David L. Rabin

Projecting US Primary Care Physician Workforce Needs: 2010-2025

PURPOSE We sought to project the number of primary care physicians required to meet US health care utilization needs through 2025 after passage of the Affordable Care Act. METHODS In this projection of workforce needs, we used the Medical Expenditure Panel Survey to calculate the use of office-based primary care in 2008. We used US Census Bureau projections to account for demographic changes and the American Medical Associations Masterfile to calculate the number of primary care physicians and determine the number of visits per physician. The main outcomes were the projected number of primary care visits through 2025 and the number of primary care physicians needed to conduct those visits. RESULTS Driven by population growth and aging, the total number of office visits to primary care physicians is projected to increase from 462 million in 2008 to 565 million in 2025. After incorporating insurance expansion, the United States will require nearly 52,000 additional primary care physicians by 2025. Population growth will be the largest driver, accounting for 33,000 additional physicians, while 10,000 additional physicians will be needed to accommodate population aging. Insurance expansion will require more than 8,000 additional physicians, a 3% increase in the current workforce. CONCLUSIONS Population growth will be the greatest driver of expected increases in primary care utilization. Aging and insurance expansion will also contribute to utilization, but to a smaller extent.

Genome-wide search for sarcoidosis susceptibility genes in African Americans

Sarcoidosis, a systemic granulomatous disease of unknown etiology, likely results from an environmental insult in a genetically susceptible host. In the US, African Americans are more commonly affected with sarcoidosis and suffer greater morbidity than Caucasians. We searched for sarcoidosis susceptibility loci by conducting a genome-wide, sib pair multipoint linkage analysis in 229 African-American families ascertained through two or more sibs with a history of sarcoidosis. Using the Haseman–Elston regression technique, linkage peaks with P-values less than 0.05 were identified on chromosomes 1p22, 2p25, 5p15-13, 5q11, 5q35, 9q34, 11p15 and 20q13 with the most prominent peak at D5S2500 on chromosome 5q11 (P=0.0005). We found agreement for linkage with the previously reported genome scan of a German population at chromosomes 1p and 9q. Based on the multiple suggestive regions for linkage found in our study population, it is likely that more than one gene influences sarcoidosis susceptibility in African Americans. Fine mapping of the linked regions, particularly on chromosome 5q, should help to refine linkage signals and guide further sarcoidosis candidate gene investigation.

Job and industry classifications associated with sarcoidosis in a case-control etiologic study of sarcoidosis (ACCESS)

Objectives: Objective: To determine whether specific occupations and industries may be associated with sarcoidosis. Methods: A Case Control Etiologic Study of Sarcoidosis (ACCESS) obtained occupational and environmental histories on 706 newly diagnosed sarcoidosis cases and matched controls. We used Standard Industrial Classification (SIC) and Standard Occupational Classification (SOC) to assess occupational contributions to sarcoidosis risk. Results: Univariable analysis identified elevated risk of sarcoidosis for workers with industrial organic dust exposures, especially in Caucasian workers. Workers for suppliers of building materials, hardware, and gardening materials were at an increased risk of sarcoidosis as were educators. Work providing childcare was negatively associated with sarcoidosis risk. Jobs with metal dust or metal fume exposures were negatively associated with sarcoidosis risk, especially in Caucasian workers. Conclusions: In this study, we found that exposures in particular occupational settings may contribute to sarcoidosis risk.

Who's using medicines?

Data derived from a 1968–69 household survey of 3,481 persons in the Baltimore Standard Metropolitan Statistical Area revealed rates of medicine use and characteristics of users. In the 2 days before interview, 56% of the study population used one or more medicines. Users of prescribed medicine (33%) averaged 1.8 different kinds, and users of nonprescribed medicine (36%) averaged 1.4 kinds. Among users of prescribed medicine, 39% were also self-medicating. Pain relievers, vitamins, and cough and cold medicines were the most frequently used types. Two-thirds of physician visits were associated with an injection, immunization, medicine, or prescription. Rates of use for both prescribed and nonprescribed medicine were higher in females and varied with age, with nonprescribed varying less than prescribed. Nonwhites were less likely than whites to use either prescribed or nonprescribed medicines in all social status categories. Use of prescribed medicine increased with the increasing severity of acute and chronic illness, but use of nonprescribed medicine varied little with morbidity. Use of prescribed or nonprescribed medicine did not vary with economic class. Differences in use by age, sex, and race could not be accounted for by differences in morbidity, physician visits, or use of oral contraceptives.Data derived from a 1968–69 household survey of 3,481 persons in the Baltimore Standard Metropolitan Statistical Area revealed rates of medicine use and characteristics of users. In the 2 days before interview, 56% of the study population used one or more medicines. Users of prescribed medicine (33%) averaged 1.8 different kinds, and users of nonprescribed medicine (36%) averaged 1.4 kinds. Among users of prescribed medicine, 39% were also self-medicating. Pain relievers, vitamins, and cough and cold medicines were the most frequently used types. Two-thirds of physician visits were associated with an injection, immunization, medicine, or prescription. Rates of use for both prescribed and nonprescribed medicine were higher in females and varied with age, with nonprescribed varying less than prescribed. Nonwhites were less likely than whites to use either prescribed or nonprescribed medicines in all social status categories. Use of prescribed medicine increased with the increasing severity of acute and chronic illness, but use of nonprescribed medicine varied little with morbidity. Use of prescribed or nonprescribed medicine did not vary with economic class. Differences in use by age, sex, and race could not be accounted for by differences in morbidity, physician visits, or use of oral contraceptives.

TGF-β1 Variants in Chronic Beryllium Disease and Sarcoidosis

Evidence suggests a genetic predisposition to chronic beryllium disease (CBD) and sarcoidosis, which are clinically and pathologically similar granulomatous lung diseases. TGF-β1, a cytokine involved in mediating the fibrotic/Th1 response, has several genetic variants which might predispose individuals to these lung diseases. We examined whether certain TGF-β1 variants and haplotypes are found at higher rates in CBD and sarcoidosis cases compared with controls and are associated with disease severity indicators for both diseases. Using DNA from sarcoidosis cases/controls from A Case Control Etiologic Study of Sarcoidosis Group (ACCESS) and CBD cases/controls, TGF-β1 variants were analyzed by sequence-specific primer PCR. No significant differences were found between cases and controls for either disease in the TGF-β1 variants or haplotypes. The −509C and codon 10T were significantly associated with disease severity indicators in both CBD and sarcoidosis. Haplotypes that included the −509C and codon 10T were also associated with more severe disease, whereas one or more copies of the haplotype containing the −509T and codon 10C was protective against severe disease for both sarcoidosis and CBD. These studies suggest that the −509C and codon 10T, implicated in lower levels of TGF-β1 protein production, are shared susceptibility factors associated with more severe granulomatous disease in sarcoidosis and CBD. This association may be due to lack of down-regulation by TGF-β1, although future studies will be needed to correlate TGF-β1 protein levels with known TGF-β1 genotypes and assess whether there is a shared mechanisms for TGF-β1 in these two granulomatous diseases.

Physician Care in Nursing Homes

Excerpt The costs and quality of care for the aged in nursing homes have become matters of great national concern. The concern for costs is understandable. Nearly 30% of the nations health care bi...

The Use of Medicines: Historical Trends and International Comparisons

An historical review of the development of current levels of medicine consumption is presented with a literature review of cross-national and limited surveys and national statistics on rates of medicine use. Medicine use has increased worldwide at rates exceeding increases in national incomes in many countries. Variations in estimates of medicine use are documented by cross-national data on expenditure and prescription rates adjusted to increase comparability. Differences in levels of use appear greater than can be accounted for by methodologic problems of comparison. That differences are great is supported by results of the World Health Organization International Collaborative Study of Medical Care Utilization (WHO/ICS-MCU) which indicate that age-sex standardized medicine use rates developed from a household survey in 12 areas of seven countries show several-fold differences in rates of prescribed and nonprescribed medicine use. Differences in these rates are not explained by area levels of morbidity or variations in physician visiting or prescribing patterns. Areas tend to be high or low in rates of use of both prescribed and nonprescribed drugs. Problems in the use of data for international comparison of medicine use are discussed.

Sarcoidosis: social predictors of severity at presentation

To determine relationships among social predictors and sarcoidosis severity at presentation, demographic characteristics, socioeconomic status, and barriers to care, A Case-Control Etiologic Study of Sarcoidosis (ACCESS) was set up. Patients self-reported themselves to be Black or White and were tissue-confirmed incident cases aged ≥l8-yrs-old (n=696) who had received uniform assessment procedures within one of 10 medical centres and were studied using standardised questionnaires and physical, radiographical, and pulmonary function tests. Severity was measured by objective disease indicators, subjective measures of dyspnoea and short form-36 subindices. The results of the study showed that lower income, the absence of private or Medicare health insurance, and other barriers to care were associated with sarcoidosis severity at presentation, as were race, sex, and age. Blacks were more likely to have severe disease by objective measures, while women were more likely than males to report subjective measures of severity. Older individuals were more likely to have severe disease by both measures. In conclusion, it was found that low income and other financial barriers to care are significantly associated with sarcoidosis severity at presentation even after adjusting for demographic characteristics of race, sex, and age.

Using Simulated Patients to Train Physicians in Sexual Risk Assessment and Risk Reduction.

No abstract available.

Sarcoidosis severity and socioeconomic status

Several chronic diseases are more severe in persons who are Black, of low socioeconomic status (SES), and underinsured. The authors ask if this is true for sarcoidosis. Associations among sarcoidosis disease severity, SES, insurance coverage, and functional limitations were analysed. Back and White sarcoidosis patients (n=110) of a municipal and university hospital sarcoidosis registry were interviewed by telephone. Data on disease severity were abstracted from patient charts. Most patients reported good or excellent health by demographic characteristics. Low SES and no or public insurance were associated with worse health status and more severe dyspnoea. More advanced radiographic stage was associated with lower income, and forced vital capacity impairment with less education. Physical and social activity limitations due to physical and emotional disability were related to no or public insurance and lower income, but not education. Sarcoidosis severity is associated with socioeconomic status and insurance indicators; no or public insurance and low income are associated with functional limitations. Sarcoidosis-associated limitations are substantial, emphasizing the social significance of sarcoidosis. Lack of private insurance may inhibit the use of medical care, contributing to disease severity and impairment.