Determinants of rural-urban differences in health care provider visits among women of reproductive age in the United States.

BACKGROUND: Rural health disparities and access gaps may contribute to higher maternal and infant morbidity and mortality. Understanding and addressing access barriers for specialty women's health services is important in mitigating risks for adverse childbirth events. The objective of this study was to investigate rural-urban differences in health care access for women of reproductive age by examining differences in past-year provider visit rates by provider type, and quantifying the contributing factors to these findings. METHODS AND FINDINGS: Using a nationally-representative sample of reproductive age women (n = 37,026) from the Medical Expenditure Panel Survey (2010-2015) linked to the Area Health Resource File, rural-urban differences in past-year office visit rates with health care providers were examined. Blinder-Oaxaca decomposition analysis quantified the portion of disparities explained by individual- and county-level sociodemographic and provider supply characteristics. Overall, there were no rural-urban differences in past-year visits with women's health providers collectively (65.0% vs 62.4%), however differences were observed by provider type. Rural women had lower past-year obstetrician-gynecologist (OB-GYN) visit rates than urban women (23.3% vs. 26.6%), and higher visit rates with family medicine physicians (24.3% vs. 20.9%) and nurse practitioners/physician assistants (NPs/PAs) (24.6% vs. 16.1%). Lower OB-GYN availability in rural versus urban counties (6.1 vs. 13.7 providers/100,000 population) explained most of the rural disadvantage in OB-GYN visit rates (83.8%), and much of the higher family physician (80.9%) and NP/PA (50.1%) visit rates. Other individual- and county-level characteristics had smaller effects on rural-urban differences. CONCLUSION: Although there were no overall rural-urban differences in past-year visit rates, the lower OB-GYN availability in rural areas appears to affect the types of health care providers seen by women. Whether rural women are receiving adequate specialized women's health care services, while seeing a different cadre of providers, warrants further investigation and has particular relevance for women experiencing high-risk pregnancies and deliveries.

The emergence of the physician assistant role in a Canadian acute care surgery setting.

BACKGROUND: The role of physician assistants (PAs) in surgical care in Canada is expanding. Similarly, the acute care surgery (ACS) model continues to evolve, and PAs are increasingly being considered as members of ACS teams. However, their exact impact and contribution has not been well studied. Our study describes the contribution of a PA who worked full time on weekdays on an ACS team in a Canadian academic tertiary hospital. METHODS: To quantify the PA's contributions, an ACS database was created in September 2016. Data on the number of ACS patient encounters, the number of ACS surgical consults, the number of ACS admissions, the PA's involvement in the operating room, the number of PA patient encounters and the number of multidisciplinary meetings were prospectively collected. We report data for 365 consecutive days from Dec. 30, 2016, to Dec. 29, 2017. RESULTS: The ACS team had 11 651 patient encounters during the year, with a mean of 31.92 per day. The mean number of surgical consults per day was 5.89, and a mean of 2.08 surgical procedures were performed per day. The PA was involved in 53.5% of all patient encounters, despite working only during daytime hours on weekdays. Multidisciplinary meetings were conducted by the PA 94.9% of the time. Alternate level of care patients were seen by the PA 96.2% of the time. The PA was directly involved in 2.0% of the operating room procedures during the study period. CONCLUSION: Integrating a PA on an ACS team adds value to patient care by providing consistency and efficient management of ward issues and patient care plans, including multidisciplinary discharge planning, timely emergency department consultations and effective organization of the ACS team members.

CONTEXTE: Les adjoints au médecin (AM) jouent un rôle croissant dans les soins chirurgicaux au Canada. Suivant la même tendance, le modèle de chirurgie en soins actifs (CSA) poursuit son évolution, et on considère de plus en plus les AM comme des membres des équipes de CSA. Cependant, les retombées de leur travail et leur contribution ont été peu étudiées, et de façon imprécise. Notre étude décrit la contribution d'un AM travaillant à temps plein, en semaine, au sein d'une équipe de CSA dans un centre hospitalier universitaire canadien de soins tertiaires. MÉTHODES: Afin de quantifier la contribution de l'AM, nous avons créé une base de données de CSA en septembre 2016. Nous avons collecté les données ­ nombre de rencontres avec des patients, de consultations et d'admissions de l'équipe; participation de l'AM au bloc opératoire; nombre de rencontres de l'AM avec des patients; nombre de réunions multidisciplinaires ­ de manière prospective. Nos données décrivent une période de 365 jours consécutifs, qui s'étale du 30 décembre 2016 au 29 décembre 2017. RÉSULTATS: L'équipe de CSA a tenu 11 651 rencontres avec des patients dans l'année, pour une moyenne de 31,92 par jour. En moyenne, elle a réalisé 5,89 consultations et 2,08 interventions chirurgicales quotidiennement. L'AM a participé à 53,5 % des rencontres avec les patients, et ce malgré son horaire de jour et de semaine. L'AM a aussi dirigé 94,9 % des réunions multidisciplinaires, a vu 96,2 % des patients d'autres niveaux de soins, et a participé à 2,0 % des interventions au bloc opératoire. CONCLUSION: L'intégration d'un AM aux équipes de CSA est une valeur ajoutée pour les soins aux patients. Elle contribue à la gestion cohérente et efficace des événements au sein du service et des plans de soins, y compris la planification multidisciplinaire des congés, les consultations rapides à l'urgence et l'organisation efficace de l'équipe.

The Russian feldsher: A PA prototype in transition.

The feldsher is a physician assistant (PA) prototype. Developed in Russia during the 19th century to serve as healthcare personnel at a time of physician scarcity, feldshers provided medical services throughout the Russian Empire and later Soviet Union. Their medical role from the mid-19th century until the Bolshevik revolution in 1917 was crucial, particularly in rural and underserved regions. During wartime, many served in the military as medics. During the late 20th century, feldshers' numbers waned compared with physicians and nurses. In the 21st century, they remain a presence in the Russian medical system but their future is in transition as their numbers decline. However, earlier this year, Russian President Vladimir Putin urged the Russian State Duma to create more feldsher-midwife stations in rural areas. This indicates that the Russian government, at the highest levels, see the need for more feldshers to serve, essentially, as PAs in remote areas.

Health Care Provider Perceptions of the Safety of IUDs for Women with HIV.

CONTEXT: Women who are living with HIV use IUDs at a lower rate than the general population, and it is unclear whether health care providers' misconceptions about IUD safety contribute to this disparity. METHODS: A 2013-2014 nationwide survey of 1,998 U.S. family planning providers assessed perceptions of IUD safety for women with HIV or other medical conditions. Multivariable logistic regression was used to examine associations between provider characteristics and whether individuals believed IUDs were safe for HIV-positive women. Data from public-sector providers and office-based physicians were analyzed separately. RESULTS: Seven in 10 providers considered IUDs safe for women with HIV, and there were no differences by provider type. Among public-sector providers, some of the characteristics associated with believing that IUDs were unsafe for seropositive women were working at a clinic without Title X funding (odds ratio, 1.5), not being trained in IUD insertion (2.1) and not using the U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) for clinical guidance (1.8). Office-based physicians who did not use the guidelines also had an increased likelihood of believing that IUDs were unsafe for women with HIV (2.9), and physicians who had completed training 25 or more years ago were more likely than those who had done so less than five years ago to consider IUDs unsafe (3.3). CONCLUSIONS: Greater use of evidence-based contraceptive guidance such as the U.S. MEC may help inform provider perceptions of IUD safety and hence contribute to increased contraceptive choice for women with HIV.

Exploring the Uptake of Long-Acting Reversible Contraception in South Dakota Women and the Importance of Provider Education.

BACKGROUND: Long-acting reversible contraception (LARC) methods, including the intrauterine device (IUD) and the birth control implant, are the most effective form of prescribed birth control for pregnancy prevention. However, uptake of this highly effective form of birth control is slow. The purpose of this study was to explore use of the LARC methods in South Dakota women prescribed contraception and the importance of the provider in promoting this type of contraception. METHODS: This was a cross-sectional study of female patients who had been prescribed contraception at one of five locations in a South Dakota hospital system. Records were obtained through electronic health records for a six-month period. Descriptive analysis was performed using chi-square with counts and percentages. Logistic regression was used to determine differences in LARC prescriptions by patient age and provider title. RESULTS: A total of 2,174 individual patients were included in analysis. Of the 378 (17.4 percent) who were prescribed LARC methods, most (78.6 percent) were prescribed an IUD. Younger women (aged 11-19) were less likely to be prescribed LARCs compared to women aged 30-34. There were also significant differences in LARC prescriptions by provider type. Futhermore, we noted differences in LARC prescriptions for a provider who received a specific education and training on LARC from the American College of Obstetrics and Gynecology. CONCLUSIONS: There are many important factors to consider by the patient when choosing the most appropriate contraceptive method, including safety, effectiveness, accessibility, and affordability. Provider education may play an important role in promoting LARC methods.

Single Health System Adherence to 2012 Cervical Cancer Screening Guidelines at Extremes of Age and Posthysterectomy.

OBJECTIVE: To estimate the proportion of guideline nonadherent Pap tests in women aged younger than 21 years and older than 65 years and posthysterectomy in a single large health system. Secondary objectives were to describe temporal trends and patient and health care provider characteristics associated with screening in these groups. METHODS: A retrospective cross-sectional chart review was performed at Fairview Health Services and University of Minnesota Physicians. Reasons for testing and patient and health care provider information were collected. Tests were designated as indicated or nonindicated per the 2012 cervical cancer screening guidelines. Point estimates and descriptive statistics were calculated. Patient and health care provider characteristics were compared between indicated and nonindicated groups using χ and Wilcoxon rank-sum tests. RESULTS: A total of 3,920 Pap tests were performed between September 9, 2012, and August 31, 2014. A total of 257 (51%; 95% confidence interval [CI] 46.1-54.9%) of tests in the younger than 21 years group, 536 (40%; 95% CI 37.7-43.1%) in the older than 65 years group, and 605 (29%; 95% CI 27.1-31.0%) in the posthysterectomy group were not indicated. White race in the older than 65 years group was the only patient characteristic associated with receipt of a nonindicated Pap test (P=.007). Health care provider characteristics associated with nonindicated Pap tests varied by screening group. Temporal trends showed a decrease in the proportion of nonindicated tests in the younger than 21 years group but an increase in the posthysterectomy group. CONCLUSION: For women aged younger than 21 years and older than 65 years and posthysterectomy, 35% of Pap tests performed in our health system were not guideline-adherent. There were no patient or health care provider characteristics associated with guideline nonadherent screening across all groups.

Clinician burnout and satisfaction with resources in caring for complex patients.

OBJECTIVE: To describe primary care clinicians' self-reported satisfaction, burnout and barriers for treating complex patients. METHODS: We conducted a survey of 1554 primary care clinicians in 172 primary care clinics in 18 health care systems across 8 states prior to the implementation of a collaborative model of care for patients with depression and diabetes and/or cardiovascular disease. RESULTS: Of the clinicians who responded to the survey (n=709; 46%), we found that a substantial minority (31%) were experiencing burnout that was associated with lower career satisfaction (P<.0001) and lower satisfaction with resources to treat complex patients (P<.0001). Less than 50% of clinicians rated their ability to treat complex patients as very good to excellent with 21% rating their ability as fair to poor. The majority of clinicians (72%) thought that a collaborative model of care would be very helpful for treating complex patients. CONCLUSIONS: Burnout remains a problem for primary care clinicians and is associated with low job satisfaction and low satisfaction with resources to treat complex patients. A collaborative care model for patients with mental and physical health problems may provide the resources needed to improve the quality of care for these patients.

[The functioning of feldsher-midwife stations].

The article presents the materials based on the statistical data and results of sociological survey. They characterize the condition of feldsher-midwife stations, their field of services, personnel issues and certain issues of everyday life of feldshers of Perm kray. The proposals concerning the development of feldsher-midwife stations functioning are analyzed. The comparative analysis with the data of similar survey of 1982 is done. The study results support the necessity to maintain and develop feldsher-midwife stations in the system of primary medical sanitary care of rural population, especially on the territories with low population density.

Recent trends in clinicians providing care to pregnant women in the United States.

INTRODUCTION: Health care needs of pregnant women are met by a variety of clinicians in a changing policy and practice environment. This study documents recent trends in types of clinicians providing care to pregnant women in the United States. METHODS: We used a repeat cross-sectional design and data from the Integrated Health Interview Series (2000-2009), a nationally representative data set, for respondents who reported being pregnant at the time of the survey (N = 3204). Using longitudinal logistic regression models, we analyzed changes over time in pregnant women's reported use of care from 1) obstetrician-gynecologists; 2) midwives, nurse practitioners (NPs), or physician assistants (PAs); or 3) both an obstetrician-gynecologist and a midwife, NP, or PA. RESULTS: The percentage of pregnant women who reported seeing an obstetrician-gynecologist (87%) remained steady from 2000 through 2009. After controlling for demographic and clinical variables, the percentage who reported receiving care from a midwife, NP, or PA increased 4% annually (yearly adjusted odds ratio [AOR] 1.04; P < .001), indicating a cumulative increase of 48% over the decade. The percentage of pregnant women who received care from both an obstetrician-gynecologist and a midwife, NP, or PA also increased (AOR 1.027; P < .001), for a cumulative increase of 30%. DISCUSSION: The increasing role of midwives, NPs, and PAs in the provision of maternity care suggests changes in the perinatal workforce and practice models that may promote collaborative care and quality improvement. However, better data collection is required to gather detailed information on specific provider types, these trends, and their implications.

A systematic review: The role and impact of the physician assistant in the emergency department.

This systematic review describes the role and impact of physician assistants (PAs) in the ED. It includes reports of surveys, retrospective and prospective studies as well as guidelines and reviews. Seven hundred and twelve studies were identified of which only 66 were included, and many of these studies were limited by methodological quality. Generally the use of PAs in the ED is modest with 13-18% of US EDs having PAs although academic medical centres report PA use in 65-68% of EDs. The evidence indicates that PAs are reliable in assessing certain medical complaints and performing procedures, and are well accepted by ED staff and patients alike. There is limited evidence as to whether PAs improve ED flow or are cost-effective. Future studies on work processes, cost-effectiveness, unfamiliar patients' willingness to be treated by non-physician providers, and ED physicians' acceptability of PAs are needed to inform and guide the integration of PAs into EDs.

What do clinicians want? Interest in integrative health services at a North Carolina academic medical center.

BACKGROUND: Use of complementary medicine is common, consumer driven and usually outpatient focused. We wished to determine interest among the medical staff at a North Carolina academic medical center in integrating diverse therapies and services into comprehensive care. METHODS: We conducted a cross sectional on-line survey of physicians, nurse practitioners and physician assistants at a tertiary care medical center in 2006. The survey contained questions on referrals and recommendations in the past year and interest in therapies or services if they were to be provided at the medical center in the future. RESULTS: Responses were received from 173 clinicians in 26 different departments, programs and centers. There was strong interest in offering several specific therapies: therapeutic exercise (77%), expert consultation about herbs and dietary supplements (69%), and massage (66%); there was even stronger interest in offering comprehensive treatment programs such as multidisciplinary pain management (84%), comprehensive nutritional assessment and advice (84%), obesity/healthy lifestyle promotion (80%), fit for life (exercise and lifestyle program, 76%), diabetes healthy lifestyle promotion (73%); and comprehensive psychological services for stress management, including hypnosis and biofeedback (73%). CONCLUSION: There is strong interest among medical staff at an academic health center in comprehensive, integrated services for pain, obesity, and diabetes and in specific services in fitness, nutrition and stress management. Future studies will need to assess the cost-effectiveness of such services, as well as their financial sustainability and impact on patient satisfaction, health and quality of life.

Rates of complication in first-trimester manual vacuum aspiration abortion done by doctors and mid-level providers in South Africa and Vietnam: a randomised controlled equivalence trial.

BACKGROUND: We assessed whether the safety of first-trimester manual vacuum aspiration abortion done by health-care providers who are not doctors (mid-level providers) is equivalent to that of procedures done by doctors in South Africa and Vietnam, where mid-level providers are government trained and accredited to do first-trimester abortions. METHODS: We did a randomised, two-sided controlled equivalence trial to compare rates of complication in abortions done by the two groups of providers. An a-priori margin of equivalence of 4.5% with 80% power and 95% CI (alpha=0.05) was used. 1160 women participated in South Africa and 1734 in Vietnam. Women presenting for an induced abortion at up to 12 weeks' gestation were randomly assigned to a doctor or a mid-level provider for manual vacuum aspiration and followed-up 10-14 days later. The primary outcome was complication of abortion. Complications were recorded during the abortion procedure, before discharge from the clinic, and at follow-up. Per-protocol and intention-to-treat analyses were done. This trial is registered at with the identifier . FINDINGS: In both countries, rates of complication satisfied the predetermined statistical criteria for equivalence: rates per 100 patients in South Africa were 1.4 (eight of 576) for mid-level providers and 0 for doctors (difference 1.4, 95% CI 0.4 to 2.7); in Vietnam, rates were 1.2 (ten of 824) for mid-level providers and 1.2 (ten of 812) for doctors (difference 0.0, 95% CI -1.2 to 1.1). There was one immediate complication related to analgesics. Delayed complications were caused by retained products and infection. INTERPRETATION: With appropriate government training, mid-level health-care providers can provide first trimester manual vacuum aspiration abortions as safely as doctors can.

Physician assistants in occupational medicine: how do they compare to occupational physicians?

BACKGROUND: Physician assistants (PAs) have been present in occupational and environmental medicine (OEM) in the USA since 1971, yet remarkably little is known about their activity. METHODS: An administrative study of PA activities was undertaken and compared with the activities of physicians in the same occupational medicine setting. Patients were not triaged to either provider and all resources of care were recorded for the visit. An episode of care approach was used for the analysis. RESULTS: The characteristics of patients seen by each provider were similar in age, gender ratio and severity of injury. Physicians saw a mean of 2.9 patients/h and PAs 2.5, but PAs worked more hours and saw more patients per year than physicians. The average charge per patient visit and total charge for an episode of care were similar. Differences between PAs and physicians were seen in the areas of 'limited duty' duration given to patients and on average PAs prescribed 15 days and physicians 17 days. PAs referred a patient 19.7% of the time, while physicians referred 17.4%. Most of the referrals were to physical therapy. The salary of a physician, based on an hourly rate, was approximately twice as much as a PA. CONCLUSION: The use of PAs in OEM may represent a cost-effective advantage from an administrative standpoint. Clearly, more research is necessary in determining the role and utilization of PAs in OEM and how they may improve the delivery of physician services.

Current and projected workforce of nonphysician clinicians.

Nonphysician clinicians (NPCs) are becoming increasingly prominent as health care providers. This study examines 10 such disciplines: nurse practitioners (NPs), physician assistants (PAs), nurse-midwives, chiropractors, acupuncturists, naturopaths, optometrists, podiatrists, nurse anesthetists, and clinical nurse specialists. The aggregate number of NPCs graduating annually in these 10 disciplines doubled between 1992 and 1997, and a further increment of 20% is projected for 2001. Assuming that enrollments remain at the levels attained in 2001, NPC supply will grow from 228000 in 1995 to 384000 in 2005, and it will continue to expand at a similar rate thereafter. The greatest growth is projected among those NPCs who provide primary care services. Moreover, the greatest concentrations of both practicing NPCs and NPC training programs are in those states that already have the greatest abundance of physicians. On a per capita basis, the projected growth in NPC supply between 1995 and 2005 will be double that of physicians. Because of the existing training pipeline, it is probable that most of the growth projected for 2005 will occur. The further expansion of both NPC and physician supply thereafter warrants careful reconsideration.

Nurse practitioners, certified nurse midwives, and physician assistants in California.

California's health care industry includes workers prepared in many ways to perform many jobs. One significant group of health care workers prepared to provide care that often overlaps with physician-generated services is known as "nonphysician providers." Commonly, this label refers to nurse practitioners (NPs), certified nurse midwives (CNMs), and physician assistants (PAs). In this article, we will describe this group in five main areas: (1) the characteristics of the current and projected workforce and programs preparing these professionals; (2) the current skill expectations and knowledge bases of each; (3) trends in the education of these health professionals; (4) innovative models of education of these health professionals; and (5) the inclusion of NPs, PAs, and CNMs in workforce planning in a changing health care system. We conclude that, particularly in light of the overlapping functions of this provider group with many physician functions, the NP, CNM, and NP workforces must be recognized and considered when planning for the future of the physician workforce.