Regional Variations in Maternal Mortality and Health Workforce Availability in the United States.

BACKGROUND: Skilled, high-quality health providers and birth attendants are important for reducing maternal mortality. OBJECTIVE: To assess whether U.S. regional variations in maternal mortality rates relate to health workforce availability. DESIGN: Comparison of regional variations in maternal mortality rates and women's health provider rates per population and identification of a relationship between these measures. SETTING: U.S. health system. PARTICIPANTS: Women of child-bearing age and women's health providers, as captured in federal data sources from the Centers for Disease Control and Prevention, Census Bureau, and Health Resources and Services Administration. MEASUREMENTS: Regional-to-national rate ratios for maternal mortality and women's health provider availability, calculated per population for women of reproductive age. Provider availability was examined across occupations (obstetrician-gynecologists, internal medicine physicians, family medicine physicians, certified nurse-midwives), in service-based categories (birth-attending and primary care providers), and across the entire women's health workforce (all studied occupations). RESULTS: Maternal deaths per population increased nationally from 2009 to 2017 and, in 2017, were significantly higher in the South and lower in the Northeast (P < 0.001) than nationally. The occupational composition and per-population availability patterns of the women's health workforce varied regionally in 2017. The South had the lowest availability in the nation for nearly every health occupation and category studied, and the Northeast had the highest. This exploratory analysis suggests that subnational levels of provider availability across a region may be associated with higher maternal mortality rates. LIMITATIONS: No causal relationship was established. Nationally representative maternal mortality and health workforce data sources have well-known limitations. Low numbers of observations limit statistical analyses. CONCLUSION: Regional variations in maternal mortality rates may relate to the availability of birth-attending and primary care providers. PRIMARY FUNDING SOURCE: None.

The geographic alignment of primary care Health Professional Shortage Areas with markers for social determinants of health.

BACKGROUND: The Health Resources and Services Administration (HRSA), an agency within the U.S. Department of Health and Human Services (HHS), works to ensure accessible, quality, health care for the nation's underserved populations, especially those who are medically, economically, or geographically vulnerable. HRSA-designated primary care Health Professional Shortage Areas (pcHPSAs) provide a vital measure by which to identify underserved populations and prioritize locations and populations lacking access to adequate primary and preventive health care-the foundation for advancing health equity and maintaining health and wellness for individuals and populations. However, access to care is a complex, multifactorial issue that involves more than just the number of health care providers available, and pcHPSAs alone cannot fully characterize the distribution of medically, economically, and geographically vulnerable populations. METHODS AND FINDINGS: In this county-level analysis, we used descriptive statistics and multiple correspondence analysis to assess how HRSA's pcHPSA designations align geographically with other established markers of medical, economic, and geographic vulnerability. Reflecting recognized social determinants of health (SDOH), markers included demographic characteristics, race and ethnicity, rates of low birth weight births, median household income, poverty, educational attainment, and rurality. Nationally, 96 percent of U.S. counties were either classified as whole county or partial county pcHPSAs or had one or more established markers of medical, economic, or geographic vulnerability in 2017, suggesting that at-risk populations were nearly ubiquitous throughout the nation. Primary care HPSA counties in HHS Regions 4 and 6 (largely lying within the southeastern and south central United States) had the most pervasive and complex patterns in population risk. CONCLUSION: HHS Regions displayed unique signatures with respect to SDOH markers. Descriptive and analytic findings from our work may help inform health workforce and health care planning at all levels, and, by illustrating both the complexity of and differences in county-level population characteristics in pcHPSA counties, our findings may have relevance for strengthening the delivery of primary care and addressing social determinants of health in areas beset by provider shortages.

Impact of the Health Resources and Services Administration's state oral health workforce grant program on dental workforce density and access to oral health care.

BACKGROUND: The Health Resources and Services Administration's Grants to States to Support Oral Health Workforce Activities, otherwise known as the State Oral Health Workforce Program (SOHWP), help states develop and implement innovations that address the workforce needs of dental Health Professional Shortage Areas in a manner appropriate to the states' individual needs. AIM: This cross-sectional study explores the broad impact of the SOHWP by comparing measures of dental workforce density and access to oral health care in states with multiple years of funding versus states with few or no years of funding. METHODS: We used data for 2006-2016 SOHWP awardees together with data from the 2016-2017 Area Health Resources Files and the 2016 Behavioral Risk Factor Surveillance System to compare numbers of dentists per 100,000 population and age-adjusted prevalence of annual dental visits among adults for long-term SOHWP-funded states versus states with few or no years of funding. RESULTS: Multi-year SOHWP funding is associated with higher workforce density and greater access to oral health care, especially in the Midwest and West. CONCLUSION: Allowing states funding utilization flexibility may result in improved outcomes. This finding can help inform planning and policy about whether and how to scale future training and workforce programs to achieve greater impact.

Perspectives: Using Results from HRSA's Health Workforce Simulation Model to Examine the Geography of Primary Care.

OBJECTIVE: Inform health planning and policy discussions by describing Health Resources and Services Administration's (HRSA's) Health Workforce Simulation Model (HWSM) and examining the HWSM's 2025 supply and demand projections for primary care physicians, nurse practitioners (NPs), and physician assistants (PAs). DATA SOURCES: HRSA's recently published projections for primary care providers derive from an integrated microsimulation model that estimates health workforce supply and demand at national, regional, and state levels. PRINCIPAL FINDINGS: Thirty-seven states are projected to have shortages of primary care physicians in 2025, and nine states are projected to have shortages of both primary care physicians and PAs. While no state is projected to have a 2025 shortage of primary care NPs, many states are expected to have only a small surplus. CONCLUSIONS: Primary care physician shortages are projected for all parts of the United States, while primary care PA shortages are generally confined to Midwestern and Southern states. No state is projected to have shortages of all three provider types. Projected shortages must be considered in the context of baseline assumptions regarding current supply, demand, provider-service ratios, and other factors. Still, these findings suggest geographies with possible primary care workforce shortages in 2025 and offer opportunities for targeting efforts to enhance workforce flexibility.

Veterans' Location in Health Professional Shortage Areas: Implications for Access to Care and Workforce Supply.

OBJECTIVE: To describe the distribution of Veterans in areas of the United States where there are potentially inadequate supplies of health professionals, and to explore opportunities suggested by this distribution for fostering health workforce flexibility. DATA SOURCES: County-level data from the 2015-2016 Health Resources and Services Administration's (HRSA's) Area Health Resources Files (AHRF) were used to estimate Veteran populations in HRSA-designated health professional shortage areas (HPSAs). This information was then linked to 2015 VA health facility information from the Department of Veterans Affairs. STUDY DESIGN: Potential Veteran populations living in Shortage Area Counties with no VHA facilities were estimated, and the composition of these populations was explored by Census division and state. PRINCIPAL FINDINGS: Nationwide, approximately 24 percent of all Veterans and 23 percent of Veterans enrolled in VHA health care live in Shortage Area Counties. These estimates mask considerable variation across states. CONCLUSIONS: An examination of Veterans residing in Shortage Area Counties suggests extensive maldistribution of health services across the United States and the continued need to find ways to improve health care access for all Veterans. Effective avenues for doing so may include increasing health workforce flexibility through expansion of nurse practitioner scopes of practice.

Arsenic exposure and type 2 diabetes: a systematic review of the experimental and epidemiological evidence.

Chronic arsenic exposure has been suggested to contribute to diabetes development. We performed a systematic review of the experimental and epidemiologic evidence on the association of arsenic and type 2 diabetes. We identified 19 in vitro studies of arsenic and glucose metabolism. Five studies reported that arsenic interfered with transcription factors involved in insulin-related gene expression: upstream factor 1 in pancreatic beta-cells and peroxisome proliferative-activated receptor gamma in preadipocytes. Other in vitro studies assessed the effect of arsenic on glucose uptake, typically using very high concentrations of arsenite or arsenate. These studies provide limited insight on potential mechanisms. We identified 10 in vivo studies in animals. These studies showed inconsistent effects of arsenic on glucose metabolism. Finally, we identified 19 epidemiologic studies (6 in high-arsenic areas in Taiwan and Bangladesh, 9 in occupational populations, and 4 in other populations). In studies from Taiwan and Bangladesh, the pooled relative risk estimate for diabetes comparing extreme arsenic exposure categories was 2.52 (95% confidence interval, 1.69-3.75), although methodologic problems limit the interpretation of the association. The evidence from occupational studies and from general populations other than Taiwan or Bangladesh was inconsistent. In summary, the current available evidence is inadequate to establish a causal role of arsenic in diabetes. Because arsenic exposure is widespread and diabetes prevalence is reaching epidemic proportions, experimental studies using arsenic concentrations relevant to human exposure and prospective epidemiologic studies measuring arsenic biomarkers and appropriately assessing diabetes should be a research priority.