The impact of graduate medical education financing policies on pediatric residency training.

OBJECTIVE: To review special issues related to pediatric residency training in managed care organizations, the effects of the changing health care system on the demand for pediatricians and the potential impact on financial support for residency training, current methods of financing graduate medical education (GME), possible future approaches to financing GME, and policy directions to support training of pediatricians well prepared for future practice. METHODS: We reviewed current information on residency education in managed care settings, including the rationale for training in such settings and the realities of such educational experiences. We then assessed the evidence concerning the supply and demand for pediatricians in the present health care marketplace, with its evolution to managed systems of health care. We summarized current approaches to financing GME through Medicare, Medicaid, private insurers and purchasers, and direct federal and state support, with emphasis on the financing of ambulatory training which could occur in managed care settings. Lastly, we described factors influencing the upcoming revolution in GME financing and outlined possible new policy directions for the financing of relevant GME training experiences. RESULTS: Appropriate training experiences in managed care organizations may be a valuable strategy to address the current disconnect between the traditional hospital-based education of pediatricians and the expanded competencies necessary to practice in intensively managed, integrated and accountable health systems. Present pediatrician supply appears to be in relative balance with health maintenance organization staffing patterns and with needs-based requirements estimates. However, the pediatrician-to-child population ratio is predicted to increase rapidly over the next decade, leading to an oversupply of pediatricians under likely future health care delivery system scenarios. Medicare is the largest explicit payer of GME training costs, historically directing reimbursement primarily for hospital-based education. Numerous innovative financing strategies are being considered to facilitate funding of GME training in ambulatory settings and to open up funding to greater public scrutiny and accountability. CONCLUSIONS: Although reforms in federal GME financing have been limited to date and other significant changes have been largely state-based, it is likely in the future that explicit funds will be targeted to specialties in demand that prepare physicians well for future practice. Pediatricians and medical educators must intensify their voices in the financing debate to ensure a productive future for quality pediatric residency training.

The impact of airbags and seat belts on the incidence and severity of maxillofacial injuries in automobile accidents in New York State.

OBJECTIVE: To evaluate the effect driver-side and passenger-side airbags have had on the incidence and severity of maxillofacial trauma in victims of automobile accidents. DESIGN: Retrospective analysis of all automobile (passenger cars and light trucks) accidents reported in 1994. SETTING: New York State. PATIENTS: Of the 595910 individuals involved in motor vehicle accidents in New York in 1994, 377054 individuals were initially selected from accidents involving cars and light trucks. Of this subset, 164238 drivers and 62755 right front passengers were selected for analysis. MAIN OUTCOME MEASURES: Each case is described in a single record with approximately 100 variables describing the accident, eg, vehicle, safety equipment installed and utilized or deployed, occupant position, patient demographics, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses, and procedural treatments rendered. A maxillofacial trauma severity scale was devised, based on the ICD-9-CM diagnoses. RESULTS: Individuals using airbags and seat belts sustained facial injuries at a rate of 1 in 449, compared with a rate of 1 in 40 for individuals who did not use seat belts or airbags (P<.001). Those using airbags alone sustained facial injuries at the intermediate rate of 1 in 148, and victims using seat belts without airbags demonstrated an injury rate of 1 in 217 (P<.001). CONCLUSION: Use of driver-side airbags, when combined with use of seat belts, has resulted in a decrease in the incidence and severity of maxillofacial trauma.

An analysis of nonconfirmation rates. Experiences of a surgical second opinion program.

A review was conducted of the first 12 months' experience with a voluntary second opinion surgery consultation program. The program covers approximately 950,000 persons: employees of the city of New York, retirees, and their dependents. On a simple yes or no basis, the program's surgical nonconfirmation rate was 25%. More detailed analysis of consultants' narrative suggestions for patient care showed that a firm rejection of surgical intervention occurred in only 8% of the cases reviewed. Nonconfirmation rates were found to be unsatisfactory measures of program success in preventing potentially unnecessary surgery. Data from second surgical opinion programs should not be used to estimate the prevalence of unnecessary surgery in a community. The key benefit of such programs may be to facilitate and to encourage patient-physician communication.

Somatic cell counts: associated factors and relationship to production.

Factors affecting somatic cell counts and the association between somatic cell counts and milk production were evaluated. Data were collected from 748 Ontario Dairy Herd Improvement Corporation supervised herds that were on production and somatic cell count programs between April 1981 and March 1983. Two data files were created; one, the lactation summary file, contained one record per cow on each of 9406 Holsteins and the other, the test day file, included results of all tests during the complete lactation on each of the above cows. The latter file contained 85,236 records. Multiple curvilinear least squares regression was used to create five separate models. The dependent variables used in the models were natural logarithms (Loge) of the geometric mean of the somatic cell count for the lactation, 305 day milk production and breed class average for milk from the lactation summary file, and loge of the 24 hour somatic cell count and 24 hour milk production from the test day file. The somatic cell count at both the lactation and test day level increased with age up to approximately ten years and thereafter slowly decreased. The variable "days in milk" was not significantly associated with the lactation average somatic cell count. A curvilinear relationship was found between days in lactation at the time of test and the somatic cell count of 24 hour milk production. The somatic cell count increased until approximately 250 days in lactation and thereafter slowly decreased. It was found that the highest cell counts occurred in summer and the lowest in winter.(ABSTRACT TRUNCATED AT 250 WORDS)

Graduate medical education and physician supply in New York State.

OBJECTIVES: To estimate the supply of physicians and residents in New York State and to assess the impact of state policies on the supply and distribution of physicians in the state. DESIGN: A comparison of the number of residents in New York State for 1988 and 1994 (from the American Medical Association Medical Education Database) and the number of active patient care physicians in New York by specialty and age (from the 1995 New York State Physician File). MAIN OUTCOME MEASURES: Changes in the number of residents in New York State between 1988 and 1994 by specialty and medical school location; estimates of the numbers of physicians by age and specialty in New York for 1995; the migration of new physicians into and out of the state. RESULTS: The number of residents in New York State grew by nearly 21% between 1988 and 1994, despite a number of policies and programs encouraging maintenance of production levels. This growth is attributed to increases in the number of international medical graduates (IMGs) entering residency training through a widening "IMG window." Projection models show that, if production of new physicians continues as current levels, the supply of physicians will grow substantially during the next 2 decades. CONCLUSIONS: Past policies to influence the supply, production, and distribution of physicians in New York State have not had their desired effects. Future policies and incentives must be carefully framed and coordinated to avoid similar failures.