The use of physician-patient email: a follow-up examination of adoption and best-practice adherence 2005-2008.

BACKGROUND: Improved communication from physician- patient emailing is an important element of patient centeredness. Physician-patient email use has been low; and previous data from Florida suggest that physicians who email with patients rarely implement best-practice guidelines designed to protect physicians and patients. OBJECTIVE: Our objective was to examine whether email use with patients has changed over time (2005-2008) by using two surveys of Florida physicians, and to determine whether physicians have more readily embraced the best-practice guidelines in 2008 versus 2005. Lastly, we explored the 2008 factors associated with email use with patients and determined whether these factors changed relative to 2005. METHODS: Our pooled time-series design used results from a 2005 survey (targeting 14,921 physicians) and a separate 2008 survey (targeting 7003 different physicians). In both years, physicians practicing in the outpatient setting were targeted with proportionally identical sampling strategies. Combined data from questions focusing on email use were analyzed using chi-square analysis, Fisher exact test, and logistic regression. RESULTS: A combined 6260 responses were available for analyses, representing a participation rate of 28.2% (4203/14,921) in 2005 and 29.4% (2057/7003) in 2008. Relative to 2005, respondents in 2008 were more likely to indicate that they personally used email with patients (690/4148, 16.6% vs 408/2001, 20.4%, c(2) (1) = 13.0, P < .001). However, physicians who reported frequently using email with patients did not change from 2005 to 2008 (2.9% vs 59/2001, 2.9%). Interest among physicians in future email use with patients was lower in 2008 (58.4% vs 52.8%, c(2) (2) = 16.6, P < .001). Adherence to email best practices remained low in 2008. When comparing 2005 and 2008 adherences with each of the individual guidelines, rates decreased over time in each category and were significantly lower for 4 of the 13 guidelines. Physician characteristics in 2008 that predicted email use with patients were different from 2005. Specifically, in multivariate analysis female physicians (OR 1.48, 95% CI 1.12-1.95), specialist physicians (OR 1.43, 95% CI 1.12-1.84), and those in a multispecialty practice (OR 1.76, 95% CI 1.30-2.37) were more likely than their counterparts to email with patients. Additionally, self-reported computer competency levels (on a 5-point Likert scale) among physicians predicted email use at every level of response. CONCLUSIONS: Email use between physicians and patients has changed little between 2005 and 2008. However, future physician interest in using email with patients has decreased. More troubling is the decrease in adherence to best practices designed to protect physicians and patients when using email. Policy makers wanting to harness the potential benefits of physician-patient email should devise plans to encourage adherence to best practices. These plans should also educate physicians on the existence of best practices and methods to incorporate these guidelines into routine workflows.

Physician and practice characteristics associated with longitudinal increases in electronic health records adoption.

This article identifies practice- and physician-related characteristics associated with the increased use of EHRs by physicians in outpatient practices. Two Florida surveys conducted in 2005 and 2008 on physician use of EHRs were examined to determine the practice and physician characteristics associated with increased EHR use over time. Based on multivariate analysis, several variables were found to influence increased EHR adoption. Practice variables included participation in a single-specialty practice and percentage of Medicare patients in the practice, but not percentage of Medicaid patients in the practice. Physician characteristics included younger physician age, but not specialty nor years practicing in the community. Factors associated with EHR adoption at any given point in time did not necessarily predict longitudinal increases in EHR adoption. These results are important for physicians to consider in their potential adoption of EHRs and should also be considered by policymakers interested in promoting increased use of EHRs by physicians.

The influence of payer mix on electronic prescribing by physicians.

BACKGROUND: Limited studies have examined electronic prescribing (e-prescribing) adoption in physician office practices. Specifically, none have explored the influence of payer mix on e-prescribing adoption among physicians. PURPOSE: This study examines the impact of practice composition of Medicare, Medicaid, and private insurance on e-prescribing adoption among physicians. METHODOLOGY/APPROACH: Logistic regression was used to analyze data collected from a large-scale information technology-related survey of Florida physicians. FINDINGS: After controlling for practice and physician characteristics, physicians with the highest (odds ratio = 1.67, 95% confidence interval = 1.01-2.78) and above-average (odds ratio [OR] = 1.83, 95% confidence interval = 1.04-3.22) volume of Medicare patients were significantly more likely to e-prescribe as compared with those in the low-volume category. No differences in adoption were found across all Medicaid and private insurance practice composition categories. PRACTICE IMPLICATIONS: Our findings support the notion that direct incentives, such as those in the Medicare Modernization Act of 2003, may influence physician adoption of e-prescribing.

Quality improvement in local health departments: results of the NACCHO 2008 survey.

OBJECTIVES: To assess the current status of quality improvement (QI) within local health departments (LHDs) and examine the characteristics associated with such QI efforts. METHODS: A QI module was administered to a representative sample of 545 LHDs along with the core instrument in the 2008 NACCHO Profile survey of all LHDs nationally. Using the Profile survey data set, a quantitative approach was employed to determine the current status of QI within LHDs. Statistical analysis was performed to identify characteristics of LHDs associated with QI. The response rate to the QI module was 82 percent. RESULTS: Of the 448 LHDs that responded to the QI Module, 55 percent reported conducting formal QI efforts during the previous 2 years. Forty-four percent of these LHDs used a specific framework for QI, 56 percent used at least one of four commonly employed QI tools or techniques, and customer focus and satisfaction was the most frequently reported area (76%) of QI efforts. LHDs with large size of jurisdiction population and those with centralized governance were more likely to have engaged in quality or performance improvement, have managers who received formal QI training, and have provided QI training to staff. CONCLUSION: The 2008 NACCHO Profile QI module furnishes an excellent baseline for measuring progress of health department QI activities as accreditation and other related activities intensify. A clear definition of QI in public health that is understood by practitioners will greatly increase our ability to measure the adoption of QI by LHDs. Further research is necessary to identify and explore some of the predictors and possible barriers to increasing the application of QI by LHDs.

Reducing the impact of the health care access crisis through volunteerism: a means, not an end.

In the absence of meaningful health reform, Florida implemented a volunteer health care program to strengthen the existing safety net. Since program implementation in 1992, over $1 billion of services have been provided to uninsured and underserved populations. Currently, over 20,000 volunteers participate statewide. Key incentives for provider participation have been an organized framework for volunteering and liability protection through state-sponsored sovereign immunity. Volunteerism, although not a solution to the health care crisis, serves as a valuable adjunct pending full-scale health care reform.

The role of information technology usage in physician practice satisfaction.

BACKGROUND: Despite the growing use of information technology (IT) in medical practices, little is known about the relationship between IT and physician satisfaction. PURPOSE: The objective of this study was to examine the relationship between physician IT adoption (of various applications) and overall practice satisfaction, as well as satisfaction with the level of computerization at the practice. METHODS: Data from a Florida survey examining physicians' use of IT and satisfaction were analyzed. Odds ratios (ORs), adjusted for physician demographics and practice characteristics, were computed utilizing logistic regressions to study the independent relationship of electronic health record (EHR) usage, PDA usage, use of e-mail with patients, and the use of disease management software with satisfaction. In addition, we examined the relationship between satisfaction with IT and overall satisfaction with the current medical practice. RESULTS: In multivariate analysis, EHR users were 5 times more likely to be satisfied with the level of computerization in their practice (OR = 4.93, 95% CI = 3.68-6.61) and 1.8 times more likely to be satisfied with their overall medical practice (OR = 1.77, 95% CI = 1.35-2.32). PDA use was also associated with an increase in satisfaction with the level of computerization (OR = 1.23, 95% CI = 1.02-1.47) and with the overall medical practice (OR = 1.30, 95% CI = 1.07-1.57). E-mail use with patients was negatively related to satisfaction with the level of computerization in the practice (OR = 0.69, 95% CI = 0.54-0.90). Last, physicians who were satisfied with IT were 4 times more likely to be satisfied with the current state of their medical practice (OR = 3.97, 95% CI = 3.29-4.81). IMPLICATIONS: Physician users of IT applications, especially EHRs, are generally satisfied with these technologies. Potential adopters and/or policy makers interested in influencing IT adoption should consider the positive impact that computer automation can have on medical practice.

Aligning public health financing with essential public health service functions and National Public Health Performance Standards.

The purpose of this study was to assess the alignment of state and local health department financing with the 10 essential public health service (10EPHS) categories and National Public Health Performance Standards (NPHPS). To determine this, we collected primary data from the Florida Department of Health (FDOH) for fiscal year 2005-2006 and compared it with secondary data collected in the same year through NPHPS survey instruments. A structured interview technique was used to collect primary budget data from each program office at the FDOH and assign each program budget to 10EPHS categories. Local county health department (CHD) expenditures were assessed through an interview with the director and budget chief of one small, medium, and large CHD, and results were then extrapolated for other local CHDs. It was possible for almost 98 percent of the FDOH budget to be allocated into the 10EPHS categories. A majority of resources (68.7%) were used for individual healthcare services, category 7b (assuring provision of services) and category 7a (linking people to needed services). No direct correlation was found between the level of funding by 10EPHS category and the performance standards scores at state or local levels. Public health continues to utilize a majority of its available resources for individual healthcare services, despite increasing requests for improved population-based programs.

Quality improvement in local health departments: progress, pitfalls, and potential.

OBJECTIVES: To assess the current deployment of quality improvement (QI) approaches within local health departments (LHDs) and gain a better understanding of the depth and intensity of QI activities. METHODS: A mixed quantitative and qualitative approach was employed to determine the current status of QI utilization within LHDs. All respondents from the 2005 NACCHO Profile QI module questionnaire who indicated that their LHD was involved in some kind of QI activity received a follow-up Web-based survey in 2007. A smaller convenience sample of 30 LHDs representing all groups of respondents was selected for the follow-up interview to validate and expound upon survey data. RESULTS: Survey response rate was 62 percent (181/292). Eighty-one percent of LHDs reported QI programmatic activities, with 39 percent occurring agency-wide. Seventy-four percent of health departments had staff trained in QI methods. External funding sources for QI were infrequent (28%). LHDs that were serving large jurisdictions and LHDs that were subunits of state health agencies (centralized states) were more likely to engage in most QI activities. However, interview responses did not consistently corroborate survey results and noted a need for shared definitions. CONCLUSION: Multiple factors, including funders and accreditation, may be driving the increase of QI for public health. Additional research to confirm and validate these findings is necessary. A common QI vocabulary is also recommended.

Quality of care in accredited and nonaccredited ambulatory surgical centers.

BACKGROUND: Little is known about quality outcomes in accredited and nonaccredited ambulatory surgical centers (ASCs). Quality outcomes in ASCs accredited by either the Accreditation Association for Ambulatory Health Care (AAAHC) or The Joint Commission were compared with those of nonaccredited ASCs in Florida. METHODS: Patient-level ambulatory surgery and hospital discharge data from Florida for 2004 were merged and analyzed. Multivariate logistic regressions were estimated separately for the five most common ambulatory surgical procedures: colonoscopy, cataract removal, upper gastroendoscopy, arthroscopy, and prostate biopsy. Statistical models examined differences in risk-adjusted 7-day and 30-day unexpected hospitalizations between nationally accredited and nonaccredited ASCs. In addition to risk adjustment, each model controlled for facility volume of procedure and patient demographic characteristics including gender, race, age, and insurance type. RESULTS: In multivariate analyses that controlled for facility volume and patient characteristics, patients at Joint Commission-accredited facilities were still significantly less likely to be hospitalized after colonoscopy. Specifically, compared with patients treated in nonaccredited ASCs regulated by the state agency, patients treated at those facilities were 10.9% less likely to be hospitalized within 7 days (adjusted odds ratio [OR] = 0.891; 95% confidence interval [C.I.], 0.799-0.993) and 9.4% less likely to be hospitalized within 30 days (adjusted OR = 0.906; 95% C.I., 0.850-0.966). No other differences in unexpected hospitalization rates were detected in the other procedures examined. DISCUSSION: With the exception of one procedure, systematic differences in quality of care do not exist between ASCs that are accredited by AAAHC, those accredited by the Joint Commission, or those not accredited in Florida.

Market effects on electronic health record adoption by physicians.

BACKGROUND: Despite the advantages of electronic health record (EHR) systems, the adoption of these systems has been slow among community-based physicians. Current studies have examined organizational and personal barriers to adoption; however, the influence of market characteristics has not been studied. PURPOSE: The purpose of this study was to measure the effects of market characteristics on EHR adoption by physicians. METHODOLOGY: Generalized hierarchal linear modeling was used to analyze EHR survey data from Florida which were combined with data from the Area Resource File and the Florida Office of Insurance Regulation. The main outcome variable was self-reported use of EHR by physicians. FINDINGS: A total of 2,926 physicians from practice sizes of 20 or less were included in the sample. Twenty-one percent (n = 613) indicated that they personally and routinely use an EHR system in their practice. Physicians located in counties with higher physician concentration were found to be more likely to adopt EHRs. For every one-unit increase in nonfederal physicians per 10,000 in the county, there was a 2.0% increase in likelihood of EHR adoption by physicians (odds ratio = 1.02, confidence interval = 1.00-1.03). Health maintenance organization penetration rate and poverty level were not found to be significantly related to EHR adoption. However, practice size, years in practice, Medicare payer mix, and measures of technology readiness were found to independently influence physician adoption. PRACTICE IMPLICATIONS: Market factors play an important role in the diffusion of EHRs in small medical practices. Policy makers interested in furthering the adoption of EHRs must consider strategies that would enhance the confidence of users as well as provide financial support in areas with the highest concentration of small medical practices and Medicare beneficiaries. Health care leaders should be cognizant of the market forces that enable or constrain the adoption of EHR among their practices and those of their competitors.

Incomplete EHR adoption: late uptake of patient safety and cost control functions.

Many functions important to realizing the full potential from electronic health records (EHRs) may not be selected by all physicians using EHRs in the ambulatory setting. This article examines the extent to which EHR systems used by Florida physicians include functionalities that the Institute of Medicine has designated as being critical for optimal performance. Results indicate that EHR systems used by recent adopters, when compared with early adopters, appear to be missing key patient safety and cost control functions. Overall, many physicians are only partially adopting EHR technologies, suggesting that published adoption rates may be exaggerating the true rate of diffusion.

Quality of care differs by patient characteristics: outcome disparities after ambulatory surgical procedures.

The surgery literature is filled with reports on racial or gender disparities in quality. However, whether patient demographics are risk factors for complications or death from ambulatory surgical procedures is unknown. This study explores whether racial, age, and gender outcome disparities exist after ambulatory surgeries. Patients studied included adults (>18 years) receiving common ambulatory surgical procedures (N = 3,174,436) in either a freestanding ambulatory surgical center or a hospital-based outpatient department during 1997-2004 in Florida. Results demonstrate that African Americans were at a significantly increased risk for either mortality or unexpected hospitalization in 4 of the 5 procedures examined, even after controlling for confounders. For women, unexpected hospital admission or mortality was less likely to occur after almost all procedures examined. Thus, many of the racial and gender disparities in the inpatient surgical literature are also observed in the ambulatory setting. More research is needed to determine the source of these disparities.

The relationship between pediatric volume and information technology adoption in hospitals.

OBJECTIVE: Numerous studies have identified organizational factors related to the adoption of information technology (IT) by hospitals. However, no study has examined whether patient characteristics of hospitals are related to the adoption of health IT. This study examines IT adoption in hospitals that care for either a large number or a large proportion of children. METHODS: Primary data from an IT survey of acute care hospitals were combined with secondary data on hospital discharges. Pediatric volume was both categorically and continuously operationalized in several ways. IT adoption was examined both at the individual IT application level and in several aggregate measures of organizational adoption. Univariate and linear regression models were used to analyze the data. Regression models controlled for average patient severity of illness (case mix), public insurance volume, bed size, and system affiliation for each hospital. RESULTS: All 98 acute care hospitals that participated in the survey were matched to the hospital discharge data. Analyses suggest that IT adoption is positively correlated with a higher absolute number of pediatric discharges from hospitals. Similarly, as children make up a higher percentage of a given hospital's discharges, the propensity to adopt clinical and nonclinical IT applications increases significantly as well. CONCLUSION: Acute care hospitals caring for a large number, or a large proportion, of children are more likely to adopt health IT. This relationship may be because children, when hospitalized, are more likely to seek care in technologically and clinically advanced facilities. However, it is unclear whether the IT adopted is calibrated for optimal pediatric use. More research on the use of IT is needed and should focus on other pediatric clinical settings as well.

Hospital adoption of information technologies and improved patient safety: a study of 98 hospitals in Florida.

Most of the studies linking the use of information technology (IT) to improved patient safety have been conducted in academic medical centers or have focused on a single institution or IT application. Our study explored the relationship between overall IT adoption and patient safety performance across hospitals in Florida. Primary data on hospital IT adoption were combined with secondary hospital discharge data. Regression analyses were used to examine the relationship between measures of IT adoption and the Patient Safety Indicators (PSIs) of the Agency for Healthcare Research and Quality. We found that eight PSIs were related to at least one measure of IT adoption. Compared with administrative IT adoption, clinical IT adoption was related to more patient safety outcome measures. Hospitals with the most sophisticated and mature IT infrastructures performed significantly better on the largest number of PSIs. Adoption of IT is associated with desirable performance on many important measures of hospital patient safety. Hospital leaders and other decision makers who are examining IT systems should consider the impact of IT on patient safety.

Managed care penetration and other factors affecting computerized physician order entry in the ambulatory setting.

OBJECTIVES: To estimate the current uses level of ambulatory computerized physician order entry (A-CPOE) among physicians and to examine the relationship of managed care penetration as well as other market and practice characteristics to use of A-CPOE by physicians. DATA SOURCES: This study uses both primary and secondary data sources. The primary data source was a large-scale survey of physicians' use of information technologies in Florida. Secondary data on managed care penetration were obtained from the Florida Agency for Health Care Administration, and other market-level data were extracted from the area resource file. METHODS: A hierarchical logistic regression model was used to examine the correlation of county-level and practice-level characteristics with physicians' self-reported use of A-CPOE systems. RESULTS: Overall, 1360 physicians (32.4%) indicated use of an A-CPOE system. Findings suggest that 1% more managed care penetration was associated with 2.1% lower use of A-CPOE (P = .003). Additionally, practice size, multispecialty affiliation, and primary care practice were significantly and positively correlated with the use of A-CPOE. Physician age was negatively associated with A-CPOE use. CONCLUSION: Managed care organizations may experience significant financial savings from A-CPOE use by physicians; however, managed care penetration in a community negatively affects A-CPOE use among physicians in their practices. Further study regarding the causal nature of this association is warranted.

Are community health centers prepared for bioterrorism?

Community health centers (CHCs) are essential in the delivery of primary care services to underserved populations. Given the critical function of CHCs, surprisingly little is known about their role in preparing for or responding to acts of terrorism. This survey-based study examines the state of CHCs in terrorism preparedness and assesses their training needs. Of the administrators who responded to the survey, 87% indicated that their centers had an emergency response or disaster plan. Of those, 78% indicated they had updated their plans within the past year. Among those who had a written plan, 41% addressed bioterrorism preparedness, 38% had contingencies for a mass influx of patients, and 3% indicated that their plans addressed increasing operational capacity. Additionally, while 48% reported having assessed the education and training needs of their professional staff in the area of disease surveillance and reporting, only 24% had assessed these needs in relation to bioterrorism. Our findings suggest that CHCs have made great strides in preparing for some emergencies but that preparedness does not yet extend to specifically include terrorism events. Policy and practice recommendations are included to more fully develop CHCs as a resource.

A state-based analysis of public health preparedness programs in the United States.

OBJECTIVES: Given the national effort to respond to the challenge of terrorism post-9/11, this study examined the organizational structure of state public health preparedness programs across the country, their administration, and the personnel and resources supported through federal cooperative agreements and state funds. METHODS: In Fall 2004, the Association of State and Territorial Health Officials surveyed state public health preparedness directors of all 50 states and territories of the United States regarding the organizational structure, administration, personnel, and resources of the state public health preparedness programs. RESULTS: Individuals representing 45 states and the District of Columbia responded to the web-based questionnaire for a response rate of 88.2%, States tended to subdivide their organizations into regions for preparedness purposes. More than half the established preparedness regions (53.8%) were created post-9/11. Preparedness program directors frequently reported directly to either the state health official (40.0%) or a deputy state health official (33.3%). Responsibility for both the Centers for Disease Control and Prevention (CDC) and Health Resources and Services Administration (HRSA) cooperative agreements was predominantly vested in one person (73.3%). Federal resources were found to support needed preparedness workforce (CDC mean = 117.1 full-time equivalents [FTEs]; HRSA mean = 10.6 FTEs). In addition, 36.6% of the states also contributed to the public health preparedness budget. CONCLUSIONS: This study of state public health agency preparedness provides new information about state-level organizational structure, administration, and support of preparedness programs. It offers the first comprehensive insights into the approaches states have adopted to build infrastructure and develop capacity through CDC and HRSA funding streams.

A study of the efficacy of various home filtration substrates in the removal of microcystin-LR from drinking water.

This study was conducted to determine whether common water filtration and purification systems bought by consumers and used in the home would remove cyanotoxins from water. Commonly used universal filter housings and filter sizes were utilized to identify filter media that may be effective in the removal of microcystin-LR in deionized water. Results suggest that the efficacy of home filtration devices in removing microcystin-LR varies considerably with the type of device being used. Carbon filters successfully removed microcystin-LR allowing only 0.05-0.3% of the toxin load to pass through the filter. On the other hand, pleated paper and string wound filters allowed > 90% of microcystin-LR present in the sample to pass through the filters. Theoretically, the use of carbon home filtration devices tested in this study may provide protection against human exposure to cyanotoxin in addition to protection provided by water treatment methodologies utilized in water treatment facilities. Further studies need to be done to assess the efficacy of home filtration devices for various cyanotoxins and for other filtering conditions such as increased toxin load, the presence of other contaminants in drinking water, and the repetitive use of the same filter over longer time intervals.

Charting the use of electronic health records and other information technologies among child health providers.

BACKGROUND: Previous studies regarding the use of information technologies (IT) specifically among pediatricians and other physicians who treat children are lacking. As such, the objective of this study is to examine the use of electronic health record (EHR) systems and other IT applications among pediatricians and other child health providers (CHPs) in Florida. METHODS: We focus on pediatricians and other CHPs who responded to a state-wide physician survey of IT use. CHPs included general pediatricians, pediatric sub-specialists, and family physicians who self-reported a practice composition of at least 20% children. We compared general pediatricians to other CHPs and all CHPs (including pediatricians) to other physicians with respect to computer and internet availability, and to the use of personal digital assistants and EHRs. Those with an EHR were also compared regarding the availability of key functions available in their system. Statistical analyses included chi-square analysis and logistic regression models which controlled for numerous factors. RESULTS: A total of 4,203 surveys (28.2% response) including 1,021 CHPs, were returned. General pediatricians (13.7%) were significantly less likely to be using an EHR than both CHP family physicians (26.1%) and pediatric sub-specialists (29.6%; p < .001). In multivariate analysis, only general pediatricians were significantly less likely than other physicians to indicate the use of an EHR system (OR = .43; 95% C.I. = .29 - .64). Overall, CHPs were less likely to have key functions available in their EHR system including electronic prescribing (53.3% vs. 61.9%; p = .028), and electronic order entry (47.7% vs. 57.2%; p = .017) among others. General pediatricians and pediatric sub-specialists frequently lagged behind CHP family physicians with respect to key EHR functions. In contrast, CHPs had growth charts (51.3% vs. 24.0%; p < .001) and weight-based dosing functions (35.5% vs.22.7%; p < .001) more frequently than others. CONCLUSION: Physicians caring for children, and especially pediatricians, in Florida, are significantly slower than other doctors to adopt EHRs, and important electronic patient safety functionalities, into their office practices.

Availability of physician services in Florida, revisited: the effect of the professional liability insurance market on access to health care.

BACKGROUND: Access to care remains a key part of improving health care outcomes in the United States. Recent reports have suggested that the number of physicians able to meet the demands for access to care may be decreasing. METHODS: We surveyed physicians practicing in rural and urban/suburban areas of Florida in 2004 to determine whether changes were occurring in health care service delivery. Secondary outcomes assessed included changes in professional liability insurance and their possible effects on changes in service delivery. RESULTS: Overall, 727 (54.4%) of responding physicians stated that the delivery of services had been decreased or eliminated in the previous year. The most commonly eliminated services were nursing home coverage (42.1%), vaginal deliveries (29.1%), cesarean deliveries (26.0%), emergency department coverage (22.8%), and mental health services (21.2%). Surgical specialists (70.2%) and general surgeons (68.5%) were the groups with the highest number of decreased or eliminated services, but this trend was broad, with 63.6% of obstetrician/gynecologists and 60.2% of family medicine physicians also decreasing or eliminating services. Decreases in services seem to be related to changes in professional liability insurance premiums when assessed by both percentage of change and total premium increases for physicians. Rural and urban/suburban physicians did not differ significantly in these assessments. CONCLUSION: The findings suggest that physicians across Florida have continued to decrease or eliminate important health services and that these decreases seem to be related to the difficulty of finding or paying for professional liability insurance.