James J. Diamond

Medical School Programs to Increase the Rural Physician Supply: A Systematic Review and Projected Impact of Widespread Replication

Purpose To systematically review the outcomes of comprehensive medical school programs designed to increase the rural physician supply, and to develop a model to estimate the impact of their widespread replication. Method Relevant databases were searched, from the earliest available date to October 2006, to identify comprehensive programs (with available rural outcomes), that is, those that had (1) a primary goal of increasing the rural physician supply, (2) a defined cohort of students, and (3) either a focused rural admissions process or an extended rural clinical curriculum. Descriptive methodology, definitions, and outcomes were extracted. A model of the impact of replicating this type of program at 125 allopathic medical schools was then developed. Results Ten studies met all inclusion criteria. Outcomes were available for more than 1,600 graduates across three decades from six programs. The weighted average of graduates practicing in rural areas ranged from 53% to 64%, depending on the definition of rural. If 125 medical schools developed similar programs for 10 students per class, this would result in approximately 11,390 rural physicians during the next decade, more than double the current estimation of rural doctors produced during that time frame (5,130). Conclusions All identified comprehensive medical school rural programs have produced a multifold increase in the rural physician supply, and widespread replication of these models could have a major impact on access to health care in thousands of rural communities. The current recommendation to expand U.S. medical school class size represents a unique and timely opportunity to replicate these programs.

Long-term retention of graduates from a program to increase the supply of rural family physicians.

Purpose To determine the long-term retention of rural family physicians graduating from the Physician Shortage Area Program (PSAP) of Jefferson Medical College. Method Of the 1,937 Jefferson graduates from the classes of 1978–1986, the authors identified those practicing rural family medicine when their practice location was first determined. The number and percent of PSAP and non-PSAP graduates practicing family medicine in the same rural area in 2002 were then identified, and compared to the number of those graduates practicing rural family medicine when they were first located in practice 11–16 years earlier. Results After 11–16 years, 68% (26/38) of the PSAP graduates were still practicing family medicine in the same rural area, compared with 46% (25/54) of their non-PSAP peers (p= .03). Survival analysis showed that PSAP graduates practice family medicine in the same rural locality longer than non-PSAP graduates (p = .04). Conclusions These results are the first to show long-term rural primary care retention that is longer than the median duration. This outcome combined with previously published outcomes show that the PSAP represents the only program that has resulted in multifold increases in both recruitment (eight-fold) and long-term retention (at least 11–16 years). In light of recent national recommendations to increase the total enrollment in medical schools, allocating some of this growth to developing and expanding programs similar to the PSAP would make a substantial and long lasting impact on the rural physician workforce.

Impact of Provider Continuity on Quality of Care for Persons With Diabetes Mellitus

BACKGROUND Many patients with diabetes fail to receive recommended monitoring tests. One reason might be inadequate continuity of care. This study examined the association between provider continuity and completion of monitoring tests for patients with diabetes mellitus. METHODS A cross-sectional analysis was conducted on claims data from a private national health plan for 1 year (January 1,1999, through December 31,1999). Participants had a diagnosis of diabetes mellitus and at least 2 outpatient visits during the study year (N = 1,795). The association was measured between continuity of care with an individual provider and completion of 3 diabetes monitoring tests: a glycosylated hemoglobin test, a lipid profile, and an eye examination. RESULTS Eighty-one percent of patients had a glycosylated hemoglobin test, 66% had a lipid profile, and 28% had an eye examination during the study year. After controlling for demographics, number of diabetes visits, case mix, and diabetes complications, provider continuity was not significantly associated with the receipt of a glycosylated hemoglobin test (odds ratio [OR] = 0.61, 95% confidence interval [CI], 0.32-1.16), a lipid profile (OR = 0.97, 95% CI, 0.57-1.64) or an eye examination (OR = 0.60, 95% CI, 0.30-1.19). When continuity was measured only among primary care providers, there was no significant association for receipt of a glycosylated hemoglobin test (OR = 0.73, 95% CI, 0.41-1.33), a lipid profile (OR = 0.88, 95% CI, 0.53-1.47) or an eye examination (OR = 0.70, 95% CI, 0.35-1.36). CONCLUSIONS This study found no association between provider continuity and completion of diabetes monitoring tests in a national privately insured population. Whereas continuity might benefit other aspects of health care, it does not appear to benefit improved monitoring for diabetes.

HEALTH BELIEFS AND ATTITUDES TOWARD THE PREVENTION OF OSTEOPOROSIS IN OLDER WOMEN

ObjectiveA pilot study to determine health belief factors associated with osteoporosis prevention behaviors in peri-and postmenopausal women. DesignWe administered a survey to a convenience sample of 60 women aged 40–95 years old in an urban family practice center and an associated retirement community. The self-reported questionnaire addressed demographics, osteoporosis risk factors, current preventive behaviors for osteoporosis, and health beliefs. ResultsThe majority of women (89%) believed that osteoporosis is a serious condition, but only 29% perceived a personal susceptibility. Women were less concerned about osteoporosis when compared with cancer, cardiovascular disease, and neurologic disorders. Only 40% of women were taking active measures to prevent osteoporosis. There was no significant relationship between active osteoporosis prevention behaviors and five health belief factors (motivation, barrier, active participant in health care, frustration, and benefit) (p ≥ 0.43). However, active behaviors to prevent osteoporosis were found to correlate with the single item “I am worried about developing osteoporosis” (p = 0.03). Most women surveyed would be willing to exercise and take calcium and a multivitamin to prevent osteoporosis. ConclusionFew women are taking active measures to prevent osteoporosis despite their belief that it is a serious condition. Our data suggest that most women do not perceive a personal susceptibility to the disease. Only women who reported actively worrying about developing osteoporosis were more likely to be engaged in significant osteoporosis preventive behaviors.

The need for complex technology in radiation oncology. Correlations of facility characteristics and structure with outcome

The Patterns of Care Study data are used to correlate therapy equipment and practice characteristics with outcome, using Hodgkins disease, prostate cancer, and cervix cancer as examples. The shift to linear accelerators and higher photon energy is supported, as is the increased use of treatment simulators. Part‐time practitioners of radiation therapy and facilities whose only equipment is a less‐than‐80‐cm cobalt unit have poor technical support and exhibit poor staging, poor achievement of minimum tumor dose, and poor patient follow‐up as compared to the national average or best‐performing strata of practice. These facilities should either upgrade their equipment, technical support, and level of practice or close.

Increasing the Supply of Rural Family Physicians: Recent Outcomes From Jefferson Medical College's Physician Shortage Area Program (psap)

Purpose The shortage of primary care physicians in rural areas is an enduring problem with serious implications for access to care. Although studies have previously shown that medical school rural programs—such as Jefferson Medical Colleges Physician Shortage Area Program (PSAP)—significantly increase the rural workforce, determining whether these programs continue to be successful is important. Method The authors obtained, from the Jefferson Longitudinal Study, the 2007 practice location and specialty for the 2,394 PSAP and non-PSAP graduates of 11 previously unreported Jefferson graduating classes (1992–2002). They determined the relative likelihood both of PSAP versus non-PSAP graduates practicing rural family medicine and of all PSAP versus non-PSAP graduates practicing in Pennsylvanias rural counties. Results PSAP graduates were much more likely both to practice rural family medicine than their non-PSAP peers (32.0% [31/97] versus 3.2% [65/2,004]; relative risk [RR] = 9.9, confidence interval [CI] 6.8–14.4, P < .001) and to practice any specialty in rural Pennsylvania (PSAP 24.7% [24/97] versus non-PSAP 2.0% [40/2,004]; RR = 12.4, CI 7.8–19.7, P < .001). Conclusions Despite major changes in health care in recent decades, Jeffersons PSAP continues to represent a successful model for substantially increasing the supply and distribution of rural family physicians. Especially with the forthcoming expansion in health insurance, access to care for rural residents will require an increased supply of providers. These results may also be important for medical schools planning to develop similar rural programs, given the new Rural Physician Training Grants program.

A prospective evaluation of the effect of activated charcoal before oral N-acetylcysteine in acetaminophen overdose

STUDY OBJECTIVE To evaluate whether activated charcoal (AC) reduces the efficacy of subsequent oral N-acetylcysteine therapy during acute acetaminophen overdose. DESIGN Prospective observational case series of all acute acetaminophen overdoses reported to three certified regional poison centers. TYPES OF PATIENTS: All patients with acute acetaminophen overdose in whom N-acetylcysteine therapy was initiated within 16 hours after ingestion. INTERVENTIONS All patients were treated with oral N-acetylcysteine therapy for 72 hours. The decision to use AC was left to the treating physician without input from the investigator. MEASUREMENTS AND RESULTS One hundred twenty-two patients were evaluated. Maximum recorded SGOT levels of more than 125 U/mL were defined as evidence of hepatotoxicity. AC was used in addition to N-acetylcysteine in 82 of 122 patients. Hepatotoxicity developed in four of 82 patients who received AC versus ten of 40 patients who did not receive AC (P < .005). An increasing dose of N-acetylcysteine provided no additional benefit (P > .05). Spacing the administration of AC and oral N-acetylcysteine less than or more than two hours apart did not affect outcome (P > .05). CONCLUSION Administration of AC before the administration of oral N-acetylcysteine in acetaminophen overdose does not reduce the efficacy of N-acetylcysteine therapy and may provide some additional hepatoprotective benefit. The practice of increasing the dose of oral N-acetylcysteine therapy after the administration of AC appears unwarranted.

Family Factors in End-of-Life Decision-Making: Family Conflict and Proxy Relationship

BACKGROUND Few studies have examined proxy decision-making regarding end-of-life treatment decisions. Proxy accuracy is defined as whether proxy treatment choices are consistent with the expressed wishes of their index elder. The purpose of this study was to examine proxy accuracy in relation to two family factors that may influence proxy accuracy: perceived family conflict and type of elder-proxy relationship. METHODS Telephone interviews with 202 community-dwelling elders and their proxy decision makers were conducted including the Life-Support Preferences Questionnaire (LSPQ), and a measure of family conflict, and sociodemographic characteristics, including type of relationship. RESULTS Elder-proxy accuracy was associated with the type of elder-proxy relationship. Adult children demonstrated the lowest elder-proxy accuracy and spousal proxies the highest elder-proxy accuracy. Elder-proxy accuracy was associated with family conflict. Proxies reporting higher family conflict had lower elder-proxy accuracy. No interaction between family conflict and relationship type was revealed. CONCLUSIONS Spousal proxies were more accurate in their substituted judgment than adult children, and proxies who perceive higher degree of family conflict tended to be less accurate than those with lower family conflict. Health care providers should be aware of these family factors when discussing advance care planning.

Perception, Intention, and Action in Adolescent Obesity

Background: Insight into adolescents’ weight-loss behavior is needed. Methods: Survey data were obtained from overweight and obese adolescents in the Youth Risk Behavioral Survey (YRBS) in Delaware. Cross tabulations were used to determine the frequency of accurate perception, recent action, and current intention regarding weight loss. Multivariable analysis identified factors associated with recent action to lose weight. Results: From 2728 records, 482 overweight adolescents and 398 obese adolescents were identified. Most obese (83%) and overweight (79%) adolescents reported recent action to lose weight. Most obese (75%) and overweight (65%) adolescents intended to lose weight. Obese and overweight adolescents who reported a current intention to lose weight were more likely to have taken recent action to lose weight (odds ratio [OR], 11.6 and 6.6, respectively). Conclusions: The percentage of obese and overweight adolescents who have an accurate perception of weight, intend to lose weight, and have taken recent action to lose weight suggests that this group is highly engaged in weight-related behavior change. Compared with their obese peers, overweight adolescents seem less engaged in weight change behavior. There is a strong association in both groups between intention and recent action, and this association indicates that obese and overweight adolescents are highly motivated to change their weight.

Accuracy of screening for diabetic retinopathy by family physicians.

BACKGROUND We wanted to examine the accuracy of family physicians’ screening for diabetic retinopathy using standardized criteria and a nonmydriatic ophthalmoscope. METHODS Eleven family physicians assessed 28 standardized patients with diabetes mellitus using the PanOptic ophthalmoscope. Their assessments of whether the patients required referral to an ophthalmologist were compared with the reference standard of retinal diagrams. RESULTS The mean sensitivity for the family physicians was 87% (95% confidence interval [CI], 83%–91%) with a specificity of 57% (95% CI, 46%–68%). Overall agreement was moderate, with a mean κ = .43 (95% CI, 0.39%–0.47%). CONCLUSIONS Using standardized criteria and a nonmydriatic ophthalmoscope, family physicians were fairly accurate in screening patients for diabetic retinopathy. Whereas this technique is not sufficiently accurate to replace routine referral for all patients with diabetes, it can be used to improve care for those patients who fail to get routine eye screenings.