Report on the 1990 - 2018 John A. Burns School of Medicine Medical Student Specialty Match and Residency Position Data.

The physician shortage is expected to worsen both in Hawai'i and nationally, with primary care remaining the most needed medical specialty. The University of Hawai'i John A. Burns School of Medicine (JABSOM) plays a critical role in physician workforce development through its undergraduate (Medical School) and graduate medical education (Residency) programs. This report summarizes the Residency match results of all JABSOM Medical School graduates, their trends over time, and the total number of positions available in the JABSOM Residency programs between 1990 and 2018. Overall, 1652 JABSOM Medical School graduates successfully matched into Residency between 1990-2018. There was a negative trend of JABSOM Medical School graduates matching into all 3 primary care Residency programs during this reporting period. The total number of JABSOM Residency positions decreased during the study period, while there was an increase in the number of primary care JABSOM Residency positions. Alignment of the increasing JABSOM Medical School class size with the available JABSOM Residency positions in Hawai'i will be an important health workforce development strategy going forward.

COVID-19 Containment Ship Model: A Case Study for Pacific Island Response.

The Republic of the Marshall Islands, American Samoa, the Federated States of Micronesia, and the Republic of Palau have been without any COVID-19 community transmission since the beginning of the global pandemic. The Commonwealth of the Northern Mariana Islands has experienced modest community transmission, and Guam has had significant COVID-19 community transmission and morbidity. Although several of these United States Affiliated Pacific Island jurisdictions made difficult strategic choices to prevent the spread of COVID-19 which have been largely successful, the built environment and the population density in the urban areas of the Pacific remain inherently conducive to rapid COVID-19 transmission. Rapid transmission could result in devastating health and economic consequences in the absence of continued vigilance and long-term strategic measures. The unique COVID-19 vulnerability of islands in the Pacific can be modeled through examination of recent outbreaks onboard several United States Naval ships and other marine vessels. The environmental characteristics that pose challenges to infection control on an isolated naval ship are analogous to the environmental characteristics of these Pacific island communities. Considering a collection of case studies of COVID-19 transmission on ships and applying to Pacific Island environments, provides a heuristic, easily accessible epidemiologic framework to identify methods for interventions that are practical and reliable towards COVID-19 containment, prevention, and control. Using accessible evidence based public health policies, infection risk can be decreased with the objective of maintaining in-country health and social stability. These case studies have also been examined for their relevance to current discussions of health care infrastructure and policy in the Pacific Islands, especially that of vaccination and repatriation of citizens marooned in other countries. The need for aggressive preparation on the parts of territories and nations not yet heavily exposed to the virus is critical to avoid a rapid "burn-through" of disease across the islands, which would likely result in catastrophic consequences.

Racial/ethnic differences in health-related quality of life among Hawaii adult population.

BACKGROUND: This study examined racial/ethnic differences in health-related quality of life (HRQOL) among adults and identified variables associated with HRQOL by race/ethnicity. METHODS: This study was conducted under a cross-sectional design. We used the 2011-2016 Hawaii Behavioral Risk Factor Surveillance System data. HRQOL were assessed by four measures: self-rated general health, physically unhealthy days, mentally unhealthy days, and days with activity limitation. Distress was defined as fair/poor for general health and 14 days or more for each of the other three HRQOL measures. We conducted multivariable logistic regressions with variables guided by Anderson's behavioral model on each distress measure by race/ethnicity. RESULTS: Among Hawaii adults, 30.4% were White, 20.9% Japanese, 16.8% Filipino, 14.6% Native Hawaiian and Pacific Islander (NHPI), 5.9% Chinese, 5.2% Hispanics, and 6.2% Other. We found significant racial/ethnic differences in the HRQOL measures. Compared to Whites, Filipinos, Japanese, NHPIs, and Hispanics showed higher distress rates in general health, while Filipinos and Japanese showed lower distress rates in the other HRQOL measures. Although no variables were consistently associated with all four HRQOL measures across all racial/ethnic groups, history of diabetes were significantly associated with general health across all racial/ethnic groups and history of depression was associated with at least three of the HRQOL measure across all racial/ethnic groups. CONCLUSIONS: This study contributes to the literature on disparities in HRQOL and its association with other variables among diverse racial/ethnic subgroups. Knowing the common factors for HRQOL across different racial/ethnic groups and factors specific to different racial/ethnic groups will provide valuable information for identifying future public health priorities to improve quality of life and reduce health disparities.

Racial/Ethnic and County-level Disparity in Inpatient Utilization among Hawai'i Medicaid Population.

We investigated racial/ethnic and county-level disparities in inpatient utilization for 15 clinical conditions among Hawaii's Medicaid population. The study was conducted using inpatient claims data from more than 200,000 Hawai'i Medicaid beneficiaries, reported in the year 2010. The analysis was performed by stratifying the Medicaid population into three age groups: children and adolescent group (1-20 years), adult group (21-64 years), and elderly group (65 years and above). Among the differences found, Asians had a low probability of inpatient admissions compared to Whites for many disease categories, while Native Hawaiian/Pacific Islanders had higher probabilities than Whites, across all age groups. Pediatric and adult groups from Hawai'i County (Big Island) had lower probabilities for inpatient admissions compared to Honolulu County (O'ahu) for most disease conditions, but higher probabilities were observed for several conditions in the elderly group. Notably, the elderly population residing on Kaua'i County (Kaua'i and Ni'ihau islands) had substantially increased odds of hospital admissions for several disease conditions, compared to Honolulu.

GIS residency footprinting: analyzing the impact of family medicine graduate medical education in Hawai'i.

BACKGROUND: Access to care for patients in Hawai'i is compromised by a significant primary care workforce shortage. Not only are there not enough primary care providers, they are often not practicing in locations of high need such as rural areas on the neighbor islands or in the Pacific. METHODS: This study used geographic information systems (GIS) spatial analysis to look at practice locations for 86 University of Hawai'i Family Medicine and Community Health graduates from 1993 to the 2010. Careful alumni records were verified and entered into the data set using the street address of major employment. Questions to be answered were (1) what percentage of program graduates remain in the state of Hawai'i and (2) what percentage of graduates practice in health professional shortage areas (HPSAs) throughout the United States. RESULTS: This study found that 73 percent of graduates remain and practice in Hawai'i with over 36 percent working in Health Professional Shortage Areas. DISCUSSION: Spatial analysis using GIS residency footprinting may be an important analytic tool to ensure that graduate medical education programs are meeting Hawai'i's health workforce needs.

Health consequences of disparity: the US Affiliated Pacific Islands.

Health disparities and the social determinants of health are often discussed, but their relationship to political forces, the integrity of cultures, social and environmental change, and mental health outcomes are not well understood. Specifically the US Affiliated Pacific Islands Jurisdictions (USPAIJ) is an area of profound isolation and deprivation with a unique sociocultural history. This article provides an overview of health disparities in the US Affiliated Pacific in the context of the environment, and international and state policies. The article explores how the political, economic, social, and environmental context of the USAPIJ shapes health status and provides a "social determinants of health" model for health improvement for the people of the region.

The "compact impact" in Hawaii: focus on health care.

The political, economic, and military relationship between the former Pacific Trust Territories of the United States is defined by the Compact of Free Association (COFA) treaty. The respective COFA treaties allow the United States military and strategic oversight for these countries, while COFA citizens can work, reside, and travel with unlimited lengths of stay in the United States. The unforeseen consequences of the diaspora of the people of the COFA nations to the United States and its territories is called the "Compact Impact." In 2007 the social, health, and welfare system costs attributed to the estimated 13,000 COFA migrants in Hawaii was $90 million. The US federal government does not take full responsibility for the adverse economic consequences to Hawaii due to COFA implementation. The lack of health and education infrastructure in the COFA nations, as well as the unique language, culture, political, and economic development of the region have contributed to the adverse elements of the Compact Impact. The Department of Human Services of Hawaii, once supportive of the COFA peoples, now looks to withdraw state sponsored health care support. This paper reviews the historical, political, and economic development, which surrounds the Compact Impact and describes Hawaii's government and community response. This paper attempts to understand, describe, and search for solutions that will mitigate the Compact Impact.

Developing the rural primary care workforce in Hawaii--a 10-point plan.

The shortage of physicians and resultant lack of access to care particularly on the rural neighbor islands of Hawaii has been well described. A recent report in the December issue of this journal by Withy, et al. documents a current shortage of 45 physicians on the Big Island. (1) Similar reports suggest that Hawaii's physician workforce lags 20% behind physician to population ratios in the continental US. It is projected that the aging population and the heavy burden of chronic disease will increase demand for health services by 40% by 2020 and even higher for specialties that focus on the care of elders. The existing physician shortage is heightened by the high percentage of doctors reaching retirement age. High business and living costs coupled with low reimbursement for health services makes it difficult to be competitive when recruiting physicians to Hawaii. Are there evidence based solutions to the state rural primary care workforce crisis? This article describes what is currently in place as well as new initiatives and a ten point plan to lay the framework for an improved state rural training pipeline.

Health information technology and physicians' knowledge of drug costs.

OBJECTIVE: To examine whether physicians' use of information technology (IT) was associated with better knowledge of drug costs. STUDY DESIGN/METHODS: A 2007 statewide survey of 247 primary care physicians in Hawaii regarding IT use and self-reported knowledge of formularies, copayments, and retail prices. RESULTS: Approximately 8 in 10 physicians regularly used IT in clinical care: 60% Internet, 54% e-prescribing, 43% electronic health records (EHRs), and 37% personal digital assistants (PDAs). However, fewer than 1 in 5 often knew drug costs when prescribing, and more than 90% said lack of knowledge of formularies and copayments remained a barrier to considering drug costs for patients. In multivariate analyses adjusting for sex, practice size, years in practice, number of formularies, and use of clinical resources (eg, pharmacists), use of the Internet -- but not e-prescribing, EHRs, or PDAs -- was associated with physicians reporting slightly better knowledge of copayments (adjusted predicted percentage of 23% vs 11%; P = .04). No type of IT was associated with better knowledge of formularies or retail prices. CONCLUSIONS: Despite high rates of IT use, there was only a modest association between physicians' use of IT and better knowledge of drug costs. Future investments in health IT should consider how IT design can be improved to make it easier for physicians to access cost information at the point of care.

Elderly patients' knowledge of drug benefit caps and communication with providers about exceeding caps.

OBJECTIVES: Many elderly persons have drug benefits with coverage gaps, such as in Medicare Part D. Because beneficiaries who have such gaps must pay all drug costs, an accurate knowledge of gap thresholds and communication with providers about exceeding caps is important for elderly persons to manage out-of-pocket drug costs. DESIGN: Cross-sectional survey. SETTING: Health plan. PARTICIPANTS: One thousand three hundred eight health plan members aged 65 and older. The study was a 2002 cross-sectional survey of elderly persons with capped drug benefits in a managed care plan in one state. Participants were sampled so that half reached coverage caps and half did not. METHODS: Participants reported cap levels, communication with providers about exceeding caps, and decreased medication use due to cost. RESULTS: Of the 1,308 participants (65.4%response rate), 68.6%did not know their correct cap level. Rates were similar in those who exceeded caps (66.2%), reported difficulty paying for medications (63.9%), or decreased medication use (66%). For participants who exceeded caps, 59.1% did not know beforehand that they were close to exceeding caps and 50.2% did not tell providers afterward. In multivariate analyses accounting for demographics and health, the oldest participants (> or =85 vs 65-74) were at greater risk for not knowing cap levels (odds ratio (OR)=2.0, 95% confidence interval (CI)=1.2-3.4) and not telling providers about exceeding caps (OR=2.2, 95% CI=1.1-4.5). CONCLUSIONS: Elderly patients often did not know correct cap levels and did not tell providers about exceeding caps. Providers, plans, and policymakers should actively assess and improve Medicare beneficiaries' knowledge of Part D coverage gaps.

The Declaration of Alma Ata on its 30th anniversary: relevance for family medicine today.

The Declaration of Alma Ata, issued on September 12, 1978, provides a moral vision for primary care that remains valuable today at a time of transformation of the specialty of family medicine. The Declaration asserts a comprehensive definition of health that recognizes health as a fundamental human right, argues persuasively that gross inequalities in health status are politically, socially, and economically unacceptable, and identifies primary health care as the key to improving health and reducing health status inequalities. The values of Alma Ata can guide the specialty of family medicine to lead positive health system change through renewed collaboration, addressing inequalities, efficient use of resources and appropriate technology, and advocacy in the spirit of social justice.

Going global: considerations for introducing global health into family medicine training programs.

Medical students and residents have shown increasing interest in international health experiences. Before attempting to establish a global health training program in a family medicine residency, program faculty must consider the goals of the international program, whether there are champions to support the program, the resources available, and the specific type of program that best fits with the residency. The program itself should include didactics, peer education, experiential learning in international and domestic settings, and methods for preparing learners and evaluating program outcomes. Several hurdles can be anticipated in developing global health programs, including finances, meeting curricular and supervision requirements, and issues related to employment law, liability, and sustainability.

Health consequences and health systems response to the Pacific U.S. Nuclear Weapons Testing Program.

Between 1946 and 1958, the United States detonated 67 thermonuclear devices in the Pacific as part of their U.S. Nuclear Weapons Testing Program (USNWTP). The aggregate explosive power was equal to 7,200 Hiroshima atomic bombs. Recent documents released by the U.S. government suggest that the deleterious effects of the nuclear testing were greater and extended farther than previously known. The Republic of the Marshall Islands (RMI) government and affected communities have sought refress through diplomatic routes with the U.S. government, however, existing medical programs and financial reparations have not adequately addressed many of the health consequences of the USNWTP. Since radiation-induced cancers may have a long latency, a healthcare infrastructure is needed to address both cancer and related health issues. This article reviews the health consequences of the Pacific USNWTP and the current health systems ability to respond.

Physicians' willingness and barriers to considering cost when prescribing.

Many patients have difficulty affording medication. This pilot study examined physicians' willingness and barriers to considering cost when prescribing. Of 54 physicians surveyed, nearly all said considering cost was important (98%) but many reported lacking formulary (65%) or copayment information (59%). Insurers can help physicians by providing easy access to drug coverage information at the point of prescribing.