L. Gary Hart

Physician office visits for low back pain: Frequency, clinical evaluation, and treatment patterns from a u.s. national survey

Study Design. This study is an analysis of national survey data from 5 sample years. Objectives. The authors characterized the frequency of office visits for low back pain, the content of ambulatory care, and how these vary by physician specialty. Summary of Background Data. Few recent data are available regarding ambulatory care for low back pain or how case mix and patient management vary by physician specialty. Methods. Data from the National Ambulatory Medical Care Survey were grouped into three time periods (1980–81, 1985, 1989–90). Frequency of visits for low back pain, referral status, tests, and treatments were tabulated by physician speciatly. Results. There were almost 15 million office visity for “mechanical” low back pain in 1990, ranking this problem fifth as a reason for all physician visits. Low back pain accounted for 2.8 percent of office visity in all three time periods. Nonspecific diagnostic lables were most common, and 56 percent of visits were to primary care physicians. Specialty variations were observed in caseload, diagnostic mix, and management. Conclusion. Back pain remains a major reason for all physician office visity. This study describes visit, referral, and management patterns among specialties providing the most care.

The migration of physicians from sub-Saharan Africa to the United States of America: measures of the African brain drain

BackgroundThe objective of this paper is to describe the numbers, characteristics, and trends in the migration to the United States of physicians trained in sub-Saharan Africa.MethodsWe used the American Medical Association 2002 Masterfile to identify and describe physicians who received their medical training in sub-Saharan Africa and are currently practicing in the USA.ResultsMore than 23% of Americas 771 491 physicians received their medical training outside the USA, the majority (64%) in low-income or lower middle-income countries. A total of 5334 physicians from sub-Saharan Africa are in that group, a number that represents more than 6% of the physicians practicing in sub-Saharan Africa now. Nearly 86% of these Africans practicing in the USA originate from only three countries: Nigeria, South Africa and Ghana. Furthermore, 79% were trained at only 10 medical schools.ConclusionsPhysician migration from poor countries to rich ones contributes to worldwide health workforce imbalances that may be detrimental to the health systems of source countries. The migration of over 5000 doctors from sub-Saharan Africa to the USA has had a significantly negative effect on the doctor-to-population ratio of Africa. The finding that the bulk of migration occurs from only a few countries and medical schools suggests policy interventions in only a few locations could be effective in stemming the brain drain.

Who is Caring for the Underserved? A Comparison of Primary Care Physicians and Nonphysician Clinicians in California and Washington

PURPOSE: Little is known about whether different types of physician and nonphysician primary care clinicians vary in their propensity to care for underserved populations. The objective of this study was to compare the geographic distribution and patient populations of physician and nonphysician primary care clinicians. METHODS: This study was a cross-sectional analysis of 1998 administrative and survey data on primary care clinicians (family physicians, general internists, general pediatricians, nurse practitioners, physician assistants, and certified nurse-midwives) in California and Washington. For geographic analysis, main outcome measures were practice in a rural area, a vulnerable population area (communities with high proportions of minorities or low-income residents), or a health professions shortage area (HPSA). For patient population analysis, outcomes were the proportions of Medicaid, uninsured, and minority patients in the practice. RESULTS: Physician assistants ranked first or second in each state in the proportion of their members practicing in rural areas and HPSAs, and in California physician assistants also had the greatest proportion of their members working in vulnerable populations areas (P < .001). Compared with primary care physicians overall, nurse practitioners and certified nurse-midwives also tended to have a greater proportion of their members in rural areas and HPSAs (P < .001). Family physicians were much more likely than other primary care physicians to work in rural areas and HPSAs (P < .001). Compared with physicians, nonphysician clinicians in California had a substantially greater proportion of Medicaid, uninsured, and minority patients (P < .001). CONCLUSIONS: Nonphysician primary care clinicians and family physicians have a greater propensity to care for underserved populations than do primary care physicians in other specialties. Achieving a more equitable pattern of service to needy populations will require ongoing, active commitment by policy makers, educational institutions, and the professions to a mission of public service and to incentives that support and promote care to the underserved.

A longitudinal analysis of the general surgery workforce in the United States, 1981-2005

HYPOTHESIS The overall supply of general surgeons per 100 000 population has declined in the past 2 decades, and small and isolated rural areas of the United States continue to have relatively fewer general surgeons per 100 000 population than urban areas. DESIGN Retrospective longitudinal analysis. SETTING Clinically active general surgeons in the United States. PARTICIPANTS The American Medical Associations Physician Masterfiles from 1981, 1991, 2001, and 2005 were used to identify all clinically active general surgeons in the United States. MAIN OUTCOME MEASURES Number of general surgeons per 100 000 population and the age, sex, and locale of these surgeons. RESULTS General surgeon to population ratios declined steadily across the study period, from 7.68 per 100 000 in 1981 to 5.69 per 100 000 in 2005. The overall urban ratio dropped from 8.04 to 5.85 (-27.24%) across the study period, and the overall rural ratio dropped from 6.36 to 5.02 (-21.07%). The average age of rural surgeons increased compared with their urban counterparts, and women were disproportionately concentrated in urban areas. CONCLUSIONS The overall number of general surgeons per 100 000 population has declined by 25.91% during the past 25 years. The decline has been most marked in urban areas. However, more remote rural areas continue to have significantly fewer general surgeons per 100 000 population. These findings have implications for training, recruiting, and retaining general surgeons.

The functional status of ESRD patients as measured by the sickness impact profile

This study describes and compares the perceived sickness-related behavioral dysfunction of 859 end-stage renal disease (ESRD) patients from 11 centers according to treatment modality via the Sickness Impact Profile (SIP). The unadjusted functional status of ESRD patients differed significantly by treatment modality. Transplantation patients were least functionally limited followed in order by home dialysis, continuous peritoneal dialysis, and in-center dialysis patients. The largest overall differences were for the sleep and rest, work, recreation and pastimes, and home management SIP categories. Regression analysis revealed that many of the large observed intermodality differences in functional status may have resulted from casemix variations (e.g. age and comorbidity differences). Only SIP score differences between transplantation and other treatment modality patients remained significant following the introduction of casemix controls. Results do not justify choosing one dialysis modality over another because of differences in perceived dysfunction.

Trends in Professional Advice to Lose Weight Among Obese Adults, 1994 to 2000

AbstractCONTEXT: Obesity is a fast-growing threat to public health in the U.S., but information on trends in professional advice to lose weight is limited. OBJECTIVE: We studied whether rising obesity prevalence in the U.S. was accompanied by an increasing trend in professional advice to lose weight among obese adults. DESIGN AND PARTICIPANTS: We used the Behavioral Risk Factor Surveillance System, a cross-sectional prevalence study, from 1994 (n= 10,705), 1996 (n=13,800), 1998 (n=18,816), and 2000 (n=26,454) to examine changes in advice reported by obese adults seen for primary care. MEASUREMENTS: Self-reported advice from a health care professional to lose weight. RESULTS: From 1994 to 2000, the proportion of obese persons receiving advice to lose weight fell from 44.0% to 40.0%. Among obese persons not graduating from high school, advice declined from 41.4% to 31.8%; and for those with annual household incomes below

Access to Cancer Services for Rural Colorectal Cancer Patients

25,000, advice dropped from 44.3% to 38.1%. In contrast, the prevalence of advice among obese persons with a college degree or in the highest income group remained relatively stable and high (>45%) over the study period. CONCLUSIONS: Disparities in professional advice to lose weight associated with income and educational attainment increased from 1994 to 2000. There is a need for mechanisms that allow health care professionals to devote sufficient attention to weight control and to link with evidence-based weight loss interventions, especially those that target groups most at risk for obesity.

Perinatal and Infant Health Among Rural and Urban American Indians/Alaska Natives

CONTEXT Cancer care requires specialty surgical and medical resources that are less likely to be found in rural areas. PURPOSE To examine the travel patterns and distances of rural and urban colorectal cancer (CRC) patients to 3 types of specialty cancer care services--surgery, medical oncology consultation, and radiation oncology consultation. METHODS Descriptive cross-sectional study using linked Surveillance, Epidemiology, and End Results (SEER) cancer registry and Medicare claims data for 27,143 individuals ages 66 and older diagnosed with stages I through III CRC between 1992 and 1996. FINDINGS Over 90% of rural CRC patients lived within 30 miles of a surgical hospital offering CRC surgery, but less than 50% of CRC patients living in small and isolated small rural areas had a medical or radiation oncologist within 30 miles. Rural CRC patients who traveled outside their geographic areas for their cancer care often went great distances. The median distance traveled by rural cancer patients who traveled to urban cancer care providers was 47.8 miles or more. A substantial proportion (between 19.4% and 26.0%) of all rural patients bypassed their closest medical and radiation oncology services by at least 30 miles. CONCLUSIONS Rural CRC patients often travel long distances for their CRC care, with potential associated burdens of time, cost, and discomfort. Better understanding of whether this travel investment is paid off in improved quality of care would help rural cancer patients, most of whom are elderly, make informed decisions about how to use their resources during their cancer treatment.

Is nondashmetropolitan residence a risk factor for poor birth outcome in the U.S.

OBJECTIVES We sought to provide a national profile of rural and urban American Indian/Alaska Native (AI/AN) maternal and infant health. METHODS In this cross-sectional study of all 1989-1991 singleton AI/AN births to US residents, we compared receipt of an inadequate pattern of prenatal care, low birthweight (< 2500 g), infant mortality, and cause of death for US rural and urban AI/AN and non-AI/AN populations. RESULTS Receipt of an inadequate pattern of prenatal care was significantly higher for rural than for urban mothers of AI/AN infants (18.1% vs 14.4%, P </=.001); rates for both groups were over twice that for Whites (6.8%). AI/AN postneonatal death rates (rural = 6.7 per 1000; urban = 5.4 per 1000) were more than twice that of Whites (2.6 per 1000). CONCLUSIONS Preventable disparities between AI/ANs and Whites in maternal and infant health status persist.

The Use of Medical Resources by Residency-trained Family Physicians and General Internists: Is There a Difference?

The association between non-metropolitan residence and the risk of poor birth outcome in the United States was examined using the records of 11.06 million singleton births in the United States between 1985 and 1987. Rates of neonatal and post-neonatal death, low birth weight and late prenatal care among non-metropolitan residents were compared to the rates among metropolitan residents. The association between residence in a non-metropolitan area and the risk of poor birth outcome was assessed in national and state level regression analyses. Residence in a non-metropolitan county was not found to be associated with increased risk of low birth weight or neonatal mortality at the national level or in most states, after controlling for several demographic and biological risk factors. Non-metropolitan residence was associated with greater risk of post-neonatal mortality at the national level. Non-metropolitan residence was strongly associated with late initiation of prenatal care at both the national level and in a majority of the states. Residence in non-metropolitan areas does not appear to be associated with higher risk of adverse birth outcome. Regionalization of perinatal care and other changes in the rural health care system may have mitigated the risk associated with residing in areas relatively isolated from tertiary care. High levels of late prenatal care among non-metropolitan residents suggest a continuing problem of access to routine care for rural women and their infants that may be associated with higher levels of post-neonatal mortality and childhood morbidity.