Stephen Petterson

Effects of Poverty and Maternal Depression on Early Child Development

Researchers have renewed an interest in the harmful consequences of poverty on child development. This study builds on this work by focusing on one mechanism that links material hardship to child outcomes, namely the mediating effect of maternal depression. Using data from the National Maternal and Infant Health Survey, we found that maternal depression and poverty jeopardized the development of very young boys and girls, and to a certain extent, affluence buffered the deleterious consequences of depression. Results also showed that chronic maternal depression had severe implications for both boys and girls, whereas persistent poverty had a strong effect for the development of girls. The measures of poverty and maternal depression used in this study generally had a greater impact on measures of cognitive development than motor development.

Projecting US Primary Care Physician Workforce Needs: 2010-2025

PURPOSE We sought to project the number of primary care physicians required to meet US health care utilization needs through 2025 after passage of the Affordable Care Act. METHODS In this projection of workforce needs, we used the Medical Expenditure Panel Survey to calculate the use of office-based primary care in 2008. We used US Census Bureau projections to account for demographic changes and the American Medical Associations Masterfile to calculate the number of primary care physicians and determine the number of visits per physician. The main outcomes were the projected number of primary care visits through 2025 and the number of primary care physicians needed to conduct those visits. RESULTS Driven by population growth and aging, the total number of office visits to primary care physicians is projected to increase from 462 million in 2008 to 565 million in 2025. After incorporating insurance expansion, the United States will require nearly 52,000 additional primary care physicians by 2025. Population growth will be the largest driver, accounting for 33,000 additional physicians, while 10,000 additional physicians will be needed to accommodate population aging. Insurance expansion will require more than 8,000 additional physicians, a 3% increase in the current workforce. CONCLUSIONS Population growth will be the greatest driver of expected increases in primary care utilization. Aging and insurance expansion will also contribute to utilization, but to a smaller extent.

The Social Mission of Medical Education: Ranking the Schools

BACKGROUND The basic purpose of medical schools is to educate physicians to care for the national population. Fulfilling this goal requires an adequate number of primary care physicians, adequate distribution of physicians to underserved areas, and a sufficient number of minority physicians in the workforce. OBJECTIVE To develop a metric called the social mission score to evaluate medical school output in these 3 dimensions. DESIGN Secondary analysis of data from the American Medical Association (AMA) Physician Masterfile and of data on race and ethnicity in medical schools from the Association of American Medical Colleges and the Association of American Colleges of Osteopathic Medicine. SETTING U.S. medical schools. PARTICIPANTS 60 043 physicians in active practice who graduated from medical school between 1999 and 2001. MEASUREMENTS The percentage of graduates who practice primary care, work in health professional shortage areas, and are underrepresented minorities, combined into a composite social mission score. RESULTS The contribution of medical schools to the social mission of medical education varied substantially. Three historically black colleges had the highest social mission rankings. Public and community-based medical schools had higher social mission scores than private and non-community-based schools. National Institutes of Health funding was inversely associated with social mission scores. Medical schools in the northeastern United States and in more urban areas were less likely to produce primary care physicians and physicians who practice in underserved areas. LIMITATIONS The AMA Physician Masterfile has limitations, including specialty self-designation by physicians, inconsistencies in reporting work addresses, and delays in information updates. The public good provided by medical schools may include contributions not reflected in the social mission score. The study was not designed to evaluate quality of care provided by medical school graduates. CONCLUSION Medical schools vary substantially in their contribution to the social mission of medical education. School rankings based on the social mission score differ from those that use research funding and subjective assessments of school reputation. These findings suggest that initiatives at the medical school level could increase the proportion of physicians who practice primary care, work in underserved areas, and are underrepresented minorities.

Rurality, Gender, and Mental Health Treatment

Mental health problems are common and costly, yet many individuals with these problems either do not receive care or receive care that is inadequate. Gender and place of residence contribute to disparities in the use of mental health services. The objective of this study was to identify the influence of gender and rurality on mental health services utilization by using more sensitive indices of rurality. Pooled data from 4 panels of the Medical Expenditure Panel Survey (1996–2000) yielded a sample of 32,219 respondents aged 18 through 64. Variables were stratified by residence using rural–urban continuum codes. We used logistic and linear regression to model effects of gender and rurality on treatment rates. We found that rural women are less likely to receive mental health treatment either through the general healthcare system or through specialty mental health systems when compared to women in metropolitan statistical areas (MSA) or urbanized non-MSA areas. Rural men receive less mental health treatment than do rural women and less specialty mental health treatment than do men in MSAs or least rural non-MSA areas. Reported mental health deteriorates as the level of rurality increases. There is a considerable unmet need for mental health services in most rural areas. The general health sector does not seem to contribute remarkably to mental health services for women in these areas.

Rurality and Mental Health Treatment

Diversity within rural areas renders rural–urban comparisons difficult. The association of mental health treatment rates with levels of rurality is investigated here using Rural–Urban Continuum Codes. Data from the 1996–1999 panels of the Medical Expenditure Panel Survey are aggregated to provide annual treatment rates for respondents reporting mental health problems. Data show that residents of the most rural areas receive less mental health treatment than those residing in metropolitan areas. The adjusted odds of receiving any mental health treatment are 47% higher for metropolitan residents than for those living in the most rural settings, and the adjusted odds for receiving specialized mental health treatment are 72% higher. Findings suggest rural community size and adjacency to metropolitan areas influence treatment rates.

Spending Patterns in Region of Residency Training and Subsequent Expenditures for Care Provided by Practicing Physicians for Medicare Beneficiaries

IMPORTANCE Graduate medical education training may imprint young physicians with skills and experiences, but few studies have evaluated imprinting on physician spending patterns. OBJECTIVE To examine the relationship between spending patterns in the region of a physicians graduate medical education training and subsequent mean Medicare spending per beneficiary. DESIGN, SETTING, AND PARTICIPANTS Secondary multilevel multivariable analysis of 2011 Medicare claims data (Part A hospital and Part B physician) for a random, nationally representative sample of family medicine and internal medicine physicians completing residency between 1992 and 2010 with Medicare patient panels of 40 or more patients (2851 physicians providing care to 491,948 Medicare beneficiaries). EXPOSURES Locations of practice and residency training were matched with Dartmouth Atlas Hospital Referral Region (HRR) files. Training and practice HRRs were categorized into low-, average-, and high-spending groups, with approximately equal distribution of beneficiary numbers. There were 674 physicians in low-spending training and low-spending practice HRRs, 180 in average-spending training/low-spending practice, 178 in high-spending training/low-spending practice, 253 in low-spending training/average-spending practice, 417 in average-spending training/average-spending practice, 210 in high-spending training/average-spending practice, 97 in low-spending training/high-spending practice, 275 in average-spending training/high-spending practice, and 567 in high-spending training/high-spending practice. MAIN OUTCOMES AND MEASURES Mean physician spending per Medicare beneficiary. RESULTS For physicians practicing in high-spending regions, those trained in high-spending regions had a mean spending per beneficiary per year

Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions

1926 higher (95% CI,

Psychological distress, hopelessness and welfare.

889-

Estimating the Residency Expansion Required to Avoid Projected Primary Care Physician Shortages by 2035

2963) than those trained in low-spending regions. For practice in average-spending HRRs, mean spending was

Measures of social deprivation that predict health care access and need within a rational area of primary care service delivery

897 higher (95% CI,