Health Geography

The Robert Graham Center has always had an interest in the role of geography in health care. From its earliest days, the Graham Center included geography in the research we conducted. Geography helps us to understand the context in which patients live; it helps us to better understand the distribution of the health care workforce; it helps us to evaluate medical education programs in terms of the areas in which their graduates practice.

Social Deprivation Index (SDI)

The Robert Graham Center has compiled the Social Deprivation Index (SDI), which is a composite measure of area level deprivation.

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Explore a vast library of data related to health and social determinants of health, upload your own data, and make and print customizable maps that tell stories important to health policy and primary care in your area.

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Med School Mapper

Visualize map data and create reports on the community and national impact of any US Medical School.

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Primary Care Physician Mapper

Explore the distribution of primary care physicians by state, county, or census tracts in metropolitan areas.

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Residency Footprinting Mapper

View interactive maps that depict the historical relationship between residency programs, community, state and region.

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UDS Mapper

Explore existing Health Center Program service areas, where gaps in the safety net might exist, and which neighborhoods or regions might hold the highest priorities for health center expansion.

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Narrow Results:

  • Mobility of US Rural Primary Care Physicians During 2000-2014

    Articles | Jul 11, 2017 | Matthew R. McGrail, PhD; Peter Wingrove, BS; Stephen Petterson, PhD; and Andrew Bazemore, MD, MPH

    Rural populations continue to experience relative shortages of the supply of primary care physicians. Difficulties of both recruitment and retention of physicians in rural areas, which greatly contribute to experienced shortages, are well acknowledged. This manuscript builds on considerable research on this topic with a specific focus on primary care physician mobility.

  • Regional Variation in Primary Care Involvement at the End of Life

    Articles | Jan 14, 2017 | Claire Ankuda, MD, MPH1; Stephen M. Petterson, PhD; Peter Wingrove, BS; and Andrew W. Bazemore, MD, MPH

    Regions with greater primary care physician involvement in end-of-life care have overall less intensive end-of-life care.

  • Rural Opioid Use Disorder Treatment Depends on Family Physicians

    One Pagers | Oct 03, 2016 | Peter Wingrove, BS; Brian Park, MD, MpH; and Andrew Bazemore, MD, MpH

    The nation’s growing opioid use disorder epidemic disproportionately impacts rural areas.

  • Community Vital Signs: Taking the Pulse of the Community While Caring for Patients

    Articles | Jun 01, 2016 | Lauren S. Hughes, MD, MPH, MSc; Robert L. Phillips Jr., MD, MSPH; Jennifer E. DeVoe, MD, DPhil; and Andrew W. Bazemore, MD, MPH

    Community vital signs—aggregated community-level information about the neighborhoods in which our patients live, learn, work, and play—convey contextual social deprivation and associated chronic disease risks based on where patients live.

  • Teaching Health Center Graduate Medical Education Locations Predominantly Located in Federally Designated Underserved Areas

    Articles | May 16, 2016 | Songhai C. Barclift , MD, FACOG; Elizabeth J. Brown, MD, MSHP; Sean C. Finnegan, MS; Elena R. Cohen, BA; and Kathleen Klink , MD, FAAFP

    The objective of this study was to describe and quantify federally designated clinical continuity training sites of the THCGME program.

  • Supporting Health Reform in Mexico: Experiences and Suggestions From an International Primary Health Care Conference

    Articles | May 16, 2016 | Chris van Weel, MD, PhD; Deborah Turnbull, MPsy, PhD; José Ramirez, MD; Andrew Bazemore, MD, MSHP; Richard H. Glazier, MD; Carlos Jaen, MD, PhD; Bob Phillips, MD, MSHP; and Jon Salsberg, PhD

    A pre-conference at the 2015 Cancun NAPCRG conference aimed to develop an action plan and build leadership

  • Access to Primary Care in U.S. Counties Is Associated with Lower Obesity Rates

    Articles | Apr 14, 2016 | Anne H. Gaglioti, MD; Stephen Petterson, PhD; Andrew Bazemore, MD, MPH; and Robert Phillips, MD

    Obesity causes substantial morbidity and mortality in the United States. Evidence shows that primary care physician (PCP) supply correlates positively with improved health, but its association with obesity in the United States as not been adequately characterized.

  • Only 15% of FPs Report Using Telehealth; Training and Lack of Reimbursement Are Top Barriers

    One Pagers | Jan 15, 2016 | Miranda A. Moore, Phd; Megan Coffman, MS; Anuradha Jetty, MPH; Stephen Petterson, PhD; and Andrew Bazemore, MD, MPH

    Little is known about primary care clinicians’ implementation of, awareness of, and attitudes toward telehealth.

  • 2015 PCORI Report38 page PDF

    Reports | Dec 01, 2015 | The Robert Graham Center

  • “Community Vital Signs”: Incorporating Geocoded Social Determinants into Electronic Records to Promote Patient and Population Health

    Articles | Aug 01, 2015 | Andrew Bazemore, MD, MPH; Erika Cottrell, PhD; Rachel Gold, PhD; Lauren Hughes, MD, MPH; Robert Phillips, MD, MSPH; Heather Angier, MA; Timothy Burdick, MD; Mark Carrozza, MA; and Jennifer DeVoe, MD, DPhil

    Knowing Community VS could inform clinical recommendations for individual patients, facilitate referrals to community services, and expand understanding of factors impacting treatment adherence and health outcomes.

  • 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.

  • 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.

  • 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.

  • 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.

  • 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.

  • Rural Primary Care Physician Workforce Expansion: An Opportunity for Bipartisan Legislation

    Articles | Dec 02, 2013 | Richard Rieselbach, MD; Robert Phillips, MD; Byron Crouse, MD; and Thomas Nasca, MD

    The primary care physician workforce crisis has eluded solution for many years. There is an estimated shortage of 16 000 primary care physicians (PCPs) necessary to meet today's needs; this deficit will grow to 52 000 in the next decade. An aging population, with an aging population of physicians themselves, will exacerbate this situation. We believe that expansion of primary care graduate medical education (GME) to address this shortage is urgently needed, and represents an opportunity for bipartisan support of GME expansion legislation.

  • 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.

  • The Characteristics and Distribution of International Medical Graduates from Mainland China, Taiwan and Hong Kong in the US

    Articles | Nov 01, 2013 | Imam Xierali, PhD

    As healthcare systems around the world are facing increasing physician shortages, more physicians are migrating from low to high income countries. Differences in medical education and international interaction may have significant effect on physician flows. The Chinese Medical Graduates (CMGs) in the US present an interesting case to examine this effect.

  • 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

  • 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.

  • 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

  • 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.

  • 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.

  • 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

  • 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

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

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

    Evidence About Your Value (and the return on investment)

  • 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

    Primary Care Present and Future

  • 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

  • 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

  • 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, PhD; 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.

  • 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.

  • 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.

  • 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.

  • 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.

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

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

    House draft bill H.R. 3200 was introduced in the House on July 13, 2009. Since then it has undergone committee consideration and a mark-up session. Section 1721 of HR 3200 relates to payments to primary care physicians and “requires that State Medicaid programs reimburse for primary care services furnished by physicians and other practitioners at no less than 80% of Medicare rates in 2010, 90% in 2011, and 100% in 2012 and after.” It further “maintains the Medicare payment differentials between physicians and other practitioners. The federal government would pay 100% of the incremental costs attributable to this requirement.” This white paper reports on analyses to assess and estimate the effects of Section 1721 of draft bill HR 3200 on the total gross revenue of the average physician nationally and the total gross revenue of the average family physician in each state. It shows the widely variable but important impact.

  • 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.

  • 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

    The US Senate Finance Committee and the Medicare Payment Advisory commission have both proposed incentive payments for primary care physicians who meet certain thresholds of "primary care-ness." With the support of the AAFP Foundation, the Graham Center analyzed how many physicians would meet proposed thresholds, and the potential impact on both physician revenue and Medicare costs. A 60% threshold (60% of claims dollars are for home, nursing home, or office visits) will capture about 60% of family physicians but only 40% of general internists. This suggests that a substantial bonus may influence more primary care physicians to deliver more primary care. But because it excludes more rural physicians than urban, these threshold codes may also be excluding physicians doing a broader scope of appropriate primary care. We do not yet suggest additional codes to be considered but suggest that Congress and the Administration need to re-evaluate their choices to avoid the unintended consequence of overly restricting the range of services needed for the Patient Centered Medical Home.

  • 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.

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

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

    Specialty and geographic distribution of the physician workforce: What influences medical student & resident choices?

  • The Robert Graham Center Update 200847 page PDF

    Presentations | Jul 15, 2008 | Robert Graham Center

    A compendium of slides for public use that includes original and adapted analyses and commentary from the staff of the Robert Graham Center.

  • 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.

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

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

  • 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.

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

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

  • 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

    GIS and General Practice: Where are we going and when will we get there? A REPORT FROM THE 2007 APHCRI / ROBERT GRAHAM CENTER VISITING FELLOWSHIP

  • 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.

  • Democratizing and Displaying Health Data: Introducing

    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.

  • 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

    The distribution of IMGs in the U.S.: The interplay of poverty, rurality, and length of practice

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

    Articles | Apr 15, 2007 | Robert L. Phillips Jr, Stephen Petterson, PhD; George E. Fryer Jr; and 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.

  • 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

    Impact of Title VII funding on community health center staffing and the National Health Service Corps

  • An Acess Deprivation Index & HealthLandscape14 page PDF

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

    An access deprivation index and HealthLandscape

  • 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

    The National Health Service Corps in rural counties: A historical review and impact assessment

  • 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.

  • 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.

  • 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.

  • 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

  • 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

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  • 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

    Examining the impact of closing family medicine residency programs

  • 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.

  • 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.

  • 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.

  • 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 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.

  • 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.

  • 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.

  • 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.)

  • 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.

  • 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.

  • 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.

  • 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 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.

  • 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.