Peggy G. Chen

Nurse-managed health centers and patient-centered medical homes could mitigate expected primary care physician shortage.

Numerous forecasts have predicted shortages of primary care providers, particularly in light of an expected increase in patient demand resulting from the Affordable Care Act. Yet these forecasts could be inaccurate because they generally do not allow for changes in the way primary care is delivered. We analyzed the impact of two emerging models of care--the patient-centered medical home and the nurse-managed health center--both of which use a provider mix that is richer in nurse practitioners and physician assistants than todays predominant models of care delivery. We found that projected physician shortages were substantially reduced in plausible scenarios that envisioned greater reliance on these new models, even without increases in the supply of physicians. Some less plausible scenarios even eliminated the shortage. All of these scenarios, however, may require additional changes, such as liberalized scope-of-practice laws; a larger supply of medical assistants, licensed practical nurses, and aides; and payment changes that reward providers for population health management.

Dissemination of Results in Community-Based Participatory Research

CONTEXT Community-based participatory research (CBPR) has been promoted as an approach to understanding complex health problems not amenable to research conducted solely by outside investigators. Although broad dissemination of research results is a key element of the CBPR approach, existing dissemination efforts have not been assessed. EVIDENCE ACQUISITION In this systematic review, researchers evaluated studies utilizing the CBPR approach to characterize dissemination of research results beyond scientific publication. Specifically, the focus was on dissemination to community participants and the general public. The literature search encompassed articles published between January 1, 2005, and December 31, 2009. Corresponding authors were also invited to complete a web-based survey. Data were collected and analyzed between July 1, 2008, and March 8, 2010. EVIDENCE SYNTHESIS In all, 101 articles met inclusion criteria. All articles were assessed for the quality of community involvement in research. Scores ranged from 1.4 to 3.0 (on a 3-point scale), with a mean of 2.3. The 21 articles in which an intervention was evaluated were scored for the rigor of research methods. Scores ranged from 2.0 to 2.9 (on a 3-point scale), with a mean of 2.4. Dissemination beyond scientific publication was reported in 48% of publications with varying levels of detail. However, among survey respondents, 98% reported dissemination of results to community participants and 84% reported dissemination to the general public. CONCLUSIONS Among research meeting strict criteria for inclusion as CBPR, dissemination beyond scientific publication is largely occurring. However, myriad challenges to timely and widespread dissemination remain, and current dissemination to community participants and the general public is variable.

Female genital cutting: current practices and beliefs in western Africa

OBJECTIVE To conduct a cross-national comparative study of the prevalence and correlates of female genital cutting (FGC) practices and beliefs in western Africa. METHODS Data from women who responded to the Multiple Indicator Cluster Surveys between 2005 and 2007 were used to estimate the frequencies of ever having been circumcised, having had a daughter circumcised, and believing that FGC practices should continue. Weighted logistic regression using data for each country was performed to determine the independent correlates of each outcome. FINDINGS The prevalence of FGC was high overall but varied substantially across countries in western Africa. In Sierra Leone, Gambia, Burkina Faso and Mauritania, the prevalence of FGC was 94%, 79%, 74% and 72%, respectively, whereas in Ghana, Niger and Togo prevalence was less than 6%. Older age and being Muslim were generally associated with increased odds of FGC, and higher education was associated with lower odds of FGC. The association between FGC and wealth varied considerably. Burkina Faso was the only country in our study that experienced a dramatic reduction in FGC prevalence from women (74%) to their daughters (25%); only 14.2% of the women surveyed in that country said that they believe the practice should continue. CONCLUSION The prevalence of FGC in western Africa remains high overall but varies substantially across countries. Given the broad range of experiences, successful strategies from countries where FGC is declining may provide useful examples for high-prevalence countries seeking to reduce their own FGC practices.

Professional experiences of international medical graduates practicing primary care in the United States.

BackgroundInternational medical graduates (IMGs) comprise approximately 25% of the US physician workforce, with significant representation in primary care and care of vulnerable populations. Despite the central role of IMGs in the US healthcare system, understanding of their professional experiences is limited.ObjectiveTo characterize the professional experiences of non-US born IMGs from limited-resource nations practicing primary care in the US.DesignQualitative study based on in-depth in-person interviews.ParticipantsPurposeful sample of IMGs (n = 25) diverse in country of origin, length of practice in the US, specialty (internal medicine, family medicine and pediatrics), age and gender. Participants were currently practicing primary care physicians in New York, New Jersey or Connecticut.ApproachA standardized interview guide was used to explore professional experiences of IMGs.Key ResultsFour recurrent and unifying themes characterize these experiences: 1) IMGs experience both overt and subtle forms of workplace bias and discrimination; 2) IMGs recognize professional limitations as part of “the deal”; 3) IMGs describe challenges in the transition to the culture and practice of medicine in the US; 4) IMGs bring unique skills and advantages to the workplace.ConclusionsOur data reveal that IMGs face workplace challenges throughout their careers. Despite diversity in professional background and demographic characteristics, IMGs in our study reported common experiences in the transition to and practice of medicine in the US. Findings suggest that both workforce and workplace interventions are needed to enable IMG physicians to sustain their essential and growing role in the US healthcare system. Finally, commonalities with experiences of other minority groups within the US healthcare system suggest that optimizing IMGs’ experiences may also improve the experiences of an increasingly diverse healthcare workforce.

Media Exposure and Tobacco, Illicit Drugs, and Alcohol Use Among Children and Adolescents: A Systematic Review

The authors systematically reviewed 42 quantitative studies on the relationship between media exposure and tobacco, illicit drug, and alcohol use among children and adolescents. Overall, 83% of studies reported that media was associated with increased risk of smoking initiation, use of illicit drugs, and alcohol consumption. Of 30 studies examining media content, 95% found a statistically significant association between increased media exposure and negative outcomes. Similarly, of the 12 studies evaluating the quantity of media exposure, 67% reported an association with a negative outcome. Overall, all 17 of the identified longitudinal studies supported a causal association between media exposure and negative outcomes over time. The evidence was strongest for links between media exposure and tobacco use; it was moderate for illicit drug use and alcohol use. Substantial variability in methodological rigor across studies and expanding definitions of media exposure contribute to persistent gaps in the knowledge base.

Do we really need more physicians? Responses to predicted primary care physician shortages.

Predicted primary care shortages have spurred action to increase the number of primary care physicians. However, simply increasing the number of primary care providers is not the only solution to resolving the imbalance between the supply of primary care physicians and the demand for primary care services. In this point-counterpoint, we highlight the limitations of existing primary care shortage predictions and discuss strategies to deliver primary care services without necessarily increasing the number of primary care physicians for a given population. Innovative solutions can be used to reduce or even eliminate projected primary care shortages while changing the prevailing paradigm of primary care.

Experiences of leadership in health care in sub-Saharan Africa.

BackgroundLeadership is widely regarded as central to effective health-care systems, and resources are increasingly devoted to the cultivation of strong health-care leadership. Nevertheless, the literature regarding leadership capacity building has been developed primarily in the context of high-income settings. Less research has been done on leadership in low-income settings, including sub-Saharan Africa, particularly in health care, with attention to historical, political and sociocultural context. We sought to characterize the experiences of individuals in key health-care leadership roles in sub-Saharan Africa.MethodsWe conducted a qualitative study using in-person interviews with individuals (n = 17) in health-care leadership roles in four countries in sub-Saharan Africa: the Federal Democratic Republic of Ethiopia, the Republic of Ghana, the Republic of Liberia and the Republic of Rwanda. Individuals were identified by their country’s minister of health as key leaders in the health sector and were nominated to serve as delegates to a global health leadership conference in June 2010, at Yale University in the United States. Interviews were audio recorded and professionally transcribed. Data analysis was performed by a five-person multidisciplinary team using the constant comparative method, facilitated by ATLAS.ti 5.0 software.ResultsFive key themes emerged as important to participants in their leadership roles: having an aspirational, value-based vision for improving the future health of the country, being self-aware and having the ability to identify and use complementary skills of others, tending to relationships, using data in decision making, and sustaining a commitment to learning.ConclusionsCurrent models of leadership capacity building address the need for core technical and management competencies. While these competencies are important, skills relevant to managing relationships are also critical in the sub-Saharan African context. Developing such skills may require more time and a deeper level of engagement and collaboration than is typically invested in efforts to strengthen health systems.

Surgery for Degenerative Lumbar Scoliosis: The Development of Appropriateness Criteria.

Study Design. The RAND/UCLA Appropriateness Method is a well-established means of developing criteria for assessing the appropriateness of surgery in specific subpopulations. It involves a systematic review of the literature and ratings by a multidisciplinary panel of national experts. Objective. To evaluate the appropriateness of surgical interventions for degenerative lumbar scoliosis (DLS), including identifying clinical characteristics that influence when surgery is inappropriate, appropriate, or necessary, and which procedures are preferable. Summary of Background Data. DLS presents with diverse clinical symptoms and radiographic findings. Variability exists in both nonoperative and operative management. The appropriateness of surgery, and of specific surgical procedures, has not been defined for this important pathology of the aging spine. Methods. We selected a panel of 11 experts, including surgical specialists from multiple disciplines. Next, we systematically reviewed relevant literature. Finally, in a three-round, modified-Delphi process, panelists rated the appropriateness and necessity of five different surgical procedures (dependent variables) on a nine-point scale for 260 different clinical scenarios that stratified patients according to age, medical comorbidities, symptoms, signs, and radiographic variables (independent variables). Results. The 59 eligible studies identified via the systematic review were generally small or used weak designs. Panelists judged that surgery was generally appropriate for patients with at least moderate symptoms and larger or progressive deformities, moderate spinal or foraminal stenosis, or sagittal plane imbalance. Surgery was generally inappropriate for mild symptoms and smaller stable deformities, without sagittal imbalance or moderate stenosis, particularly among patients with advanced age and multiple comorbidities. For patients with larger or progressive deformities, imbalance, or severe multilevel stenosis, more extensive fusion and deformity correction procedures were generally preferred. Conclusion. Defining the appropriateness of surgery for patients with DLS will be useful to improve evidence-based clinical decision making as well as the consistency and quality of care for patients with DLS. Level of Evidence: 3

Effects of Health Care Payment Models on Physician Practice in the United States

The project reported here, sponsored by the American Medical Association (AMA), aimed to describe the effects that alternative health care payment models (i.e., models other than fee-for-service payment) have on physicians and physician practices in the United States. These payment models included capitation, episode-based and bundled payment, shared savings, pay for performance, and retainer-based practice. Accountable care organizations and medical homes, which are two recently expanding practice and organizational models that frequently participate in one or more of these alternative payment models, were also included. Project findings are intended to help guide efforts by the AMA and other stakeholders to make improvements to current and future alternative payment programs and help physician practices succeed in these new payment models-i.e., to help practices simultaneously improve patient care, preserve or enhance physician professional satisfaction, satisfy multiple external stakeholders, and maintain economic viability as businesses. The article provides both findings and recommendations.

Patients' experiences managing cardiovascular disease and risk factors in prison.

BackgroundDespite greater risk of cardiovascular disease (CVD) mortality in patients with a history of incarceration, little is known about how prisons manage CVD risk factors (CVD-RF) to mitigate this risk.MethodsWe conducted in-depth interviews with individuals with CVD-RF who had been recently released from prison (n = 26). These individuals were recruited through community flyers and a primary care clinic in Connecticut. Using a grounded theory approach and the constant comparative method, we inductively generated themes about CVD-RF care in prisons. Data collection and analysis occurred iteratively to refine and unify emerging themes.ResultsFour themes emerged about care in prison: (1) Participants perceive that their CVD-RFs are managed through acute, rather than chronic, care processes; (2) Prison providers’ multiple correctional and medical roles can undermine patient-centered care; (3) Informal support systems can enhance CVD-RF self-management education and skills; and (4) The trade-off between prisoner security and patient autonomy influences opportunities for self-management.ConclusionsPatients develop self-management skills through complex processes that may be compromised by the influence of correctional policies on medical care. Our findings support interventions to engage peers, medical providers, care delivery systems, and correctional staff in cultivating effective self-management strategies tailored to prison settings.