Outcomes of rural training tracks: a review.

Rural training tracks (RTTs) have developed as a strategy to encourage family medicine resident entrance into rural practice. Because most programs are small (two to four residents), data must be aggregated to determine RTT impact on practice preparation and location. Several studies over the last decade reveal that 76 percent of RTT graduates are practicing in rural America and that graduates describe themselves as prepared for rural practice. Sixty-five percent are providing obstetrical services, and half are performing cesarean sections. From 1989 to 1999, there were a total of 107 graduates of rural training programs, making it unlikely that, without significant investment, this model could supply an adequate quantity of family physicians for rural America.

Rural residency tracks in family practice: graduate outcomes.

BACKGROUND: Because the distribution of physician services in the rural United States continues to be a problem, rural residency tracks in family practice have been developed as a strategy to acculturate residents into a rural practice model. Residents complete the first year of training in an urban-based program and the last 2 years in a rural community. METHODS: We surveyed all 77 graduates of 13 nationally distributed rural training tracks that had graduates between 1988 and 1997. RESULTS: The response rate was 83% (n = 64). Seventy-six percent of respondents practice in a rural community, and 61% practice in federally designated health professional shortage areas. A total of 69% of respondents admitted patients to rural hospitals, 67% provided labor and delivery services, and 48% performed Cesarean sections. Existing physician groups were major influences on practice location. Thirty-nine percent were near their hometown, and 45% were near the community in which they completed residency training. Only 14% had a financial obligation to the community, and 94% reported that their rural training was adequate or better. CONCLUSIONS: Most graduates of rural training tracks have located their practice sites in rural communities, and most graduates provide labor and delivery services. Location decisions were associated with existing physician groups, hospitals, hometowns, and proximity to training sites.

Implementing a comprehensive relative-value-based incentive plan in an academic family medicine department.

The authors describe the implementation and first three years (1997-1999) of a department-wide incentive plan of the Department of Family Medicine at the State University of New York at Buffalo School of Medicine and Biomedical Sciences. By using a consensus approach, a representative elected committee designed a clinical relative value unit (explained in detail) that could be translated to equally value and reward faculty efforts in patient care, education, and research and which allowed the department to avoid the imposition of a model that could have undervalued scholarship and teaching. By 1999, the plan's goal of eight patient-care-equivalent points per four-hour session had been exceeded for pure clinical care. Clearly, only a small financial incentive was necessary (in 1999, an incentive pool of 4% of providers' gross salary) to motivate the faculty to be more productive and to self-report their efforts. Long-term productivity for pure clinical care rose from 9.8 points per session in 1997 to 10.4 in 1999. Of the mean total of 3,980 points for the year 1999, the contribution from teaching was 1,146, or 29%, compared with 25% in 1997. For scholarship, the number of points was 775, or 20%, in 1999, compared with 11% in 1997. The authors describe modifications to the original plan (e.g., integration of quality measures) that the department's experience has fostered. Problems encountered included the lack of accurate and timely billing information from the associated teaching hospitals, the inherent problems of self-reported information, difficulties of gaining buy-in from the faculty, and inherent risks of a pay-for-performance approach. But the authors conclude that the plan is fulfilling its goal of effectively and fairly quantifying all areas of faculty effort, and is also helping the department to more effectively demonstrate clinical productivity in negotiations with teaching hospitals.

Soft tissue sarcomas: integrating primary care recognition with tertiary care center treatment.

Soft tissue sarcomas account for fewer than 1 percent of malignancies diagnosed annually in the United States. These tumors usually present as an asymptomatic mass. Any lesion larger than 5 cm in diameter should be considered suspicious. Radiographs should be obtained as the initial step in assessing a suspicious lesion. Magnetic resonance imaging has become the preferred diagnostic examination for tumors involving the extremities, and computed tomographic scanning may be the best technique for imaging lesions in the thoracic, abdominal, and head and neck areas. In general, the patient with a suspicious soft tissue mass located in a surgically difficult area should be referred to a regional center for biopsy and multidisciplinary consultation before resection is attempted. Careful preoperative planning is necessary for a good outcome. The prognosis for the patient with a soft tissue sarcoma is primarily determined by the grade, size and depth of the tumor and the presence of tumor at the surgical margins.

Screening for genetic risk of breast cancer.

Approximately 10 to 15 percent of all breast cancers are thought to be familial and about one third of these cases are due to an inherited mutation in a BRCA1 or BRCA2 breast cancer-susceptibility gene. The lifetime incidence of breast cancer in mutation carriers is above 50 percent, and carriers of BRCA1 mutation also have a substantially increased risk of ovarian cancer. BRCA1 and 2 mutations are associated with early-onset breast cancer, and some experts call for aggressive screening of affected persons. Monthly self-examination of the breasts beginning at age 18 and annual clinical examinations and mammography after age 25 have been recommended but are of unproven benefit. Prophylactic mastectomy and oophorectomy have been advocated by some authorities, but these interventions are disfiguring and for some carriers of the gene, they are unnecessary. The patient's decision to undergo genetic screening is complicated by the technical difficulty of the test, the substantial cost and the still incomplete understanding of the penetrance of disease in known mutation carriers.

Readiness for Medicaid managed care reform initiatives: a profile of rural family physicians.

Medicaid managed care is now an important factor in the financing of rural health care delivery. The participation of rural family physicians in Medicaid managed care is vital for the rural poor to access health services. This study examined 855 family physicians practicing in nonmetropolitan counties across the United States to determine their readiness to participate in Medicaid managed care. Physicians were asked about their experience with prepaid programs and the factors that would influence their participation in such a program. A shortage of health care providers and low reimbursement rates were most frequently cited as barriers to successful implementation. Physicians who had participated in prepaid programs in the past but were no longer participating had the most negative opinions about the potential for Medicaid managed care programs to enhance care for the poor in their communities. Overall, physicians reported potential for the program to improve access and quality of care, but they also expressed reservations about the financial and administrative effects on their practices. These results reveal that negative attitudes were associated with prepaid programs that failed to meet expectations, but physicians also expressed an optimism about the potential to serve the poor within a managed care model.

Natural history of asymptomatic gallstones in family practice office practices.

BACKGROUND: Improved access to less invasive testing has resulted in more Americans being diagnosed with asymptomatic gallstones. The family physician has had to rely on community-based or referral patient studies to advise their office-based patients about treatment options. OBJECTIVE: To understand the natural history of asymptomatic gallstones discovered through a routine patient care process in a rural, office-based research network of 9 family physician practices. PARTICIPANTS AND METHODS: Nine family physician practices agreed to comb their records for medical records of patients found to have asymptomatic gallstones during their routine primary care practice. Medical records were then reviewed annually for 5 years for evidence of gallstone-related problems Results were compared with previous English-language literature studies. RESULTS: Asymptomatic gallstones were found in 32 patients (19 women [59%] and 13 men [41%] with an average age of 59.5 years). Symptoms developed in 8 patients (25%) after an average latency period of 3 years 5 months. Seven patients underwent cholecystectomy; there was no gallstone-related mortality in this group. One patient who developed a ruptured gallbladder required an emergency procedure. CONCLUSIONS: Routine office practice is detecting only a small percentage of the asymptomatic gallstones expected by community-based screening studies. While more of these patients became symptomatic than in general population studies, most patients with asymptomatic gallstones required no treatment. Those patients in family practice offices who are serendipitously found to have gallstones can generally be followed up conservatively.

One-two rural residency tracks in family practice: are they getting the job done?

BACKGROUND: In the 1990s, the Residency Review Committee for Family Practice (RRCFP) and the American Board of Family Practice used the development of rural training programs as a strategy to bridge training experiences across urban referral centers and rural community hospitals. These programs are relatively small and attract trainees who are predisposed to rural practice. Aggregating data from several programs yields insight about their challenges and their ability to produce graduates who enter rural practice. METHODS: This descriptive analysis is based on self-reported data from a 1996 survey mailed to the residency program directors of rural training programs, identified by the RRCFP office as one-two programs. RESULTS: More than half of the rural training programs surveyed were located in health professions shortage areas, most in communities with little urban influence. These programs are equally likely to be sponsored by university- or community-based residency programs. Most (75%) placed two or fewer residents per year in the rural site; minorities accounted for 4% of placements. Thirty percent of programs report unfilled positions. Seventy-five percent use televideo communications and find experiences in surgery and obstetrics relatively easy to arrange but dermatology and critical care difficult. Seventy-six percent of graduates enter rural practice after graduation. CONCLUSIONS: This survey suggests that family practice rural one-two residencies are meeting the goal of providing trainees with a rural immersion experience, in anticipation of selecting rural practice after graduation.

A consortium, graduate medical education, and Buffalo: defining a common ground.

Regional graduate medical education (GME) consortia are a strategy to align public support for GME with societal goals. One such consortium was established in Buffalo, NY, to pool financial resources, facilitate processing of Accreditation Council for Graduate Medical Education requirements, guarantee quality education, and more appropriately use community resources. Cooperation has attracted external funding from state and federal governments and private foundations, fostering community-wide undergraduate medical education, as well as GME. The American Association of Medical Colleges has identified 36 GME consortia in the United States. New York may lead the nation on a strategy to use consortia for the distribution of all state-appropriated GME support. The relationships fostered by consortial interactions have benefitted family medicine and provided opportunities for leading regional medical education into a primary care-specialty balanced future.

Rural physicians, rural networks, and free market health care in the 1990s.

The changes brought about by managed care in America's urban communities will have profound effects on rural physicians and hospitals. The rural health care market characterized by small, independent group practices working with community hospitals is being offered affiliations with large, often urban-based health care organizations. Health care is evolving into a free market system characterized by large networks of organizations capable of serving whole regions. Rural provider-initiated networks can assure local representation when participating in the new market and improve the rural health infrastructure. Although an extensive review of the literature from 1970 to 1996 reveals little definitive research about networks, many rural hospitals have embraced networking as one strategy to unify health care systems with minimal capitalization. These networks, now licensed in Minnesota and New York, offer rural physicians the opportunity to team up with their community hospital and enhance local health care accessibility.

Physician location survey: self-reported and census-defined rural/urban locations.

Using a survey of New York State Residence-Trained Family Physicians and the 1990 census data, this paper assesses the relative importance and consistency of factors associated with physician practice locations when different definitions of community size are used. By matching the zip code information with 434 physicians' practice locations, physician respondents' self-reported communities are linked to census-defined communities. It was found that the significant level of some variables could be affected when community classifications were based on survey responses rather than census data. It concludes that caution should be taken for interpreting rural-urban differences when data are solely based on self-reported practice locations.

Medicaid primary care services in New York State: partial capitation vs full capitation.

BACKGROUND: Forty-nine states have applied to the Health Care Financing Administration for waivers to allow special program development for Medicaid recipients. In an effort to identify issues relevant to making the transition of its entire Medicaid population into a capitation model, New York State has encouraged the development of partial capitation and full capitation models. This paper is a critical description analysis of a 1-year experience, utilizing data provided by the New York State Department of Social Services. METHODS: Data collected by the New York State Department of Social Services were used to compare the costs for matched cohorts enrolled in partial capitation programs in which the primary care physician is paid a monthly fee to provide ambulatory primary care for Medicaid recipients; and full capitation programs in which a health maintenance organization (HMO) or a hospital-based prepaid health services program (PHSP) is paid a more encompassing monthly fee to provide a larger range of services, including inpatient, outpatient, and specialty care. RESULTS: Partial capitation programs were reported to save the state 38% compared with a matched control group enrolled in traditional, fee-for-service Medicaid (P<.05), and offered greater savings than HMOs and PHSPs (P=NS). The HMOs and PHSPs saved the state 9.3% and 16.8%, respectively, compared with traditional enrollment. Quality measures and patient satisfaction for partial and full capitation programs were equivalent. CONCLUSIONS: These data suggest that New York State primary care physicians who participated in programs that reimburse a prepaid monthly fee for outpatient primary care services achieved savings comparable to those of HMOs. A partial capitation primary care model may offer an affordable and more flexible alternative to full-service HMOs in caring for Medicaid recipients, especially in communities with limited HMO penetration.

Providing birthing services in rural health networks: coping with change in New York State.

Making prenatal and birthing services accessible in rural communities no longer able to support a local full-service hospital and the introduction of managed care cost control has led to consideration of alternative models. One such model, the freestanding birth center located in an isolated rural community, challenges the guidelines of several state and professional organizations directed at assuring adequate emergency response, including cesarean sections. An extensive review of freestanding birth centers and their effect on birth outcomes revealed little outcomes data about birth centers distant from full-service hospitals. Most states have modeled their birth center regulations on recommendations from the National Association of Childbearing Centers, but others, such as New York, have more rigidly defined transport parameters that exclude many rural locations. A consensus panel convened by the New York State Rural Health Council concluded that demonstrations projects featuring a rural birthing center farther than 20 minutes from a full-service hospital and operated within a networked rural health system should be developed. Consumers would need to be fully informed about the implications of their choice of birth services and all qualified providers, including midwives, should be included in a team approach to care giving.

Preserving the patient referral process in the managed care environment.

Referrals are a central component of the American health care system, defining the relationship among generalists, patients, and specialists. The dynamics of the referral process as they existed in a fee-for-service medical environment will evolve under managed care, but retain the basic "Try-out" approach of the generalist and "Rule-out" approach of the specialist. A managed care, contract-based health care system alters some of the assumptions on which the referral relationship has been structured. A four-step approach to assuring quality interactions among patient, generalist, and specialist within the managed care environment is described, including: (1) engage; (2) anticipate; (3) feedback; and (4) reassess. When the referral process is structured as suggested, it can be evaluated for quality and efficacy. Armed with mutual respect and understanding, the forces that polarized specialist and generalist care in the 1980s can be redirected to enhancing patient care in the 1990s.

Implementation of an inpatient case management program in rural hospitals.

The objective of the study was to identify factors that affected the implementation of an inpatient case management program in rural hospitals. The hospitals studied were from the Western New York Rural Health Care Cooperative. Five of the hospitals implemented the program in 1992. A qualitative evaluation was conducted by analyzing tape-recorded interviews with nurses and chief executive officers to identify obstacles to and facilitators of program implementation. Many obstacles to implementation could be traced to workload and time constraints, physician autonomy concerns, and limited nursing staff and physician participation. Implementation was facilitated foremost by the effort and supportive attitudes of nursing leaders and hospital chief executive officers. This study concluded that it should be possible to successfully implement conceptually sound managed care and case management programs in rural hospitals, but it will require a relatively long period of support, especially from hospital administration and nursing leaders.

HIV/AIDS in the rural United States: epidemiology and health services delivery.

This integrated research review addresses the epidemiology of rural human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and the organization, financing, and delivery of health services for rural persons living with HIV or AIDS (PLWHIVs, PLWAs). Several abstracting services, indexing services, and bibliographies were searched. An annotation form served as the guideline for data extraction. Several conclusions emerged from this review. Epidemiological evidence indicates that there has been a dramatic increase in the relative proportion of rural HIV/AIDS incident cases over the past 5 years. Explanations for the rural increase focus on injection drug use, heterosexual behavior, and sexually transmitted disease levels. Dramatically elevated rates of infection in rural Black women are indicated. Rural areas experience important levels of in-migration of HIV/AIDS-infected individuals. The health services literature suggests that rural providers and institutions have limited resources and little experience with PLWHIVs or PLWAs.

The impact of informal care giving on labor force participation by rural farming and nonfarming families.

Using data from the National Survey of Families and Households, 1987, this study contrasts urban versus rural, and farm versus rural nonfarm informal care givers of the elderly and disabled to illustrate the conflicts that each group experiences when combining work and care giving. Women are the primary care givers in both rural and urban areas. Rural care givers spent more time providing care than urban care givers, whether the dependent resided in the care giver's home or elsewhere in the community. A moderate difference existed in the number of hours care givers spent at work, although the rural care giver's spouses worked significantly more hours than urban spouses. Rural nonfarm care givers spent more hours caring for individuals residing in their communities, while farm care givers spent the most time in household-related activities when caring for someone in their homes. In-home activity decreased the number of hours spent at work, while community care giving did not.

The use of ultrasonography to scan the abdomen of patients presenting for routine physical examinations.

BACKGROUND: Ultrasonography has become an increasingly important diagnostic tool, producing high-quality images at a low cost. However, except in obstetrics, ultrasonography has not been used for screening purposes in asymptomatic persons. METHODS: This prospective study included 189 patients on whom an abdominal ultrasound scan was performed by a family physician as part of a routine physical examination. During the 2-year follow-up period, the screening was evaluated by determining whether the ultrasound findings contributed to the patient's health care management. RESULTS: Forty-two of the patients (22%) were found to have previously undiagnosed conditions. The most common findings were gallstones, urinary retention, and renal cysts. Six patients (3%) received treatment for the condition detected by the screening, but three of these patients received treatment only after they developed symptoms during the 2-year follow-up period. One patient developed symptoms for gallstones that may have been missed by the screening ultrasound. The internal and external reliability rates for the screening examination were 96% and 82%, respectively. CONCLUSIONS: Ultrasound findings altered the treatment plan for 3% of the screened patients but was the sole factor leading to treatment in only 1.6%. Abdominal ultrasound can be performed accurately and at a reasonable cost by generalist physicians. Patient acceptance was high, and many reported feeling reassured by the ultrasound screening.