing (vs strong agreeing, odds ratio [OR] 1.0) that they had enough clinical freedom (OR 7.89; 95% confident interval [CI], 4.86-12.83); continuous patient relationships (OR 7.11; 95% CI, 4.90-10.33); no financial penalties for clinical decisions (OR 4.44; 95% CI, 3.13-6.31); adequate time with patients (OR 4.42; 95% CI, 2.84-6.87); ability to provide quality care (OR 4.26; 95% CI, 2.88-6.31); and sufficient communication with specialists (OR 3.57; CI 2.20-5.80). CONCLUSIONS: An inability to care for patients is significantly associated with career dissatisfaction. This relationship has implications for the achievement of policy objectives related to access, having a usual source of care and quality.

  • Length and Content of Family Practice Residency Training

    Articles | Mar 15, 2002 | Marguerite Duane, MD, MHA; Larry A. Green, MD; Susan Dovey, MPH, PhD; Sandy Lai, MD; Robert Graham, MD; and George E. Fryer, PhD

    BACKGROUND: Family practice residency programs are based largely on a model implemented more than thirty years ago. Substantial changes in medical practice, technology, and knowledge necessitate reassessment of how family physicians are prepared for practice. METHOD: We simultaneously surveyed samples of family practice residency directors, first year residents, and family physicians due for their first board recertification to determine, using both quantitative and qualitative methods, their opinions about the length and content of family practice residencies in the United States. RESULTS: Twenty seven percent of residency directors, 32% of residents, and 28% of family physicians favored extending family practice residency to four years; very few favored 2 or 5 year programs. There was dispersion of opinions about possible changes within each group and among the three groups. A majority of all three groups would be willing to extend residency for more training in office based procedures and sports medicine, but many were unwilling to extend training for more training in surgery or hospital based care. Residents expressed more willingness to change training than program directors or family physicians. Barriers to change included disagreement about the need to change; program financing and opportunity costs, such as loss of income and delay in debt repayment; and potential negative impact on student recruitment. CONCLUSION: Most respondents support the current three year model of training. There is considerable interest in changing both the length and content of family practice training. Lack of consensus suggests a period of elective experimentation may be needed to assure that family physicians are prepared to meet the needs and expectations of their patients.

  • Patients' Rights in the United States: From 'Down-Under' the Situation Seems Upside-Down

    Articles | Feb 15, 2002 | Gauld R

    Patients' rights in the United States: From 'down-under' the situation seems upside-down

  • The Role of Family Practice in Different Health Care Systems: A comparison of reasons for encounter, diagnoses, and interventions in primary care populations in the Netherlands, Japan, Poland, and the United States

    Articles | Jan 15, 2002 | Okkes IM, Polderman GO, Fryer GE, Yamada T, Bujak M, Oskam SK, Green LA, Lamberts H

    OBJECTIVE: Our goal was to compare the content of family practice in different countries using databases containing information on reasons for encounter, diagnoses, and interventions that are coded with or can be addressed by the International Classification of Primary Care (ICPC). STUDY DESIGN: In the Netherlands, Japan and Poland data were collected identically with an electronic patient record (Transhis). For all face-to-face encounters the reasons for encounter, diagnoses, and interventions were coded according to the ICPC within an episode of care structure; prescriptions were coded with the ICPC drug code. We derived comparable estimates for the United States using visit data from the National Ambulatory Care Survey (NAMCS), with specific emphasis on the contribution of family physicians. NAMCS data were mapped to the ICPC and the ICPC drug code, and Dutch, Polish, and Japanese data were directly standardized for the 1996 US population. Data on utilization, reasons for encounter, encounters per episode of care, new episodes of care, and prescriptions were compared. We also present World Health Organization and Organisation for Economic Co-operation and Development data on health care delivery, efficiency, expenditure, and health status for each country. RESULTS: We found important differences and striking similarities. Differences in the numbers of episodes and of encounters per patient per year were small compared with differences in utilization per episode of care, including diagnostic and therapeutic interventions. Substantial differences were found in prescribing antibiotics, oral contraceptives, cardiovascular medications, and gastrointestinal therapies. Prescribing behavior in the Netherlands and the United States are similar, while very different patterns were found in Japan and Poland. Similarities were much higher in patients’ reasons for encounter than in diagnoses. Only 35 groups of symptoms/complaints covered the top 30 in all databases, at the same time including 45% to 60% of all symptom/complaint reasons for encounter. The contribution of the US family physicians to care for common symptoms and episodes was generally high, but patients evidently also see other providers; the overall US distribution was similar to the Dutch data. With approximately 50 diagnoses, 45% to 60% of all new episodes of care were covered. Large differences existed in the contribution of family practice to gynecology/obstetrics and psychosocial problems. The proportion of all encounters per 1000 patients per year covered by the top 30 was 70% to 75%. CONCLUSION: Even under different conditions there was substantial overlap in the top 30 symptom/complaint reasons for encounter, incidence rates, and encounters per diagnosis in the 4 countries we studied. This striking resemblance supports the concept of the reason for encounter as a core element of the consultation with a family physician. Similarities between the databases are much better reflected by the way patients formulate their demand for care than in the diagnoses by the family physician. US patients also see providers other than family physicians for common problems; it remains unclear whether a limited group brings most of their health problems to a family physician or whether most people visit a series of primary care physicians. Possibilities to further develop episode-oriented epidemiology in family practice have considerably increased with this study. The potential for comparative studies has also increased with the introduction of complete electronic patient records based on the documentation of episodes of care with the ICPC and with its mapping to International Classification of Disease-10th revision (or the 9th revision clinical modification.)

  • It Takes a Balanced Health Care System to Get it Right

    Commentaries & Editorials | Dec 15, 2001 | Green LA, Dovey SM, and Fryer GE

    It takes a balanced health care system to get it right

  • Using Geographic Information Systems to Understand Health Care Access

    Articles | Nov 15, 2001 | Robert L. Phillips, Jr., MD MSPH, Michael L. Parchman, MD, Thomas J. Miyoshi, MSW

    Geographically locating patients to understand access to care and potential influences on health is not a new concept in primary care. However, it is only the more recent advances geographic information systems (GIS) that have made this process more accessible and robust for primary care. In this paper, we describe briefly some key steps in the integration of GIS in primary care research, and summarize an effort to use GIS for improving access to a community health center (CHC). given the relative universality of such data collection from CHCs nation-wide 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.

  • Taking Necessary Steps to Position U.S. Health Care to be the Best

    Articles | Nov 15, 2001 | Larry A Green

    Taking necessary steps to position U.S. health care to be the best

  • Uncoordinated Growth of the Primary Care Workforce

    One Pagers | Nov 01, 2001 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    Family physicians, nurse practitioners and physician assistants are distinctly different in their clinical training, yet they function interdependently. Together, they represent a significant proportion of the primary care work force. Training capacity for these three professions has increased rapidly over the past decade, but almost no collaborative work force planning has occurred.

  • Role Conflicts of Physicians and Their Family Members: Rules but no Rulebook

    Articles | Oct 15, 2001 | Chen FM, Rhodes LA, Green LA

    OBJECTIVES: To elucidate the difficulties physicians have when a family member becomes ill and to elicit their underlying causes. DESIGN: Using a key informant technique, we solicited chairs of family medicine departments for their experiences with health care provided to seriously ill family members. We then conducted in-depth, semistructured telephone interviews that were than transcribed, coded and labeled for themes. SUBJECTS: Eight senior family physicians whose parents have experienced a serious illness within the past 5 years. All of the subjects reflected on experiences stemming from their fathers' illness. RESULTS: These physicians faced competing expectations: at an internal level, those of their ideal role in their family and their ideal profession identity; and at an external level, those originating from other family members and from other physicians. Reconciling these conflicting expectations was made more difficult by what they deemed to be suboptimal circumstances of the modern health care system. CONCLUSIONS: Conflicting rules of appropriate conduct, compounded by the inadequacies of modern health care, make the role of physician-family member especially challenging. The medical profession needs a clearer, more trenchant understanding of this role.

  • Family Physicians' Experiences of Their Fathers' Health Care

    Articles | Oct 15, 2001 | Chen FM, Rhodes LA, Green LA

    OBJECTIVE: The American health care system is complicated and can be difficult to navigate. The physician who observes the care of a family member has a uniquely informed perspective on this system. We hoped to gain insight into some of the shortcomings of the health care system from the personal experiences of physician family members. STUDY DESIGN: Using a key informant technique, we invited by E-mail any of the chairpersons of US academic departments of family medicine to describe their recent personal experiences with the health care system when their parent was seriously ill. In-depth, semi-structured telephone interviews were conducted with each of the study participants. The interviews were transcribed, coded, and labeled for themes. POPULATION: Eight family physicians responded to the E-mail, and each was interviewed. These physicians had been in practice an average of 19 years, were nationally distributed, and included both mean and women. Each discussed his or her father's experience. RESULTS: All participants spoke of the importance of an advocate for their fathers who would coordinate medical care. These physicians witnessed various obstacles in their fathers' care, such as poor communication and fragmented care. As a result, many of them felt compelled to intervene in their fathers' care. The physicians expressed concern about the care their fathers received, believing that the system does not operate the way it should. CONCLUSIONS: Even patients with a knowledgeable physician family member face challenges in receiving optimal medical care. Patients might receive better treatment if health care systems reinforced the role of an accountable attending physician, encouraged continuity of care, and emphasized the value of knowing the patient as a person.

  • The Ecology of Medical Care Revisited

    Articles | Oct 15, 2001 | Green LA, Fryer GE, Yawn BP, Lanier D, Dovey SM

    The ecology of medical care revisited

  • Trumping Professional Roles: Collaboration of Nurse Practitioners and Physicians for a Better U.S. Health Care System

    One Pagers | Oct 15, 2001 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD

    Professional turf battles have yielded variations in the scope of practice for nurse practitioners (NPs) obstructing collaboration with physicians that would enhance patient care. Patients would be better served if NPs and physicians worked together to develop better combined models of education and service that take advantage of the benefits of both professions' contributions to care.

  • The Contemporary Ecology of U.S. Medical Care Confirms the Importance of Primary Care

    One Pagers | Sep 15, 2001 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    More women, men, and children receive medical care each month in the offices of primary care physicians than any other professional setting. There is an urgent need for health policies that encourage further innovation and implementation of first-rate primary care for everyone.

  • Hispanic Versus White, Non-Hispanic Physician Medical Practices in Colorado

    Articles | Aug 15, 2001 | Fryer GE Jr, Green LA, Vojir CP, Krugman RD, Miyoshi TJ, Stine C, Miller ME.

    The purpose of the study was to extend the scope of earlier research on minority physicians attending to the needs of the poor and their own ethnicity by contrasting practice characteristics of Hispanic doctors in Colorado with those of their white, non-Hispanic counterparts. It was found that Hispanic physicians spent more hours per week in direct patient care, were more likely to have a primary care specialty, and were less often specialty board certified than white, non-Hispanic doctors. Hispanic generalists established practices in areas in which the percentages of the population that were (1) below poverty level, (2) Hispanic, (3) Hispanic and below poverty level, and (4) white, non-Hispanic, and below poverty level were greater than in areas in which white, non-Hispanic primary care physicians practiced. These findings argue for special provision to admit ethnic minorities to undergraduate and graduate medical education programs.

  • Direct Graduate Medical Education Payments to Teaching Hospitals by Medicare: Unexplained Variation and Public Policy Contradictions

    Articles | May 15, 2001 | Fryer GE, Green LA, Dovey SM

    PURPOSE: To comprehensively examine both inter - and intrastate variations in Medicare's cost-rate structure for teaching hospitals and to assess the Medicare payment system for graduate medical education (GME), as presently configured, as an instrument to promote physician workforce reform, specifically sufficient public access to primary care physician services. METHOD: Using Public Use Files of hospital cost reports from the Health Care Financing Administration for fiscal year 1997, 648 hospitals that met inclusion criteria fro moderate GME volume were identified. The average and range of direct costs of resident training were computed for these teaching hospitals to illustrate differences within and between the 45 states that had at least two teaching hospitals that qualified for comparison. The cost rate upon which direct medical education (DME) payments are based was then correlated with the percentage of a state's counties that were wholly designated primary care health personnel shortage areas (PCHPSAs) in 1997 and with its primary care physician-to-population ratio, as determined by the Area Resource File. RESULTS: Variations in inter - and intrastate DME costs exist. In some states, the range in DME rates substantially exceeded the mean cost. DME funding policies are more generous toward teaching hospitals in states with greater primary care physician-to-population ratios and smaller proportions of counties wholly designated PCHPSAs. CONCLUSION: Inherent inequities in DME funding seriously undermine the current Medicare GME payment system's capacity to contribute to US physician workforce reform and to improve access to care. There is actually a financial incentive to train residents in areas in which there is relatively less need for their services.

  • The United States Relies on Family Physicians, Unlike Any Other Specialty

    One Pagers | May 01, 2001 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD

    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.

  • The View from 2020: How Family Practice Failed

    Articles | Apr 15, 2001 | Larry A. Green, MD

    This article is part of a special issue of Family Medicine dedicated to The Keystone Papers: Formal Discussion Papers from Keystone III.

  • Practice Based Primary Care Research Networks: They Work and are Ready for Full Development and Support

    Commentaries & Editorials | Mar 15, 2001 | Green LA, Dovey SM

    Practice based primary care research networks: They work and are ready for full development and support

  • The Patient Safety Grid: Toxic Cascades in Health Care Settings

    One Pagers | Mar 15, 2001 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    The Patient Safety Grid shows the fields where action is necessary in a comprehensive national effort to reduce harm from medical errors. Each segment of the grid is important and connected to others, sometimes forming a toxic cascade.

  • Toxic Cascades: A Comprehensive Way to Think About Medical Errors

    One Pagers | Mar 01, 2001 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    Current thinking about threats to patient safety caused by medical errors is often focused in hospital on the immediate consequences of mistakes that affect specific aspects of care, such as testing procedures or medications. Some mistakes, however, become apparent distant from where they were committed and only after a lapse in time. The model of a toxic cascade organizes an approach to making U.S. health care safer for patients by locating upstream sources and downstream consequences of errors within a comprehensive, multilevel scheme.

  • Shortchanging Adolescents: Room for Improvement in Preventive Care by Physicians

    Articles | Feb 15, 2001 | Merenstein D, Green LA, Fryer GE, Dovey SM

    BACKGROUND AND OBJECTIVES: Behaviors developed in adolescence influence health later in life. Adolescents seldom visit physicians to discuss health-related behaviors. Instead, physicians must incorporate health counseling into the exams for which the adolescents do come. We studied the frequency and duration of adolescents' consultations with family physicians and pediatricians involving counseling about diet and nutrition, exercise, weight reduction, cholesterol reduction, HIV transmission, injury prevention, and tobacco use. METHODS: Data were analyzed from the National Ambulatory Medical Care Survey for the 3-year period from 1995 through 1997. This survey uses a multistate national probability sample of patient visits to nonfederal, office-based physicians. We described patterns of counseling provided to adolescents and compared patterns for family physicians/general practitioners and pediatricians. RESULTS: Of 91,395 physician-reported visits analyzed, 4,242 (4.6%) were by adolescents ages 12-19. Visits to family physicians and pediatricians accounted for 1,846 (43.5%) of these visits. Counseling about any of the seven areas studied was included in 15.8% of family physician visits and 21.6% of pediatrician visits. The length of consultation increased from 13.8 to 17.6 minutes if counseling was included. CONCLUSION: Adolescents visit physicians infrequently. When they do, few receive counseling on critical adolescent health issues. Both family physicians and pediatricians have room for improvement.

  • The Importance of Primary Care Physicians as the Usual source of Health Care in the Achievement of Prevention Goals

    One Pagers | Nov 01, 2000 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD

    Having a usual source of care enhances achieving clinical prevention goals for both children and adults. There is room for improvement, and differences between the practices of internists and family physicians suggest that slightly longer visits and having health insurance might contribute to achieving proven prevention strategies.

  • The Importance of Having a Usual Source of Health Care

    One Pagers | Aug 01, 2000 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD

    Most people (82%) in the United States have and use for much of their health care 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.

  • The Effect of Accredited Rural Training Tracks on Physician Placement

    One Pagers | Jul 01, 2000 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD

    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.

  • Educating Doctors to Provide Counseling and Preventive Care: Turning 20th Century Professional Values Head over Heels

    Articles | Mar 15, 2000 | Dovey S, Green L, Fryer GE

    Internationally, 20th century medical education concentrated on equipping new graduates with technical skills and pushing the frontiers of technological sciences to extend and enhance life in ways unimaginable in previous decades. In the 21st century, health services are expected to be characterized not by the "fix-up-when-things-go-wrong" type of care that 20th century physicians have become so good at, but by preventive care that can obviate much of the need for these fix-up services. Enabling doctors to deal with the different health care needs of future patients will require a values shift in medical education. The United States leads the world in per capita health care expenditure yet trails in many important measures of health status. It epitomizes many elements of both the good and the bad in current medical education that may be less obvious in other countries that are less wealthy, less technologically oriented, and less committed to individual freedoms. In this paper we use the US as a case study to argue the need for a fundamental shift in values away from the 20th century emphasis on disease, specialization and treatment, and towards health, generalization and prevention. We draw on data from the National Ambulatory Medical Care Survey to compare roles of primary care physicians and other office-based medical specialties in delivering preventive health care. We also estimate the cost of providing preventive care in terms of physician time. Finally, we contemplate how medical education values must change in the US and other countries if 21st century physicians are to be prepared to meet the health care needs of their communities.

  • Rhetoric, Reality and Revolution in Family Practice and Primary Care

    Commentaries & Editorials | Dec 15, 1999 | Larry A Green, MD

    It is distressing to an observer from south of Canada to read the paper from the Ontario College of Family Physicians (Rosser and Kasperski). It indicates disruption and confusion within an admirable healthcare system - a system with a reputation of getting things right when it comes to family practice and primary care. Apparently, all is not well.

  • The Development and Goals of the AAFP Center for Policy Studies in Family Practice and Primary Care

    Articles | Nov 15, 1999 | Larry A. Green, MD, and George E. Fryer, PhD

    In this article we describe the creation and role of the Center for Policy Studies in Family Practice and Primary Care established by the American Academy of Family Physicians in Washington, DC, this year. We recount the events leading to the decision to implement the Center, list its guiding assumptions, and explain its initial structure and function. We also identify the three themes that will guide the early work of the Center: sustaining the functional domain of family practice and primary care; investing in key infrastructures; and securing universal health coverage.

  • Multi-Method Assessment of Access to Primary Medical Care in Rural Colorado

    Articles | Mar 15, 1999 | Fryer GE, Drisko J, Krugman RD, Vojir CP, Prochazka A, Miyoshi TJ, Miller ME.

    POLICY RELEVANCE: This paper introduces new analytical techniques helpful in evaluating the adequacy of accessibility to generalist physician resources for residents of non-MSA areas. Using methods which reveal provider caseload implications for the results of distance to care normative modeling can inform configuration of primary care delivery systems sensitive to the distribution of rural populations. OBJECTIVES: To conduct an analysis of access to primary medical care in rural Colorado, through simultaneous consideration of primary care physician-to-population and distance-to-nearest provider indices. Analysis examined the potential development and implications of excessively large, perhaps unmanageable patient caseloads which might result from every rural Coloadoan's exclusive use of the nearest generalist physician as a regular source of care. METHODS: Using American Medical Association Physician Masterfile data for 1995 and coordinates for latitude and longitude from U.S. Census files, the authors calculated distance to the nearest primary care physician for residents of each of the 1317 block groups in Colorado's 52 rural counties. Caseloads for each generalist physician were computed assuming the population used the nearest provider for care. RESULTS: Straight-line mileage to primary medical care was modest for rural Coloradoans; median distance of 2.5 miles. Almost two-thirds (65%) resided within 5 miles and virtually all (99%) within 30 miles of a generalist physician. But had everyone traveled the shortest possible distance to care, demand for service from many of the 343 primary care doctors in rural regions of the state would have been overwhelming. CONCLUSIONS: 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.

  • The Continued Importance of Small Practices in the Primary Care Landscape

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