C. Holly A Andrilla

Predictors of comprehensive surgical treatment in patients with ovarian cancer

Providing appropriate surgical treatment for women with ovarian cancer is one of the most effective ways to improve ovarian cancer outcomes. In this study, the authors identified factors that were associated with a measure of comprehensive surgery, so that interventions may be targeted appropriately to improve surgical care.

Dietary Assessment Instruments are Susceptible to Intervention-associated Response Set Bias

OBJECTIVE Evaluations of trials of the effectiveness of dietary intervention programs may be compromised by response set biases, such as those attributable to social desirability. Participants who receive a behavioral intervention may bias their reports of diet to appear in compliance with intervention goals. This study examined whether responses to standard dietary assessment instruments could be affected by a brief dietary intervention. DESIGN We assigned 192 undergraduate students randomly to (a) see a 17-minute videotape on the consequences of eating a high-fat diet or a placebo videotape on workplace management and (b) receive preintervention and post-intervention assessments or only postintervention assessment. Dietary assessments included 4 independent measures of fat intake. RESULTS Among women, bias (intervention minus control) was -9.7 g fat (from a short food frequency questionnaire) and -0.6 high-fat foods (from a questionnaire about use of 23 foods in the previous day) (P < .05 for both). No results were significant among men or for 2 instruments that measured more qualitative aspects of fat-related dietary habits. APPLICATIONS Even a modest dietary intervention can affect responses to dietary assessment instruments. Nutritionists should recognize that assessment of adherence to dietary change recommendations, when based on dietary self-report, can be overestimated as a result of response set biases.

Geographic and Specialty Distribution of US Physicians Trained to Treat Opioid Use Disorder

PURPOSE The United States is experiencing an epidemic of opioid-related deaths driven by excessive prescribing of opioids, misuse of prescription drugs, and increased use of heroin. Buprenorphine-naloxone is an effective treatment for opioid use disorder and can be provided in office-based settings, but this treatment is unavailable to many patients who could benefit. We sought to describe the geographic distribution and specialties of physicians obtaining waivers from the Drug Enforcement Administration (DEA) to prescribe buprenorphine-naloxone to treat opioid use disorder and to identify potential shortages of physicians. METHODS We linked physicians authorized to prescribe buprenorphine on the July 2012 DEA Drug Addiction Treatment Act (DATA) Waived Physician List to the American Medical Association Physician Masterfile to determine their age, specialty, rural-urban status, and location. We then mapped the location of these physicians and determined their supply for all US counties. RESULTS Sixteen percent of psychiatrists had received a DEA DATA waiver (41.6% of all physicians with waivers) but practiced primarily in urban areas. Only 3.0% of primary care physicians, the largest group of physicians in rural America, had received waivers. Most US counties therefore had no physicians who had obtained waivers to prescribe buprenorphine-naloxone, resulting in more than 30 million persons who were living in counties without access to buprenorphine treatment. CONCLUSIONS In the United States opioid use and related unintentional lethal overdoses continue to rise, particularly in rural areas. Increasing access to office-based treatment of opioid use disorder—particularly in rural America—is a promising strategy to address rising rates of opioid use disorder and unintentional lethal overdoses.

Reported referral for genetic counseling or BRCA 1/2 testing among United States physicians†‡

Genetic counseling and testing is recommended for women at high but not average risk of ovarian cancer. National estimates of physician adherence to genetic counseling and testing recommendations are lacking.

Barriers to Primary Care Physicians Prescribing Buprenorphine

PURPOSE Despite the efficacy of buprenorphine-naloxone for the treatment of opioid use disorders, few physicians in Washington State use this clinical tool. To address the acute need for this service, a Rural Opioid Addiction Management Project trained 120 Washington physicians in 2010–2011 to use buprenorphine. We conducted this study to determine what proportion of those trained physicians began prescribing this treatment and identify barriers to incorporating this approach into outpatient practice. METHODS We interviewed 92 of 120 physicians (77%), obtaining demographic information, current prescribing status, clinic characteristics, and barriers to prescribing buprenorphine. Residents and 7 physicians who were prescribing buprenorphine at the time of the course were excluded from the study. We analyzed the responses of the 78 remaining respondents. RESULTS Almost all respondents reported positive attitudes toward buprenorphine, but only 22 (28%) reported prescribing buprenorphine. Most (95%, n = 21) new prescribers were family physicians. Physicians who prescribed buprenorphine were more likely to have partners who had received a waiver to prescribe buprenorphine. A lack of institutional support was associated with not prescribing the medication (P = .04). A lack of mental health and psychosocial support was the most frequently cited barrier by both those who prescribe and who do not prescribe buprenorphine. CONCLUSION Interventions before and after training are needed to increase the number of physicians who offer buprenorphine for treatment of addiction. Targeting physicians in clinics that agree in advance to institute services, coupled with technical assistance after they have completed their training, their clinical teams, and their administrations is likely to help more physicians become active providers of this highly effective outpatient treatment.

Quality of Care for Myocardial Infarction in Rural and Urban Hospitals

BACKGROUND In the mid-1990s, significant gaps existed in the quality of acute myocardial infarction (AMI) care between rural and urban hospitals. Since then, overall AMI care quality has improved. This study uses more recent data to determine whether rural-urban AMI quality gaps have persisted. METHODS Using inpatient records data for 34,776 Medicare beneficiaries with AMI from 2000-2001, unadjusted and logistic regression analysis compared receipt of 5 recommended treatments between admissions to urban, large rural, small rural, and isolated small rural hospitals as defined by Rural Urban Commuting Area codes. RESULTS Substantial proportions of hospital admissions in all areas did not receive guideline-recommended treatments (eg, 17.0% to 23.6% without aspirin within 24 hours of admission, 30.8% to 46.6% without beta-blockers at arrival/discharge). Admissions to small rural and isolated small rural hospitals were least likely to receive most treatments (eg, 69.2% urban, 68.3% large rural, 59.9% small rural, 53.4% isolated small rural received discharge beta-blocker prescriptions). Adjusted analyses found no treatment differences between admissions to large rural and urban area hospitals, but admissions to small rural and isolated small rural hospitals had lower rates of discharge prescriptions such as aspirin and beta-blockers than urban hospital admissions. CONCLUSIONS Many simple guidelines that improve AMI outcomes are inadequately implemented, regardless of geographic location. In small rural and isolated small rural hospitals, addressing barriers to prescription of beneficial discharge medications is particularly important. The best quality improvement practices should be identified and translated to the broadest range of institutions and providers.

Access to specialty health care for rural American Indians in two states

CONTEXT The Indian Health Service (IHS), whose per capita expenditure for American Indian and Alaska Native (AI/AN) health services is about half that of the US civilian population, is the only source of health care funding for many rural AI/ANs. Specialty services, largely funded through contracts with outside practitioners, may be limited by low IHS funding levels. PURPOSE To examine specialty service access among rural Indian populations in two states. METHODS A 31-item mail survey addressing perceived access to specialty physicians, barriers to access, and access to non-physician clinical services was sent to 106 primary care providers in rural Indian health clinics in Montana and New Mexico (overall response rate 60.4%) and 95 primary care providers in rural non-Indian clinics within 25 miles of the Indian clinics (overall response rate 57.9%). FINDINGS Substantial proportions of rural Indian clinic providers in both states reported fair or poor non-emergent specialty service access for their patients. Montanas rural Indian clinic providers reported poorer patient access to specialty care than rural non-Indian clinic providers, while New Mexicos rural Indian and non-Indian providers reported comparable access. Indian clinic providers in both states most frequently cited financial barriers to specialty care. Indian clinic providers reported better access to most non-physician services than non-Indian clinic providers. CONCLUSIONS Reported limitations in specialty care access for rural Indian clinic patients appear to be influenced by financial constraints. Health care systems factors may play a role in perceived differences in specialty access between rural Indian and non-Indian clinic patients.

The contribution of physicians, physician assistants, and nurse practitioners toward rural primary care: findings from a 13-state survey.

Background:Estimates of the relative contributions of physicians, physician assistants (PAs), and nurse practitioners (NPs) toward rural primary care are needed to inform workforce planning activities aimed at reducing rural primary shortages. Objectives:For each provider group, this study quantifies the average weekly number of outpatient primary care visits and the types of services provided within and beyond the outpatient setting. Methods:A randomly drawn sample of 788 physicians, 601 PAs, and 918 NPs with rural addresses in 13 US states responded to a mailed questionnaire that measured reported weekly outpatient visits and scope of services provided within and beyond the outpatient setting. Analysis of variance and &khgr;2 testing were used to test for bivariate associations. Multivariate regression was used to model average weekly outpatient volume adjusting for provider sociodemographics and geographical location. Results:Compared with physicians, average weekly outpatient visit quantity was 8% lower for PAs and 25% lower for NPs (P<0.001). After multivariate adjustment, this gap became negligible for PAs (P=0.56) and decreased to 10% for NPs (P<0.001). Compared with PAs and NPs, primary care physicians were more likely to provide services beyond the outpatient setting, including hospital care, emergency care, childbirth attending deliveries, and after-hours call coverage (all P<0.001). Conclusions:Although our findings suggest that a greater reliance on PAs and NPs in rural primary settings would have a minor impact on outpatient practice volume, this shift might reduce the availability of services that have more often been traditionally provided by rural primary care physicians beyond the outpatient clinic setting.

Professional Liability Issues and Practice Patterns of Obstetric Providers in Washington State

OBJECTIVE: To describe recent changes in obstetric practice patterns and liability insurance premium costs and their consequences to Washington State obstetric providers (obstetrician–gynecologists, family physicians, certified nurse midwives, licensed midwives). METHODS: All obstetrician–gynecologists, rural family physicians, certified nurse midwives, licensed midwives, and a simple random sample of urban family physicians were surveyed about demographic and practice characteristics, liability insurance characteristics, practice changes and limitations due to liability insurance issues, obstetric practices, and obstetric practice environment changes. RESULTS: Fewer family physicians provide obstetric services than obstetrician–gynecologists, certified nurse midwives, and licensed midwives. Mean liability insurance premiums for obstetric providers increased by 61% for obstetrician–gynecologists, 75% for family physicians, 84% for certified nurse midwives, and 34% for licensed midwives from 2002 to 2004. Providers’ most common monetary responses to liability insurance issues were to reduce compensation and to raise cash through loans and liquidating assets. In the 2 years of markedly increased premiums, obstetrician–gynecologists reported increasing their cesarean rates, their obstetric consultation rates, and the number of deliveries. They reported decreasing high-risk obstetric procedures during that same period. CONCLUSION: Liability insurance premiums rose dramatically from 2002 to 2004 for Washington’s obstetric providers, leading many to make difficult financial decisions. Many obstetric providers reported a variety of practice changes during that interval. Although this study’s results do not document an impending exodus of providers from obstetric practice, rural areas are most vulnerable because family physicians provide the majority of rural obstetric care and are less likely to practice obstetrics. LEVEL OF EVIDENCE: III

The productivity of Washington State's obstetrician-gynecologist workforce: Does gender make a difference?

OBJECTIVE: To compare the practice productivity of female and male obstetrician–gynecologists in Washington State. METHODS: The primary data collection tool was a practice survey that accompanied each licensed practitioners license renewal in 1998–1999. Washington State birth certificate data were linked with the licensure data to obtain objective information regarding obstetric births. RESULTS: Of the 541 obstetrician–gynecologists identified, two thirds were men and one third were women. Women were significantly younger than men (mean age 43.3 years versus 51.7 years). Ten practice variables were evaluated: total weeks worked per year, total professional hours per week, direct patient care hours per week, nondirect patient care hours per week, outpatient visits per week, inpatient visits per week, percent practicing obstetrics, number of obstetrical deliveries per year, percentage working less than 32 hours per week, and percentage working 60 or more hours per week. Of these, only 2 variables showed significant differences: inpatient visits per week (women 10.1 per week, men 12.8 per week, P ≤ .01) and working 60 or more hours per week (women 22.1% versus men 31.5%, P ≤ .05). After controlling for age, analysis of covariance and multiple logistic regression confirmed these findings and in addition showed that women worked 4.1 fewer hours per week than men (P < .01). When examining the ratio of female-to-male practice productivity in 10-year age increments from the 30–39 through the 50–59 age groups, a pattern emerged suggesting lower productivity in many variables in the women in the 40–49 age group. CONCLUSION: Only small differences in practice productivity between men and women were demonstrated in a survey of nearly all obstetrician–gynecologists in Washington State. Changing demographics and behaviors of the obstetrician–gynecologist workforce will require ongoing longitudinal studies to confirm these findings and determine whether they are generalizable to the rest of the United States. LEVEL OF EVIDENCE: II-3