Race-ethnicity and sex differences in 1-year survival following percutaneous coronary intervention among Medicare fee-for-service beneficiaries.

RATIONALE: Existing literature describing differences in survival following percutaneous coronary intervention (PCI) by patient sex, race-ethnicity and the role of socioeconomic characteristics (SEC) is limited. AIMS AND OBJECTIVES: Evaluate differences in 1-year survival after PCI by sex and race-ethnicity, and explore the contribution of SEC to observed differences. METHODS: Using a 20% sample of Medicare claims data for beneficiaries aged 65+, we identified fee-for-service patients who received PCI from 2007 to 2015. We performed logistic regression to assess how sex and race-ethnicity relate to procedural indication, inpatient versus outpatient setting, and 1-year mortality. We evaluated whether these relationships are moderated by sequentially controlling for factors including age, comorbidities, presence of acute myocardial infarction (AMI), county SEC, medical resource availability and inpatient versus outpatient procedural status. RESULTS: We identified 300,491 PCI procedures, of which 94,863 (31.6%) were outpatient. There was a significant transition to outpatient PCI during the study period, especially for men compared with women and White patients compared with Black patients. Black patients were 3.50 percentage points (p < 0.001) and women were 3.41 percentage points (p < 0.001) more likely than White and male patients to undergo PCI at the time of AMI, which typically occurs in the inpatient setting. Controlling for age and calendar year, Black patients were 2.87 percentage points more likely than non-Hispanic White patients to die within 1 year after PCI. After controlling for Black-White differences in comorbidities, the differences in 1-year mortality decreased to 0.95 percentage points, which then became nonsignificant when further controlling for county resources and state of residence. CONCLUSION: Women were more likely to experience PCI in the setting of AMI and had less transition to outpatient care during the period. Black patients experienced higher 1-year mortality following PCI, which is explained by differences in baseline comorbidities, county medical resources, and state of residence.

Scholarship Criteria for Promotion in the Age of Diverse Faculty Roles and Digital Media.

BACKGROUND AND OBJECTIVES: In academic medical centers, scholarship is essential to advancing scientific knowledge, clinical care, and teaching and is a requirement for faculty promotion. Traditional evidence of scholarship, such as publications in peer-reviewed academic journals, remains applicable to the promotions of physician and nonphysician researchers. Often, however, the same evidence does not fit the scholarly work and output of clinician-educators, whose scholarship is often disseminated through digital communications and social media. This difference challenges promotion and tenure committees to evaluate the scholarship of all faculty fairly and consistently. This study aimed to generate a list of the features that a faculty product should demonstrate to be considered scholarship, regardless of how it is disseminated. METHODS: The full professors of one academic department of family medicine engaged in a mini-Delphi deliberative process to identify criteria to assess whether a scholarly product put forth by faculty in the promotion process is indeed scholarship. RESULTS: The full professors identified seven criteria to evaluate a faculty product to assess whether it represents scholarship-specifically its demonstration of faculty expertise, faculty contribution, originality, peer review, quality, relative permanence, and impact. CONCLUSIONS: These criteria may help promotion committees more easily and consistently assess the full scope of a faculty member's scholarly work within today's changing approaches to its dissemination.

Outcomes of States' Loan Repayment and Forgiveness Programs From the Perspective of Safety Net Practice Administrators.

BACKGROUND: Nearly every state offers loan repayment (LRP) and some offer loan forgiveness to clinicians who commit to work in safety net practices. The effectiveness of these programs from the perspective of safety net practices is largely unknown. OBJECTIVES: To assess safety net practice administrators' assessments of key outcomes for the 3 principal types of state service programs: LRPs funded by states, LRPs funded jointly by states and National Health Service Corps, and loan forgiveness programs. SUBJECTS: Administrators of safety net sites where primary care, behavioral health and dental health clinicians began serving in 26 state service programs in 14 states from 2011 to 2018. Survey responses were received from 455 administrators reporting on 754 of 1380 clinicians (54.6%). OUTCOME MEASURES: Administrators' ratings of their sites' difficulty recruiting clinicians; relative ease, quickness and cost of recruiting the participating (index) clinician with the service program; program expected effects on participants' retention; participants' job performance. RESULTS: Most administrators (66.1%) reported that recruiting clinicians of the index clinician's discipline is generally difficult but made easier (81.7%) and quicker (65.4%) with the service program, but only sometimes less expensive (34.8%). 78.8% of administrators anticipate that the clinicians will remain longer because of program participation. Participants are perceived to practice good quality care (96.9%) and be positive contributors (92.4%). Administrators' assessments are generally similar for the 3 types of programs. CONCLUSIONS: Administrators of safety net practices generally perceive states' loan repayment and loan forgiveness programs succeed in helping them recruit and retain good clinicians.

Satisfaction of the Primary Care, Mental Health, and Dental Health Clinicians of the National Health Service Corps Loan Repayment Program.

The National Health Service Corps (NHSC) aims to foster a positive service experience for its clinicians to promote long-term retention. We assess the satisfaction of primary care, dental, and mental health clinicians in the NHSC's Loan Repayment Program (LRP). Survey data are from 1,193 clinicians (72.4% response) who completed NHSC LRP contracts in 16 states from July 2015 through December 2016. Eighty-one percent reported overall satisfaction with their work and practice, without differences across disciplines. Nearly 95% were satisfied with the mission and patients of their practices. Fewer clinicians were satisfied with compensation (51%) and time demands of work (36%). Ninety-four percent reported the NHSC experience met or exceeded their expectations, and 94% recommend the NHSC LRP to others. In summary, the NHSC LRP experience is generally positive for clinicians of all disciplines. Clinicians' issues with their incomes and with the time demands of their work deserve attention from the NHSC.

Physician assistants and nurse practitioners in the National Health Service Corps.

OBJECTIVES: This study describes the experiences of physician assistants (PAs) and nurse practitioners (NPs) in the National Health Service Corps' (NHSC) loan repayment program in 2010. METHODS: In 2011, a stratified random sample of NHSC clinicians was surveyed. Data from the 148 PA and 137 NP respondents were analyzed (52.4% response rate). RESULTS: PAs were younger than NPs (mean age 31 versus 35 years), less often female (68% versus 91%), and more often carried educational debt over $100,000 (56% versus 24%). Both groups were serving in states familiar to them and within communities where they felt accepted. The groups were generally satisfied on most measures of work, with PAs more satisfied than NPs on some measures. CONCLUSION: The NHSC's PAs and NPs are well matched to communities and satisfied with their work. Maximizing their NHSC experiences and retention requires recognizing their differences in demographics, debt, and areas of job satisfaction.

An evaluation of state-based support-for-service programs targeting nurse faculty.

AIM: The aim of the study was to assess how state-based support-for-service (SFS) programs are used by deans and directors of nursing programs and to evaluate their perceived impact. BACKGROUND: Given projected nurse faculty shortages, stakeholders are looking for ways to address the maldistribution and shortage of nurse faculty. One state-level strategy is the implementation of loan repayment and scholarship programs, which incentivize individuals with, or currently pursuing, graduate degrees to become or remain nurse faculty. METHOD: This study used a mixed-method and multilevel approach to assess the impact of SFS programs in seven states. RESULTS: Programs are perceived to affect both recruitment and retention of faculty and play a role in increasing the educational qualifications of current nurse faculty. CONCLUSION: Nurse educators need to be aware of SFS programs and how best to use them to support nurse faculty.

Mexican immigrants' attitudes and interest in health insurance: a qualitative descriptive study.

Mexican immigrants to the U.S. are nearly three times more likely to be without health insurance than non-Hispanic native citizens. To inform strategies to increase the number of insured within this population, we elicited immigrants' understanding of health insurance and preferences for coverage. Nine focus groups with Mexican immigrants were conducted across the State of North Carolina. Qualitative, descriptive methods were used to assess people's understanding of health insurance, identify their perceived need for health insurance, describe perceived barriers to obtaining coverage, and prioritize the components of insurance that immigrants value most. Individuals have a basic understanding of health insurance and perceive it as necessary. Participants most valued insurance that would cover emergencies, make care affordable, and protect family members. Barriers to obtaining insurance included cost, concerns about immigration status discovery, and communication issues. Strategies that address immigrants' preferences for and barriers to insurance should be considered.

The contribution of "plasticity" to modeling how a community's need for health care services can be met by different configurations of physicians.

This article introduces the concept of "plasticity" to health care workforce modeling and policy analysis. The authors define plasticity as the notion that individual physicians within the same specialty each provide a different scope of service, while the scope of service of physicians in different specialties may overlap. This notion represents a departure from the current, silo-based conception of physician supply as physician headcounts by specialty; the implication is that multiple configurations of physicians (and, by further application, other health care professionals) can meet a community's utilization of health care services.Within-specialty plasticity and between-specialty plasticity are two facets of plasticity. Within-specialty plasticity is the idea that individual physicians within the same specialty may each provide a different mix and scope of services, and between-specialty plasticity is the idea that patterns of service provision overlap across specialties. Changes in physician specialty supply in a community affect both the between-specialty and within-specialty plasticity of that community's physicians. Notably, some physician specialties are more "plastic" than others.The authors demonstrate how to implement a plasticity matrix by assessing the sufficiency of physician supply in a specific community (Wayne County, North Carolina). Additional literature and data can provide further insights into the influences on (and of) plasticity, improving this approach and expanding it to include task-shifting across health care professions.

States' experiences with loan repayment programs for health care professionals in a time of state budget cuts and NHSC expansion.

PURPOSE: The landscape of education loan repayment programs for health care professionals has been turbulent in recent years, with doubling of the funding for the National Health Service Corps (NHSC) and cuts in funding for some states' programs. We sought to understand how this turbulence is being felt within the state offices involved in recruiting clinicians to rural and urban underserved communities. METHODS: We conducted key informant telephone interviews with staff of state offices of rural health, primary care organizations, and/or related organizations within 28 diverse states to answer questions about perceived changes and interplay among solely state-funded loan repayment programs, joint state-federal programs, and the NHSC federal program. Interviews were transcribed, formally analyzed, and key issues summarized. FINDINGS: Informants reported that solely state-funded and joint state-federal loan repayment programs are greatly valued for their ability to target a state's particular needs and to complement the NHSC federal program. However, budgets for state programs have been threatened, reduced, or eliminated entirely in many cases. All informants positively perceived the NHSC's recent growth and changes, which they feel are helping fill important workforce needs for their states. Nevertheless, the much larger NHSC federal program now competes with some states' programs for clinicians and service sites; states' programs are pushed to adjust their operations to maintain a unique "niche". CONCLUSIONS: States' key recruiters lament reductions in funding for states' loan repayment programs, and welcome the NHSC's recent growth and changes. Better coordination is needed to minimize competition and maximize complementarity between state and federal programs.

Growth and changes in the National Health Service Corps (NHSC) workforce with the American Recovery and Reinvestment Act.

BACKGROUND: From March 2009 through February 2011, the National Health Service Corps (NHSC) received a $300 million supplement through the American Recovery and Reinvestment Act to grant more loan repayment awards to clinicians who agree to work in underserved areas. This study assesses how this unprecedented funding increase affected the size, composition, and location of the NHSC's workforce. METHODS: This was a descriptive, time-linked, observational study using NHSC administrative data. Main outcomes were growth and changes in disciplinary composition of the NHSC's workforce and in its rural/urban and state-to-state distribution. RESULTS: During the Recovery Act period, the NHSC's workforce increased by 156%, from 3017 to 7713 clinicians. Mental health clinicians grew most numerically (210%) and as a proportion of the NHSC's workforce (from 22.7% to 27.4%). Primary care clinicians grew least and decreased as a proportion of the NHSC's workforce to 58.9%; dental health clinicians remained steady at approximately 13.5%. Among individual disciplines, physicians decreased most as a component of the NHSC's overall workforce, from 38.6% to 26.7%, whereas the proportion of nurse practitioners grew most, from 10.1% to 16.0%. Proportions of the NHSC's workforce serving in rural areas changed only modestly. NHSC clinician numbers grew most in states with the lowest NHSC clinician-to-poverty population ratios before the Recovery Act. CONCLUSIONS: With Recovery Act funding, the NHSC's workforce become far larger and more diverse than ever and more evenly distributed across states. The NHSC should now set targets and be more deliberate in managing its growth across disciplines and where its clinicians serve.

Use of data by hospitals in North Carolina to identify disparities in the care and outcomes of minority patients.

BACKGROUND: Hospitals are now called upon to use available data--information on the use of services, patient satisfaction, and core quality measures--to identify disparities in the use and outcomes of services for minority patients. This study assesses whether and in what ways hospitals in North Carolina use data to understand the experiences of minority patients. METHODS: Semistructured telephone interviews were completed with chief executive officers (CEOs) and other administrators from a broad sample of North Carolina hospitals. Participants were asked about their hospitals' use of data to compare experiences of minority and nonminority patients and about any other minority-focused initiatives. Responses were analyzed using a grounded theory approach. RESULTS: A total of 28 CEOs and administrators from 17 (77%) of 22 targeted hospitals participated fully in the interviews. Participating hospitals ranged in size from fewer than 60 beds to more than 700 beds and were equally distributed across the state's 3 geographic regions. Three hospitals (18%) reportedly analyzed data by patient race to assess satisfaction, specific clinical outcomes, adverse events, and/or use of services. Respondents cited barriers to analyzing hospital data by patient race and ethnicity as lack of resources, not knowing how to perform these analyses, and not seeing the need. Respondents for 10 hospitals (59%) reported other types of hospital programs targeting the needs of minority patients, including cultural-sensitivity training for staff and initiatives in local communities. LIMITATIONS: Participating hospitals may not reflect all North Carolina hospitals in their minority-focused efforts, and respondents may not have known about all relevant programs in their hospitals. CONCLUSIONS: Few hospitals in North Carolina are proactively identifying disparities between minority and nonminority patients by use of data.

The contribution of hypertension to black-white differences in likelihood of coronary artery disease detected during elective angiography.

BACKGROUND: Black patients in the United States undergoing angiography for suspected coronary artery disease (CAD) have consistently been found to have less disease than whites. As the effects of hypertension are greater in blacks than whites, and hypertensive heart disease may mimic CAD and lead to catheterization, we examined the association between race and hypertension as an explanation for the disparities in angiographic CAD. METHODS: Using an academic hospital's institutional database, we studied patients undergoing first-time elective angiography from 2001 to 2008. Using multivariable logistic regression with data on patient demographics, CAD risk factors, and coronary stenoses, we compared rates of angiographic disease for blacks and whites, creating models separately for patients with and without hypertension. We then tested the significance of an interaction term between race and hypertension on angiographic findings. RESULTS: We identified 1,203 black and 2,538 white patients who underwent initial elective angiography. Black patients were less likely to have a significant stenotic lesion (≥50% stenosis in the left main artery or ≥70% stenosis elsewhere) than whites (adjusted risk ratio 0.65; 95% confidence interval (CI) 0.55-0.75). Among patients with hypertension this difference was exaggerated (adjusted risk ratio 0.60; 95% CI 0.51-0.71). However, among patients without hypertension, the risk of having a significant lesion was similar in blacks and whites (adjusted risk ratio 0.97; 95% CI 0.67-1.37). The interaction term for race and hypertension was confirmed as statistically significant. CONCLUSIONS: Among patients electively referred for angiography, hypertension, and its effects may contribute to the lower rate of CAD found in blacks compared to whites.

Are there enough doctors in my rural community? Perceptions of the local physician supply.

PURPOSE: To assess whether people in the rural Southeast perceive that there is an adequate number of physicians in their communities, assess how these perceptions relate to county physician-to-population (PtP) ratios, and identify other factors associated with the perception that there are enough local physicians. METHODS: Adults (n = 4,879) from 150 rural counties in eight southeastern states responded through a telephone survey. Agreement or disagreement with the statement "I feel there are enough doctors in my community" constituted the principal outcome. Weighted chi-square analysis and a generalized estimating equation (GEE) assessed the strength of association between perceptions of an adequate physician workforce and county PtP ratios, individual characteristics, attitudes about and experiences with medical care, and other county characteristics. FINDINGS: Forty-nine percent of respondents agreed there were enough doctors in their communities, 46% did not agree, and 5% were undecided. Respondents of counties with higher PtP ratios were only somewhat more likely to agree that there were enough local doctors (Pearson's correlation coefficient = 0.09, P < .001). Multivariate analyses revealed that perceiving that there were enough local physicians was more common among men, those 65 and older, whites, and those with lower regard for physician care. Perceptions that the local physician supply was inadequate were more common for those who had longer travel distances, problems with affordability, and little confidence in their physicians. Perceptions of physician shortages were more common in counties with higher poverty rates. CONCLUSIONS: County PtP ratios only partially account for rural perceptions that there are or are not enough local physicians. Perceptions of an adequate local physician workforce are also related to how much people value physicians' care and whether they face other barriers to care.

Effectiveness of a grant program's efforts to promote synergy within its funded initiatives: perceptions of participants of the Southern Rural Access Program.

BACKGROUND: Foundations and public agencies commonly fund focused initiatives for individual grantees. These discrete, stand-alone initiatives can risk failure by being carried out in isolation. Fostering synergy among grantees' initiatives is one strategy proposed for promoting the success and impact of grant programs. We evaluate an explicit strategy to build synergy within the Robert Wood Johnson Foundation's Southern Rural Access Program (SRAP), which awarded grants to collaboratives within eight southeastern U.S. states to strengthen basic health care services in targeted rural counties. METHODS: We interviewed 39 key participants of the SRAP, including the program director within each state and the principal subcontractors heading the program's funded initiatives that supported heath professionals' recruitment, retention and training, made loans to health care providers, and built networks among providers. Interews were recorded and transcribed. Two investigators independently coded the transcripts and a third investigator distilled the main points. RESULTS: Participants generally perceived that the SRAP yielded more synergies than other grant programs in which they had participated and that these synergies added to the program's impact. The synergies most often noted were achieved through relationship building among grantees and with outside agencies, sharing information and know-how, sharing resources, combining efforts to yield greater capacity, joining voices to advocate for common goals, and spotting gaps in services offered and then filling these gaps. The SRAP's strategies that participants felt fostered synergy included targeting funding to culturally and geographically similar states, supporting complementary types of initiatives, promoting opportunities to network through semi-annual meetings and regular conference calls, and the advocacy efforts of the program's leadership. Participants noted that synergies were sometimes hindered by turf issues and politics and the conflicting perspectives and cultures of participating organizations and racial groups. Inadequate funding through the SRAP, restricting program involvement to only a few needy counties, and instances of over- and under-involvement by the program's leadership were sometimes felt to inhibit synergies and/or their sustainability. CONCLUSION: Participants of the SRAP generally perceived that the SRAP's deliberate strategies yielded synergies that added to the program's impact.

Service-linked scholarships, loans, and loan repayment programs for nurses in the southeast.

A variety of public and private programs provide financial support for the costs of nurses' training in exchange for service commitments to work in rural, underserved, and other needy areas. Little is known about the number, size, and operations of these support-for-service programs for nurses. We identified and in this article describe such programs in eight southeastern states. Eligible programs were those that in 2004 paid for all or a portion of nurses' education costs in exchange for a period of clinical nursing service within one or more of the eight targeted states. Programs obligating nurses to a specific hospital, practice, or community or to teaching roles were excluded. Programs were identified through available compendia, online searches, and telephone contacts with program directors, nursing school administrators, and state officials. Additional data on eligible programs were gathered through telephone interviews and questionnaires mailed to program staff and from publicly available documents. Data were double coded, and qualitative and quantitative analyses were conducted. Twenty-four nursing support-for-service programs met our eligibility criteria in the eight-state region: nine scholarship programs; six loan repayment programs; five service-cancelable loan programs; two loan interest rate reduction programs; and two direct incentive programs. These programs had fiscal year 2004 budgets totaling approximately $28.8-31.8 million; collectively, they received approximately 11,700 applications from nurses, signed approximately 8,300 contracts, and had a combined field strength of approximately 4,900 nurses working to fulfill their program obligations. Individual states offered between zero and five eligible programs each. Support-for-service programs are a substantial component of federal and state nursing workforce distribution efforts in the Southeast. Future research should identify and describe these programs for other regions, measure outcomes, and offer recommendations to maximize their effectiveness in alleviating nursing shortages.

Do adults who believe in periodic health examinations receive more clinical preventive services?

BACKGROUND: Individuals who have periodic health examinations ("check-ups") with physicians even if they feel well have higher rates of screening and other preventive services than individuals who only see physicians when ill. This study assessed whether individuals' beliefs about the advisability of periodic health examinations contribute to the likelihood that they receive recommended clinical preventive services. METHODS: This study used data from a 2002-2003 telephone survey of adults in 150 rural counties in 8 states of the U.S. southeast. Weighted Chi-square and logistic regression analyses were used to assess associations between attitudes towards periodic health examinations and the receipt of preventative services. RESULTS: Of the 4879 respondents, 37% were African American, and 43% had annual household incomes of less than $25,000. A total of 8.5% (n=374) did not endorse periodic health examinations. Not endorsing periodic examinations was more common among subjects who were male, younger, white and had no health insurance. Compared to those who endorsed periodic examinations, persons who did not were less likely to have had a periodic examination (42% versus 80%, p<0.001) or mammogram (28% versus 60%, p<0.001) in the previous year, a Pap smear in past 3 years (74% versus 90%, p<0.001), a cholesterol check in the last 5 years (56% versus 81%, p<0.001) or to ever have had endoscopic screening (28% versus 48%, p<0.001). These rate differences remained after adjusting for sociodemographic characteristics. CONCLUSION: People's beliefs about the value of periodic health examinations are associated with the likelihood that they receive recommended preventative services. Understanding individuals' beliefs about health, disease prevention and the role of physicians in prevention could lead to improved targeted interventions aimed at increasing uptake of preventative services.

Adults' lack of a usual source of care: a matter of preference?

PURPOSE: We wanted to identify characteristics of adults who do not have a usual source of care and then stratify the analysis by those who prefer vs those who do not prefer to have a usual source of care. METHODS: We analyzed data from a nationally representative sample of 9,011 adults to identify characteristics of those more likely to not have a usual source of care. Based on stated reasons for lacking a usual source of care, we created 2 subpopulations of adults without a usual source of care: those who had no preference and those who did. We identified and compared characteristics of each subpopulation. RESULTS: In the year 2000, 20% of adults did not have a usual source of care. Among all adults, lack of insurance (odds ratio [OR] = 3.2; 95% confidence interval [CI], 2.6-3.9) was independently associated with lacking a usual source of care, as were male sex (OR = 2.1; 95% CI, 1.7-2.4), excellent reported health (OR = 2.0; 95% CI, 1.2-3.2), younger age (for ages 18-29 years, OR = 4.1; 95% CI, 3.1-5.4) and Hispanic ethnicity (OR = 1.5; 95% CI,1.2-1.9). Of those without a usual source of care, 72% cited reasons indicating no preference to have one. Associations among such respondents were similar to those found among adults as a whole. Among respondents who preferred to have a usual source of care, however, the sex of the respondent became less significant, lack of insurance became more significant, and reported health status became nonsignificant. CONCLUSIONS: Most adults who lack a usual source of care do so for reasons of preference, evidently placing little value on having a usual source of care. Helping these persons have a usual source of care will likely require different interventions than needed to help those who want a usual source of care but cannot get one.

Differences in access to outpatient medical care for black and white adults in the rural South.

OBJECTIVES: We compared black and white adults in the rural South on multiple indicators of access to outpatient medical care and assessed whether any differences might be explained by group differences in socioeconomic situations or proximity to medical resources. DESIGN: Cross-sectional telephone survey. SUBJECTS: Survey respondents were 1237 black and 2158 white adults from 113 rural counties in 6 southern states. MEASURES: Blacks and whites were compared on a variety of commonly used survey measures of access, some followed in the Healthy People 2010 Initiative. Access comparisons were adjusted for age, gender, and health status and then reassessed with adjustments for individual socioeconomic indicators and county medical resources: physician-to-population ratios, the presence of hospitals and federally qualified health centers, and urban adjacency. RESULTS: Compared with whites, blacks reported similar or higher use of outpatient services over the previous year, including the likelihood of having had an outpatient physician visit and regular checkup. Nevertheless, blacks more often reported forgoing needed care, encountering various barriers, and experiencing dissatisfaction with some aspects of care. Adjusting for socioeconomic factors generally reduced but did not eliminate black-white access differences, whereas adjusting for county medical care resources did not affect measured group differences. CONCLUSIONS: Blacks and whites in the rural South report similar use rates of outpatient medical care, but blacks more often report unmet needs, barriers to care, and dissatisfaction with care. Beyond socioeconomic differences, black versus white differences in sites of care, the quality of care received, the quality of interactions with providers, and expectations for their care may explain group reported access differences.