Ernest Moy

Access to Ambulatory Care for Adolescents: The Role of a Usual Source of Care

Using data from the 1987 National Medical Expenditure Survey, characteristics of ambulatory service utilization for adolescents aged 11 through 17 were examined. Access to health care was further explored by identifying adolescents at risk of not receiving an ambulatory service in the event of symptomatology. Approximately two-thirds of an estimated 25 million adolescents experienced an outpatient visit. African American race, Hispanic ethnicity, middle income, and lack of insurance and a usual source of care placed adolescents at risk for not receiving an ambulatory service. Sixteen million adolescents experienced symptomatology, but only one-third saw a physician. Those lacking a usual source of care were at greater odds of not receiving care. For symptom-based care, inequities were related more to lack of usual source of care rather than socioeconomic characteristics. Health care reform efforts may benefit from ensuring that adolescents have an identified usual source of care to ensure equity of access to care.

Distribution of Research Awards from the National Institutes of Health among Medical Schools

BACKGROUNDnPrevious studies have demonstrated that a small number of the 125 medical schools in the United States receive a disproportionately large share of the research awards granted by the National Institutes of Health (NIH). We assessed whether the distribution of NIH research awards to medical schools changed between 1986 and 1997.nnnMETHODSnWe used NIH data to rank medical schools in each year from 1986 to 1997 according to the number of awards each school received (as a measure of each schools activity in research, also referred to as research intensity). The proportion of awards received by schools ranked 1 to 10, 11 to 30, 31 to 50, and 51 or lower in research activity was then calculated, and changes over time were examined. We also examined changes in the distribution of awards and changes in award amounts according to the type of department, the type of academic degree held by the principal investigator, and the awarding institute.nnnRESULTSnBetween 1986 and 1997, the proportion of research awards granted by the NIH to the 10 most research intensive medical schools increased slightly (from 24.6 percent of all awards to 27.1 percent), whereas the 75 least research intensive medical schools (those ranked 51 or lower) received proportionately fewer awards (declining from 24.3 percent to 21.8 percent). The increased proportion of awards to top-10 schools consisted primarily of increases in awards to clinical departments, awards to physicians, and awards from highly competitive NIH institutes. Basic-science departments received a smaller proportion of awards than clinical departments, both in 1986 and in 1997.nnnCONCLUSIONSnResearch funded by the NIH is becoming more concentrated in the medical schools that are most active in research.

Academic medical centers and the care of underserved populations

As the number of Americans at risk of being underserved continues to rise, a better understanding of safety-net providers of health care is needed to help ensure continuing care for the underserved. In this article, the authors have begun the process of defining the role of academic medical centers (AMCs) as a group in the care of those persons most at risk of being underserved--the medically indigent and members of minority and poor populations--by quantifying the amount of inpatient care that AMCs provide to these individuals. The study went beyond previous work by using nationally representative sources of data (from 1989 to 1994) and by examining more than one underserved population rather than only the medically indigent. The study focused on AMCs and other hospitals in urban areas and excluded hospitals in rural areas. The detailed findings confirm previous observations that urban AMCs of all types provide a large and disproportionate share of care for the medically indigent and the underserved members of minority and poor populations and that members of these populations constituted the majority of patients cared for in many AMCs in recent years. The findings show that the proportion of patients from underserved groups admitted to all urban hospitals is rising and that this growth is faster among AMCs than other hospitals. The authors comment that AMCs, because of their prominent and historical role in caring for the underserved, have the opportunity to lead efforts to continue such service through innovative approaches to health care and the prevention of illness. Whether AMCs can seize this opportunity when confronted by price competition and government policies that reduce AMCs capacity to care for the underserved remains to be seen.

Racial differences in estrogen use among middle-aged and older women.

Estrogen replacement therapy in postmenopausal women is believed to reduce morbidity and mortality from a variety of conditions. Since the latter part of the 1980s, consideration of estrogen therapy in postmenopausal women has been promoted as a primary and secondary preventive measure against coronary artery disease (CAD).1 Current recommendations are largely a result of the emergence of epidemiologic data suggesting considerable reductions in risk for coronary artery disease among women who used estrogen. Grady et al2 summarized the results of 31 observational studies, three meta-analyses, and one randomized controlled trial examining the effect of postmenopausal hormone use on the relative risk of developing CAD. They concluded that hormonal therapy reduces the risk for CAD by 35–50%, with the greatest reductions seen in women diagnosed with CAD. Although most of the participants in these observational studies examining the effects of estrogen on cardiovascular disease were white women, estimates about the effects of estrogen therapy for black women suggest reductions in lifetime probabilities of CAD and gains of 0.9 to 1.9 years of life expectancy.2 Many professional organizations now recommend consideration of estrogen therapy for all postmenopausal women regardless of race.3,4 Data regarding the national prevalence of hormone use, however, are lacking as there is no national survey of estrogen use executed on a regular basis.5,6 Several regional and local studies in the United States and Europe report the prevalence of estrogen use among postmenopausal women as ranging from 7% to 33%.7–13 Among women who underwent natural menopause the following characteristics have been shown to be associated with estrogen use: younger age, postmenopausal status, alcohol use, less exercise, and leaner body mass. A search of the literature from 1966 to the present revealed four studies specifically examining the relationship between estrogen use and race. A retrospective study of 2,137 women in the Pittsburgh area examined race as a correlate of current estrogen use in a multivariable * This research was supported by The Jacobs Institute-Ortho Pharmaceutical Scholar in Women’s Health Care. The purpose of the grant is to enable the efforts of individual scientists to find new ways to improve health care services for women.

Changes in Usual Sources of Medical Care Between 1987 and 1992

This study is a secondary analysis of data from the 1987 and 1992 National Health Interview Surveys. Analyses compared adults who do not have a usual source of care and those who identified usual sources of care in 1987 and 1992. Between these years, the estimated number of adult Americans without a usual source of care rose from 29.7 to 39.4 million. Adults were 0.75 times less likely to identify a physicians office and 1.8 times more likely to identify an outpatient clinic as that source of care in 1992 than they were in 1987. These changes were observed among Americans of all demographic and socioeconomic backgrounds. Increasing numbers of adult Americans without a usual source of care and shifts in care from physicians offices to outpatient clinics may reflect deteriorating access to care. This may affect quality and costs of medical care, demanding continued surveillance of sources and access to care.

Market influences on internal medicine residents' decisions to subspecialize

A general consensus has developed that the United States is approaching a surplus of specialist physicians [1], a view supported by physician workforce projections [2] and an analysis of the staffing needs of managed care organizations [3]. Several organizations, including the Council on Graduate Medical Education, the Physician Payment Review Commission, and the Association of American Medical Colleges (AAMC), have noted the oversupply and have suggested that an increased proportion of medical students follow generalist, rather than specialist, career paths in response to this trend [4, 5]. Despite the recent rapid development of managed care, little is known about whether market conditions, such as managed care penetration, are influencing the career decisions of medical trainees and, if so, how [6]. Internal medicine resides at the interface between generalist and specialty medicine. Although internal medicine is the largest primary care specialty, about two thirds of internists have chosen to subspecialize during the past several decades [7]. Medical subspecialties seem to be strongly affected by changing market conditions; the workforce in many specialty areas currently seems to be highly oversupplied. For example, 3.3% to 6.2% of physicians completing training in 1994 who pursued careers in medical subspecialties had not found full-time jobs in their specialties in 1995 (excluding geriatric medicine, for which an oversupply did not exist) compared with only 1.5% of those practicing general internal medicine [8]. The number of recruitment advertisements for internal medicine specialists decreased by 75% between 1990 and 1995, the highest decline of any career category [9]. In response to the growing number of internal medicine subspecialists, the Federated Council for Internal Medicine, representing a variety of internal medicine organizations, has advocated the goal that 50% of internal medicine graduates enter general medicine practice [10, 11]. Internal medicine residency programs have expanded primary care tracks to encourage trainees to pursue generalist careers, but no empirical evidence has shown whether the desired 50% goal is being achieved. The changing trend in internal medicine subspecialization seems to be an important marker in the wider generalist-specialist question, and several previous studies have identified factors associated with generalist versus specialist career decisions. One recent survey of third-year internal medicine residents suggests that those in training programs located in markets with higher managed care penetration were less likely to pursue careers as specialists [12]. Personal characteristics (age, ethnicity, and sex) [13, 14] and undergraduate medical school characteristics (public compared with private ownership and research intensiveness) [15] have also been associated with generalist versus specialist career choice. We expected that the market environment in the area where general internal medicine training took place would influence residents career decisions. Many market characteristics may influence career choice, but we focused on one-local managed care presence-that we believed was particularly important. We thus sought to determine whether the increased prevalence of managed care has catalyzed a shift away from specialty medicine toward generalism by influencing the career decisions of individual medical trainees. We hypothesized that general internal medicine residents in markets with increasing managed care penetration would be less likely to subspecialize. To gain insight about individual residents, we analyzed a longitudinal census of individual graduate medical education records maintained by the AAMC. The present analysis extends the one previous demonstration of the influence of managed care on generalist versus specialist career choice by controlling for U.S. Census division, several individual characteristics, and characteristics of undergraduate medical institutions that have previously been associated with the decision to pursue a generalist career. Methods Study Sample Information about graduate medical education was obtained from the AAMCs Graduate Medical Education Tracking Census, which is collected by an annual survey of directors of medical education at all U.S. graduate medical education training locations [16]. These data document the entire graduate medical education training history of all residents and fellows enrolled in graduate medical education in the United States, including U.S. and international medical graduates. Completion of general internal medicine training was determined by tracking each residents graduate medical education data until at least 3 years of general internal medicine training were completed and specialty training was begun or graduate medical education was discontinued (presumably so that the resident could enter practice). The activity after the completion of general internal medicine training was the outcome. We tested the influence of local managed care penetration on subspecialization decisions, controlling for region, individual characteristics, and undergraduate medical school characteristics. It was therefore necessary to restrict the sample to only those residents for whom data on all of these variables were available. In 1993, 4922 residents completed general internal medicine residency training at U.S. training sites. Residents who completed graduate medical education training in areas where data on managed care penetration were not available (81 in Puerto Rico or rural areas; 53 in metropolitan statistical areas not available in the market database), and 1763 graduates of international, Canadian, or U.S. osteopathic undergraduate medical schools (for whom individual characteristics and information on undergraduate medical education were not available) were eliminated from the sample. We excluded an additional 424 residents because data on National Institutes of Health (NIH) awards to the undergraduate medical school were missing, and we excluded 2 residents because of missing information on ethnicity. To allow adequate and uniform follow-up, we excluded 181 general internal medicine residents who did not complete graduate medical education in consecutive years and 61 residents who completed more than 4 years of general internal medicine training. Finally, 94 residents were excluded because they enrolled for training in specialties other than internal medicine (for example, dermatology and emergency medicine). Analyses included the remaining 2263 residents who completed general internal medicine training in 1993. Outcome Variable Graduate Medical Education Tracking Census data records were compiled into longitudinal profiles that contained historical information about the graduate medical education fields in which residents were enrolled each year. Residents who enrolled in internal medicine subspecialty training programs after completing 3 or 4 consecutive years of general internal medicine training were categorized as electing to subspecialize. Residents who were not enrolled in graduate medical education the year after they completed general internal medicine training were categorized as entering practice, presumably as generalists. The outcome variable in this study, subspecialization, was coded as 1 for residents who pursued subspecialty training and as 0 for residents who entered practice. Explanatory Variables Managed care penetration was indexed by a health maintenance organization (HMO) penetration variable derived from the Interstudy Competitive Edge Database, 6.1 Regional Market Analysis [17]. We calculated 1993 HMO penetration by dividing the HMO enrollment in a metropolitan statistical area by the population in that area, after adjusting the 1995 values to 1993 levels using change variables present in the Interstudy data set (1993 Interstudy data are not available at the metropolitan statistical area level). The HMO penetration index ranges from 0 to 1; values closer to 1 indicate greater HMO penetration (the actual range in our study was 0 to 0.64). The Interstudy HMO penetration variable is superior to other, similar calculations because it adjusts the numerator for HMO cross-coverage in contiguous metropolitan statistical areas. The HMO penetration variable was linked to the metropolitan statistical area where each resident in the study sample completed his or her general internal medicine residency. Sites where general internal medicine training was completed were grouped into nine U.S. Census divisions [18]. Individual characteristics for graduates of U.S. medical schools were taken from the AAMCs Student and Applicant Information Management System (SAIMS) database, a repository of information about all applicants, matriculants, and graduates of U.S. allopathic medical schools. Individual characteristics included sex, ethnic group (white or other), age at first general internal medicine year, and average Medical College Admission Test (MCAT) subject test score. The SAIMS database also provided information about ownership (public or private) of U.S. medical schools. Research intensiveness was indicated by the amount of NIH research funds awarded to each medical school, averaged over the years 1988 to 1991. The NIH award variable was log-transformed to correct for extreme values. This information was taken from the Information for Management, Planning, Analysis, and Coordination (IMPAC) system maintained by the Division of Research Grants at the NIH [19]. School information was linked to the last medical school attended by U.S. allopathic medical graduates in the study sample. Statistical Analysis We used logistic regression analysis to test the effect of HMO penetration on the odds of subspecialization, controlling for Census division, individual characteristics, and undergraduate medical school characteristics. As stated previously, individual characteristics included sex, age,

Organizational, Financial, and Environmental Factors Influencing Deans' Tenure.

At a time when continuity of leadership in medical schools is most crucial, the tenures of deans continue to decrease. In the present study of factors influencing the tenures of 382 U.S. medical school deans from 1985 to 1994, the authors focused on issues that were likely to have had a greater impact on deans tenures in recent years. They assumed that longer tenures are associated with less complex organizational factors and more stable environmental factors. Conversely, they assumed that deans and their tenures are adversely affected by an institutions declining financial health, a complex organizational structure, and a changing clinical marketplace where there is rapid growth of managed care. The authors compared the relationships between these factors and the length of deans tenures during the ten-year period studied. Among the most important findings were the fact that schools that were less healthy financially, that had the same owner as the primary teaching hospital, and that had smaller numbers of faculty tended to have shorter deans tenures and higher turnovers of deans. While the reason for shorter tenures of deans at schools that are less financially healthy is understandable, the effect of common ownership of the school and teaching hospital is less obvious, but perhaps the greater preoccupation of deans with the clinical enterprise in that circumstance is a significant constraint. The authors hope that the insights from their findings will be useful to future candidates for deanships in their negotiations with university officials and will help all parties reach more explicit agreements on such issues as expectations for financial performance of the medical school and the roles and relationships of the dean and the teaching hospital director.

The Volume and Mix of Inpatient Services Provided by Academic Medical Centers.

This is the first in a series of AAMC Papers that analyze the clinical spectrum of patients treated in the nations teaching hospitals. As stated in the separate Introduction, “The Transformation of Data into Knowledge,” subsequent papers will examine trends in the provision of care to the indigent and make comparisons of quality of care among teaching and non-teaching hospitals. These analyses, carried out by the AAMCs Center for the Assessment and Management of Change in Academic Medicine (CAMCAM), are made possible by a reorganization of the AAMCs information infrastructure, in which many formerly separate databases have been linked. The Introduction concludes with a description of specific AAMC-CAMCAM initiatives that are being planned. This initial analysis examines the volume and mix of clinical services provided by AMCs, examines trends in these services over time, and compares services provided at different AMCs, in different markets, and between AMCs and non-teaching hospitals. Data from a variety of sources were used in these secondary analyses. The American Hospital Associations Annual Survey of Hospitals database was used to analyze volumes of inpatient services provided in AMCs and other hospitals. The AAMCs Clinical-Administrative Data Service database was used to analyze the volume and mix of clinical services provided in individual AMCs. The Agency for Health Care Policy and Researchs Nationwide Inpatient Sample was used to compare the mix of clinical services provided in AMCs and other hospitals. Volumes of inpatient services in AMCs changed little between 1991 and 1994 and totaled six million hospitalizations, 41 million inpatient days, and two million inpatient surgeries in 1994. The mix of inpatient services in AMCs also showed little variation over time among individual AMCs, in markets with both high and low managed care penetrations, between public and private AMCs, or between AMCs and non-teaching hospitals, with the ten most frequent diagnoses accounting for significant proportions of total services. In contrast, several specialized services were much more likely to be offered and provided by AMCs. Despite rapid change in the health care environment, the volume and mix of clinical services provided by AMCs have been relatively stable. Implications for hospital planners, service chiefs and administrators, medical educators, clinical investigators, and health policymakers are discussed.