Roger A. Rosenblatt

Access to obstetric care in rural areas: effect on birth outcomes.

Hospital discharge data from 33 rural hospital service areas in Washington State were categorized by the extent to which patients left their local communities for obstetrical services. Women from communities with relatively few obstetrical providers in proportion to number of births were less likely to deliver in their local community hospital than women in rural communities with greater numbers of physicians practicing obstetrics in proportion to number of births. Women from these high-outflow communities had a greater proportion of complicated deliveries, higher rates of prematurity, and higher costs of neonatal care than women from communities where most patients delivered in the local hospital.

Do medicare patients with disabilities receive preventive services? A population-based study

OBJECTIVE To compare health maintenance procedure rates of Medicare patients with different levels of disability. STUDY DESIGN Observational study analyzing data from the 1995 Medicare Current Beneficiary Survey (MCBS, n = 15,590). Self-reported Pap smears, mammograms, and influenza and pneumococcal vaccinations were compared between groups with different levels of health-related difficulties in six activities of daily living (ADL). RESULTS Compared to those without disabilities, the most severely disabled women (limitations in 5 or 6 ADL) reported fewer Pap smears (age < or =70, 23% vs 41%, p < .001) and mammograms (age > or = 50, 13% vs 44%, p < .001). In a controlled analysis, individuals with this high level of disability were 57% (95% confidence interval [CI], 33% to 72%) and 56% (95% CI, 43% to 76%) less likely to report receiving Pap smears and mammograms, respectively, compared with able-bodied women, regardless of their age, whether they were in an HMO, or whether they lived in a long-term care facility. Functional limitations were not a deterrent to receiving vaccinations. In general, patients in HMOs reported more procedures than those in fee-for-service, while those in long-term care facilities reported fewer procedures than those living in the community. CONCLUSIONS Disability among Medicare patients is a significant, independent risk factor for not receiving mammograms and Pap smears. Efforts should be made to identify the most severely disabled because they are at particular risk.

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.

How well do birth certificates describe the pregnancies they report? The Washington State experience with low-risk pregnancies.

Objectives: Birth certificates are a major source of population-based data on maternal and perinatal health, but their value depends on the accuracy of the data. This study assesses the validity of information recorded on the birth certificates for women in Washington State who were considered to be low risk at entry into care. Methods: Birth certificates were matched to data abstracted from prenatal and intrapartum clinic and hospital records of a sample of 1937 Washington State obstetrical patients who were considered to be low risk at the beginning of their pregnancies. Accuracy of a variety of pregnancy characteristics (e.g., complications, procedures) on the birth certificate was analyzed using percentage agreement and sensitivity with record abstracts as the “gold standard.” Next, we weighted the data from each source to produce estimates of pregnancy characteristics in the population. We compared these estimates from the two data sources to see whether they provide similar pictures of this subpopulation. Results: Missing data for specific items on the birth certificates ranged from 0% to 24%. The birth certificate accurately captured gravidity and parity, but was less likely to report prenatal and intrapartum complications. The population estimates of the two data sources were significantly different. Conclusions: Because birth certificates significantly underestimated the complications of pregnancies, number of interventions, number of procedures, and prenatal visits, use of these data for health policy development or resource allocation should be tempered with caution.

Interspecialty differences in the obstetric care of low-risk women.

OBJECTIVES This study examined differences among obstetricians, family physicians, and certified nurse-midwives in the patterns of obstetric care provided to low-risk patients. METHODS For a random sample of Washington State obstetrician-gynecologists, family physicians, and certified nurse-midwives, records of a random sample of their low-risk patients beginning care between September 1, 1988, and August 31, 1989, were abstracted. RESULTS Certified nurse-midwives were less likely to use continuous electronic fetal monitoring and had lower rates of labor induction or augmentation than physicians. Certified nurse-midwives also were less likely than physicians to use epidural anesthesia. The cesarean section rate for patients of certified nurse-midwives was 8.8% vs 13.6% for obstetricians and 15.1% for family physicians. Certified nurse-midwives used 12.2% fewer resources. There was little difference between the practice patterns of obstetricians and family physicians. CONCLUSIONS The low-risk patients of certified nurse-midwives in Washington State received fewer obstetrical interventions than similar patients cared for by obstetrician-gynecologists or family physicians. These differences are associated with lower cesarean section rates and less resource use.

The effect of expanding Medicaid prenatal services on birth outcomes.

OBJECTIVES Over 80% of US states have implemented expansions in prenatal services for Medicaid-enrolled women, including case management, nutritional and psychosocial counseling, health education, and home visiting. This study evaluates the effect of Washington States expansion of such services on prenatal care use and low-birthweight rates. METHODS The change in prenatal care use and low-birthweight rates among Washingtons Medicaid-enrolled pregnant women before and after initiation of expanded prenatal services was compared with the change in these outcomes in Colorado, a control state. RESULTS The percentage of expected prenatal visits completed increased significantly, from 84% to 87%, in both states. Washingtons low-birthweight rate decreased (7.1% to 6.4%, P = .12), while Colorados rate increased slightly (10.4% to 10.6%, P = .74). Washingtons improvement was largely due to decreases in low-birthweight rates for medically high-risk women (18.0% to 13.7%, P = .01, for adults; 22.5% to 11.5%, P = .03, for teenagers), especially those with preexisting medical conditions. CONCLUSIONS A statewide Medicaid-sponsored support service and case management program was associated with a decrease in the low-birthweight rate of medically high-risk women.

Diagnosis Clusters: A New Tool for Analyzing the Content of Ambulatory Medical Care

A clustering method for the analysis of ambulatory morbidity data is presented. This approach reduces spurious variations resulting from idiosyncratic diagnosis labeling and coding habits of physicians and facilitates the analysis of the content of ambulatory medical care through the use of aggregate morbidity data. The clusters provide a tool that allows for the comparison of the content of practice based on different factors such as provider training, practice organization, and patient characteristics. Ninety-two diagnosis clusters were derived using the 1977 and 1978 National Ambulatory Medical Care Survey (NAMCS). These clusters incorporate 86 per cent of all ambulatory visits to office-based physicians in the contiguous United States. The clusters were constructed based on the consensus of a group of clinicians including both generalists, as well as selected subspecialists representing the spectrum of ambulatory medical practice. The diagnosis clusters presented are compatible with the International Classification of Diseases (ICDA-8 and ICD-9-CM) and the International Classifications of Health Problems in Primary Care (ICHPPC and ICHPPC-2). Several applications demonstrating the utility of the method are presented, and directions for future applications are suggested.

Access to maternity care in rural Washington: its effect on neonatal outcomes and resource use.

OBJECTIVES This study sought to ascertain the effects of poor local access to obstetric care on the risks of having a neonate diagnosed as non-normal, a long hospital stay, and/or high hospital charges. METHODS Washington State birth certificates linked with hospital discharge abstracts of mothers and neonates were used to study 29809 births to residents of rural areas. Births to women from rural areas where more than two thirds of the women left for care were compared with births to women from rural areas where fewer than one third left for care. RESULTS Poor local access to providers of obstetric care was associated with a significantly greater risk of having a non-normal neonate for both Medicaid and privately insured patients. However, poor local access to care was consistently associated with higher charges and increased hospital length of stay only if the patient was privately insured. CONCLUSIONS These results indicate that local maternity services may help prevent non-normal births to rural women and, among privately insured women, might decrease use of neonatal resources.

Geographic and Specialty Distribution of US Physicians Trained to Treat Opioid Use Disorder

PURPOSE The United States is experiencing an epidemic of opioid-related deaths driven by excessive prescribing of opioids, misuse of prescription drugs, and increased use of heroin. Buprenorphine-naloxone is an effective treatment for opioid use disorder and can be provided in office-based settings, but this treatment is unavailable to many patients who could benefit. We sought to describe the geographic distribution and specialties of physicians obtaining waivers from the Drug Enforcement Administration (DEA) to prescribe buprenorphine-naloxone to treat opioid use disorder and to identify potential shortages of physicians. METHODS We linked physicians authorized to prescribe buprenorphine on the July 2012 DEA Drug Addiction Treatment Act (DATA) Waived Physician List to the American Medical Association Physician Masterfile to determine their age, specialty, rural-urban status, and location. We then mapped the location of these physicians and determined their supply for all US counties. RESULTS Sixteen percent of psychiatrists had received a DEA DATA waiver (41.6% of all physicians with waivers) but practiced primarily in urban areas. Only 3.0% of primary care physicians, the largest group of physicians in rural America, had received waivers. Most US counties therefore had no physicians who had obtained waivers to prescribe buprenorphine-naloxone, resulting in more than 30 million persons who were living in counties without access to buprenorphine treatment. CONCLUSIONS In the United States opioid use and related unintentional lethal overdoses continue to rise, particularly in rural areas. Increasing access to office-based treatment of opioid use disorder—particularly in rural America—is a promising strategy to address rising rates of opioid use disorder and unintentional lethal overdoses.

The content of ambulatory medical care in the United States. An interspecialty comparison.

Ambulatory care, accounting for over half a billion visits to physicians per year, is a major component of the health-care system and is the core of primary health care. This study uses data from the National Ambulatory Medical Care Survey to describe the most common problems seen in an ambulatory-care setting, to identify the medical specialties that provide the greater part of this care, and to characterize the major specialties in terms of the diagnoses in the patients who constitute their ambulatory practice. Fifteen diagnosis clusters account for 50 per cent of all ambulatory-care visits; only 8 of the 28 specialties account for a substantial amount (more than 25 per cent) of the ambulatory care rendered to patients with any of these 15 diagnoses. General and family physicians, general internists, and general pediatricians account for 65.9 per cent of all outpatient visits to physicians for the 15 most common problems; general and family physicians alone are responsible for more than half this total. The individual specialties differ markedly in the diagnostic and demographic variety of their outpatient workload. These differences have important implications for the training of physicians and the organization of their practices.