U.S. Primary Care Provider Needs: An Analysis of Workforce Projections and Policy Implications.

The primary care (PC) physician workforce has consistently been projected as requiring additional numbers to meet the needs of the U.S. The Health Resources and Service Administration (HRSA) has reported the PC nurse practitioner (NP) workforce to be 90,000 NPs more than required to meet the PC needs of the U.S. With both clinician types contributing to the PC workforce in the country, it is difficult to understand such an oversupply of NPs with continued deficit in PC physicians. The purpose of this study was to investigate results and methods used for HRSAs current PC workforce projections and compare those with the same used for Bureau of Labor Statistics (BLS) and American Association of Medical Colleges (AAMC) projections. Methods included a review of technical documents, dashboards, and published reports. Interviews with subject matter experts were also completed. Projections were found to differ significantly, as did data and assumptions. Two of the three projections modeled physicians as the sole provider of PC. An integrated model gives the most comprehensive and accurate picture of PC workforce needs. The utilization of NPs as PC providers has been demonstrated to be safe and effective, with the potential to alleviate predicted shortages, improve patient care outcomes, reduce cost, and address PC inequities. Implications include improving workforce data, creating projections that mirror clinical integration in PC, adjusting workforce preparation funding, incentivizing interprofessional collaboration in research, addressing barriers to practice among non-physician providers, and leveraging growth in the NP workforce.

Antihypertensive medication adherence and persistence among Black women: A qualitative study.

ABSTRACT: The prevalence of hypertension in Black women (57.6%) is among the highest in the world. Many of those who identify as Black do not readily adhere to prescribed antihypertensive medications nor persist with long-term therapy. This qualitative study describes self-reported approaches used by Black women with consistent adherence and persistence to medication-taking for BP control.

Osmotic stimulation of vasopressin acutely impairs glucose regulation: a counterbalanced, crossover trial.

BACKGROUND: Epidemiological studies in humans show increased concentrations of copeptin, a surrogate marker of arginine vasopressin (AVP), to be associated with increased risk for type 2 diabetes. OBJECTIVES: To examine the acute and independent effect of osmotically stimulated AVP, measured via the surrogate marker copeptin, on glucose regulation in healthy adults. METHODS: Sixty subjects (30 females) participated in this crossover design study. On 2 trial days, separated by ≥7 d (males) or 1 menstrual cycle (females), subjects were infused for 120 min with either 0.9% NaCl [isotonic (ISO)] or 3.0% NaCl [hypertonic (HYPER)]. Postinfusion, a 240-min oral-glucose-tolerance test (OGTT; 75 g) was administered. RESULTS: During HYPER, plasma osmolality and copeptin increased (P < 0.05) and remained elevated during the entire 6-h protocol, whereas renin-angiotensin-aldosterone system hormones were within the lower normal physiological range at the beginning of the protocol and declined following infusion. Fasting plasma glucose did not differ between trials (P > 0.05) at baseline and during the 120 min of infusion. During the OGTT the incremental AUC for glucose from postinfusion baseline (positive integer) was greater during HYPER (401.5 ± 190.5 mmol/L·min) compared with the ISO trial (354.0 ± 205.8 mmol/L·min; P < 0.05). The positive integer of the AUC for insulin during OGTT did not differ between trials (HYPER 55,850 ± 36,488 pmol/L·min compared with ISO 57,205 ± 31,119 pmol/L·min). Baseline values of serum glucagon were not different between the 2 trials; however, the AUC of glucagon during the OGTT was also significantly greater in HYPER (19,303 ± 3939 ng/L·min) compared with the ISO trial (18,600 ± 3755 ng/L·min; P < 0.05). CONCLUSIONS: The present data indicate that acute osmotic stimulation of copeptin induced greater hyperglycemic responses during the oral glucose challenge, possibly due to greater glucagon concentrations.This study was registered at clinicaltrials.gov as NCT02761434.

Dehydration Impairs Cycling Performance, Independently of Thirst: A Blinded Study.

PURPOSE: The aim of the present study was to examine the effect of dehydration on exercise performance independently of thirst with subjects blinded of their hydration status. METHODS: Seven male cyclists (weight, 72 ± 9 kg; body fat, 14% ± 6%; peak oxygen uptake, 59.4 ± 6 mL·kg·min) exercised for 2 h on a cycle ergometer at 55% peak oxygen uptake, in a hot-dry environment (35°C, 30% relative humidity), with a nasogastric tube under euhydrated-non-thirst (EUH-NT) and dehydrated-non-thirst (DEH-NT) conditions. In both trials, thirst was matched by drinking 25 mL of water every 5 min (300 mL·h). In the EUH-NT trial, sweat losses were fully replaced by water via the nasogastric tube (calculated from the familiarization trial). After the 2 h of steady state, the subjects completed a 5-km cycling time trial at 4% grade. RESULTS: Body mass loss for the EUH-NT and DEH-NT after the 2 h was -0.2% ± 0.6% and -2.2% ± 0.4%, whereas after the 5-km time trial, it was -0.7% ± 0.5% and 2.9% ± 0.4%, respectively. Thirst (35 ± 30 vs 42 ± 31 mm) and stomach fullness (46 ± 21 vs 35 ± 20 mm) did not differ at the end of the 2 h of steady state between EUH-NT and DEH-NT trials (P > 0.05). Subjects cycled faster during the 5-km time trial in the EUH-NT trial compared with the DEH-NT trial (23.2 ± 1.5 vs 22.3 ± 1.8 km·h, P < 0.05), by producing higher-power output (295 ± 29 vs 276 ± 29 W, P < 0.05). During the 5-km time trial, core temperature was higher in the DEH-NT trial (39.2°C ± 0.7°C) compared with the EUH-NT trial (38.8°C ± 0.2°C; P > 0.05). CONCLUSIONS: These data indicated that hypohydration decreased cycling performance and impaired thermoregulation independently of thirst, while the subjects were unaware of their hydration status.

Reduced water intake deteriorates glucose regulation in patients with type 2 diabetes.

Epidemiological research has demonstrated that low daily total water intake is associated with increased diagnosis of hyperglycemia. Possible mechanisms for this increase include hormones related to the hypothalamic pituitary axis as well as the renin-angiotensin-aldosterone system (RAAS). Therefore, the hypothesis of the present study was that acute low water intake would result in differential hormonal profiles and thus impaired blood glucose regulation during an oral glucose tolerance test (OGTT) in people with type 2 diabetes mellitus (T2DM). Nine men (53 ± 9 years, 30.0 ± 4.3 m∙kg-2, 32% ± 6% body fat) diagnosed with T2DM completed OGTTs in euhydrated (EUH) and hypohydrated (HYP) states in counterbalanced order. Water restriction led to hypohydration of -1.6% of body weight, with elevated plasma (EUH: 288 ± 4, HYP: 298 ± 6 mOsm·kg-1; P < .05) and urine (EUH: 512 ± 185, HYP: 994 ± 415 mOsm·kg-1; P < .05) osmolality. There was a significant main effect of condition for serum glucose (at time 0 minute 9.5 ± 4.2 vs 10.4 ± 4.4 mmol∙L-1 and at time 120 minutes 19.1 ± 4.8 vs 21.0 ± 4.1 mmol∙L-1 for EUH and HYP, respectively; P < .001) but not insulin (mean difference between EUH and HYP -12.1 ± 44.9 pmol∙L-1, P = .390). An interaction between time and condition was observed for cortisol: decrease from minute 0 to 120 in EUH (-85.3 ± 82.1 nmol∙L-1) vs HYP (-25.0 ± 43.0 nmol∙L-1; P = .017). No differences between conditions were found within RAAS-related hormones. Therefore, we can conclude that 3 days of low total water intake in people with T2DM acutely impairs blood glucose response during an OGTT via cortisol but not RAAS-mediated glucose regulation.

Monitoring worksite clinic performance using a cost-benefit tool.

OBJECTIVE: The purpose of this study was to explore the usefulness of continuously assessing the return on investment (ROI) of worksite medical clinics as a means of evaluating clinic performance. METHODS: Visit data from January 1, 2007, to December 31, 2008, were collected from all the on-site clinics operated for the Pepsi Bottling Group. An average system-wide ROI was calculated from the time of each clinic's opening and throughout the study period. A multivariate linear regression model was used to determine the association of average ROI with penetration/utilization rate and plant size. RESULTS: A total of 26 on-site clinics were actively running as of December 2008. The average ROI at the time of start up was 0.4, which increased to 1.2 at approximately 4 months and 1.6 at the end of the first year of operation. Overall, it seems that the cost of operating a clinic becomes equal to the cost of similar care purchased in the community (ROI = 1) at approximately 3 months after a clinic's opening and flattens out at the end of the first year. The magnitude of the ROI was closely related to the number of visits (a function of the penetration/utilization rate) and the size of the plant population served. CONCLUSION: Serial monitoring of ROIs is a useful metric in assessing on-site clinic performance and quantifying the effect of new initiatives aimed at increasing a clinic's cost effectiveness.