Are we ready for terrorism? Emergency medical technicians' and paramedics' training and self-perceived competence since September 11.

The US continues to be a target for terrorist activities that threaten the lives of the populace. Training on preparedness and response for emergency medical technicians (EMTs) and paramedics is critical to the success of an early response to any such attack. Previous surveys have suggested that terrorism-specific training has been modest at best since September 11. In order to gain further insight into emergency personnel's level of training and competence, we sent surveys to 4,000 EMTs and paramedics in the state of Florida in late 2005 and early 2006. Results show a much higher level of training than previously reported from other states and suggest a direct correlation between the amount and type of training and self-reported competence. Our results suggest that most emergency personnel are receiving terrorism-specific training, but gaps in competencies exist and require the attention of educators and policymakers.

PTSD and substance use: unrecognized sequelae of bioterrorism in primary care providers.

BACKGROUND: Psychological casualties following public health emergencies are likely to significantly outnumber physical casualties. However, postevent psychological disorders may be underrecognized by primary care providers (PCPs). METHODS: Rural PCPs in northern and central Florida were interviewed using a series of open-ended questions to assess knowledge of likely mental disorders, their risk factors, and preferred treatment options following such events (n=21). RESULTS: PTSD was identified by 14% and substance abuse by 10% of the sample. Physicians were significantly more likely to identify posttraumatic stress disorder (PTSD) as an expected postevent psychological disorder than nonphysician providers. PCPs were significantly more likely to endorse counseling (86%) than medications (43%) as a preferred treatment option. CONCLUSIONS: Our findings support the need for increased education and training regarding the mental health consequences of bioterrorism in rural PCPs, particularly for nursing-level and other nonphysician providers. Improvements in knowledge may enhance preparedness for such emergencies.

Are community health centers prepared for bioterrorism?

Community health centers (CHCs) are essential in the delivery of primary care services to underserved populations. Given the critical function of CHCs, surprisingly little is known about their role in preparing for or responding to acts of terrorism. This survey-based study examines the state of CHCs in terrorism preparedness and assesses their training needs. Of the administrators who responded to the survey, 87% indicated that their centers had an emergency response or disaster plan. Of those, 78% indicated they had updated their plans within the past year. Among those who had a written plan, 41% addressed bioterrorism preparedness, 38% had contingencies for a mass influx of patients, and 3% indicated that their plans addressed increasing operational capacity. Additionally, while 48% reported having assessed the education and training needs of their professional staff in the area of disease surveillance and reporting, only 24% had assessed these needs in relation to bioterrorism. Our findings suggest that CHCs have made great strides in preparing for some emergencies but that preparedness does not yet extend to specifically include terrorism events. Policy and practice recommendations are included to more fully develop CHCs as a resource.

Continuing decline in service delivery for family physicians: is the malpractice crisis playing a role?

PURPOSE: This study was conducted to monitor trends in the reduction and elimination of services offered by family physicians. In addition, we examined whether the malpractice situation may be influencing these trends. METHODS: We surveyed all family physicians in rural Florida and an equal number of randomly selected, urban, family physicians in the state. We examined changes in professional liability insurance (PLI) premiums, and changes in services offered, practice satisfaction, and future practice plans. RESULTS: Overall, 308 (42.1%) family physicians responded. Results suggest that 60.3% of them reduced or eliminated services in the last year. Specifically, almost two thirds of respondents had eliminated hospital-based surgeries (65.2%) and vaginal deliveries (64.5%). Furthermore, endoscopies were decreased or eliminated by 69% of survey participants, and coverage of emergency departments and nursing homes was reduced or eliminated by 64.1% and 56.4% of respondents, respectively. Increases in the PLI averaged 78.2%. Overall increases in the PLI were significantly related to a decrease or elimination of services offered by family physicians. Dissatisfaction with practice was relatively high (36.8%) and was associated with both the reduction of services and an intention to leave practice within 2 years. No major differences in these trends were noted between rural and urban family physicians. CONCLUSIONS: Access to care provided by rural and urban family physicians in Florida is being hampered by the malpractice situation and other factors. Policymakers may need to focus on these factors in an effort to relieve additional barriers to care for vulnerable populations.

A state-based analysis of public health preparedness programs in the United States.

OBJECTIVES: Given the national effort to respond to the challenge of terrorism post-9/11, this study examined the organizational structure of state public health preparedness programs across the country, their administration, and the personnel and resources supported through federal cooperative agreements and state funds. METHODS: In Fall 2004, the Association of State and Territorial Health Officials surveyed state public health preparedness directors of all 50 states and territories of the United States regarding the organizational structure, administration, personnel, and resources of the state public health preparedness programs. RESULTS: Individuals representing 45 states and the District of Columbia responded to the web-based questionnaire for a response rate of 88.2%, States tended to subdivide their organizations into regions for preparedness purposes. More than half the established preparedness regions (53.8%) were created post-9/11. Preparedness program directors frequently reported directly to either the state health official (40.0%) or a deputy state health official (33.3%). Responsibility for both the Centers for Disease Control and Prevention (CDC) and Health Resources and Services Administration (HRSA) cooperative agreements was predominantly vested in one person (73.3%). Federal resources were found to support needed preparedness workforce (CDC mean = 117.1 full-time equivalents [FTEs]; HRSA mean = 10.6 FTEs). In addition, 36.6% of the states also contributed to the public health preparedness budget. CONCLUSIONS: This study of state public health agency preparedness provides new information about state-level organizational structure, administration, and support of preparedness programs. It offers the first comprehensive insights into the approaches states have adopted to build infrastructure and develop capacity through CDC and HRSA funding streams.

Availability of physician services in Florida, revisited: the effect of the professional liability insurance market on access to health care.

BACKGROUND: Access to care remains a key part of improving health care outcomes in the United States. Recent reports have suggested that the number of physicians able to meet the demands for access to care may be decreasing. METHODS: We surveyed physicians practicing in rural and urban/suburban areas of Florida in 2004 to determine whether changes were occurring in health care service delivery. Secondary outcomes assessed included changes in professional liability insurance and their possible effects on changes in service delivery. RESULTS: Overall, 727 (54.4%) of responding physicians stated that the delivery of services had been decreased or eliminated in the previous year. The most commonly eliminated services were nursing home coverage (42.1%), vaginal deliveries (29.1%), cesarean deliveries (26.0%), emergency department coverage (22.8%), and mental health services (21.2%). Surgical specialists (70.2%) and general surgeons (68.5%) were the groups with the highest number of decreased or eliminated services, but this trend was broad, with 63.6% of obstetrician/gynecologists and 60.2% of family medicine physicians also decreasing or eliminating services. Decreases in services seem to be related to changes in professional liability insurance premiums when assessed by both percentage of change and total premium increases for physicians. Rural and urban/suburban physicians did not differ significantly in these assessments. CONCLUSION: The findings suggest that physicians across Florida have continued to decrease or eliminate important health services and that these decreases seem to be related to the difficulty of finding or paying for professional liability insurance.

Information technologies in Florida's rural hospitals: does system affiliation matter?

CONTEXT: The recent explosive growth of information technology in hospitals promises to improve hospital and patient outcomes. Financial barriers may cause rural hospitals to lag in adoption of information technology, however, formal studies that examine rural hospital adoption of information technology are lacking. PURPOSE: To determine the extent to which rural Florida hospitals utilize clinical and other information technology applications, to identify related information technology issues and barriers, and to explore differences between stand-alone and system-affiliated hospitals. METHODS: Chief information officers in rural Florida hospitals were surveyed from June 2003-October 2003. A comprehensive set of questions assessed hospital demographics, information technology priorities and barriers, clinical and other information technology systems, and staffing needs. FINDINGS: In rural Florida, current information technology priorities included upgrading security on information technology systems to meet Health Insurance Portability and Accountability Act requirements (53.6%), implementing technology to reduce medical errors and to promote patient safety (50.0%), and implementing wireless systems (46.4%). With respect to current information technology adoption, system-affiliated rural hospitals were statistically more likely than their stand-alone counterparts to have laboratory information systems (93% vs 39%), pharmacy (87% vs 46%), pharmacy dispensing (53% vs 8%), chart deficiency (60% vs 15%), and order communication results (60% vs 23%). Financial barriers to successful information technology implementation were noted by 69% of stand-alone and 20% of system-affiliated rural hospitals. CONCLUSIONS: Although top information technology priorities are similar for all rural hospitals examined, differences exist between system-affiliated and stand-alone hospitals in adoption of specific information technology applications and with barriers to information technology adoption.

Patient safety-related information technology utilization in urban and rural hospitals.

Ongoing research has linked certain information technology applications to reduction of medical errors and improved patient outcomes. The purpose of this study was to assess both the use of patient safety-related information technologies (PSIT) in urban and rural hospitals, as well as the organizational factors which may be linked to overall PSIT adoption. Florida's 199 acute care hospitals (170 urban; 29 rural) were surveyed regarding their utilization of PSIT. Of the 10 technologies studied, rural hospitals averaged 30% utilization compared to 48% for urban hospitals. Individual PSIT applications such as pharmacy-based systems, clinical decision support systems, and outcomes and quality management tools were all more likely to be present in urban hospitals. Hospital bed size (less than 100 beds), tax status (not-for-profit vs. for-profit), and system-affiliation appeared to be related to overall PSIT utilization. These findings are valuable for those interested in the current status of hospital PSIT and set the stage for further studies relating these applications to clinical outcomes in urban and rural hospitals.

The changing face of access to family physician services in rural Florida.

OBJECTIVES: This study's purpose was to determine whether access to services performed by Florida family physicians in rural areas is changing and whether the recent changes in the availability or cost of professional liability insurance may be influencing service provision. METHODS: We conducted a survey of all family physicians in rural Florida, asking about changes in health care services and procedures provided, insurance coverage and premiums, satisfaction with practice, and plans for future practice. RESULTS: Of the 204 respondents, 96 (49.5%) indicated that they have decreased or eliminated some health care services during the last year. Overall, 69.8% decreased or eliminated vaginal deliveries, 66.2% Cesarean sections, 56.6% endoscopies, 50.9% hospital-based surgeries, 50.7% emergency room coverage, 40.8% office-based surgeries, and 33.6% mental health services. Malpractice premiums increased a mean of 98.5%. Difficulty with finding or paying for insurance was listed as an important factor both by those reducing or eliminating services and by those planning to leave the community within the next 2 years. CONCLUSIONS: Access to some services provided by family physicians in rural areas is decreasing and may be influenced by recent changes in professional liability insurance costs and other factors in Florida. Given the number of states currently experiencing similar insurance cost changes, access to health care in rural areas may be affected nationwide.

Impact of the medical professional liability insurance crisis on access to care in Florida.

BACKGROUND: Almost half of the US states face serious problems with professional liability insurance (PLI). Despite this, little is known about how this crisis is affecting access to care, particularly in rural areas. METHODS: We surveyed physicians practicing in rural Florida in 2003. The primary assessment was on changes in health care delivery by service type and specialty. Secondary outcomes included changes in PLI premiums and the effect of changes in premiums on service delivery and practice satisfaction. RESULTS: Four hundred eleven (52.6%) of 781 physicians decreased or eliminated health care services during the past year. Overall, 73 (61.3%) of 119 decreased or eliminated vaginal deliveries; 60 (52.6%) of 114, cesarean sections; 186 (51.7%) of 360, hospital-based surgical procedures; 209 (46.4%) of 450, emergency department coverage; 103 (41.7%) of 247, endoscopic procedures; 187 (40.9%) of 457, office-based surgical procedures; and 105 (34.5%) of 304, mental health services. Elimination of services was highest for general surgeons (78.4%), surgical specialists (73.6%), and obstetricians/gynecologists (70.2%). Premiums for PLI rose a mean of 93.5%. Difficulty finding or paying for PLI was listed as an important factor by those reducing or eliminating services and by those planning to leave the community within the next 2 years. CONCLUSIONS: The current crisis in medical PLI in Florida has a major impact on the availability and delivery of health care services to rural areas. Given the number of states that are experiencing similar insurance market upheavals, adverse effects on access to care are likely occurring nationwide.

The cost of trauma center readiness.

BACKGROUND: Trauma centers and the services they provide are a unique and necessary component of our health system. By design trauma centers treat all injured patients regardless of their clinical or economic needs. The purpose of this study was to quantify the costs associated with the preparation of the capacity to provide trauma care at trauma centers within the State of Florida. METHODS: Utilizing a survey tool and multiple retreats, we assessed the capability of 20 verified trauma centers throughout the State of Florida. The survey focused on general attributes of each hospital, the costs associated with physician on call coverage, costs associated with verification, and lastly the costs associated with administration, outreach, and prevention. RESULTS: Data were acquired from 10 trauma centers. Ninety percent of the respondents pay on-call coverage. The median annual physician compensation for on-call coverage was approximately 2.1 million US dollars. The total medial cost of readiness for each trauma center approximated 2.7 million US dollars annually. CONCLUSIONS: Trauma centers like fire departments and police services are required to be available 24 hours a day, 7 days a week. This level of commitment by trauma centers and the reciprocal expectation from the community force trauma centers to make considerable investments in readiness. This cost of readiness is expended regardless of the patient volume or insurance status. Thus trauma centers have a large component of costs that are not captured by the traditional billing and cost accounting mechanisms within health systems and this fixed expense is extraordinarily difficult to recover given the current reimbursement environment.

The rural physician workforce in Florida: a survey of US- and foreign-born primary care physicians.

CONTEXT: To meet the challenge of primary care needs in rural areas, continuing assessment of the demographics, training, and future work plans of practicing primary care physicians is needed. PURPOSE: This study's goal was to assess key characteristics of primary care physicians practicing in rural, suburban, and urban communities in Florida. METHODS: Surveys were mailed to all of Florida's rural primary care physicians (n = 399) and a 10% sampling (n = 1236) of urban and suburban primary care physicians. FINDINGS: Responses from 1000 physicians (272 rural, 385 urban, 343 suburban) showed that rural physicians were more likely to have been raised in a rural area, foreign-born and trained, a National Health Service Corps member, or a J-1 visa waiver program participant. Rural physicians were more likely to have been exposed to rural medical practice or living in a rural environment during their medical school and residency training. Factors such as rural upbringing and medical school training did not predict future rural practice with foreign-born physicians. Overall, future plans for practice did not seem to differ between rural, urban, and suburban physicians. CONCLUSIONS: Recruiting and retaining doctors in rural areas can be best supported through a mission-driven selection of medical students with subsequent training in medical school and residency in rural health issues. National programs such as the National Health Service Corps and the J-1 visa waiver program also play important roles in rural physician selection and should be taken into account when planning for future rural health care needs.

Protecting rural communities from terrorism: a statewide, community-based model.

Given the number of Americans who live in rural areas and the unique challenges they face in the provision of health care services, special attention to planning for and responding to terrorist acts is warranted. After September 11, 2001, Florida developed a statewide, community-based model that applies the public health principles of assessment, policy development, and assurance. This model can serve as a possible framework for other states and communities.

The roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: a review of the literature.

PURPOSE: A systematic review of factors associated with recruitment and retention of primary care physicians in rural areas. METHOD: Using PubMed and Medline databases, 21 quantitative articles analyzing recruitment and retention of primary care physicians in rural areas from 1990 to 2000 were found. To assess the methodologic strengths of these articles, a formal evaluation was conducted based on study design, study population, response rate, years studied, data source, and statistical methods (total possible score = 60 points). Studies were grouped by whether the factors assessed were related to pre-medical school, medical school, or residency. RESULTS: A total of six studies (score range: 30-52) analyzed pre-medical school factors, 15 (score range: 30-52) considered medical school factors, and six (score range: 20-52) analyzed residency factors related to rural recruitment and retention. Pre-medical school factors such as rural upbringing and specialty preference were most strongly correlated with recruitment of physicians to rural areas. Training factors such as commitment to rural curricula and rotations, particularly during residency, were most strongly correlated with retention in rural areas. CONCLUSIONS: Although important gaps exist, scientific studies available to health educators and policymakers show there are predictable factors that influence recruitment and retention in rural areas. Policies for staffing rural areas with primary care physicians should be aimed at both selecting the right students and giving them during their formal training the curriculum and the experiences that are needed to succeed in primary care in rural settings.