Nurse practitioner malpractice data: Informing nursing education.

BACKGROUND: Nurse practitioners (NPs) are often identified in medical malpractice claims. However, the use of malpractice data to inform the development of nursing curriculum is limited. The purpose of this study is to examine medical errors committed by NPs. METHODS: Using National Practitioner Data Bank public use data, years 1990 to 2014, NP malpractice claims were classified by event type, patient outcome, setting, and number of practitioners involved. RESULTS: The greatest proportion of malpractice claims involving nurse practitioners were diagnosis related (41.46%) and treatment related (30.79%). Severe patient outcomes most often occurred in the outpatient setting. Nurse practitioners were independently responsible for the event in the majority of the analyzed claims. CONCLUSION: Moving forward, nurse practitioner malpractice data should be continuously analyzed and used to inform the development of nurse practitioner education standards and graduate program curriculum to address areas of clinical weakness and improve quality of care and patient safety.

Race/Ethnicity and Health Care Communication: Does Patient-Provider Concordance Matter?

BACKGROUND: Although many minority patients would prefer a provider of their own race/ethnicity, the influence of this relationship on patient-provider communication remains unknown. This analysis examined the effect of patient-provider race/ethnicity concordance on patient-reported provider communication quality using data from the Medical Expenditure Panel Survey years 2002-2012. METHODS: Ordinary least squares regressions were executed on communication rating, measured by the Consumer Assessment of Health Providers and Systems. RESULTS: Only 13.8% of black, non-Hispanic patients reported their usual source of care provider matched their race/ethnicity, compared with 94.4% of white, non-Hispanic patients and 43.8% of Hispanic patients. Differences in communication ratings were driven by patient race, rather than provider race. Although black, non-Hispanic patients rate their communication significantly higher than their counterparts overall, there was no significant influence of patient-provider racial concordance on ratings of communication when controlling for other sociodemographic variables. CONCLUSIONS: Minorities may seek the services of minority providers, but they are not more satisfied with patient-provider communication experience than when in race-discordant provider arrangements.

Neighborhoods and obesity in New York City.

Recent studies reveal disparities in neighborhood access to food and fitness facilities, particularly in US cities; but few studies assess the effects of multiple neighborhood factors on obesity. This study measured the multilevel relations between neighborhood food availability, opportunities and barriers for physical activity, income and racial composition with obesity (BMI> or =30 kg/m(2)) in New York City, controlling for individual-level factors. Obesity rates varied widely between neighborhoods, ranging from 6.8% to 31.7%. Obesity was significantly (p<0.01) associated with neighborhood-level factors, particularly the availability of supermarkets and food stores, fitness facilities, percent of commercial land use and area income. These findings are consistent with the growing literature showing that area income and availability of food and physical activity resources are related to obesity.

Digging deeper: quality of patient-provider communication across Hispanic subgroups.

BACKGROUND: Recent research suggests that ethnic subgroup designation plays an important role in health-related disparities among Hispanics. Our objective was to examine the influence of Hispanics' self-reported ethnic subgroup designation on perceptions of their health care providers' communication behaviors. METHODS: Cross-sectional analysis of the 2005 Medical Expenditure Panel Survey (MEPS). Participants included non-institutionalized Hispanics (n = 5197; US population estimate = 27,070,906), aged > or = 18 years, reporting visiting a health care provider within the past 12 months. Six (n = 6) items were used to capture respondents' perceptions of their health care providers' communication behaviors. RESULTS: After controlling for socio-demographic covariates, compared to Other Hispanics (reference group), very few differences in perceptions of health care providers communication emerged across ethnic subgroups. Puerto Ricans were more likely to report that their health care provider "always" showed respect for what they had to say (OR = 2.16, 95% CI 1.16-4.03). Both Puerto Ricans (OR = 2.28, 95% CI 1.06-4.92) and Mexicans (OR = 1.88, 95% CI 1.02-3.46) were more likely to indicate that their health care provider "always" spent enough time with them as compared to Other Hispanics. CONCLUSIONS: We observed very few differences among Hispanics respondents in their perceived quality of interactions with health care providers as a function of their ethnic subgroup designation. While our findings somewhat contradict previous research, they do suggest that other underlying factors may influence the quality of perceived interactions with health care providers.

Morbidity in obese adolescents who meet the adult National Institutes of Health criteria for bariatric surgery.

PURPOSE: Some have suggested that the criteria for weight loss surgery in adolescents be stricter than those currently recommended for adults by the National Institutes of Health (NIH). The aim of the current study is to define the characteristics of adolescents who meet NIH consensus criteria for bariatric surgery in adults to determine their level of morbidity. MATERIALS AND METHODS: Using the Medical Expenditure Panel Survey 2000-2004, children designated as meeting NIH criteria were 13 to 17 years of age with (1) a body mass index >or=40 or (2) a body mass index >35, and one or more comorbidity. We contrasted surgery candidates with noncandidates. We examined items that comprise a screener for identifying children with special health care needs. The Columbia Impairment Scale (CIS) was used to assess child functioning. RESULTS: There were 134 children identified as candidates for bariatric surgery and 4736 noncandidates in the same age range. Candidates were more likely to have special health care needs (36% vs 23%) and more likely to have a CIS above 16 (34% vs 16%). Candidates for weight loss surgery were 2.36 times as likely to have a CIS score of 16 or higher and 1.87 times as likely to be identified as a child with special health care needs (P

Usual source of care: an important source of variation in health care spending.

Health care spending varies in unexplained ways, and physicians' behavior is thought to explain much of the variation. We studied the spending effects of having different usual sources of care, focusing on variations associated with the type of facility or physician specialty. Based on analyses of data from the 2001-2004 Medical Expenditure Panel Surveys, we found significant differences in annual spending, especially for adults. Use of and spending for subspecialists were similar to those for general internists, and both were significantly higher than those for family physicians. Variation in spending might be the result of training differences among primary care specialties.

Measuring patients' perceptions of communication with healthcare providers: do differences in demographic and socioeconomic characteristics matter?

BACKGROUND: National governments across the globe have set goals to improve healthcare delivery. Understanding patient-provider communication is essential for the development of policies that measure how well a healthcare system delivers care. OBJECTIVES: This study was designed to determine which, if any, demographic factors were independently associated with how US patients perceive various aspects of communication with their healthcare providers. DESIGN AND METHODS: The study was a secondary, cross-sectional analysis of nationally representative data from the 2002 Medical Expenditure Panel Survey (MEPS). Among US adults with a healthcare visit in the past year (n = approximately 16,700), we assessed the association between several covariate demographic and socioeconomic factors and four dependent measures of patient perceptions of communication with their healthcare providers. RESULTS: Across all four measures of communication, older patients were more likely to report positively. Having health insurance and a usual source of care were consistent predictors of positive perceptions of communication. Hispanic patients also reported better perceptions of communication across all four measures. The most economically disadvantaged patients were less likely to report that providers always explained things so that they understood. Male patients were more likely to report that providers always spent enough time with them. CONCLUSIONS: This study suggests that patient perceptions of communication in healthcare settings vary widely by demographics and other individual patient characteristics. In this paper, we discuss the relevance of these communication disparities to design policies to improve healthcare systems, both at the individual practice level and the national level.

Patient age influences perceptions about health care communication.

OBJECTIVE: The study's objective was to determine if a patient's age is independently associated with how he/she perceives interactions with health care providers. METHODS: We used a secondary, cross-sectional analysis of nationally representative data from the 2002 Medical Expenditure Panel Survey (MEPS). We measured the independent association between patient age and six outcomes pertaining to communication and decision-making autonomy, while simultaneously controlling for gender, race, ethnicity, family income, educational attainment, census region, rural residence, insurance status, and usual source of care. RESULTS: Compared to patients>or=65 years, patients ages 18-64 were less likely to report that their provider "always" listened to them, "always" showed respect for what they had to say, and "always" spent enough time with them. DISCUSSION: Patient perceptions of health care interactions vary by age. A better understanding of how and why age is associated with patient-provider communication could be useful to design practice-level interventions that enhance services and also to develop national policies that improve health care delivery and health outcomes.

Language preference and perceptions of healthcare providers' communication and autonomy making behaviors among Hispanics.

BACKGROUND: To examine influence of language preference-English versus Spanish-on Hispanics' perceptions of their healthcare providers' communication behaviors. METHODS: Using the 2005 Medical Expenditure Panel Survey (MEPS), we observed non-institutionalized Hispanics (n = 5197; US population estimate = 27,070,906), aged >or=18 years, reporting visiting a healthcare provider within the past 12 months. RESULTS: When compared to Spanish responders (reference group), English responders were more likely to report that their healthcare provider "always" listened to them carefully (adjusted odds ratio (OR) = 1.39, 95% confidence interval (CI) 1.09-1.78), "always" explained things so that they understood (adjusted OR 1.37, 95% CI 1.08-1.73), "always" spent enough time with them (adjusted OR = 1.62, 95% CI 1.24-2.11),"always" asked them to help make decisions (adjusted OR 1.37, 95% CI 1.03-1.82), and "always" showed respect for treatment decisions (adjusted OR = 1.66, 95% CI 1.27-2.19). DISCUSSION: Healthcare providers should consider the complex needs of Hispanic patients whose language of choice is not English.

Increased rates and severity of child and adult food insecurity in households with adult smokers.

OBJECTIVE: To investigate rates and severity of child and adult food insecurity (the inability to access enough food in a socially acceptable way for every day of the year) in households with and without smokers. DESIGN: Cross-sectional survey. SETTING: Nationally representative sample of the US population from 1999 to 2002. PARTICIPANTS: Households with children through age 17 years (n = 8817) in the National Health and Nutrition Examination Survey. Main Exposure Presence or absence of adult smokers in the household. Covariates included age, sex, and race/ethnicity of the child, and the poverty index ratio. Main Outcome Measure Rates and severity of food insecurity were ascertained using the US Department of Agriculture Food Security Survey Module. RESULTS: Food insecurity was more common and severe in children and adults in households with smokers. Of children in households with smokers, 17.0% were food insecure vs 8.7% in households without smokers (P < .001). Rates of severe child food insecurity were 3.2% vs 0.9% (P < .04), respectively. For adults, 25.7% in households with smokers and 11.6% in households without smokers were food insecure, and rates of severe food insecurity were 11.8% and 3.9%, respectively (P < .003 for each). Food insecurity was higher in low-income compared with higher income homes (P < .01). At multivariate analyses, smoking was independently associated with food insecurity and severe food insecurity in children (adjusted odds ratio, 2.0; 95% confidence interval, 1.5-2.7, and adjusted odds ratio, 3.1; 95% confidence interval, 1.4-6.9, respectively) and adults (adjusted odds ratio, 2.2; 95% confidence interval, 1.6-3.0, and adjusted odds ratio, 2.3; 95% confidence interval, 1.4-3.7, respectively). CONCLUSIONS: Living with adult smokers is an independent risk factor for adult and child food insecurity, associated with an approximate doubling of its rate and tripling of the rate of severe food insecurity.

Comprehending care in a medical home: a usual source of care and patient perceptions about healthcare communication.

OBJECTIVE: To examine whether having a usual source of care (USC) is associated with positive patient perceptions of health care communication and to identify demographic factors among patients with a USC that are independently associated with differing reports of how patients perceive their involvement in health care decision making. METHODS: Cross-sectional analyses of nationally representative data from the 2002 Medical Expenditure Panel Survey. Among adults with a health care visit in the past year (n = approximately 16,700), we measured independent associations between having a USC and patient perceptions of health care communication. Second, among respondents with a USC (n = approximately 18,000), we assessed the independent association between various demographic factors and indicators of patients' perceptions of their autonomy in making health care decisions. RESULTS: Approximately 78% of adults in the United States reported having a USC. Those with a USC were more likely to report that providers always listened to them, always explained things clearly, always showed respect, and always spent enough time with them. Patients who perceived higher levels of decision-making autonomy were non-Hispanic, had health insurance coverage, lived in rural areas, and had higher incomes. CONCLUSIONS: Patients with a USC were more likely to perceive positive health care interactions. Certain demographic factors among the subgroups of Medical Expenditure Panel Survey respondents with a USC were associated with patient perceptions of greater decision-making autonomy. Efforts to ensure universal access to a USC must be partnered with broader awareness and training of USC providers to engage patients from various demographic backgrounds equally when making health care decisions at the point of care.

Impact of Title VII training programs on community health center staffing and national health service corps participation.

PURPOSE: Community health centers (CHCs) are a critical component of the health care safety net. President Bush's recent effort to expand CHC capacity coincides with difficulty recruiting primary care physicians and substantial cuts in federal grant programs designed to prepare and motivate physicians to practice in underserved settings. This article examines the association between physicians' attendance in training programs funded by Health Resources and Services Administration (HRSA) Title VII Section 747 Primary Care Training Grants and 2 outcome variables: work in a CHC and participation in the National Health Service Corps Loan Repayment Program (NHSC LRP). METHODS: We linked the 2004 American Medical Association Physician Master-file to HRSA Title VII grants files, Medicare claims data, and data from the NHSC. We then conducted retrospective analyses to compare the proportions of physicians working in CHCs among physicians who either had or had not attended Title VII-funded medical schools or residency programs and to determine the association between having attended Title VII-funded residency programs and subsequent NHSC LRP participation. RESULTS: Three percent (5,934) of physicians who had attended Title VII-funded medical schools worked in CHCs in 2001-2003, compared with 1.9% of physicians who attended medical schools without Title VII funding (P<.001). We found a similar association between Title VII funding during residency and subsequent work in CHCs. These associations remained significant (P<.001) in logistic regression models controlling for NHSC participation, public vs private medical school, residency completion date, and physician sex. A strong association was also found between attending Title VII-funded residency programs and participation in the NHSC LRP, controlling for year completed training, physician sex, and private vs public medical school. CONCLUSIONS: Continued federal support of Title VII training grant programs is consistent with federal efforts to increase participation in the NHSC and improve access to quality health care for underserved populations through expanded CHC capacity.

The health impact of resolving racial disparities: an analysis of US mortality data.

The US health system spends far more on the "technology" of care (e.g., drugs, devices) than on achieving equity in its delivery. For 1991 to 2000, we contrasted the number of lives saved by medical advances with the number of deaths attributable to excess mortality among African Americans. Medical advances averted 176 633 deaths, but equalizing the mortality rates of Whites and African Americans would have averted 886202 deaths. Achieving equity may do more for health than perfecting the technology of care.

Perceptions of healthcare providers' communication skills: do they differ between urban and non-urban residents?

We examined the association of place of residence--urban versus non-urban--with patients' perceptions regarding communication and interactions with healthcare providers. Respondents' perceptions of their healthcare providers' communication skills were assessed by responses to six items from the 2002 Medical Expenditure Panel Survey, a nationally representative survey of the civilian, non-institutionalized US population. After controlling for several covariates, respondents in urban areas reported poorer communication by their healthcare providers than non-urban respondents. Differences in perceived quality of communication could contribute to reduce use of preventive healthcare and indicates a need to improve healthcare provider-patient communication in the urban setting.

Changing policies on vaginal birth after cesarean: impact on access.

BACKGROUND: The issue of vaginal birth after cesarean (VBAC) has become highly visible and contentious. In 1999, the American College of Obstetricians and Gynecologists advocated a policy that surgical capability be "immediately available" for women in labor attempting VBAC. METHODS: Every hospital in Colorado, Montana, Oregon, and Wisconsin was contacted by telephone at least once during the period 2003 to 2005. Using a semistructured interview, respondent hospitals were asked whether and when their policies for VBAC had changed and what was the availability of VBAC services before and after the 1999 policy was issued. RESULTS: Of 314 hospitals contacted, 312 responded to the survey (response rate 99.4%). Babies were delivered at 230 (74%) respondent hospitals. Almost one-third, 68 of 222 (30.6%), of responding delivery hospitals that previously offered VBAC services had stopped doing so; seven hospitals had never allowed VBAC. Of the hospitals that still allowed VBAC, 68 percent had changed their VBAC policies since 1999, with the most frequent changes requiring the in-house presence of surgery (53%) and anesthesia (44%) personnel when women desiring VBAC presented in labor. Compared with hospitals that stopped allowing VBAC, those that currently permit VBAC were larger (156.6 vs 58.1 beds, t = 7.02, p < 0.001), closer to other delivery hospitals (20.9 vs 39.2 miles, t = 4.33, p < 0.001), annually delivered more babies (1009.9 vs 458.3, t = 4.41, p < 0.001), and annually had more cesarean deliveries (226.7 vs 105.7, t = 3.91, p < 0.001). CONCLUSIONS: In the years following advocacy of the 1999 policy, the availability of VBAC services significantly decreased, especially among smaller or more isolated hospitals.

The primary care physician workforce: ethical and policy implications.

PURPOSE: We undertook a study to examine the characteristics of countries exporting physicians to the United States according to their relative contribution to the primary care supply in the United States. METHODS: We used data from the World Health Organization and from the American Medical Association Physician Masterfile to gather sociodemographic, health system, and health characteristics of countries and the number of international medical graduates (IMGs) for the countries, according to the specialty of their practice in the United States. RESULTS: Countries whose medical school graduates added a relatively greater percentage of the primary care physicians than the overall percentage of primary care physicians in the United States (31%) were poor countries with relatively extreme physician shortages, high infant mortality rates, lower life expectancies, and lower immunization rates than countries contributing relatively more specialists to the US physician workforce. CONCLUSION: The United States disproportionately uses graduates of foreign medical schools from the poorest and most deprived countries to maintain its primary care physician supply. The ethical aspects of depending on foreign medical graduates is an important issue, especially when it deprives disadvantaged countries of their graduates to buttress a declining US primary care physician supply.

The medical dialogue: disentangling differences between Hispanic and non-Hispanic whites.

BACKGROUND: Patients' race and ethnicity play an important role in quality of and access to healthcare in the United States. OBJECTIVES: To examine the influence of ethnicity--Hispanic whites vs. non-Hispanic whites--on respondents' self-reported interactions with healthcare providers. To understand, among Hispanic whites, how demographic and socioeconomic characteristics impact their interactions with healthcare providers. DESIGN: Cross-sectional analysis of the 2002 Medical Expenditure Panel Survey, a nationally representative survey on medical care conducted by the Agency for Healthcare Research and Quality. PARTICIPANTS: Civilian, noninstitutionalized U.S. population aged > or = 18 years who reported visiting a healthcare provider within the past 12 months prior to data collection. RESULTS: After controlling for several demographic and socioeconomic covariates, compared to non-Hispanic whites (reference group), Hispanic whites who had visited a doctor's office or clinic in the past 12 months were more likely to report that their healthcare provider "always" listened to them [odds ratio (OR) = 1.36, 95% confidence interval (CI) 1.21-1.53], explained things so that they understood (OR = 1.25, 95% CI 1.10-1.41), showed respect for what they had to say (OR = 1.52, 95% CI 1.35-1.72), and spent enough time with them (OR = 1.22, 95% CI 1.08-1.38). However, Hispanics were less likely to indicate that their health care provider "always" gave them control over treatment options (OR = 0.83, 95% CI 0.72-0.95) as compared to non-Hispanics. Within the Hispanic population exclusively, age, place of residence, census region, health insurance status, and presence of a usual source of care influenced self-reported interactions with healthcare providers. CONCLUSION: Hispanic white respondents were more likely to report that some aspects of provider-patient interactions were indicative of high quality, whereas those related to decision-making autonomy were not. These somewhat paradoxical results should be examined more fully in future research.

The Canadian contribution to the US physician workforce.

BACKGROUND: A physician shortage has been declared in both Canada and the United States. We sought to examine the migration pattern of Canadian-trained physicians to the United States, the contribution of this migration to the Canadian physician shortage and policy options in light of competing shortages in both countries. METHODS: We performed a cross-sectional analysis of the 2004 and 2006 American Medical Association Physician Masterfiles, the 2002 Area Resource File and data from the Canadian Institute for Health Information, the Canadian Medical Association and the Association of Faculties of Medicine of Canada. We describe the migration pattern of Canadian medical school graduates to the United States, the number of Canadian-trained physicians in the United States in 2006, the proportion who were in active practice, the proportion who were practising in rural or underserved areas and the annual contribution of Canadian-trained physicians to the US physician workforce. RESULTS: Two-thirds of the 12 040 Canadian-educated physicians living in the United States in 2006 were practising in direct patient care, 1023 in rural areas. About 186, or 1 in 9, Canadian-educated physicians from each graduating class joined the US physician workforce providing direct patient care. Canadian-educated physicians are more likely than US-educated physicians to practise in rural areas. INTERPRETATION: Minimizing emigration, and perhaps recruiting physicians to return to Canada, could reduce physician shortages, particularly in subspecialties and rural areas. In light of competing physician shortages, it will be important to consider policy options that reduce emigration, improve access to care and reduce reliance on physicians from developing countries.

Congruent satisfaction: is there geographic correlation between patient and physician satisfaction?

CONTEXT: Satisfaction among both physicians and patients is optimal for the delivery of high-quality healthcare. Although some links have been drawn between physician and patient satisfaction, little is known about the degree of satisfaction congruence among physicians and patients living and working in geographic proximity to each other. OBJECTIVE: We sought to identify patients and physicians from similar geographic sites and to examine how closely patients' satisfaction with their overall healthcare correlates with physicians' overall career satisfaction in each selected site. METHODS: We undertook a cross-sectional analysis of data from 3 rounds of the Community Tracking Study (CTS) Household and Physician Surveys (1996-1997, 1998-1999, 2000-2001), a nationally representative telephone survey of patients and physicians. We studied randomly selected participants in the 60 CTS communities for a total household population of 179,127 patients and a total physician population of 37,238. Both physicians and patients were asked a variety of questions pertaining to satisfaction. RESULTS: Satisfaction varied by region but was closely correlated between physicians and patients living in the same CTS sites. Physician career satisfaction was more strongly correlated with patient overall healthcare satisfaction than any of the other aspects of the healthcare system (Spearman's rank correlation coefficient 0.628, P<0.001). Patient trust in the physician was also highly correlated with physician career satisfaction (0.566, P<0.001). CONCLUSIONS: Despite geographic variation, there is a strong correlation between physician and patient satisfaction living in similar geographic locations. Further analysis of this congruence and examination of areas of incongruence between patient and physician satisfaction may aid in improving the healthcare system.

National Health Service Corps staffing and the growth of the local rural non-NHSC primary care physician workforce.

CONTEXT: Beyond providing temporary staffing, National Health Service Corps (NHSC) clinicians are believed by some observers to contribute to the long-term growth of the non-NHSC physician workforce of the communities where they serve; others worry that NHSC clinicians compete with and impede the supply of other local physicians. PURPOSE: To assess long-term changes in the non-NHSC primary care physician workforce of rural underserved counties that have received NHSC staffing support relative to workforce changes in underserved counties without NHSC support. METHODS: Using data from the American Medical Association and NHSC, we compared changes from 1981 to 2001 in non-NHSC primary care physician to population ratios in 2 subsets of rural whole-county health professional shortage areas: (1) 141 counties staffed by NHSC physicians, nurse practitioners, and/or physician assistants during the early 1980s and for many of the years since and (2) all 142 rural health professional shortage area counties that had no NHSC clinicians from 1979 through 2001. FINDINGS: From 1981 to 2001, counties staffed by NHSC clinicians experienced a mean increase of 1.4 non-NHSC primary care physicians per 10,000 population, compared to a smaller, 0.57 mean increase in counties without NHSC clinicians. The finding of greater non-NHSC primary care physician to population mean ratio increase in NHSC-supported counties remained significant after adjusting for baseline county demographics and health care resources (P < .001). The estimated number of "extra" non-NHSC physicians in NHSC-supported counties in 2001 attributable to the NHSC was 294 additional physicians for the 141 supported counties, or 2 extra physicians, on average, for each NHSC-supported county. Over the 20 years, more NHSC-supported counties saw their non-NHSC primary care workforces grow to more than 1 physician per 3,500 persons, but no more NHSC-supported than nonsupported counties lost their health professional shortage area designations. CONCLUSIONS: These data suggest that the NHSC contributed positively to the non-NHSC primary care physician workforce in the rural underserved counties where its clinicians worked during the 1980s and 1990s.