Challenges of including dietitians, nurses, occupational therapists, and pharmacists in the Federal Credentialing Program.

Credentialing and recredentialing of federal health care providers involves hundreds of hours of labor and associated costs. This article presents the history of credentialing and efforts to expand the Federal Credentialing Program to include dietitians, nurses, occupational therapists, and pharmacists and discusses barriers to this possible expansion. Representatives from federal and civilian health care service delivery agencies and credentialing and licensure bodies will gather to establish common credentialing information for these professions. Discussing barriers to these efforts will help to ensure success. In addition, a more efficient and streamlined system could easily be adopted by the civilian sector for these professions.

The workforce in otolaryngology-head and neck surgery: moving into the next millennium.

OBJECTIVE: The goal was to examine the current scope of otolaryngologists' practices, their geographic distribution, and the roles otolaryngologists and other specialists play in caring for patients with otolaryngic and related conditions of the head and neck. STUDY DESIGN: A large national survey and administrative claims databases were examined to develop practice profiles and compile a physician supply for otolaryngology. A focus group of otolaryngologists provided information to model future scenarios. RESULTS: The current and predicted workforce supply and demographics are at a satisfactory level and are decreasing as a proportion of the increasing population. Empiric data analysis supports the diverse nature of an otolaryngologist's practice and the unique role for otolaryngologists that is not shared by many other providers. Together with the focus group results, the study points to areas for which more background and training are warranted. CONCLUSIONS: This study represents a first step in a process to form coherent workforce recommendations for the field of otolaryngology.

[Proper use and the ability to teach the use of pressurized hand-held inhalers in patients with chronic airway obstruction].

Inhaling drugs via hand-held inhalers in recommended for those with chronic obstructive airway disease (COPD). Approximately 8%-9% of Israel's population use hand-held inhalers, many of them pressurized. Skill in using them and ability of chronic users to learn their proper use have not been assessed. During 1993 and 1994 we studied 200 patients with bronchial asthma or COPD who regularly used a pressurized hand-held inhaler (PI), but were not trained to use it in our out-patient pulmonary clinic. Only a third were found to be skilled in its use. About half were completely unable to use it properly, and 17% used it in a suboptimal way. Remarkably, only 40% had been taught anything with regard to its use. About 75% of the suboptimal users significantly improved their skill in its use immediately after receiving a single individual teaching and corrective demonstration session. While 15% failed to learn the proper use of the PI, many of those who improved immediately after a single teaching session retained the learned skills for months. We conclude that the physician who recommends the use of a PI is responsible for the patient's being taught its proper use in a demonstration session. Skill in its use should be reassessed periodically during the entire treatment period.

Modeling the future workforce of obstetrics and gynecology.

OBJECTIVE: To examine the current supply and distribution of obstetrician-gynecologists and project future supply under various scenarios. METHODS: A discrete actuarial supply model was developed, and practice patterns were analyzed. Supply projections under different scenarios, distributions, and practice profiles were examined. RESULTS: Women are expected to become the majority of practitioners by 2014. Continuation of current residency output will result in slow to no growth in obstetrician-gynecologist-to-female population ratios over the next 20 years. A minor (10%) reduction in specialty training would slow specialty growth over the next decade, followed by a slight reduction in supply. Services provided chiefly involve ambulatory reproductive health care, pregnancy, and surgical correction of conditions specific to the female genitourinary system. Even though the proportion of deliveries performed by midwives has increased and family practitioners have maintained their share, obstetrician-gynecologists provide the vast majority of obstetric care and virtually all services for perinatal complications. Generalist services represent relatively minor aspects of their practices. Care of the aged female population is highly fragmented among specialties; more than 50% of all aged Medicare beneficiaries who saw an obstetrician-gynecologist at least once failed to receive a majority of services from any one physician specialty. CONCLUSION: On the basis of trends in patient demographics and care patterns, obstetrician-gynecologists must resolve whether to provide more generalist office-based care, especially to the rapidly growing older female population, or to invest more intensively in surgical specialty care. The specialty's unique contributions to women's health should influence this decision.

Fatal pulmonary barotrauma due to obstruction of the central circulation with air.

Cardiac arrest in cases of barotraumatic arterial gas embolism (AGE) is usually ascribed to reflex dysrhythmias secondary to brainstem embolization or secondary to coronary artery embolization. Several case reports suggest that obstruction of the central circulation (i.e., the heart, pulmonary arteries, aorta, and arteries to the head and neck) may play a role in the pathogenesis of sudden death in victims of pulmonary barotrauma. We report three consecutive cases of fatal AGE in patients in whom chest roentgenograms demonstrated confluent air lucencies filling the central vascular bed, the heart, and great vessels. In none of the victims was there evidence by history or at autopsy that the intravascular gas was iatrogenically introduced. Total occlusion of the central vascular bed with air is a mechanism of death in some victims of AGE, and resuscitation efforts for such patients should take this possibility into consideration.

Provider workforce model for regional TRICARE networks.

A model is presented that can estimate the total number and specialty mix of health care providers needed to serve a defined population. Military commanders in charge of TRICARE regions, known as "lead agents," can use this model to estimate the provider workforce composition needed to serve their area. Physician staffing patterns front managed-care organizations help define the provider-to-patient proportions on which this model is based. Data needed to perform the model's computations are derived from the regional enrolled beneficiary population and the number of active duty providers. As a result, the model provides an estimate of the number and type of civilian providers that need to be contracted to adequately serve the regional military network.

Retraining physicians for primary care. A study of physician perspectives and program development.

OBJECTIVE: To determine the number and kinds of programs that medical schools and managed care organizations offer or plan to offer to retrain physician specialists to practice primary care medicine and to discover physicians' attitudes toward such retraining. DESIGN: A survey was mailed in 1994 to all 126 medical schools and the 19 largest US managed care organizations to collect detailed information about existing and potential retraining programs. Physicians' attitudes toward retraining were elicited from participants in 3 geographically diverse focus groups. Selected specialists were polled through the national survey of the American Medical Association's Socioeconomic Monitoring System to ascertain the demand for retraining. RESULTS: The majority of institutions contacted perceived a need for retraining, but few programs had been established. Programs being "considered" varied widely in duration, class size, target audience, accreditation, and projected training settings. Although unenthusiastic about retraining, physicians preferred programs that would expand their patient base, maintain the practice population, be inexpensive and close to home, and provide hands-on training in the eventual practice environment. Physicians also preferred a goal-oriented, part-time retraining program in a large group practice or managed care setting that would allow them to practice their specialty while retraining. Few planned or existing programs incorporate many of these features. The most likely candidates for retraining are subspecialty physicians who currently provide some primary care and are employed by a medical plan. CONCLUSIONS: Despite efforts by those who perceive that a need for more generalist physicians is stimulating interest in retraining specialists and subspecialists to provide primary medical care, physician interest and program availability remain low, and programs under development are not being designed to attract those who may seek retraining. This situation is probably fortuitous, because changed perceptions about the adequacy of the generalist physician workforce since the beginning of this study have diminished the call for retraining.

Competency in health care management: a training model in epidemiologic methods for assessing and improving the quality of clinical practice through evidence-based decision making.

This article describes a training model that focuses on health care management by applying epidemiologic methods to assess and improve the quality of clinical practice. The model's uniqueness is its focus on integrating clinical evidence-based decision making with fundamental principles of resource management to achieve attainable, cost-effective, high-quality health outcomes. The target students are current and prospective clinical and administrative executives who must optimize decision making at the clinical and managerial levels of health care organizations.

[Ultrasound guided puncture of the portal vein in transjugular intrahepatic portasystemic stent shunt (TIPSS)]. / Sonographisch gesteuerte Punktion der Pfortader beim transjugulären intrahepatischen portosystemischen Stentshunt (TIPSS).

Successful completion of a transjugular intrahepatic portosystemic stentshunt (TIPSS) relies on knowledge of the individual hepatic vascular anatomy. The patients referred for TIPSS have an increased risk of contrast-medium-induced renal failure, and therefore the potential for a complete angiographic work-up during the procedure is limited. The same patient population also carries an increased risk of bleeding, which necessitates a rather accurate guiding technique for portal punctures. We have established transcutaneous sonographic guidance as a standard technique for transjugular portal puncture, reducing complication rates and intervention time. Competing imaging modalities for guidance are discussed.

Gastroenterology workforce modeling.

OBJECTIVE: To examine the current supply and distribution of gastroenterologists and project future supply under various scenarios to provide a paradigm for workforce reform. DESIGN: An analysis of current practices and distribution of gastroenterologists and a demographic model, using the 1992 gastroenterology workforce as a baseline. MAIN OUTCOME MEASURE: Comparison of current supply, distribution, and practice profiles with past data and future projections, using analyses of data from the 1993 Area Resource File, 1992 Medicare Part B file, age- and sex-specific death and retirement rates from the Bureau of Health Professions, managed care staffing patterns, the National Survey of Internal Medicine Manpower, and the Bureau of the Census. RESULTS: Rapid growth in the number of US gastroenterologists has resulted in a gastroenterologist-to-population ratio double that used on average by health maintenance organizations. In addition, the work profile of gastroenterologists is shared significantly by primary care physicians and other specialists, with the exception of a few specific and uncommon procedures. CONCLUSIONS: Empirical evidence suggests that, even in the absence of detailed models to describe the desired supply/need balance for gastroenterology, the US health care system and clinicians may benefit from a reduction in gastroenterology training programs. The Gastroenterology Leadership Council endorsed a goal of 25% to 50% reduction in trainee numbers over 5 years, and recent National Resident Matching Program data indicate that a voluntary downsizing process is in full force. This study illustrates a paradigm for workforce planning that could be useful for other medical specialties.

Physician impact on hospital admission and on mortality rates in the Medicare population.

OBJECTIVE: We assess the effect of variations in the supply and specialty distribution of physicians on admission rates for ambulatory care-sensitive conditions (ACS) and for all causes, and on mortality rates among Medicare beneficiaries of various health care service areas (HCSA). DATA SOURCES: For the Medicare beneficiaries, sources were the Health Care Financing Administration's 1992 enrollment and impatient (Part A) files for a 5 percent sample of that population; for the overall populations and for the medical resources of the HCSAs, the Area Resource File. STUDY DESIGN: This observational, cross-sectional study employed multiple linear regression to assess the influence of population characteristics and of the supply of physicians on hospital admissions, and Poisson regression in the analysis of the factors that affect mortality. PRINCIPAL FINDINGS: Physician supply levels vary nearly fourfold or more when comparing the top and bottom deciles of the HCSAs, Medicare admissions for ACS conditions vary about threefold, and admission rates for all causes and mortality rates vary about 1.5-fold. Physician supply levels and distributions have very little influence on ACS admission rates, and even less on the admissions for all causes and on mortality, except in HCSAs with very low physician supply levels (one-fourth the national average or less). However, these HCSAs account for only about 1 percent of the U.S. population. CONCLUSIONS: Physician supply levels and the proportions of specialists and generalists have negligible effects on health status as measured by mortality rates and by rates of admission for all causes and for conditions presumed to be sensitive to the adequacy of ambulatory care. Reductions in admissions for such conditions are not likely to be achieved through broadening of insurance to levels that exist under Medicare, nor through increases in the supply of physicians, nor, conversely, through a reduction in any presumed oversupply of physicians.

Disaster preparedness of poison control centers in the United States.

OBJECTIVE: To assess the state of disaster readiness of poison control centers, a survey questionnaire was sent to all 96 institutional poison control center members of the American Association of Poison Control Centers in the US, both certified and noncertified programs. DESIGN: The data reported are the results and responses from 76 of 96 (79.2%) poison control centers. RESULTS: Fifty-four percent of responding centers have written disaster plans, with 25% having drills to practice the plans. Of the centers that do not have a written plan, the majority have policies and procedures in place to address physical plant damage, increased phone traffic, loss of phone systems and malfunction of computers. Eighty-six percent of respondents have a back up generator, and 82% have an uninterruptable power supply in place. Fifty-four percent have a back up phone system and 33% have cellular phone capacity. Forty-six percent of responding centers have arrangements with other agencies in the event of a disaster. Only half of the managing directors of the responding centers believe their center can meet the public's needs in the event of a disaster.

Forecasting requirements for physical therapists.

In response to the existing undersupply of physical therapists and the projected changes of the health care reform era, it is prudent for the profession to consider implementing a training strategy that would bring the supply of physical therapists in line with requirements. Before such a training strategy could be developed, however, the physical therapy community would need to produce a requirements forecast. This article compares the uses and limitations of the two major methods for generating health professions requirements--the "need-based" and "demand-based" approaches--and recommends a pragmatic, tailored approach to determining physical therapist requirements that uses easily obtainable data on staffing patterns of managed care plans. The proposed method draws from both need-based and demand-based models to produce complementary data on which to base policy formation.