Effect of vaccination by community pharmacists among adult prescription recipients.

BACKGROUND: Millions of doses of influenza vaccine are administered each year in the United States at nontraditional sites and by nontraditional vaccine providers. Pharmacists are increasingly becoming vaccine providers. OBJECTIVES: To measure association between availability of pharmacist-immunizers and immunization delivery to adult prescription recipients, and the relative contributions of various types of vaccine providers. RESEARCH DESIGN: Mailed survey in spring 1999, contrasting adults in urban Washington State, where pharmacists administer vaccines, to adults in urban Oregon, where pharmacists did not. SUBJECTS: Cluster sample based on October 1998 prescription records suggesting need for influenza vaccine, derived from 24 community pharmacies belonging to one pharmacy chain. MEASURES: Vaccination status and choice of vaccine provider. RESULTS: Influenza vaccination rates among respondents 65 years or older increased 4.7% more in Washington than in Oregon between 1997 and 1998 (P = 0.20). The net increase in influenza vaccination rate among younger respondents taking indicator medications for chronic diseases for which influenza vaccination is recommended was 10.6% (P = 0.05). Among respondents unvaccinated against influenza in 1997, the 1998 influenza vaccination rate was 34.7% in Washington, compared with 23.9% in Oregon (P = 0.01). CONCLUSIONS: Vaccine delivery by pharmacists is associated with higher rates of vaccination among those younger than 65 taking indicator medications medications for chronic diseases, as well as prescription recipients unvaccinated against influenza in the previous year.

Understanding physicians' intentions to withdraw from practice: the role of job satisfaction, job stress, mental and physical health.

Health care organizations may incur high costs due to a stressed, dissatisfied physician workforce. This study proposes and tests a model relating job stress to four intentions to withdraw from practice mediated by job satisfaction and perceptions of physical and mental health.

Reported response rates to mailed physician questionnaires.

OBJECTIVE: To examine response rate information from mailed physician questionnaires reported in published articles. DATA SOURCES/STUDY SETTING: Citations for articles published between 1985 and 1995 were obtained using a key word search of the Medline, PsychLit, and Sociofile databases. STUDY DESIGN: A 5 percent random sample of relevant citations was selected from each year. DATA COLLECTION/EXTRACTION METHODS: Citations found to be other than physician surveys were discarded and replaced with the next randomly assigned article. Selected articles were abstracted using a standardized variable list. PRINCIPAL FINDINGS: The average response rate for mailed physician questionnaires was 61 percent. The average response rate for large sample surveys (> 1,000 observations) was 52 percent. In addition, only 44 percent of the abstracted articles reported a discussion of response bias, and only 54 percent reported any type of follow-up. CONCLUSIONS: (1) Response rates have remained somewhat constant over time, and (2) researchers need to document the efforts used to increase response rates to mailed physician questionnaires.

Medical training debt and service commitments: the rural consequences.

This study assesses how student loan debt and scholarships, loan repayment and related programs with service requirements influence the incomes young physicians seek and attain, influence whether they choose to work in rural practice settings and affect the number of Medicaid-covered and uninsured patients they see. Data are from a 1999 mail survey of a national probability sample of 468 practicing family physicians, general internists and pediatricians who graduated from U.S. medical schools in 1988 and 1992. A majority of these generalist physicians recalled "moderate" or "great" concern for their financial situations before, during and after their training. Eighty percent financed all or part of their training with loans, and one-quarter received support from federal, state or community-sponsored scholarship, loan repayment and similar programs with service obligations. In their first job after residency, family physicians and pediatricians with greater debt reported caring for more patients insured under Medicaid and uninsured than did those with less debt. For no specialty was debt associated with physicians' income or likelihood of working in a rural area. Physicians serving commitments in exchange for training cost support, compared to those without obligations, were more likely to work in rural areas (33 vs. 7 percent, respectively, p < 0.001) and provided care to more Medicaid-covered and uninsured patients (53 vs. 29 percent, p < 0.001), but did not differ in their incomes ($99,600 vs. $93,800, p = 0.11). Thus, among physicians who train as generalists, the high costs of medical education appear to promote, not harm, national physician work force goals by prompting participation in service-requiring financial support programs and perhaps through increasing student borrowing. These positive outcomes for generalists should be weighed against other known and suspected negative consequences of the high costs of training, such as discouraging some poor students from medical careers altogether and perhaps influencing some medical students with high debt not to pursue primary care careers.

The economic implications of self-care: the effect of lifestyle, functional adaptations, and medical self-care among a national sample of Medicare beneficiaries.

OBJECTIVES: Self-care includes actions taken by individuals to promote or ensure their health, to recover from diseases or injuries, or to manage their effects. This study measured associations between self-care practices (lifestyle practices, adaptations to functional limitations, and medical self-care) and Medicare expenditures among a national sample of adults 65 years and older. METHODS: Regression models of Medicare use and expenditures were estimated by using the National Survey of Self-Care and Aging and Medicare claims for 4 years following a baseline interview. RESULTS: Lifestyle factors (swimming and walking) and functional adaptations (general home modifications) were associated with reductions in monthly Medicare expenditures over a 12-month follow-up period. Expenditure reductions were found over the 48-month follow-up period for participation in active sports, gardening, and medical self-care. Practices associated with increases in expenditures included smoking, physical exercise (possibly of a more strenuous nature), and specific home modifications. CONCLUSIONS: Certain self-care practices appear to have significant implications for Medicare expenditures and presumptively for the health status of older adults. Such practices should be encouraged among older adults as a matter of national health policy.

State scholarship, loan forgiveness, and related programs: the unheralded safety net.

CONTEXT: In the mid-1980s, states expanded their initiatives of scholarships, loan repayment programs, and similar incentives to recruit primary care practitioners into underserved areas. With no national coordination or mandate to publicize these efforts, little is known about these state programs and their recent growth. OBJECTIVES: To identify and describe state programs that provide financial support to physicians and midlevel practitioners in exchange for a period of service in underserved areas, and to begin to assess the magnitude of the contributions of these programs to the US health care safety net. DESIGN: Cross-sectional, descriptive study of data collected by telephone, mail questionnaires, and through other available documents, (eg, program brochures, Web sites). SETTING AND PARTICIPANTS: All state programs operating in 1996 that provided financial support in exchange for service in defined underserved areas to student, resident, and practicing physicians; nurse practitioners; physician assistants; and nurse midwives. We excluded local community initiatives and programs that received federal support, including that from the National Health Service Corps. MAIN OUTCOME MEASURES: Number and types of state support-for-service programs in 1996; trends in program types and numbers since 1990; distribution of programs across states; numbers of participating physicians and other practitioners in 1996; numbers in state programs relative to federal programs; and basic features of state programs. RESULTS: In 1996, there were 82 eligible programs operating in 41 states, including 29 loan repayment programs, 29 scholarship programs, 11 loan programs, 8 direct financial incentive programs, and 5 resident support programs. Programs more than doubled in number between 1990 (n = 39) and 1996 (n = 82). In 1996, an estimated 1306 physicians and 370 midlevel practitioners were serving obligations to these state programs, a number comparable with those in federal programs. Common features of state programs were a mission to influence the distribution of the health care workforce within their states' borders, an emphasis on primary care, and reliance on annual state appropriations and other public funding mechanisms. CONCLUSIONS: In 1996, states fielded an obligated primary care workforce comparable in size to the better-known federal programs. These state programs constitute a major portion of the US health care safety net, and their activities should be monitored, coordinated, and evaluated. State programs should not be omitted from listings of safety-net initiatives or overlooked in future plans to further improve health care access. JAMA. 2000;284:2084-2092.

Using the American Medical Association physician masterfile to measure physician supply in small towns.

The goal of this study was to describe the magnitude, direction and sources of error of the American Medical Association's (AMA) masterfile (MF) in estimating physician supply in small towns. A random sample of nonmetropolitan towns in the United States was selected, and physicians with AMA MF (MFMDs) addresses in these towns were listed. Local pharmacists were asked to confirm or disconfirm the identities and locations of practice for the listed physicians and to add any unlisted physicians who were there. We took pharmacist confirmed or identified local source physicians (LSMDs) to be the "gold standard." The sample of 57 towns yielded 1,341 potential physician names. In these towns, there were 377 physician listings only from the MF, 188 only from local pharmacists, and 776 from both sources. About 80 percent of physicians identified by local informants were also listed on the MF; only 67 percent of physicians listed on the MF were identified by local informants as currently practicing in the town where they were listed. The error in these measures declined with increasing town size. The aggregate ratio of MFMDs to LSMDs was 1.20, ranging from 1.10 to 1.28 across size classes of towns. Given the persistence of local shortages of physicians, despite a national oversupply, accurate measurement of physician supply should be a priority of rural health care planners and advocates. Although the MF is the most comprehensive available national physician database, reliance on it alone to make local estimates of physician supply might lead one to believe that there are 20 percent more physicians in small rural communities than are actually there. Local pharmacists can be valuable informants about rural physician availability and their in- and out-migration.

Managed care, time pressure, and physician job satisfaction: results from the physician worklife study.

OBJECTIVE: To assess the association between HMO practice, time pressure, and physician job satisfaction. DESIGN: National random stratified sample of 5,704 primary care and specialty physicians in the United States. Surveys contained 150 items reflecting 10 facets (components) of satisfaction in addition to global satisfaction with current job, one's career and one's specialty. Linear regression-modeled satisfaction (on 1-5 scale) as a function of specialty, practice setting (solo, small group, large group, academic, or HMO), gender, ethnicity, full-time versus part-time status, and time pressure during office visits. "HMO physicians" (9% of total) were those in group or staff model HMOs with > 50% of patients capitated or in managed care. RESULTS: Of the 2,326 respondents, 735 (32%) were female, 607 (26%) were minority (adjusted response rate 52%). HMO physicians reported significantly higher satisfaction with autonomy and administrative issues when compared with other practice types (moderate to large effect sizes). However, physicians in many other practice settings averaged higher satisfaction than HMO physicians with resources and relationships with staff and community (small to moderate effect sizes). Small and large group practice and academic physicians had higher global job satisfaction scores than HMO physicians (P <.05), and private practice physicians had quarter to half the odds of HMO physicians of intending to leave their current practice within 2 years (P <.05). Time pressure detracted from satisfaction in 7 of 10 satisfaction facets (P <.05) and from job, career, and specialty satisfaction (P <.01). Time allotted for new patients in HMOs (31 min) was less than that allotted in solo (39 min) and academic practices (44 min), while 83% of family physicians in HMOs felt they needed more time than allotted for new patients versus 54% of family physicians in small group practices (P <.05 after Bonferroni's correction). CONCLUSIONS: HMO physicians are generally less satisfied with their jobs and more likely to intend to leave their practices than physicians in many other practice settings. Our data suggest that HMO physicians' satisfaction with staff, community, resources, and the duration of new patient visits should be assessed and optimized. Whether providing more time for patient encounters would improve job satisfaction in HMOs or other practice settings remains to be determined.

Comparison of physical activity in adolescents with cystic fibrosis versus age-matched controls.

The aims of this study were to compare self-reported vigorous physical activity and participation in sports among adolescents with cystic fibrosis (CF) to those of age matched peers from the general population, and to determine which CF patient characteristics are associated with regular physical activity. One hundred and sixteen of 141 (82%) adolescents aged 12-19 years identified through North Carolina CF Care Center registries confidentially completed a self-administered questionnaire (the CDC's Youth Risk Behavior Survey) addressing health-compromising and health-enhancing behaviors, including physical activity. They were age- and gender-matched to adolescents from North Carolina schools who completed the same survey. Adolescents with CF did not differ significantly from their matched peers with regard to participating three or more times a week in activities that "make you sweat or breathe hard" (63% vs. 67%, P = 0.37), physical education class (59% vs. 61%, P = 0.81), or team sports (52% vs. 61%, P = 0.10). For all categories of activity, participation declined among adolescents aged 17 years or older. After adjusting for gender and health status, early (14 years or younger) and middle (15-16 years) adolescents were more likely to participate in all three types of activity than older adolescents with CF. Like their peers in the general population, adolescents aged 17 and older are much less likely to report regular physical activity, or participation in physical education class or in team sports. Healthcare providers should be aware of this decline in activity in late adolescence and should consider efforts to maintain physical activity among older teenagers and young adults.

Transforming practice organizations to foster lifelong learning and commitment to medical professionalism.

Practice organizations will increasingly engage in activities that are the functional equivalents of continuing medical education. The authors maintain that if these activities are properly structured within practice organizations, they can become powerful engines of socialization to enhance physicians' lifelong learning and commitment to medical professionalism. They propose that this promise can be realized if new or reformed practice organizations combine education and service delivery and institutionalize processes of individual and collective reflection. The resulting "institutions of reflective practice" would be ones of collegial, experiential, reflective lifelong learning concerning the technical and normative aspects of medical work. They would extend recent methods of medical education such as problem-based learning into the practice setting and draw on extant methods used in complex organizations to maximize the advantages and minimize the disadvantages that practice organizations typically present for adult learning. As such, these institutions would balance the potentially conflicting organizational needs for, on the one hand, (1) self-direction, risk taking, and creativity; (2) specialization; and (3) collegiality; and, on the other hand, (4) organizational structure, (5) coordination of division of labor, and (6) hierarchy. Overall, this institutionalization of reflective practice would enrich practice with education and education with practice, and accomplish the ideals of what the authors call "responsive medical professionalism." The medical profession would both contribute and be responsive to social values, and medical work would be valued intrinsically and as central to practitioners' self-identity and as a contribution to the public good.

The work lives of women physicians results from the physician work life study. The SGIM Career Satisfaction Study Group.

OBJECTIVE: To describe gender differences in job satisfaction, work life issues, and burnout of U.S. physicians. DESIGN/PARTICIPANTS: The Physician Work life Study, a nationally representative random stratified sample of 5,704 physicians in primary and specialty nonsurgical care (N = 2,326 respondents; 32% female, adjusted response rate = 52%). Survey contained 150 items assessing career satisfaction and multiple aspects of work life. MEASUREMENTS AND MAIN RESULTS: Odds of being satisfied with facets of work life and odds of reporting burnout were modeled with survey-weighted logistic regression controlling for demographic variables and practice characteristics. Multiple linear regression was performed to model dependent variables of global, career, and specialty satisfaction with independent variables of income, time pressure, and items measuring control over medical and workplace issues. Compared with male physicians, female physicians were more likely to report satisfaction with their specialty and with patient and colleague relationships (P <.05), but less likely to be satisfied with autonomy, relationships with community, pay, and resources (P <.05). Female physicians reported more female patients and more patients with complex psychosocial problems, but the same numbers of complex medical patients, compared with their male colleagues. Time pressure in ambulatory settings was greater for women, who on average reported needing 36% more time than allotted to provide quality care for new patients or consultations, compared with 21% more time needed by men (P <.01). Female physicians reported significantly less work control than male physicians regarding day-to-day aspects of practice including volume of patient load, selecting physicians for referrals, and details of office scheduling (P <.01). When controlling for multiple factors, mean income for women was approximately $22,000 less than that of men. Women had 1.6 times the odds of reporting burnout compared with men (P <.05), with the odds of burnout by women increasing by 12% to 15% for each additional 5 hours worked per week over 40 hours (P <.05). Lack of workplace control predicted burnout in women but not in men. For those women with young children, odds of burnout were 40% less when support of colleagues, spouse, or significant other for balancing work and home issues was present. CONCLUSIONS: Gender differences exist in both the experience of and satisfaction with medical practice. Addressing these gender differences will optimize the participation of female physicians within the medical workforce.

Self-reported arthritis-related disruptions in sleep and daily life and the use of medical, complementary, and self-care strategies for arthritis: the National Survey of Self-care and Aging.

OBJECTIVE: To assess relations between self-reported arthritis-related disruptions in sleep, physical activity, and social functioning and use of medical care, complementary therapies, and self-care for arthritis in older adults. DESIGN: A survey of self-reported arthritis-related disruptions in sleep and daily life as risk factors for use of 15 medical, complementary, and self-care modalities for relief of arthritis symptoms. SETTING: General community from 38 urban and 12 rural areas in the contiguous United States. PARTICIPANTS: Nine hundred thirty-seven older persons reporting arthritis; of the 1925 in the 1993 to 1994 follow-up of the National Survey of Self-care and Aging, a population-based, stratified, random sample of noninstitutionalized Medicare beneficiaries aged 65 years and older. MAIN OUTCOME MEASURES: Use of 15 medical, self-care, and complementary modalities for relief of arthritis symptoms. RESULTS: Most respondents reported use of at least 1 medical, complementary, or self-care strategy for arthritis. Arthritis was reported to disrupt sleep and leisure in 32.8% and 33.4% of respondents, respectively. Individuals with sleep disruption were more likely than those without sleep disturbance to use medical, complementary, and self-care strategies (adjusted odds ratio [95% confidence interval], 2.31 [1.59-3.37] for seeing a physician; and 2.23 [1.60-3.10] for using physical modalities). Reported disruption in sleep from arthritis was associated with use of more medical, complementary, and self-care strategies than was any other disruption. CONCLUSIONS: Self-reported arthritis-related disruption in sleep is associated with use of a wide range of medical, complementary, and self-care strategies. Physicians, other health care providers, and researchers should not overlook the importance of this common and often-neglected symptom.

The wineglass model: tracking the locational histories of health professionals.

This paper introduces a space-time continuum model to evaluate the effectiveness of programs that encourage recruitment and retention of health professionals. Based on the shape of a wineglass, the model provides a framework to study the locational histories of a cohort of health professionals, both conceptually and quantitatively. A key component of the model is that it measures geographic dispersion over time from a medical school, residency program, or other shared location. Geographic dispersion can be studied in the model through standard deviational ellipses, standard distance, or average distance circles. The model enables analysis through structuration theory, which is used as a guide for analyzing the interplay between human agency (e.g., individual decisions on practice location) and structure (e.g., medical education). Space-time modeling is linked with structuration theory. Variations in the shape of the wineglass reveal how people may be bound by a general structure, yet through lifetime locational decisions may change that structure over space and time. Using data on University of Nebraska alumni, the authors constructed a pilot demonstration to test and confirm the model's potential usefulness. In the pilot demonstration, standard deviational ellipses represented the range of physician locations during each year, overlaid on maps of the US. The pilot demonstration indicated the model's strength in identifying changing mobility over time, while also pointing to concerns about unevenness in data availability from one year to the next. Further application of the wineglass model could be used toward studying the life histories of health professionals. The impact of community-based training on long- or short-term retention, changes in the mobility of male vs female providers, and the career trajectories of people in different health professions or medical schools are only a few examples of potential future applications of the model.

Refining the measurement of physician job satisfaction: results from the Physician Worklife Survey. SGIM Career Satisfaction Study Group. Society of General Internal Medicine.

BACKGROUND: Physician job satisfaction has been linked to various patient care and health system outcomes. A survey instrument that concisely measures physicians' satisfaction with various job facets can help diverse stake-holders to better understand and manage these outcomes. OBJECTIVE: To document the development and validation of a multidimensional physician job satisfaction measure and separate global satisfaction measures. DESIGN: Self-administered questionnaire: Physician Worklife Survey (PWS). SUBJECTS: A pilot study employed a national American Medical Association Masterfile sample of US primary care physicians and random samples from four states. Responses (n = 835; 55% return rate) were randomly assigned to developmental (n = 560) or cross-validation (n = 275) samples. A national sample (n = 2,325; 52% response rate) of physicians was used in a subsequent validation study. RESULTS: A 38-item, 10-facet satisfaction measure resulting from factor and reliability analyses of 70 pilot items was further reduced to 36 items. Reliabilities of the 10 facets ranged from .65 to .77. Three scales measuring global job, career, and specialty satisfaction were also constructed with reliabilities from .84 to .88. Results supported face, content, convergent, and discriminant validity of the measures. CONCLUSIONS: Physician job satisfaction is a complex phenomenon that can be measured using the PWS.

Measuring physician job satisfaction in a changing workplace and a challenging environment. SGIM Career Satisfaction Study Group. Society of General Internal Medicine.

BACKGROUND: Changes in the demographic, specialty, and employment sector composition of medicine have altered physicians' jobs, limiting autonomy and reducing morale. Because physician job satisfaction has been linked to clinical variables, better measurement might help to ameliorate conditions linked to medical disaffection, possibly improving health care. OBJECTIVE: To document conceptual development, item construction, and use of content experts in designing multidimensional measures of physician job satisfaction and global satisfaction scales for assessing physicians' job perceptions across settings and specialties. DESIGN: Using previous research, physician focus groups, secondary analysis of survey data, interviews with physician informants, and a multispecialty physician expert panel, distinct job facets and statements representing those facets were developed. RESULTS: Facets from previously validated instruments included autonomy, relationships with colleagues, relationships with patients, relationships with staff, pay, resources, and status. New facets included intrinsic satisfaction, free time away from work, administrative support, and community involvement. Physician status items were reconfigured into relationships with peers, patients, staff, and community, yielding 10 hypothetical facets. Global scales and items were developed representing satisfaction with job, career, and specialty. CONCLUSIONS: A comprehensive approach to assessing physician job satisfaction yielded 10 facets, some of which had not been previously identified, and generated a matching pool of items for subsequent use in field tests.

The need of community health centers for international medical graduates.

OBJECTIVES: This study sought to determine whether community health centers need international medical graduates to fill staff positions. METHODS: The authors surveyed 100 community health center administrators to learn about their perceptions of international medical graduates. RESULTS: Nationally, about one quarter of community health centers depend on international medical graduates to fill physician vacancies; most of these centers foresee unfilled positions in the event of a cutback. CONCLUSIONS: Policies calling for a national reduction in the supply of international medical graduates need to be balanced by an understanding of these individuals' role in reducing local physician shortages.

Preparing and retaining rural physicians through medical education.

PURPOSE: To identify educational approaches that best prepare physicians for rural work and small-town living, and that promote longer rural practice retention. METHOD: In two mail surveys (1991 and 1996-97), the authors collected data from primary care physicians who had moved to rural practices nationwide from 1987 through 1990. A total of 456 eligible physicians responded to both surveys (response rate of 69.0%). The authors identified those features of the physicians' training that correlated with their self-reported preparedness for rural practice and small-town living, and with how long they stayed in their rural practices. Analyses controlled for six features of the physicians and their communities. RESULTS: The physicians' sense of preparedness for small-town living predicted their retention duration (hazard ratio, 0.74, p < .0001), whereas their preparedness for rural medical practice did not predict their retention duration after controlling for preparedness for small-town living (hazard ratio, 0.92; p = .27). For the physicians who had just finished their training, only a few features of their training predicted either rural preparedness or retention. Residency rural rotations predicted greater preparedness for rural practice (p = .004) and small-town living (p = .03) and longer retention (hazard ratio, 0.43, p = .003). Extended medical school rural rotations predicted only greater preparedness for rural practice (p = .03). For the physicians who had prior practice experience, nothing about their medical training was positively associated with preparedness or retention. CONCLUSION: Physicians who are prepared to be rural physicians, particularly those who are prepared for small-town living, stay longer in their rural practices. Residency rotations in rural areas are the best educational experiences both to prepare physicians for rural practice and to lengthen the time they stay there.

The role of state policies and programs in buffering the effects of poverty on children's immunization receipt.

OBJECTIVES: This study assessed the influence of public policies on the immunization status of 2-year old children in the United States. METHODS: Up-to-dateness for the primary immunization series was assessed in a national sample of 8100 children from the 1988 National Maternal and Infant Health Survey and its 1991 Longitudinal Follow-Up. RESULTS: Documented immunization rates of this sample were 33% for poor children and 44% for others. More widespread Medicated coverage was associated with greater likelihood of up-to-dateness among poor children. Up-to-dateness was more likely for poor children with public rather than private sources of routine pediatric care, but all children living in states where most immunizations were delivered in the public sector were less likely to be up to date. Poor children in state with partial vaccine replacement programs were less likely to be up to date than those in free-market purchase states. CONCLUSIONS: While state policies can enhance immunization delivery for poor children, heavy reliance on public sector immunization does not ensure timely receipt of vaccines. Public- and private-sector collaboration is necessary to protect children from vaccine-preventable diseases.

Do international medical graduates reduce rural physician shortages?

OBJECTIVES: The authors examined whether international medical graduates (IMGs) constitute a greater percentage of the US physician workforce in rural underserved areas than in rural non-underserved areas. Research findings could help policymakers determine whether the role of international medical graduates in compensating for local physician shortages counterbalances international medical graduates' potential for exacerbating a national oversupply. METHODS: This research was based on data from the American Medical Association Physician Masterfile and the Bureau of Health Professions' Area Resource File. The authors calculated the percentage international medical graduates of all US primary care physicians in rural areas, stratified by the Health Professional Shortage Area (HPSA) designation of underservice. RESULTS: The study showed that international medical graduates do constitute a greater percentage of US primary care physicians in rural areas with physician shortages than in rural areas without physician shortages. This finding held true at the national, Census region, and state scales of analysis, but to varying degrees. The finer the scale of analysis, the greater the variation in international medical graduates' practice in rural, underserved areas. There was substantial interstate variation in the extent to which international medical graduates practice in rural underserved areas. CONCLUSIONS: International medical graduates do help reduce rural physician shortages, but interstate variation points to the role of state policies in influencing international medical graduates' distribution in rural, underserved areas. Such variation also can come about from many different causes, so there is a need for further research to determine why international medical graduates help compensate for physician shortages more so in some states than in others.

Patterns and determinants of multiple provider use in patients with acute low back pain.

OBJECTIVE: To describe the patterns of provider use associated with an acute episode of nonspecific low back pain and their impact on cost. METHODS: The analysis is based on a prospective cohort study of patients with acute low back pain followed until they recovered completely or to 6 months. Patients were followed after an initial visit to one of four provider types: private primary care physician, chiropractor, orthopedic surgeon, or HMO primary care physician. Follow-up interviews were conducted at baseline, 2, 4, 8, 12, and 24 weeks; 1,580 (97%) of the participants completed the 6-month follow-up. MAIN RESULTS: Seventy-nine percent of patients saw only the initial provider who began their care for low back pain. Logistic regression revealed that duration of pain prior to initial visit, sciatica, higher Roland disability score, days to functional recovery, interval to complete recovery, referral by initial provider, disk attribution, satisfaction, and the type of index provider were significantly (p < .05) associated with seeking care from multiple provider types. Age, race, gender, and education were not significant. The adjusted proportions of multiple provider type use were 14% (95% confidence interval [CI] 11%, 17%) for the private primary care provider stratum; 19% (95% CI 16%, 23%) for the chiropractic stratum; 30% (95% CI 23%, 37%) for the orthopedic stratum; and 9% (95% CI 5%, 14%) for the HMO primary care physician stratum. Cost of seeing only the index provider was $439 (95% CI $404, $475), and cost of seeing multiple provider types was $1,137 (95% CI $1,064, $1,211) based on the adjusted model. CONCLUSIONS: Use of multiple provider types, is associated with several factors, one of which is the initial provider type. The cost of such use is significant.