The three Tennessees: child and infant health in the three Grand Divisions of Tennessee.

Tennessee consistently ranks low among all states in measures of health. This study was undertaken to examine the differences in child and infant health conditions in the state's three Grand Divisions and the impact of these differences on Tennessee's overall rankings. An analysis of county-level data selected from the Area Resources File demonstrated that, for most measures of infant health and child health, the three divisions ranked very differently and that the overall state ranking did not accurately reflect the conditions in the divisions. Some regions, most often Middle Tennessee, ranked much higher than did the state as a whole; other regions, most often West Tennessee, ranked lower. The single overall state ranking masked these regional differences while suggesting that the entire state had equally low health outcomes. The striking health variations among the divisions that were demonstrated highlight the need to examine health conditions and implement health improvement efforts on a regional rather than a statewide basis.

Recommendations for the standardization and interpretation of the electrocardiogram: part II: Electrocardiography diagnostic statement list: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology.

This statement provides a concise list of diagnostic terms for ECG interpretation that can be shared by students, teachers, and readers of electrocardiography. This effort was motivated by the existence of multiple automated diagnostic code sets containing imprecise and overlapping terms. An intended outcome of this statement list is greater uniformity of ECG diagnosis and a resultant improvement in patient care. The lexicon includes primary diagnostic statements, secondary diagnostic statements, modifiers, and statements for the comparison of ECGs. This diagnostic lexicon should be reviewed and updated periodically.

Recommendations for the standardization and interpretation of the electrocardiogram: part I: The electrocardiogram and its technology: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology.

This statement examines the relation of the resting ECG to its technology. Its purpose is to foster understanding of how the modern ECG is derived and displayed and to establish standards that will improve the accuracy and usefulness of the ECG in practice. Derivation of representative waveforms and measurements based on global intervals are described. Special emphasis is placed on digital signal acquisition and computer-based signal processing, which provide automated measurements that lead to computer-generated diagnostic statements. Lead placement, recording methods, and waveform presentation are reviewed. Throughout the statement, recommendations for ECG standards are placed in context of the clinical implications of evolving ECG technology.

Preliminary evidence for an emerging nonmetropolitan mortality penalty in the United States.

We discovered an emerging non-metropolitan mortality penalty by contrasting 37 years of age-adjusted mortality rates for metropolitan versus nonmetropolitan US counties. During the 1980s, annual metropolitan-nonmetropolitan differences averaged 6.2 excess deaths per 100,000 nonmetropolitan population, or approximately 3600 excess deaths; however, by 2000 to 2004, the difference had increased more than 10 times to average 71.7 excess deaths, or approximately 35,000 excess deaths. We recommend that research be undertaken to evaluate and utilize our preliminary findings of an emerging US nonmetropolitan mortality penalty.

The effects of race and insurance on potentially avoidable hospitalizations in Tennessee.

This study examined effects of race and insurance on the risk of potentially avoidable hospitalizations (PAHs) in Tennessee. Applying the current Agency for Healthcare Research and Quality definitions for ambulatory-care-sensitive conditions to inpatient discharge data, the study found hospitalized Black patients more likely than their White counterparts to have experienced a PAH for chronic conditions. In contrast, Black inpatients' risk was lower than that of White inpatients for acute conditions after controlling for covariates. The results also showed the strong influence of insurance coverage. Finally, an analysis of racial differences in the relative risks for PAHs using data grouped by insurance status showed that hospitalized Blacks within each subset had a greater risk of having a PAH than hospitalized Whites, although the risk varied with insurance type. The variations of PAH risks across racial and insurance categories, together with the extra risks associated with chronic conditions, deserve greater examination.

Health care utilization data in Tennessee: inpatient discharges, 2005.

Data on the utilization of healthcare services are useful for assessing the health status of the general population and the delivery of hospital services in a state that is facing major health and healthcare challenges. They can assist health planning and health system reform efforts by allowing comparisons to other states and to national averages, by identifying patient groups with unusually high utilization rates, by tracking trends in utilization over time, and by demonstrating the effects of various healthcare reforms. This report summarizes hospital inpatient discharge data for patients treated in Tennessee's non-federal, short-stay hospitals in 2005. The analysis focuses on the hospital utilization patterns of leading acute and chronic conditions for racial and gender groups.

Health and economic development: introduction to the symposium.

This symposium explores the role of health as an 'economic engine' in the lower Mississippi River Delta region of the United States. The health as an economic engine model proposes that health is an important and perhaps critical determinant of economic growth and development. This model is the reverse of the more commonly considered paradigm in which economic conditions are major determinants of health status. This reframing of the conventional pathway draws upon an existing and extensive internationally-based body of knowledge, predominantly from research done in Africa and Asia. We suggest, in this symposium, that the health as an economic engine model can also be applied within the United States, particularly in regions that are economically underdeveloped and have poor health. This reframing has significant implications for population health policy as public health advancement can be legitimately argued to be an investment rather than just an expense. Viewing health as an economic engine supports a call to community-based participatory action on the part of policy makers, researchers, and educators to further both public and private investment in health, particularly for children and the poor.

Health and economic development: reframing the pathway.

The papers included in this symposium provide a compelling rationale for the role of health as an engine of economic growth, and thus for investing in health improvement as an important step in improving economic growth in the Mississippi Delta. This newer model of the relation between health and wealth, positioning health as an investment and as an important determinant of economic growth, has substantial implications for health-related public policy and for the business sector. Societal support of health promoting initiatives through public policy, especially for children and for the poor, are important efforts for improving health and for realizing the economic benefits of health improvement.

Health as an economic engine: evidence for the importance of health in economic development.

Most discussions on the relationships between health and economic conditions have focused on the impact of differences in personal finances or national economic conditions on health. Recently, however, the role of health as an 'economic engine' has been promoted. This paradigm proposes that better health leads to economic development. Evidence from historical, national, and transnational studies have shown that improved health increases economic growth through impacts on micro- and macro-economic factors. In this review, we will summarize the evidence supporting these concepts as a basis for discussing their implications for underdeveloped regions within the United States.

Evaluating heart disease presciptions-filled as a proxy for heart disease prevalence rates.

Heart disease is the leading cause of death in the U.S. Yet, prevalence rates are not reported at the county level. Not knowing how many have the disease, and where they are, may be a knowledge barrier to effective health care interventions. We use heart disease drug prescriptions-filled as a proxy measure for prevalence of heart disease. We test the correlation to the Behavioral Risk Factor Surveillance System (BRFSS) and find positive, statistically significant correlations. Next we illustrate the geographic patterns revealed using the county-level prevalence estimate maps. This information can be used to provide a better understanding of sub-state variations in disease patterns and subsequently target the delivery of health resources to small areas in need.

Recommendations for the standardization and interpretation of the electrocardiogram. Part I: The electrocardiogram and its technology. A scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society.

This statement examines the relation of the resting ECG to its technology. Its purpose is to foster understanding of how the modern ECG is derived and displayed and to establish standards that will improve the accuracy and usefulness of the ECG in practice. Derivation of representative waveforms and measurements based on global intervals are described. Special emphasis is placed on digital signal acquisition and computer-based signal processing, which provide automated measurements that lead to computer-generated diagnostic statements. Lead placement, recording methods, and waveform presentation are reviewed. Throughout the statement, recommendations for ECG standards are placed in context of the clinical implications of evolving ECG technology.

The TennCare graduate medical education plan: ten years later.

BACKGROUND: In 1994, Tennessee converted its Medicaid program to a managed care system--TennCare. Graduate medical education (GME) funding by TennCare was linked to several workforce goals that included increasing the number of residents training in primary care and increasing the number of primary care physicians practicing in underserved areas of Tennessee. OBJECTIVES: To determine the effects of the TennCare GME plan on GME and the physician workforce of Tennessee. DESIGN, SETTING, AND PARTICIPANTS: Bureau of TennCare GME data from 1996-2004 and American Medical Association Physician Masterfile data through 2003. MEASUREMENTS: Changes in filled residency positions and number of stipend supplements awarded after implementation of the TennCare GME plan. Changes in physician workforce characteristics between a 5-year period before and after implementation of TennCare. RESULTS: Filled primary care residency positions increased from 839 (45.2%) in 1996 to 906 (47.9%) in 2000, but declined to 862 (43.5%) by 2004. Eleven of 133 available primary care stipend supplements were awarded through 2004. The percentage of physicians remaining in Tennessee after completion of residency decreased from 46.2% before TennCare to 42.4% (P = .087) after implementation of TennCare. U.S. medical graduates remaining in state declined by 5.8% (P = .019). CONCLUSIONS: The major goals of the TennCare GME plan have not been achieved. Overall, physician retention has decreased and the number of U.S. medical graduates remaining in state has declined. State policymakers should consider other methods to increase the number of residents training in primary care and ultimately practicing in underserved areas of Tennessee.

Burnout and psychological stress among deans of colleges of medicine: a national study.

Psychological burnout may inhibit the ability of deans of colleges of medicine to effectively lead their organizations during periods of rapid change. The objective of this study was measure the prevalence and intensity of the psychological components of burnout and their correlates among deans of U.S. colleges of medicine. To do so, questionnaires that burnout, job stressors, personal support systems and job satisfaction were sent to deans of all U.S. colleges of medicine, and selected deans of nursing schools, and other academic health center leaders. Medical school deans exhibited a high prevalence of depersonalization (42.9% of respondents), emotional exhaustion (25.4%), and reduced personal accomplishment (27.0%). High levels of these subdomains and of overall burnout intensity significantly correlated with high levels of personal, job, and environmental stress; low levels of support or coping resources; high prevalence of physical and behavioral symptoms; and reduced job satisfaction. Deans of colleges of medicine frequently exhibit characteristics of burnout that may impede effective leadership. These characteristics are likely to intensify unless specific interventions are devised and implemented.